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Unscheduled bleeding (break through) whilst using the progestogen only pill (POP)

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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Unscheduled bleeding in women using hormonal contraception [i.e. combined oral contraceptive pill (COC), transdermal patch, progestogenonly pill (POP), injectable, implant or intrauterine system (IUS)]

Clinically important bleeding patterns in women aged 15-44 year

SCHEDULED BLEEDING

Menstruation or regular withdrawal bleeding with combined hormonal contraception (requiring sanitary protection

OTHER BLEEDING PATTERNS

FREQUENT BLEEDING

More than five bleeding episodes (a) within a reference period (b)

INFREQUENT BLEEDING

Fewer than three bleeding episodes (a) within a reference period (b)

PROLONGED BLEEDING

Bleeding episode (a) lasting 14 days or more

SPOTTING

Vaginal discharge containing blood, that may not require the use of sanitary protection

BREAKTHROUGH BLEEDING

Unscheduled bleeding in women using CHC

AMENORRHOEA

No bleeding or spotting days throughout the 90-day reference period (b)

(a) Bleeding episode: one or more consecutive days of bleeding, bounded by bleed-free days.

(b) Reference period: a 90-day period of time during use of a hormonal contraceptive method.

management of women who present with unscheduled bleeding while using hormonal contraception is challenging. For many women unscheduled bleeding will be due to the contraceptive method itself, and the pattern and duration of bleeding and the likelihood of this settling will vary with the method used

Expected bleeding patterns after commencing hormonal contraception and in the longer term

Contraceptive method

Bleeding patterns in women in the first 3 months

Bleeding patterns in women in the longer term

COMBINED HORMONAL CONTRACEPTION (pill, patch or ring)

Up to 20% of combined oral contraception users have irregular bleeding.

Irregular bleeding usually settles

No significant differences in bleeding between pill and patch use

The combined vaginal ring may afford better cycle control (less unscheduled bleeding) when compared to the pill

Users of estradiol COC have reported shorter, lighter bleeds and a higher rate of absent withdrawal bleeds than women using an EE-containing COC

PROGESTOGEN-ONLY CONTRACEPTION Progestogen-only pill

Bleeding is unpredictable

With traditional POPs, one-third of women have a change in bleeding

A comparative study of DSG LNG POP reported that frequent bleeding, prolonged bleeding and infrequent bleeding were more common in DSG users than LNG users in the first reference period of 90 days

Bleeding may not settle with time

Traditional POP users can be advised that frequent and irregular bleeding are common, while prolonged bleeding and amenorrhoea are less likely

As a guide, women considering DSG-only POP can be advised that after 12 months of use, over a 3-month period approximately:

  • 5 in 10 women can expect to be amenorrhoeic or have infrequent bleeding
  • 4 in 10 women can expect to have 3-5 bleeding spotting/episodes (regular)
  • 1 in 10 women can expect >=6 bleeding/spotting episodes (frequent bleeding)
  • 2 in 10 women will experience bleeding/spotting episodes lasting for more than 14 days (prolonged bleeding)

Progestogen-only implant

Bleeding disturbances are common. The bleeding pattern in the first 3 months is broadly predictive of future bleeding patterns for many women

As a guide, around:

  • 2 in 10 women are amenorrhoeic
  • 3 in 10 women have infrequent bleeding
  • Fewer than 1 in 10 women have frequent bleeding
  • 2 in 10 women have prolonged bleeding

In 75% of reference periods bleeding-spotting days are fewer than or comparable to those observed during the natural cycle, but they occur at unpredictable intervals

Levonorgestrel releasing intrauterine system (LNG-IUS)

52mg (Mirena)

Frequent bleeding/spotting is common in the first few months after insertion

There is a decrease over time in the number of bleeding and spotting days with all doses of LNG-IUS

A 90% reduction in menstrual blood loss has been demonstrated over 12 months of 52 mg LNG-IUS use

At 1 year, infrequent bleeding is usual with the LNG-IUS and some women will be amenorrhoeic. 24% of 52 mg LNG-IUS users are amenorrhoeic at 3 years

LNG-IUS 13.5 mg (Jaydess®)

Frequent bleeding/spotting is common in the first few months after insertion

There is a decrease over time in the number of bleeding and spotting days with all doses of LNG-IUS

Users of the 13.5 mg LNG-IUS report more spotting days than bleeding days over the duration of licensed use

Fewer women (13% at 3 years) will experience amenorrhoea with this dose of LNG-IUS compared to the 52 mg LNG-IUS

Progestogen-only injectable (IM and SC)

Bleeding disturbances (spotting, light, heavy or prolonged bleeding) are common.

Around 1 in 10 women may be amenorrhoeic in the first 3 months of use.

Rates of amenorrhoea increase with duration of use and are similar for IM and SC DMPA. Around 50% or more are amenorrhoeic at 12 month

CHC, combined hormonal contraception; COC, combined oral contraceptive pill; DMPA, depot medroxyprogesterone acetate; DSG, desogestrel; EE, ethinylestradiol; IM, intramuscular; LNG, levonorgestrel; LNG-IUS, levonorgestrel-releasing intrauterine system; POP, progestogen-only pill; SC, subcutaneous

Reference:

  • 1) FSRH (2015). Problematic Bleeding with Hormonal Contraception.

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