Cervicitis is an important but largely unrecognized source of unplanned bleeding in women using OCs. Causative organisms include Chlamydia trachomatis Neisseria gonorrhoeae, and Trichomonas vaginalis.22 Intermenstrual bleeding in women previously well controlled on OCs is particularly suggestive of asymptomatic chlamydial cervicitis.
Krettek et al47 found that 29.2% of women who had been taking OCs for more than 3 months and presented with intermenstrual spotting had a positive test for C. trachomatis. By comparison, chlamydial cervicitis was found in 10.7% of matched controls taking OCs without spotting who were screened for symptoms of vaginitis or high-risk sexual behavior, and in just 6.1% of women undergoing routine screening before the initiation of contraception.
Three-pronged management
Managing breakthrough bleeding involves effective pretreatment; ongoing counseling and reassurance; and timely and appropriate testing (TABLE 2). In some cases, pill-switching or other forms of medical management may be helpful, but these options are largely unproven.
Counseling reduces anxiety, improves satisfaction, adherence
In a recent survey, 649 Canadian women who were picking up prescriptions for OCs were asked to complete a questionnaire at the pharmacy while they waited.48 Over one third (34.5%) reported they had not received counseling from their healthcare provider about breakthrough bleeding. Furthermore, only 28.3% of women who were counseled, and 26.1% of women who were not counseled, gave the optimal response to breakthrough bleeding as defined in this study (“continue taking pill and not call my doctor”).
Lack of counseling can lead to poor method satisfaction and significant cost expenditures because of visits and phone calls by women experiencing unexpected bothersome side effects.5 Compared with women who reported the highest satisfaction with the care they received from their provider, those reporting the lowest scores were 1.6 to 2.2 times as likely to be dissatisfied with the pill.
Inform women that breakthrough bleeding is common in the first 3 or 4 cycles of OC use, that bleeding irregularities tend to decline with each successive cycle, and that they should not discontinue pill use without discussing their concerns with you. Remind women to keep sanitary protection with them during the first few months.
The impact of poor counseling was underscored in a study of women enrolled in clinical trials of OCs, contraceptive vaginal rings, and Depo-Provera. Women taking an OC were the least likely to have been warned of menstrual irregularities and thus tended to stop using that method more often than those using a ring or Depo-Provera.49 Of women who discontinue OCs, 47% use a less effective method and 19% use no method at all.1
Give specific instructions for specific regimens. Given the array of OC regimens available, make sure women know how to take them properly. This will help ensure contraceptive efficacy and cycle control. Women who do not understand pill-package instructions are up to 2.8 times more likely to miss pills, which increases the risk of breakthrough bleeding and impacts contraceptive efficacy.5 Among women who were counseled about the consequences of missed pills, 76% reported knowing what to do in response (“use another form of birth control that month”). Of women who received no such counseling, only 48% gave the appropriate response (P<.001>48
To improve adherence, advise women to establish a routine for pill-taking: taking the pill at the same time each day or linking pill ingestion with another daily activity, such as tooth brushing. Women without an established routine were 3.6 times more likely to miss 2 or more pills per cycle than women with a routine.5
Reassurance regarding efficacy
Reassure users who take their pills routinely that breakthrough bleeding and contraceptive efficacy are not linked.50 Breakthrough bleeding is not a sign that OCs are not working.4 On the other hand, approximately 1 million unintended pregnancies in the United States each year are associated with misuse or discontinuation of OCs.51
When to consider diagnostic testing
For OC users who continue to experience breakthrough bleeding beyond 3 to 4 cycles, other potential causes must be ruled out using appropriate diagnostic tests. A pregnancy test, appropriate testing for cervical infection, pelvic ultrasonography, Pap smear, or endometrial biopsy may be warranted, depending on clinical circumstances.
Fall-back options
If breakthrough bleeding continues beyond 3 months, and other reasons, including poor adherence and pathologic processes, are excluded, one option would be to provide the patient with estrogen or switch her to a different pill, though no clinical trials support definitive recommendations.
Aside from changing from a multiphasic to a monophasic formulation, altering the progestin component is often a first step in trying to control breakthrough bleeding.46 An OC with a gonane rather than an estrane progestin may be beneficial as this class of progestins may provide more consistent hormonal effects on the endometrium.