The recommendation grades (A to C, Good Practice Point) are defined at the end of the "Major Recommendations" field.
Bleeding Pattern Expected with Hormonal Contraceptives
Before starting hormonal contraception, women should be advised about the expected bleeding patterns, both initially and in the longer term. (Good Practice Point)
Management of Women with Unscheduled Bleeding
A clinical history should be taken from women using hormonal contraception with unscheduled bleeding to identify the possibility of an underlying cause. (Grade C)
Hormonal contraceptive users with unscheduled bleeding who are at risk of sexually transmitted infections (STIs) (i.e., those aged <25 years old, or who have a new sexual partner, or more than one partner in the last year) should be tested for Chlamydia trachomatis as a minimum. Testing for Neisseria gonorrhoeae will depend on sexual risk and local prevalence. (Good Practice Point)
Women using hormonal contraception who have unscheduled bleeding who are not participating in a National Cervical Screening Programme should have a cervical screen. (Good Practice Point)
A pregnancy test is indicated for women using hormonal contraception with unscheduled bleeding if the clinical history identifies the possibility of incorrect method use, drug interactions, or illness, which may lead to malabsorption of oral hormones. (Good Practice Point)
When May Examination NOT Be Required?
In general, in women attending with unscheduled bleeding using hormonal contraception, examination may not be required if after taking a clinical history there are no risk factors for STIs, no concurrent symptoms suggestive of underlying causes, and the woman is participating in a National Cervical Screening Programme. (Good Practice Point)
When Is Examination Required?
Providing there has been consistent and correct use of hormonal contraception, a speculum examination should be performed for women using hormonal contraception with unscheduled bleeding if they have: persistent bleeding or a change in bleeding after at least 3 months use; failed medical treatment; if they have not participated in a National Cervical Screening Programme. (Good Practice Point)
Providing there has been consistent and correct use of hormonal contraception in addition to a speculum examination, a bimanual examination should be performed for women using hormonal contraception with unscheduled bleeding if they have other symptoms (such as pain, dyspareunia, or heavy bleeding). (Good Practice Point)
When Is Further Investigation (Endometrial Biopsy, Ultrasound Scan, or Hysteroscopy) Required?
In general, an endometrial biopsy should be considered in women aged ≥45 years (or in women aged <45 years with risk factors for endometrial cancer [e.g., obesity or polycystic ovarian syndrome]) who have persistent unscheduled bleeding after the first 3 months of starting a method or who present with a change in bleeding pattern. (Good Practice Point)
The role of uterine polyps, fibroids, or ovarian cysts as a cause of unscheduled bleeding is limited. Nevertheless, for all women using hormonal contraception with unscheduled bleeding, if such a structural abnormality is suspected a transvaginal ultrasound scan and/or hysteroscopy may be indicated. (Good Practice Point)
Treatment Options for Women with Unscheduled Bleeding Using Hormonal Contraception
Treatment Options for Women Using Combined Hormonal Contraception
It is not generally recommended that a combined oral contraceptive pill (COC) is changed within the first 3 months of use as bleeding disturbances often settle in this time. (Good Practice Point)
For women using a combined oral contraceptive pill, the lowest dose of ethinylestradiol (EE) to provide good cycle control should be used. However, the dose of ethinylestradiol can be increased to a maximum of 35 micrograms to provide good cycle control. (Good Practice Point)
Treatment Options for Women Using Progestogen-Only Contraception
Bleeding is common in the initial months of progestogen-only method use and may settle without treatment. If treatment may encourage women to continue with the method, it may be considered. (Good Practice Point)
There is no evidence that changing the type and dose of progestogen-only pills will improve bleeding, but this may help some individuals. (Good Practice Point)
For women with unscheduled bleeding using a progestogen-only injectable, implant, or intrauterine system (IUS) who wish to continue with the method and are medically eligible, a combined oral contraceptive pill may be used for up to 3 months (this can be in the usual cyclic manner or continuously without a pill-free interval). (Good Practice Point)
For women using a progestogen-only injectable contraceptive with unscheduled bleeding, mefenamic acid 500 mg twice daily (or as licensed up to three times daily) for 5 days can reduce the length of a bleeding episode but has little effect on bleeding in the longer term. (Grade B)
Grades of Recommendations
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point: Where no evidence exists but where best practice is based on the clinical experience of the Multidisciplinary Group