Appendix E: Management of Bleeding Irregularities While Using Contraception
At a glance
This appendix summarizes recommendations for health care providers on management of bleeding irregularities while using contraception. This information comes from the 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR). The U.S. SPR provides recommendations for health care providers that address a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods.
Figure E1.
Figure E1. Management of bleeding irregularities while using contraception*
Management of bleeding irregularities while using contraception
Explore patient goals, including continued method use (with or without treatment for bleeding irregularities) or method discontinuation. If the patient wants to continue use, provide reassurance and advise the patient that they may contact their provider at any time to discuss bleeding irregularities or other side effects.
If the patient desires removal or discontinuation of the method at any time, remove the method (if IUD or implant), offer counseling on alternative contraceptive methods, and initiate another method if desired.
If the patient wants treatment, the following treatment options may be considered, depending on the patient’s preferences, treatment goals, and medical history:
Cu-IUD users
For spotting or light bleeding or for heavy or prolonged bleeding:
NSAIDs, 5–7 days
LNG-IUD users
No interventions identified
Implant users
For spotting or light bleeding or heavy/prolonged bleeding; treatment may be repeated as needed.
Treatments for temporary improvement in bleeding
Hormonal treatment (e.g., 20–30 μg EE COCs or estrogen)
Antifibrinolytic agents (e.g., tranexamic acid), 5 days
Treatments whose effects might persist for some time after treatment cessation:
NSAIDs (e.g., celecoxib, ibuprofen, or mefenamic acid), 5–7 days
SERMs (e.g., tamoxifen), 7–10 days
Injectable (DMPA) users
For spotting or light bleeding:
NSAIDs, 5–7 days
For heavy or prolonged bleeding:
NSAIDs, 5–7 days
Hormonal treatment (e.g., low dose COCs or estrogen), 10–20 days
CHC users (extended or continuous regimen)
Hormone-free interval for 3–4 consecutive days:
Not recommended during the first 21 days of extended or continuous CHC use
Not recommended more than once per month because contraceptive effectiveness might be reduced
* If clinically indicated, consider an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids). If an underlying health condition is found, treat the condition or refer for care.
