What are the causes and management of breakthrough bleeding in women on oral contraceptive pills?
Any woman who is prescribed oral contraceptive pills should be explained about break through bleeding which can be a simple endometrial response to pill or may indicate some pathology of the genital tract or elsewhere. When a woman presents with breakthrough bleeding, the first and foremost thing is to exclude the alternative causes of bleeding which will need detailed history, examination and certain investigations. Various causes which can give rise to breakthrough bleeding include diseases of the genital tract like invasive disease of the cervix and chlamydial infection. For this condition cervical smears and swabs for Chlamydia should be taken and appropriate antibiotic is then prescribed. Disorders of pregnancy like abortion and trophoblastic disease can also lead to breakthrough bleeding. Serum beta HCG and transvaginal scan will be required for diagnosis. Patients will then need evacuation of retained products of conception and appropriate follow up for trophoblastic disease. Another cause of breakthrough bleeding is default or missed pills. In such case break thru bleeding will start 2 to 3 days later and be very persistent thereafter. Patients should be counseled regarding hazards of missing pills to improve her compliance. Various drugs especially enzyme inducers for example antiepileptic drug carbamazepine can interact with pills. Mechanism of interaction may include inhibition of enterohepatic circulation. Management will include giving a high dose pill like 50 microgram pill or by recommending triphasic regime. Alternatively a woman may be prescribed other methods of contraception like injectable progestogens. Severe gastrointestinal disturbances like diarrohea and vomiting can impair pill absorption and lead to break thru bleeding. A higher dose preparation may be required in that instance. It is now an agreed fact that more than seven pills missed in total risk ovulation so if any woman presents with history of vomiting out the pills she should be advised that if there are seven or more pills remaining in the pack, she can leave the usual seven day break otherwise she has to start the next pack next day without a break. People strictly following vegetarian diet may have reduced gut flora involved in recycling ethinyl estradiol which may cause break thru bleeding. Sometimes breakthrough bleeding occurs for too short duration which is tolerable and may resolve after 2 to 3 months. Sometimes the dose is not adequate and in such cases a phasic pill can be tried in place of a monophasic one which can give better cycle control for a lower dose of hormone. Other measures to control breakthrough bleeding include increasing the progesterone component of the pill or using a better type like gestodene. If none of these work a higher dose of 50 microgram is effective in majority cases.
In conclusion breakthrough bleeding on pills is a common problem. Reasons may range from poor endometrial response requiring dosage alteration to any serious disease or drug interaction. Management includes exclusion of other causes of bleeding, either altering the type of pill or increasing the dose and appropriate counseling of woman.
Posted by Sarwat F.
Thankyou for checking my essay. Actually one of my friends told me that a question on breakthru bleebing on OCPs was asked in March 2004. I was trying to formulate the answer for that.
