II. Management: Overall approach to OCP associated uterine bleeding

  1. Consider Abnormal Uterine Bleeding evaluation
  2. Evaluate for missed OCP doses
    1. Pregnancy Test
    2. Counsel on compliance
  3. Anticipate uterine bleeding in first 3 months
    1. Offer anticipatory guidance
  4. Consider adjuncts to Oral Contraceptive
    1. Ibuprofen 800 mg PO tid for 1-2 weeks
    2. Supplemental Estrogen for 1-2 weeks
      1. Premarin 0.625 to 1.25 qd
      2. Ethinyl Estradiol 20 ug qd
      3. Estradiol (Estrace) 0.5 to 1 mg qd
  5. Consider alternative Oral Contraceptive
    1. Change Progesterone type as listed below
    2. Switch from Levonorgestrel to Norethindrone containing Oral Contraceptives
    3. If on Seasonal Contraception, stop for 3-4 days when breakthrough bleeding occurs
    4. Increasing Estrogen to 50 ug does not appear effective at reducing bleeding
      1. Moreau (2007) Obstet Gynecol 109(6):1277-85 [PubMed]

III. Management: Spotting

  1. Take pill at same time each day
  2. Evaluate if unresolved after 3 cycles of observation
    1. Missed doses
    2. Drug Interaction
    3. Abnormal Uterine Bleeding

IV. Management: Early Cycle Breakthrough Bleeding (Days 1-9) or all month

  1. Progestin characteristics
    1. Higher Estrogenic Activity
  2. Consider increasing Estrogen to 50 mcg Monophasic
    1. Ovcon 50
    2. Ortho-Novum 1/50
    3. Demulen 1/50
  3. Temporarily add Estrogen prn breakthrough bleeding
    1. Ethinyl Estradiol 0.02 mg PO qd for 7 days prn

V. Management: Late Cycle Breakthrough Bleeding (Days 10-21)

VI. Management: Menorrhagia or Dysmenorrhea

  1. OCP Characteristics
    1. Higher Progestin Activity
    2. Lower Estrogenic Activity
  2. Examples
    1. Loestrin 1.5/30

VII. Management: Amenorrhea or Menses too light

  1. Check Pregnancy Test!
  2. OCP Characteristics
    1. Lower Progestin Activity
    2. Higher Estrogenic Activity
    3. Higher Endometrial Activity
  3. Examples
    1. Loestrin 1.5/30
    2. Loestrin 1/20
    3. Demulen 1/35
  4. Consider additional Estrogen initially
    1. Premarin 0.625 mg qd for 7 days
    2. Start at beginning of next cycle

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