Abstract
Changes in menstrual bleeding are common with hormonal contraceptives, and unfavorable bleeding profiles are leading reasons for method dissatisfaction and discontinuation. Studies suggest that acceptance of menstrual disturbance is highly dependent on appropriate counseling. This review presents an overview of the pathophysiology of uterine bleeding related to hormonal contraceptive use, the expected bleeding profiles of the various hormonal contraceptives, and evidence supporting various management strategies for treatment of unscheduled bleeding. Published trials on treatments for bleeding with hormonal contraceptives are heterogeneous in methodology and outcome measures. Overall, data show mixed results and disappointingly small treatment effects for medications studied to manage unscheduled bleeding. Short courses of NSAIDs and oral estrogen may have modest benefits. Tranexamic acid and mifepristone require larger trials and additional study. Treatment of bleeding associated with hormonal contraception hinges on understanding the bleeding profiles of the hormonal contraceptives, employing anticipatory counseling, and understanding the spectrum and limitations of treatment options for menstrual disturbance.
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