Oral contraceptives and breakthrough bleeding: What patients need to know

Fall-back options

If breakthrough bleeding continues beyond 3 months, and other reasons including poor adherence and pathologic processes are excluded, you could consider providing estrogen or switching 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.

Choosing an OC with a higher quantity of EE may also help, particularly for women using 20 μg pills. When possible, the same progestin should be used.

You may want to start a trial of conjugated estrogen, 1.25 mg, or estradiol, 2 mg, administered for 7 days when bleeding occurs. This can be repeated if necessary; however, if breakthrough bleeding continues despite this treatment, consideration of a different pill or method should be undertaken.

CORRESPONDENCE
Patricia A. Lohr, MD, University of Pittsburgh, Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213-3180. E-mail: plohr@mail.magee.edu