Comparison of treatments for unscheduled bleeding related to hormonal contraception

Intervention	For use with contraceptive types	Dose	Duration	Notes
Observation with consistent and correct use of contraceptive	All	N/A	N/A	Incidence of unscheduled bleeding is highest in the first few months of contraceptive use and then decreases
Ibuprofen	All	400 mg orally three times a day	5 to 10 days	Limited data but is low risk, low cost, generally well tolerated, and readily available
Supplemental estrogen only	Progestin-only contraceptives			Cannot be used by women with contraindications to estrogen therapy*
Conjugated estrogen		1.25 mg orally daily	7 days
Estradiol		2 mg orally daily	7 days
Combined estrogen-progestin contraceptive (pill, patch, or ring)	Progestin-only contraceptives	For oral pill: 1 tablet daily^¶	10 to 20 days	Cannot be used by women with contraindications to estrogen therapy*
Change in dose/formulation of estrogen-progestin contraceptive	Estrogen-progestin contraceptives	Contraceptive vaginal ring Different dose or formulation of pill^Δ	As directed for method	Limited supporting data
Mefenamic acid	Progestin-only contraceptives	500 mg orally once a day	5 days	In one trial, treatment with mefenamic acid was not statistically different from placebo by 4 weeks of treatment
Tranexamic acid	Progestin-only contraceptives	650 mg orally twice a day	5 days	One supporting trial used 250 mg 4 times daily, which is not a standardly available dose Risk of thrombosis is unknown

N/A: not applicable.
* Contraindications to estrogen therapy are discussed in related UpToDate text on combined estrogen-progestin contraceptives.
¶ Estrogen dose should be 35 mcg or less.
Δ For more information on dosing and formulations of oral contraceptive pills, refer to related UpToDate content on combined estrogen-progestin oral contraceptives.

Courtesy of Alison Edelman, MD, MPH, and Bliss Kaneshiro, MD, MPH.

Graphic 121707 Version 1.0

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Comparison of treatments for unscheduled bleeding related to hormonal contraception