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Breakthrough Bleeding with Combined Hormonal Contraception

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

Epidemiology

Irregular bleeding whilst taking CHC is a common problem3 with up to 30% of women experiencing breakthrough bleeding or spotting during the first cycle of treatment.4 Such bleeding occurs unpredictably5 and may cause significant disruption and anxiety for users.6 Irregular bleeding is thus one of the most common reasons for discontinuation of CHC.7

Mechanism

Normal endometrial maturation depends on complex interactions between oestrogen and progesterone. 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 integrity4 and the opposing effect of progestogen promotes atrophy of glands and stroma. The resulting endometrium is thin, fragile and prone to bleeding.1

Contraceptive efficacy

No relationship has been identified between serum steroid levels and bleeding.8 In the absence of missed or late pills, vomiting or drug interactions, reduced contraceptive efficacy has not been proven.3

Factors which influence bleeding

Patient factors1

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

CHC formulation factors

  • COCPs containing only 20 mcg of ethinyloestradiol 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.11
  • First generation progestogens e.g. norethisterone, provide poorer cycle control than second (levonorgestrel) and third generation progestogens.12
  • 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.13
Management of breakthrough bleeding

Recommendations to prevent bleeding

  • Use COCPs containing 30 mcg of ethinyloestradiol combined with a second generation progestogen as first-choice.
  • There is no evidence that starting CHC mid-cycle reduces the incidence of bleeding.11
Recommendations to reduce bleeding

There are few comparable evidenced-based studies on which to base the management of women experiencing poor cycle control with 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.
    • A third generation progestogen.
    • A phased regimen may be beneficial.14
  • There is also a continuous-use combination oral contraceptive ethinylestradiol/levonorgestrel 20 mcg/90 mcg (which suppresses gonadotrophins) suppresses breakthrough bleeding.15
  • 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.16
  • 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:4


Document references
  1. No authors listed; Ovarian and endometrial function during hormonal contraception. Hum Reprod. 2001 Jul;16(7):1527-35. [abstract]
  2. Kaunitz AM; Enhancing oral contraceptive success: the potential of new formulations. Am J Obstet Gynecol. 2004 Apr;190(4 Suppl):S23-9. [abstract]
  3. Contraception, Clinical Knowledge Summaries. (2007)
  4. Schrager S; Abnormal uterine bleeding associated with hormonal contraception. Am Fam Physician. 2002 May 15;65(10):2073-80. [abstract]
  5. WHO (HRP); Rogers A. Progress in Reproductive Health Research. How does progestogen cause endometrial bleeding. 1999.
  6. 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. [abstract]
  7. Ansbacher R; Low-dose oral contraceptives: health consequences of discontinuation. Contraception. 2000 Dec;62(6):285-8. [abstract]
  8. FFPRHC - First prescription of combined oral contraception; Faculty of Family Planning and Reproductive Health Care RCOG. (2006)
  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. [abstract]
  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. [abstract]
  11. FPRHC Clinical Effectiveness Unit; For a woman starting the combined oral contraceptive (COC), is there any evidence to support a mid-cycle start to help reduce break through bleeding? Faculty of Family Planning and Reproductive Health Care. 2005.
  12. Maitra N, Kulier R, Bloemenkamp KW, et al; Progestogens in combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2004;(3):CD004861. [abstract]
  13. FPRHC Clinical Effectiveness Unit; New product review: Norelgestromin/ ethinyl oestradiol transdermal contraceptive system (Evra). Faculty of Family Planning and Reproductive Health Care. 2003.
  14. 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. [abstract]
  15. Wagstaff AJ; Continuous-use ethinylestradiol/levonorgestrel 20microg/90microg: as an oral contraceptive. Drugs. 2007;67(16):2473-7; discussion 2478-9. [abstract]
  16. 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. [abstract]

Internet and further reading
  • WHO World Health Organization, 2004. Selected practice recommendations for contraceptive use .
  • Department of Health; Revised guidance for health professionals on the provision of contraceptive services for under 16s (July 2004).
AcknowledgementsEMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 515
Document Version: 5
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Last Updated: 2 Jun 2008
Review Date: 2 Jun 2009




















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