* Lack of adherence is a common cause of breakthrough bleeding. Focus counseling on ensuring that patients understand and can follow pill-taking instructions before switching pills or method (A).
* If breakthrough bleeding extends beyond 4 cycles and a woman wish to continue using oral contraceptives, consider switching to a pill with a higher ethinyl estradiol (EE): progestin ratio, either by increasing the EE dose or decreasing the relative progestin dose (C).
* Breakthrough bleeding may be due to progestin type; switching from an estrane to a gonane may reduce it (C).
* Women who have breakthrough bleeding after having well-controlled menstrual cycles on oral contraceptives should be assessed for for causes not related to their birth control pills, such as pregnancy, cervicitis, smoking, or interactions with medications (A).
In 1982, more than 20% of women surveyed in a nationally representative sample had discontinued oral contraceptives (OCs) on their own or at the recommendation of their physician due to bleeding or spotting. (1) Sadly, the percentage today has not decreased much.
Understandable concern, embarrassment, and annoyance lead these women to abandon Ocs. (1,2) What they often don't know, though, is that breakthrough bleeding generally is greatest in the first 3 to 4 months after starting Ocs, (3) and it steadily declines and stabilizes by the end of the fourth cycle. (4) Timely counsel could enable many of these women to cope with the bleeding and stick with an effective contraceptive method. Additional incentives are noncontraceptive benefits of OCs: improved menstrual regularity and decreased menstrual blood loss, dysmenorrhea, and risk of ovarian and endometrial cancer.
Women who discontinue OCs on their own switch to less effective methods of birth control or use no method. (1,2) Consequences may be unexpected pregnancies and increased abortion rates. (5) With patients who are using OCs, it would be appropriate to ask periodically whether they are satisfied with OC use.
In this review we discuss the mechanisms and management of breakthrough bleeding in women taking OCs, and provide tips for counseling that may help decrease the risk of discontinuation due to menstrual abnormalities in the initial months of use.
Breakthrough bleeding in this review refers to either unplanned spotting or bleeding, regardless of requirement for protection--unless defined otherwise by a specific study under discussion.
* 4 factors contribute to breakthrough bleeding
Breakthrough bleeding may be due to any the following factors: 1) physiologic effects of OCs on the endometrium, 2) OC-related parameters, including dose, formulation, and regimen, 3) patient behavior, including compliance, using concomitant medications, and smoking, and 4) benign or malignant pathology.
OCs and the endometrium: Estrogen-progestin balance significant
Progestin and estrogen in combination OCs have profound effects on the endometrium, which, though not contributing to contraception, do lead to a predictable pattern of bleeding or such problems as breakthrough bleeding or lack of withdrawal bleed.
Normally, estrogen causes the endometrium to proliferate. Progesterone stabilizes the growing uterine lining. Since the introduction of OCs in 1960, the trend in formulation has been to use the least amount of hormone...