When Contraceptives Change Monthly Bleeding

Provider Guide: Managing Bleeding Changes Caused by Contraceptive Methods

How to use this tool: Family planning providers can use this guide to help clients manage bleeding changes caused by their contraceptive method. It includes advice that the provider can give to clients, questions to help determine the cause of the bleeding change, and options for treating the bleeding change. (Evidence about the effectiveness of treatment options is limited. Much of the evidence indicates that treatments may help in the short-term only. Providers should make clear that treatment may or may not succeed.) If, after counseling and treatment, the client is not satisfied, help her choose another method.

These recommendations will appear in the forthcoming Family Planning: A Global Handbook for Providers. Much of the guidance comes from the World Health Organization's Selected Practice Recommendations for Contraceptive Use.

Bleeding Change and Methods

Guidance

No monthly bleeding OR infrequent bleeding (fewer than 2 episodes of bleeding over 3 months)

METHODS: Progestin-only pills (POPs), progestin-only injectables, hormonal levonorgestrel-releasing IUD (LNG-IUD), combined oral contraceptives (COCs), implants, combined monthly injectables

Advice:

• Explain that this is common with POPs, progestin-only injectables, and the LNG-IUD. This also happens occasionally with COCs, implants, and combined (monthly) injectables. Reassure client that this is not harmful to her health.
• For clients over 40, this bleeding change is not a reliable indicator of menopause when using hormonal contraceptives. In general, women should continue using their contraceptive method until age 55. (Majority of women reach menopause by then.)

For the COC or POP user: Has she been taking one pill each day, at about the same time?

• If so, reassure her that she is not likely to be pregnant and advise her to continue taking one pill each day.
• If, however, she started her current pack of COCs more than 3 days late or missed 3 or more hormonal pills in a row, ask her to return if she notices signs and symptoms of early pregnancy (for pills with 20 µg or less of ethinyl estradiol, 2 days late or 2 pills missed).
• If she is not breastfeeding and took a progestin-only pill more than 3 hours late, ask her to return if she notices signs and symptoms of early pregnancy.

Treatment Options:

Progestin-only injectables:

• If she wants to continue using an injectable contraceptive method, she may want to switch to a combined (monthly) injectable, if available.

LNG-IUD:

• If she wants to continue using an IUD, she can switch to a copper IUD.

Bleeding or spotting at unexpected times

METHODS: COCs, injectables, POPs (especially among women who are not breastfeeding), implants, LNG-IUD, copper IUDs

Advice:

Is this occurring during the first few months of use (for implants, during the first year of use)?

• If so, reassure her that such bleeding changes are common initially, are not harmful, and usually lessen or stop with time.

For the COC or POP user (during the first few months of use or later):

Has she been taking one pill each day, at about the same time?

• If not, suggest that she do so.

Has she had vomiting or diarrhea?

• If so, advise her to take another pill if vomiting occurs within 2 hours after taking a pill.

Is she taking medicines for seizures or rifampicin (typically used to treat tuberculosis)?

• These medicines interfere with the absorption of hormones taken orally and may cause bleeding or spotting at unexpected times in addition to possibly reducing the effectiveness of the method. If using these medicines long-term, she may want to use another contraceptive method such as any injectable or IUD.

Treatment Options: If no reason to suspect a medical problem, try these treatments, if available, one at a time. They may help some women.

Combined (monthly) injectables:

• She can try 800 mg ibuprofen, or other non-steroidal anti-inflammatory drugs (NSAIDs), 3 times daily after meals for 5 days when the bleeding starts. NSAIDs provide short-term relief of bleeding for other contraceptive methods and may help users of monthly injectables, too.

COCs: Same as for combined (monthly) injectables, above.

• If she has been taking pills for more than a few months and NSAIDs do not help, give her a different COC formulation, if available. Ask her to use it for at least 3 months.

POPs: Same as for COCs, above.

