3. Breakthrough Bleeding with Combined Hormonal Contraception

Breakthrough Bleeding with Combined Hormonal Contraception

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Most women find that combined hormonal contraception (CHC) provides reliable cycle control.

Indeed the combined oral contraceptive pill (COCP) is often prescribed for the management of menstrual disorders such as menorrhagia and dysfunctional uterine bleeding.[1]

However, although new formulations with low doses of oestrogen offer health benefits, they may provide less satisfactory cycle control.[2] The risk of bleeding may also be related to the dose and type of progestogen. Unfortunately, methodological differences between studies have also made it difficult to compare rates of breakthrough bleeding between different preparations.[1]

Irregular bleeding whilst taking combined hormonal contraception (CHC) is a common problem with up to 30% of women experiencing breakthrough bleeding or spotting during the first cycle of treatment.[3] Such bleeding occurs unpredictably[4] and may cause significant disruption and anxiety for users.[5] Irregular bleeding is thus one of the most common reasons for discontinuation of CHC.[6]

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Normal endometrial maturation depends on complex interactions between oestrogen and progesterone. Combined hormonal contraception (CHC) provides a continuous supply of oestrogen and progestogen to the endometrium. The low dose of oestrogen in modern CHCs is insufficient to maintain endometrial integrity[3] and the opposing effect of progestogen promotes atrophy of glands and stroma. The resulting endometrium is thin, fragile and prone to bleeding.[1]

No relationship has been identified between serum steroid levels and bleeding.[7] In the absence of missed or late pills, vomiting or drug interactions, reduced contraceptive efficacy has not been proven.[8]

Patient factors[1]

  • Poor compliance with medication is the most likely cause of irregular bleeding.
  • Cigarette smoking has anti-oestrogenic properties and may affect cycle control.

Combined hormonal contraception (CHC) formulation factors

  • Combined oral contraceptive pills (COCPs) containing only 20 micrograms of ethinylestradiol (EE) cause more disrupted bleeding patterns than those containing higher doses.[9]
  • Monophasic and biphasic formulations provide similar cycle control.[10]
  • Triphasic formulations may offer better cycle control.
  • First-generation progestogens, eg norethisterone, provide poorer cycle control than second-generation (levonorgestrel) and third-generation progestogens.[11]
  • Of third-generation progestogens, gestodene may afford better cycle control than desogestrel.[11]
  • CHC patches are associated with more irregular bleeding than COCPs during initial treatment, but rates are similar after three months of use.[12]

Clinical assessment

Take a clinical history to assess:

  • The woman's concerns.
  • Correct use of the method (eg pill taking, patch use), use of interacting medication, illness altering absorption of orally administered hormones.
  • Other symptoms (eg pain, dyspareunia, abnormal vaginal discharge, heavy bleeding, postcoital bleeding).
  • Exclude sexually transmitted infections.
  • Check cervical screening history.
  • Consider the need for a pregnancy test.

Recommendations to prevent bleeding

  • Use combined oral contraceptive pills (COCPs) containing 30 micrograms of ethinylestradiol (EE) combined with a second-generation progestogen as first-choice. Data do not support increasing the dose of oestrogen in women already using a 30 microgram COCP. Nevertheless, increasing the dose of EE to 35 micrograms may improve bleeding patterns for some women.
  • There is no evidence that starting combined hormonal contraception (CHC) mid-cycle reduces the incidence of bleeding.[13]
There are few comparable evidenced-based studies on which to base the management of women experiencing poor cycle control with combined hormonal contraception (CHC). The following guidance may be useful:
  • Reassure patients that breakthrough bleeding is a common side-effect of CHC and usually resolves after 3 cycles of use.
  • Assess if use of CHC is correct and consistent.
  • If bleeding persists for 3 months, consider changing to a formulation with:
    • Either a higher or lower dose of the same progestogen.
    • A different second-generation progestogen and starting with the lowest available dose. NB: there is no evidence that changing progestogen dose or type improves cycle control but it may help on an individual basis.[14]
    • A phased regimen may be beneficial.[15]
  • There is also a continuous-use combined oral contraceptive pill (COCP) ethinylestradiol (EE)/levonorgestrel 20 micrograms/90 micrograms (which prevents breakthrough bleeding by suppressing gonadotrophins).[16]
  • Consider extended cycling regimens (beyond product licence), although there is evidence that a reduced pill-free interval (3 days) is more effective than tri-cycling.[17]
  • Consider the CHC patch if daily compliance with COCP is poor.

Other considerations

Although CHC is a common cause of irregular bleeding, other unrelated causes must also be considered such as:[3]

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Further reading & references

  1. No authors listed; Ovarian and endometrial function during hormonal contraception. Hum Reprod. 2001 Jul;16(7):1527-35.
  2. Kaunitz AM; Enhancing oral contraceptive success: the potential of new formulations. Am J Obstet Gynecol. 2004 Apr;190(4 Suppl):S23-9.
  3. Schrager S; Abnormal uterine bleeding associated with hormonal contraception. Am Fam Physician. 2002 May 15;65(10):2073-80.
  4. WHO (HRP); Rogers A. Progress in Reproductive Health Research. How does progestogen cause endometrial bleeding. 1999.
  5. Hickey M, Fraser IS; Surface vascularization and endometrial appearance in women with menorrhagia or using levonorgestrel contraceptive implants. Implications for the mechanisms of breakthrough bleeding. Hum Reprod. 2002 Sep;17(9):2428-34.
  6. Ansbacher R; Low-dose oral contraceptives: health consequences of discontinuation. Contraception. 2000 Dec;62(6):285-8.
  7. First Prescription of Combined Oral Contraception; Faculty of Family Planning and Reproductive Health Care (2007); now known as the Faculty of Sexual and Reproductive Healthcare
  8. Contraception - combined hormonal methods, Prodigy (Sept 2007)
  9. Gallo MF, Nanda K, Grimes DA, et al; 20 mcg versus >20 mcg estrogen combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003989.
  10. Van Vliet HA, Grimes DA, Helmerhorst FM, et al; Biphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev. 2006 Jul 19;3:CD002032.
  11. Maitra N, Kulier R, Bloemenkamp KW, et al; Progestogens in combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2004;(3):CD004861.
  12. Norelgestromin/ethinyl oestradiol transdermal contraceptive system (Evra), New Product Review, Faculty of Family Planning and Reproductive Healthcare (2003)
  13. Yeshaya A, Orvieto R, Kaplan B, et al; Flexible starting schedule for oral contraception: effect on the incidence of breakthrough bleeding and compliance. Eur J Contracept Reprod Health Care. 1998 Sep;3(3):121-3.
  14. Management of Unscheduled Bleeding in Women Using Hormonal Contraception, Faculty of Sexual and Reproductive Healthcare (2009)
  15. Van Vliet HA, Grimes DA, Helmerhorst FM, et al; Biphasic versus triphasic oral contraceptives for contraception. Cochrane Database Syst Rev. 2006 Jul 19;3:CD003283.
  16. Wagstaff AJ; Continuous-use ethinylestradiol/levonorgestrel 20microg/90microg: as an oral contraceptive. Drugs. 2007;67(16):2473-7; discussion 2478-9.
  17. Coffee AL, Sulak PJ, Kuehl TJ; Long-term assessment of symptomatology and satisfaction of an extended oral contraceptive regimen. Contraception. 2007 Jun;75(6):444-9. Epub 2007 Mar 23.
Original Author: Dr Hayley Willacy Current Version: Peer Reviewer: Dr Hannah Gronow
Last Checked: 28/09/2011 Document ID: 515  Version: 9 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.