GPAtlas🧭 When to suspect
Problematic (unscheduled) bleeding means any bleeding that falls outside the expected pattern for a woman’s method:
• Breakthrough bleeding
• Spotting
• Prolonged bleeding (an episode lasting ≥ 14 days)
• Frequent bleeding (more than five episodes in a 90-day period)
It is one of the commonest reasons women attend about their contraception, and the single most frequent reason they abandon an otherwise effective method.
It is especially common with progestogen-only methods (implant, injectable, IUS and POP) and in the first three months of any new method, where it is usually a benign, settling effect of the hormones on the endometrium.
First exclude pregnancy, infection and cervical or endometrial pathology.
• Then, once the bleeding can safely be attributed to the method, counsel and manage – reassure, optimise, or switch.
• Good pre-method counselling about expected bleeding is itself preventive: women who know what to expect are far more likely to persevere.
| Method | First 3 months | Longer term |
|---|---|---|
| Combined (pill/patch/ring) | Up to 1 in 5 have irregular bleeding | • Usually settles • Ring may give the best cycle control |
| Traditional POP (LNG/NET) | About 1 in 3 have a change in bleeding | • Frequent or irregular bleeding common • Amenorrhoea less likely |
| Desogestrel POP | Frequent, prolonged or infrequent bleeding | • At 12 months ~5 in 10 amenorrhoeic/infrequent • ~2 in 10 prolonged |
| Injectable (DMPA) | • Disturbance common • ~1 in 10 amenorrhoeic early |
~50% or more amenorrhoeic by 12 months |
| Implant (etonogestrel) | • Disturbance common • Early pattern broadly predictive |
~2 in 10 amenorrhoeic, ~3 in 10 infrequent, ~2 in 10 prolonged |
| LNG-IUS (52 mg) | • Frequent bleeding or spotting common • May take > 6 months to settle |
• Bleeding/spotting falls • Infrequent bleeding usual, ~24% amenorrhoeic at 3 years |
Source: FSRH Problematic Bleeding with Hormonal Contraception
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