Family Plannning Alliance Australia guidance for management of troublesome vaginal bleeding with progestogen-only long-acting reversible contraception (LARC) Show
Initial consultationProvide accurate Information about expected bleeding patterns, emphasising that troublesome bleeding is likely to improve with time:
Be proactive in offering management advice for troublesome bleeding
Management of troublesome bleeding
First line options
Second line optionsWith low level, anecdotal or conflicting evidence:
Contraindications include:
Further informationProviding accurate information and a proactive approach to management options for troublesome bleeding in users of the implant (Implanon NXT®), hormonal-IUD (Mirena®) and the DMPA injection is a useful strategy to improve use of LARC. All women should be given evidence-based information about expected bleeding patterns during the contraceptive consultation including:
Medication management strategies for progestogen-only contraception related bleeding:While medications used to manage troublesome bleeding do not have an effect on future bleeding patterns once stopped, they may support continued use of a LARC that would otherwise have been discontinued due to troublesome bleeding. Combined Hormonal ContraceptiveWomen who do not have any contraindications to oestrogen can be prescribed a pill or vaginal ring for three months. When stopped, the woman will experience a hormone withdrawal bleed and generally resume her earlier pattern of bleeding. A PBS-listed levonorgestrel or norethisterone pill is generally advised, although any pill or the vaginal ring can be used. The pill or ring can be used continuously or cyclically. Continuous users can take a four day break if troublesome bleeding recurs. The pill or ring can also be used for short periods of time intermittently. Implant Expert opinion supports the safety of use of the pill or ring to control bleeding beyond three months. These methods can be used concurrently for the duration of implant use. DMPA A pill or ring may be used to manage DMPA-related bleeding for a maximum of three months. Hormonal IUD Use of the pill or ring with the hormonal IUD may have some applicability but use beyond three months is rarely needed and is not recommended. Non-Steroidal Anti Inflammatory Drug (NSAID)A five day course of an NSAID may be used to shorten the duration of a bleeding episode and decrease blood loss in women who cannot tolerate or have a contraindication to pill or ring. It is unlikely to be useful long term, but if successful a five day course can be repeated monthly. Other medication-related strategies:Tranexamic acid There is limited information that tranexamic acid reduces the duration of bleeding episodes. If successful a five day course can be repeated monthly. Norethisterone Expert opinion in the UK suggests that high dose progestogens such as Norethisterone 5mg tds may be useful for short term control of troublesome bleeding (it should not be used by women with risk factors for VTE). Long term use is not recommended. Progestogen only pill There is limited information that the levonorgestrel progestogen-only pill (POP)reduces the duration of troublesome bleeding episodes. It can be given as a twice daily dose or two taken together. If successful a 20 day course can be repeated at any time. Early removal and replacement of a contraceptive implant or hormonal IUD or reducing the interval of DMPA injections from 12 weeks to 10 weeks may be associated with an improved bleeding pattern in some women.References 1. Mansour D, et al. Eur J Contracept Reprod Health Care. 2008;13 Suppl 1:13-28. 2. Suvisaari J, et al. Contraception. 1996;54(4):201-8. 3. Sangi-Haghpeykar H, et al. Obstet Gynecol. 1996;88(2):227-33. 4. Said S, et al. Contraception. 1987;35(6):591-610. 5. Abdel-Aleem H, et al. Cochrane Database Syst Rev. 2013;10:CD003449. 6. Mestad R, et al. Contraception. 2011;84(5):493-8. 7. O’Neil-Callahan M, et al. Obstet Gynecol. 2013;122(5):1083-91. 8. Winner B, et al. The New England journal of medicine. 2012;366(21):1998-2007. 9. Venous Thromboembolism (VTE) and Hormonal Contraception: Faculty of Sexual and Reproductive Healthcare (UK); 2014. 16 p. 2014. 10. Management of Unscheduled Bleeding in Women Using Hormonal Contraception. Faculty of Sexual & Reproductive Healthcare Clinical Guidance. Clinical Effectiveness Unit; 2009. 11. Dickson J, et al. Journal of Family Planning and Reproductive Health Care. 2014;40(3):158-60. 12. Mansour D, et al. Contraception. 2011;83(3):202-10. Will I ever stop bleeding on the implant?Sometimes the implant causes long-term spotting, or periods can get longer and heavier. But for most people, the implant makes their periods way lighter. And some people even stop getting a period at all while they're on the implant (don't worry, this is totally safe).
Is it normal to constantly bleed on the implant?For the implant, one of the most common side effects is spotting (light bleeding between periods). For every 10 women who use the implant, one will get it removed because of this irregular bleeding. Not everyone gets spotting, though, and for many people who do it goes away after a few months.
How can I stop constant bleeding on nexplanon?Adding a monophasic combined pill for a month can stop the bleeding, and help to regulate your period for the next month.
How long does bleeding on the implant last?Irregular bleeding is a common side effect and will usually settle down within 3 months. Whatever your bleeding pattern, the implant is still effective. If the bleeding does not settle or you are unhappy with the bleeding you can see a doctor for medications that can help with this.
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