Breakthrough Bleeding with Contraceptive Use
Description General Measures Referral N92.0/N92.1/N92.4 DESCRIPTION Breakthrough bleeding refers to unscheduled or irregular vaginal bleeding, which often presents as spotting, or prolonged or frequent bleeding in women using hormonal contraception. The pattern and duration of these unscheduled bleedings vary with the contraceptive method used. GENERAL MEASURES Before starting hormonal contracept
N92.0/N92.1/N92.4
DESCRIPTION
Breakthrough bleeding refers to unscheduled or irregular vaginal bleeding, which often presents as spotting, or prolonged or frequent bleeding in women using hormonal contraception. The pattern and duration of these unscheduled bleedings vary with the contraceptive method used.
GENERAL MEASURES
Before starting hormonal contraception, counsel women regarding possible bleeding patterns, both initially and in the longer term.
Clinical assessment:
- Current method of contraception and duration of use
- Drug interactions
- Cervical screening history
- Risk of sexual transmitted infections (e.g. Chlamydia trachomatis)
- Menstrual and break though bleeding history prior to current method being initiated
- Exclude pregnancy
| Hormonal contraceptives causing breakthrough bleeding | Treatment |
|---|---|
| Progestin-only injectables |
- COC containing 30 mcg ethinylestradiol, oral, for 14 days LoE:IIIb30 |
| Progestin subdermal implants | Progestins and estrogen, fixed combinations, e.g.: - Ethinylestradiol/levonorgestrel, oral, 30 mcg/150 mcg for daily for 20 days |
| Progestin intrauterine devices | Refer – see Levonorgestrel intra-uterine device (LNG-IUD) (Contraception, Hormonal) |
|
Combined oral contraceptive pill - Unscheduled bleeding with COC usually settles with time - Changing to another COC in the first 3 months is not recommended |
- Change COC to another COC containing the lowest dose of ethinylestradiol, oral, daily If bleeding persists: LoE:IVb |
REFERRAL
- Pelvic pain
- Pelvic mass
- Heavy bleeding
- Abnormal cervix on speculum examination (e.g. polyps)
- Bleeding not controlled by treatment above
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_ April 2025
Chapter 7: Family Planning_7.6 Breakthrough Bleeding with Contraceptive Use