Progestin-only injectables:

• She can try 800 mg ibuprofen 3 times daily or 500 mg mefenamic acid 2 times daily after meals for 5 days when the bleeding starts. NSAIDs provide short-term relief of bleeding for contraceptive methods and may help users of progestin-only injectables, too.

Implants: Same as for progestin-only injectables, above.

• If NSAIDs do not help, she can try:
  • COCs with the progestin levonorgestrel. Ask her to take one pill daily for 21 days when the bleeding starts.
  • 50 µg ethinyl estradiol daily for 21 days when the bleeding starts.

Copper IUDs: For short-term relief she can try:

• NSAIDs such as ibuprofen (400 mg) or indomethacin (25 mg) 2 times daily after meals for 5 days when the bleeding starts.

Heavy bleeding (twice as much bleeding as usual for her)
OR
Prolonged bleeding (longer than 8 days)

METHODS: Injectables, POPs, implants, LNG-IUD, copper IUDs

Advice:

Injectables and IUDs: Reassure her that this is common during the first few months and usually lessens over time. This is normal and usually not harmful to her health. (Users of the LNG-IUD or of a progestin-only injectable tend eventually to have infrequent or no monthly bleeding.)

POPs and implants: Explain that this occasionally occurs with her method and is not harmful.

Treatment Options: If no reason to suspect a medical problem, try these treatments, if available, one at a time. They may help some women.

Combined (monthly) injectables: Same as for unexpected bleeding or spotting, above.

Progestin-only injectables: For short-term relief, she can try:

• COCs. Ask her to begin taking one pill daily for 21 days when heavy or prolonged bleeding starts.
• 50 µg of ethinyl estradiol daily for 21 days to take when heavy or prolonged bleeding starts.

POPs: Same as for unexpected bleeding or spotting.

Implants: For short-term relief, same as for unexpected bleeding or spotting. COCs with 50 µg of ethinyl estradiol may work better than lower-dose pills.

Copper IUDs: For short-term relief, she can try:

• Tranexamic acid (1500 mg) 3 times daily for 3 days, then 1000 mg daily for 2 days when heavy or prolonged bleeding starts.
• NSAIDs such as ibuprofen (400 mg) or indomethacin (25 mg) 2 times daily after meals for 5 days when heavy or prolonged bleeding starts.

For all methods: If heavy or prolonged bleeding persists and there is no reason to suspect an underlying medical cause of bleeding, tell her that, if she wants to keep using her method, she can take iron tablets and/or eat foods containing iron, if possible, to help prevent anemia. If she shows signs of severe anemia advise her to choose another method.

When to Refer for Bleeding Changes

Sometimes bleeding changes indicate health problems unrelated to the contraceptive method. Reasons to suspect such an underlying medical condition include:

• Bleeding problems last more than a few months after starting the method, and they are not common side effects of that contraceptive.
• Bleeding problems start suddenly, after several months of a regular bleeding pattern.
• Bleeding patterns are different from the ones usually associated with the contraceptive method. For example, if a client has infrequent or no monthly bleeding with copper IUDs, or heavy or prolonged bleeding with COCs.
• Pain is associated with the bleeding.
• Bleeding occurs after sex.
• Bleeding problems started before use of the contraceptive method.

Such bleeding problems should be referred for diagnosis and care as they may indicate:

• Complications of pregnancy, such as miscarriage or ectopic pregnancy (pregnancy outside the uterus);
• Certain systemic diseases (diseases that affect the entire body), such as blood clotting disorders;
• Reproductive tract abnormalities, such as cervicitis (irritation of the cervix), sexually transmitted infections, endometritis (inflammation of the lining of the uterus), pelvic inflammatory disease, or tumors of the cervix or the lining of the uterus;
• Side effects of certain medications, such as drugs that prevent blood from clotting (anticoagulants); or
• If no specific cause can be found, dysfunctional uterine bleeding (a diagnosis of exclusion made only after ruling out all other possible causes of abnormal bleeding) (6, 82, 116).