Problematic bleeding with hormonal contraception

Question 1

“Problematic bleeding with hormonal contraception” and sexually active woman.
Next step?

Answer 1

pregnancy test.

Question 2

“Problematic bleeding with hormonal contraception” and at risk of STIs
Next step?

Answer 2

Chlamydia trachomatis as minimum.
Neisseria gonorrhea depend on
-- sexual risk
-- local prevalence
-- availability of dual testing.

Question 3

“Problematic bleeding with hormonal contraception”

when is speculum examination indicated?

Answer 3

• • persisting bleeding or change in bleeding after or at least 3 months use.
• • If medical treatment has failed.
• • if not participated in NHSCSP.

Question 4

“Problematic bleeding with hormonal contraception”

when endometral biopsy indicated?

Answer 4

45 or more older
or less than 45 years old
--risk factors for endometrial cancer
-- persisting bleeding  after  3 months use
-- or change in bleeding pattern.

Question 5

“Problematic bleeding with hormonal contraception”

TVS or hysteroscopy?

Answer 5

• if structural abnormality (endometrial polyp, fibroids or ovarian cyst) suspected.
• even though role uncertain in this condition.

Question 6

“Problematic bleeding with hormonal contraception”

and COC?

Answer 6

• Don’t change within first 3 months of use, because often settles within this time.
• Lowest dose of EE should be used, can be increase to max of 35 mcg to provide good control

Question 7

“Problematic bleeding with hormonal contraception”

and progestin only method?

Answer 7

• Common in initial months.
• May settle without treatment.
• But consider treatment if it encourages woman to continue.

Question 8

“Problematic bleeding with hormonal contraception”

counselling advice at starting.

Answer 8

expected bleeding pattern

• • initial
• • longterm

Question 9

“Problematic bleeding with hormonal contraception”

presentation, what should be done?

Answer 9

• HX to identify possibility of underlying cause.

- cervical screening if not in NHSCSP.

Question 10

“Problematic bleeding with hormonal contraception” and POP changing type or dose.

Answer 10

no evidence of improvement but change bleeding pattern , this may help some.

Question 11

“Problematic bleeding with hormonal contraception”

progestog only contraception

Answer 11

Mefenamic acid 500 mg BID (or TID as licensed) for 5 days, can reduce length of bleeding episode but little effect on bleeding long term.

Question 12

“Problematic bleeding with hormonal contraception”
progestogen only injectable, implants or IUS
who wish to continue and medically eligible

Answer 12

• COC for 3 months ( cyclic/continuous, but outside product licence)
• if bleeding recurs after 3 months use, long term use matter of clinical judgment

Question 13

“Problematic bleeding with hormonal contraception”

when examination not required?

Answer 13

Clinical HX:

• • No risk factor for STI,
• • no underlying causes,
• • in NHSCSP and
• • problematic bleeding not more than 3 months