Problematic bleeding is often a common cause for women to discontinue using hormonal contraception.¹

Let’s look at a case to illustrate this issue. A 39 lawyer comes to see you in your surgery. She wants more combined oral contraceptive pills (COCs). She has a body mass index of 30 and has been taking the COC for contraception. You have your concerns about prescribing this contraceptive as you know that both age and a raised body mass index are independent risk factors for venous thromboembolism and the progestogen only pill (POP) may possibly be an acceptable alternative choice for her. She does not want to use a long-acting reversible method of contraception (LARC) and is very reluctant to try a POP as she had ‘lots of bleeding’ when she took this before. What choices does she have?

Any progestogen-only contraceptive method may be suitable. Careful counselling before prescribing one of these methods is important. Ideally you need to describe the expected bleeding patterns experienced with each method and reassure her that the bleeding pattern may improve over time.²

Those taking a combined hormonal contraceptive normally experience a monthly bleed when using a pill, patch or vaginal ring for 21 days with a seven-day hormone free interval. However up to 20% of women may experience unscheduled bleeding in the first few months. Pills containing oestradiol and estetrol may give more unscheduled bleeding in the first few months.³

Bleeding disturbances can be common when using with progestogen only contraception. I always advise the potential user that they will have irregular bleeding and sometimes no bleeding too. The bleeding may be prolonged in the first few months but it improves for most women over time. There are several progestogen-only pills (POPs) available and they may result in different bleeding patterns.3 The most commonly used POP contains desogestrel with about 50% of women having no periods or infrequent bleeding once this has been taken for 9-12 months. The more traditional POPs containing levonorgestrel and norethisterone gives more frequent bleeding that may be more acceptable for some women.⁴

The drospirenone POP that is taken for 24 days followed by 4 days of placebo gives more scheduled bleeding around the time of the hormone-free interval and less unscheduled bleeding when compared to those taking a desogestrel POP. Fewer women experience episodes of prolonged bleeding (lasting >10 days) in the first 9 months with drospirenone POP compared to those taking the desogestrel POP too. This leads to fewer women discontinuing the drospirenone POP because of bleeding problems in the first 12 months compared to the desogestrel POP users.⁵

About 50% of progestogen-only injection users experience no periods after receiving this method for 12 months. Initially up to a third will have prolonged bleeding in the first three months but this improves with time. Bleeding patterns are not affected by body, mass index, age, parity, or previous contraception used.^6,7

Users of the progestogen-only implant should be told that they will have irregular bleeding but most find this acceptable. Women respond differently to the implant, and there’s a wide range of normal bleeding patterns. Some studies suggest that those with higher BMI may be associated with more favourable bleeding patterns and women with favourable bleeding patterns in the first few months after insertion are more likely to continue having favourable patterns. Even 50% of those with unfavourable bleeding patterns in the first few months may find they may become more favourable over time.⁸

There are three different levonorgestrel intrauterine systems (LNG-IUS) containing different doses of levonorgestrel. All give irregular bleeding initially but tend to settle over time. In women using the 52mg LNG IUS the number of bleeding and spotting days may be increased in the first 3-6 months and bleeding patterns may be irregular
Thereafter these usually decreases but bleeding may remain irregular. Amenorrhoea develops in approximately 14% between 6 and 9 months, 20% between 9 and 12 months. The greatest fall in menstrual blood loss is between months 3-6 and the greatest reduction in number of bleeding days is between months 3-6.⁹

At review if the bleeding falls outside the expected normal pattern healthcare professionals should take a clinical history to see if there may be an underlying problem prior to starting the hormonal contraceptive. Are they using their pill, patch or vaginal ring correctly? Also check they are not taking any medication which may interact with their contraception. Depending on their age, check their cervical screening history, and make sure they are up-to-date with these screens. Also consider the need for a pregnancy test. An abdominal and pelvic examination should be undertaken and, where appropriate, a sexually-transmitted infection screen.³

What are the medical options for managing bleeding problems in those using hormonal contraception where there is no underlying pathology? In women using combined hormonal contraception they should be encouraged to continue to use the pill, patch or ring for at least three months as their bleeding pattern may settle. If they are taking an ethinylestradiol COC, then the dose could be increased for example from a 20 µg to a 30 µg COC. You could consider trying a different COC or vaginal ring.^{3, 10}

For those with bleeding problems with POPs then you could suggest trying another POP such as changing from a levonorgestrel or norethisterone POP to an anovulatory POP containing desogestrel or drospirenone.3 This may result in more infrequent bleeding. A drospirenone POP may give less unscheduled and less prolonged bleeding than a desogestrel POP.⁵

Going back to the case of our 39-year-old lawyer, what does she decide to do? She liked the idea of a drospirenone POP as this had not been suggested before. After 3 months she found that the bleeding pattern was more acceptable with less prolonged and less unscheduled bleeding.