Question of the Week # 361

361)  A 22 year old woman is seen in the outpatient clinic for intermittent vaginal bleeding. For the past two months, she has had spotting and occasionally, frank bleeding  even before her scheduled menstrual period. It is unrelated to sexual activity and is not associated with pain. She denies any dysuria or fever.  She is sexually active with her fiancee and she reports taking cyclical combined oral contraceptive pills ( OC pills) for the past 2 months. She has been following the exact directions regarding the use of oral contraceptive pills and her scheduled period occurs during the contraceptive free interval however, this unscheduled spotting and bleeding is bothering her. She denies smoking or alcohol use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative and serum thyroid stimulating hormone as well as prolactin level are within normal limits. Which of the following is the most appropriate management option?

A) Pelvic ultrasound

B) Reassure and counsel on consistent OC pill use

C) Increase estrogen component of the pills

D) Switch to continuous combined OC pill regimen

E) Discontinue Oral Contraceptive pills

6 Responses

  1. B) Reassure and counsel on consistent OC pill use – breakthrough bleeding is a common a side-effect initially (esp with low dose estrogen-now common) and usually stops after 3rd cycle.. so ask pt to use the current dose consistently for 3 cycles before switching.

  2. B

  3. A,, Although spotting is a well known side effect yet we should exclude other causes of vaginal spotting ,,startin’ with pelvic US.

  4. This is what i understand :

    Vaginal bleeding in post menopausal women should raise a red flag – consider endometrial ca until proven otherwise —> do pelvic us – if the endometrial stripe thickness is more than 5mm do endometrial biopsy to rule out endometrial ca.

    But in a reproductive age woman like her if the bleeding continues after 3 cycles you can switch to another OCP with higher dose estrogen or give extra estrogen for 1 or 2 cycles until her endometrium stabilizes.

    If she still has bleeding then to pelvic us to rule out structural causes like fibroids etc

  5. Answer. B. The patient is experiencing “Breakthrough” bleeding or “Spotting” which is an unscheduled bleeding that occurs out of her scheduled period and is a common side effect of oral contraceptive pills, Depot medroxyprgesterone and Progesterone only pills.. Most patients who start taking Oral contraceptive pills experience spotting or bleeding which lasts for the first three to four cycles and gradually abate. One of the most important reasons for self-discontinuation oral contraceptive pills are menstrual abnormalities. Hence, the patients should be adequately counseled that this normal to expect and usually, diminishes with subsequent cycles.
    World health organization classifies unscheduled bleeding in to 2 categories: “Spotting” is the one that does not require sanitary protection and “Breakthrough bleeding” which requires sanitary protection. Breakthrough bleeding or spotting occurs because most of the contraceptive preparations either contain low estrogen or no estrogen. In the combined pills, the estrogen dose used is just enough to suppress ovulation but not enough to maintain the integrity of endometrium. The reason for using such low doses is to prevent unwanted side effects from estrogen ( thromboembolic events, endometrial hyperplasia and endometrial cancer). The problem of breakthrough bleeding is even more pronounced with progestin only preparation due to complete lack of estrogen. Since optimal estrogen is required to maintain the integrity of the endometrium, the menstrual irregularities mentioned above are frequently encountered with the contraceptive preparations.
    In any case of abnormal uterine bleeding, pregnancy must be ruled out because pregnancy can still occur despite oral contraceptive use and irregular bleeding is a common manifestation in early pregnancy. Once this is ruled out, no further diagnostic evaluation is needed if the patients cycles were normal prior to starting the pills and if she does not have any other features to suggest cervicitis or other conditions that can lead to intermenstrual bleeding. Patients can be observed for four cycles. If they are smokers, patients must be counseled against smoking since smoking can lead to increased incidence of breakthrough bleeding. If breakthrough bleeding extends beyond four cycles, further evaluation for other causes such as fibroids, uterine abnormalities must be investigated. Pelvic ultrasound may be of value at that time. If no explanation is found and if breakthrough bleeding extends beyond 4 cycles and if the woman likes to continue OC pills, the dose of estrogen component can be increased (with higher ethinyl estradiol:progestin ratio) or a different progestin can be used as the next steps in management. Also, if the women desires control of breakthrough bleeding well before four cycles; these management options can be implemented anytime.

    Option A is incorrect. The fact that the patient has recently started OC pills, absence of any previous abnormal bleeding and absence of any abnormal physical findings indicate that she is experiencing breakthrough bleeding. Pelvic ultrasound may be considered to evaluate for uterine pathology if the bleeding extended beyond 4 cycles.

    Option C is incorrect. These management options are appropriate if breakthrough bleeding continued beyond 4 cycles or if the patient desires to have the intermenstraul bleeding treated despite being reassured.

    Option D is incorrect. Continuous combined pill regimens ( eg: seasonale) have similar incidence of breakthrough bleeding like cyclical regimens. Progestin only pills have even higher incidence of bleeding isssues.

    Option E is incorrect. Discontinuing OC pills may fix her problem of breakthrough bleeding but puts this sexually active woman at an increased risk of unwanted pregnancy.

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