The dose and type of progestogen is also important. Over time, there has been an inexorable shift towards COCP preparations containing lower doses of oestrogen and progestogen, making regular pill-taking even more important if BTB is to be avoided. The Faculty of Sexual and Reproductive Healthcare in the UK states that this is not a concern in the absence of missed or late pills, vomiting or drug interactions. 4 One question that often concerns women and clinicians is whether BTB is a sign of reduced contraceptive efficacy. 3 It is important not only to guide expectations as to the likelihood of some initial BTB, but to be proactive in encouraging women to seek advice if it persists, especially given that this is one of the most common reasons for COCP discontinuation. The rate of BTB usually declines over time however, at 12 months of use, around 10% of women taking lower dose COCPs still report some non-scheduled bleeding. Irregular bleeding is common in the first three to four months of combined oral contraceptive pill (COCP) use, occurring in up to 30% of women in the first cycle. 1 Progestogen in combined contraceptives provides the major contraceptive effect, and oestrogen is added primarily to stabilise the bleeding pattern as an atrophic endometrium may result in asynchronous ‘breakthrough’ bleeding (BTB). The oral contraceptive pill remains the most popular contraceptive method among Australian women. Additional contraceptives are no longer recommended when antibiotics are prescribed for minor illnesses. Note: Most broad-spectrum antibiotics have no effect on steroid metabolism, although they may reduce absorption should diarrhoea occur. other drugs (eg bosentan, aprepitant, modafinil, sugammadex).several drugs used to treat human immunodeficiency virus (HIV).Interference with hormone metabolism – exogenous hormone metabolism is individually variable but can also be affected by smoking 21 and the use of liver enzyme-inducing medications such as:.
Hormonal effects on the thickness/stability of the endometrium – this is intrinsic to progestogen-only contraception, but for combined methods depends on dose, formulation and delivery system.Poor gut absorption (ie significant vomiting, severe diarrhoea, chronic malabsorption) may compromise the efficacy and cycle control of oral contraceptives.Adherence to recommended regimen – oral contraceptives require strict daily commitment.Irregular bleeding secondary to contraceptive use Some of the issues that must be considered are outlined in Box 1. patient’s readiness to cope with an altered bleeding pattern.potential to modify the method to achieve a more suitable bleeding pattern.If abnormal/irregular bleeding is determined to be secondary to contraceptive use, management will depend on the: A careful history, gynaecological examination and appropriate investigations are important in determining which cases can be safely managed in a primary care setting and which need prompt specialist referral. Irregular bleeding may also be due to underlying pathology, such as cervicitis, pelvic inflammatory disease, endometriosis, polyps, uterine fibroids or neoplasm. The possibility of pregnancy (intrauterine, ectopic, miscarriage, trophoblastic disease) should always be excluded since no contraceptive method is 100% effective. This is particularly the case if the change in bleeding pattern is a new development and/or accompanied by other symptoms. Although contraceptive use is commonly associated with alterations in patterns of bleeding, the potential for unrelated pathology should always be considered.
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