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Management of unscheduled bleeding in women using contraception

Alison Edelman, MD, MPH
Bliss Kaneshiro, MD, MPH
Section Editor
Courtney A Schreiber, MD, MPH
Deputy Editor
Kristen Eckler, MD, FACOG


A common reason women choose to discontinue hormonal contraception is dissatisfaction with its effects on uterine bleeding [1,2]. The bleeding pattern most bothersome to women is probably unscheduled bleeding and spotting, which can occur with all hormonal methods of contraception, as well as the copper intrauterine device (IUD). The frequency of unscheduled bleeding is highest in the first few months of use, and then begins to diminish. Interventions that prevent or treat unscheduled bleeding could improve contraceptive acceptability and increase compliance, and thus lead to fewer unplanned pregnancies. These interventions are discussed below and summarized in the figure (algorithm 1). They are generally in agreement with those of the United States Selected Practice Recommendations (US SPR) for Contraceptive Use (2016) (algorithm 2) [3]. The US SPR for Contraceptive Use is a companion piece to the United States Medical Eligibility Criteria (US MEC) for Contraceptive Use. The US SPR includes information for providers regarding how contraceptive methods can be used and provides clinical guidance including information on the management and treatment of breakthrough bleeding.


The following terminology has been suggested for standardizing the description of bleeding in women in contraceptive trials [4]:

Bleeding – Blood loss that requires the use of a tampon, pad or panty liner.

Spotting – Minimal blood loss that does not require use of any type of protection.

Episode of bleeding/spottingBleeding/spotting days bounded on either end by two days of no bleeding or spotting.

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Literature review current through: Oct 2017. | This topic last updated: Jan 19, 2017.
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