Unscheduled Bleeding on Contraception

Unscheduled bleeding is spotting or bleeding between expected withdrawal bleeds or menses in a patient using a hormonal method, and in intrauterine device and implant users. It is the commonest reason for method discontinuation. In most patients it is harmless, settles over the first 3 to 6 months, and needs reassurance, but it can also signal pregnancy, infection, cervical disease, missed or malabsorbed doses or an interaction.

Expected pattern by method. Combined pills, patch and ring: spotting in the first 3 months, then lighter regular bleeding. Progestin-only pills, injectables and implants: irregular spotting, frequent or prolonged bleeding, most marked in the first 6 to 8 months of injectables and the first year of implants. Intrauterine devices: spotting and heavier menses in the first 3 to 6 months.

Focused history. Method, start date and any change in brand or dose, missed or late doses, vomiting or diarrhoea, new medicines (rifampicin, rifabutin, enzyme-inducing antiseizure medicines, efavirenz, ritonavir-boosted regimens, griseofulvin, St John’s wort), smoking, pattern and timing of bleeding, postcoital bleeding, pain, discharge, fever, risk of sexually transmitted infection, last cervical screening.

Examination. Vital signs, abdominal and speculum examination of the cervix and vagina, bimanual examination, and device threads if an intrauterine device is in place.

Pregnancy. Exclude pregnancy, including ectopic pregnancy, when bleeding starts after months of regular bleeding or amenorrhoea, after missed pills or a late injection, or with pain.

Differential diagnosis.

• Method related: missed or late doses, malabsorption after vomiting or diarrhoea over 2 days, enzyme-inducing medicines, low-dose oestrogen formulation, smoking, device malposition or partial expulsion.
• Infection: chlamydia, gonorrhoea, pelvic inflammatory disease, vaginitis.
• Structural: cervical ectropion, polyp, fibroid, adenomyosis, cervical or endometrial neoplasia.
• Systemic: thyroid disease, coagulation disorder, anticoagulant use.

Investigations. Pregnancy test. Test for chlamydia and gonorrhoea when risk or symptoms are present. Cervical screening if due. Pelvic ultrasound for persistent bleeding, pain, or a suspected device problem. Haemoglobin when bleeding is heavy or prolonged. Endometrial sampling when bleeding persists in a patient over 45 years or with risk factors for endometrial neoplasia.

Reassurance. Explain that bleeding is common, not harmful, and usually lessens over the first 3 months. Advise taking pills at the same time each day.

Treatment when bleeding is bothersome and no cause is found.

Adjustments for NSAIDs. Avoid in creatinine clearance under 30 mL/min, peptic ulcer disease, anticoagulant use and after 20 weeks of pregnancy. Reduce the dose and duration in liver disease. Compatible with breastfeeding.

Combined pill rescue. Give a cycle of combined pill only to patients with no category 3 or 4 condition for combined methods.

Method specific actions.

• Late injection past 8 weeks since the last dose of DMPA with bleeding: pregnancy excluded, give the next injection and reset the schedule from that date, which may hasten amenorrhoea.
• Interaction: switch to a method not affected, or add a backup, as appropriate.
• Pill formulation with low oestrogen: a pill with a higher oestrogen content is considered after pregnancy and interactions are excluded.
• Cervicitis or pelvic inflammatory disease: treat the infection and continue the method if the patient wishes.

Follow up. Review after 3 months, or sooner for heavy bleeding, pain or fever. Check haemoglobin if bleeding has been prolonged.

Method decisions. If bleeding persists and is unacceptable after treatment and exclusion of other causes, help the patient choose another method. Remove an implant or intrauterine device if bleeding is unacceptable or there are signs of anaemia.

Referral and escalation.

• Refer unexplained bleeding that does not settle for evaluation, including cervical and endometrial assessment.
• Refer suspected cervical or endometrial neoplasia, suspected ectopic pregnancy, bleeding with haemodynamic instability, or a coagulation disorder.
• Refer to a health facility any patient seen by a community provider with bleeding side effects.