Management of bleeding problems related to the use of hormonal implants and hormone-releasing intra-uterine systems
ESC Congress Library. Roumen F. May 30, 2014; 53344; S10.2 Disclosure(s): Involvement in several industry-sponsored research projects Ad hoc medical adviser and lecturer for MSD, Bayer, and other pharmaceutical companies that manufacture contraceptives Co-author Dutch guidelines on contraception Reviewer for medical journals
Dr. Frans J.M.E. Roumen
Dr. Frans J.M.E. Roumen
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manage bleeding problems in implant and IUS users
Menstrual pattern abnormalities are the most frequently reported adverse events as well as the main reason for early discontinuation of an implant.
At the moment, there is no way of predicting which subset of women is at risk of troublesome unscheduled bleeding. No simple relationship is found between irregular bleeding and clinical characteristics like age, weight/BMI, or timing of the implantation, but in Asiatic populations a better menstrual pattern is generally observed.
The underlying mechanisms are still unclear. The bleeding can be secondary to estrogen withdrawal or incomplete ovarian suppression leading to fluctuating estrogen levels, but also vascular changes at the endometrial level may contribute. The bleeding pattern in the first three months of the implant use is broadly predictive of future bleeding patterns, although 50% of women with an initial negative pattern will have improvement, over the time, of menstrual disorders.
A detailed clinical history using a menstrual bleeding chart is helpful to decide whether a pregnancy test, an STI screen, a pelvic examination, or cervical cytology is indicated. In case of normal findings, a pelvic ultrasound is required to measure endometrial thickness and to detect possible functional ovarian cysts.
In presence of atrophic endometrium due to strong ovarian suppression, treatment with estrogen alone or oral contraceptives at a EE 30-50 mcg dose for one or two cycles could provide the necessary hormonal support. When an ovarian functional cyst or increased endometrial thickness is detected, the additional administration of high-dose oral progestin could be appropriated. In absence of one of these conditions, various treatments can be tried like NSAIDS (ibuprofen, mefenaminic acid, aspirin), tamoxifen, tranexaminic acid, doxycycline or the cyclooxygenase 2 inhibitor celecoxib, or combined regimens like doxycycline/mifepristone, mifepristone/EE or doxycycline/EE. Most of these treatments are more or less successful in the short term, but the unpredictable bleeding usually returns.
Although a few women will choose to keep the contraceptive implant and to continue with additional therapeutic interventions, most of them request removal of the implant, which should be performed as soon as possible.
Although proper counseling prior to contraceptive provision is essential, providing informed and realistic information on possible bleeding problems prior to the fitting of an implant has only a limited effect on acceptance and continuation of the method.
The hormone-releasing intra-uterine system is typically associated with an initial increase in number of bleeding-spotting days during the first few months of use, that usually improves over time resulting in decreased menstrual blood loss or even amenorrhea. Tranexamic acid, mefenamic acid, transdermal estradiol, naproxen and anti-progestins during the first 90 days after IUS placement do not alleviate nuisance bleeding or spotting. Women with uterine fibroids or endometrial polyps are at increased risk of irregular bleeding and should be treated accordingly, removal of the IUS is requested in case of displacement or uterine perforation.
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