Problematic bleeding in women on hormonal contraception

Things to look for include:

  • Pregnancy
  • STIs
  • Cervical cancer
  • Possibly polyps/fibroids/ovarian cysts – debatable whether these could cause irregular bleeding.


  • Duration of use of the hormonal method – irregular bleeding normal initially
  • Compliance with the method if not LARC – missed pills?
  • Previous bleeding patterns
  • Other symptoms – pain, heavy bleeding, PCB, dyspareunia
  • Possible chance of pregnancy
  • Possible chance of STIs
  • Cervical screening history (if up-to-date with smears, doesn’t need an extra one for bleeding)


Examination not needed for bleeding in first three months unless other risk factors, smear needs doing according to schedule, or the woman wants one. (The three months is an arbitrary cut-off and problematic bleeding on implant/IUS can often persist for longer.) Examination only needs to include cervical examination unless also associated symptoms as above in which case bimanual as well.

Pregnancy test if any risk

Chlamydia test if any risk. Possibly gonorrhoea test if indicated.

If associated symptoms, woman >45, or woman <45 with risk factors for endometrial cancer, consider scan and ?endometrial biopsy.


There are also some interesting figures on bleeding patterns in women on various types of hormonal contraception:


20% women have irregular bleeding in first three months, which usually settles down. No difference in rates between pill and patch, but ring may give better control. Zoely (17-beta-oestradiol/nomegestrol) has been found to give shorter, lighter bleeds and a higher chance of absent withdrawal bleeds than the EE-containing COCs.


Interestingly, in the first three months bleeding problems are more common on desogestrel pills than on traditional. The article didn’t give statistics on long-term patterns for traditional, but the breakdown for desogestrel at 1 year is:

  • 50% either amenorrhoeic or infrequent bleeding
  • 40% having fairly regular periods (although this covers up to 5 bleeding episodes in a 3-month period)
  • 10% having frequent bleeding (six or more episodes in three months)
  • Also, 20% having bleeding episodes lasting >14 days, which I assume come from any or all of the above groups otherwise we’ve got something really weird going on with the numbers.


Approximately 10% of women amenorrhoeic by first three months and 50% or more by twelve months.


Approximately 20% become amenorrhoeic, 30% have infrequent bleeding, and fewer than 10% have frequent bleeding. Also, 20% have prolonged bleeding.


90% reduction in overall menstrual blood flow over first twelve months with the 52 mg dose (Mirena). Infrequent bleeding still typical at one year although some women amenorrhoeic. 24% amenorrhoeic at three years with Mirena, 13% with Jaydess.


(Source: FSRH Clinical Guidance, ‘Problematic Bleeding with Hormonal Contraception’, July 2015)

Answers to questions for CPD:

1 – a  2 – c  3 – a

4 – Not sure about this one but I’m pretty sure it’s d (definitely not a as COC contraindicated, here, b wouldn’t be an option this early, so must be c or d – actually could plausibly be c as mefenamic acid shown to shorten bleeding episodes in these circumstances).

5 – again, not sure. a certainly an option but would have thought d would be as well – but if COC OK why is she on the POP in the first place? Would have thought would be easier just to switch to COC. Unless of course she’s a smoker, in which case short-term COC use followed by switch to POP might make sense. Sure it’s not b or c so probably a.

6 – c (hooray – nice straightforward one!) 7 d (in practice I’d do c as well, but d is the correct answer). 8 – c   9 – b  10 – a



About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in Contraception, Credits 2016, Gynaecology. Bookmark the permalink.

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