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Contraception - Management
What advice should I give about menstrual irregularity to women using a progestogen-only pill (POP)?

  • Many women experience irregularities in menstruation while using a progestogen-only pill (POP). Nevertheless, exclude or manage situations which could compromise the effectiveness of the POP:
    • Missed pills: check how the POP is being taken and if any pills have been missed.
    • Drug interactions: review if any new prescription or non-prescription medicines, or herbal/natural remedies, have been taken (e.g. antibiotics, St John's wort).
    • Vomiting within 2 hours of pill taking: review the cause and duration of vomiting. Check pill taking (e.g. if a second dose of POP was taken).
    • Severe diarrhoea: review the cause and duration of severe diarrhoea. Check pill taking (e.g. if additional pills have been taken to compensate for probable malabsorption).
  • Exclude or manage other situations which could result in unscheduled bleeding, such as:
    • Sexually transmitted infections.
      • Risk of STI if the woman is under 25 years, or has a new sexual partner, or more than one partner in the last year.
    • Pregnancy.
    • Gynaecological conditions such as cervical cancer. Provided there is consistent and correct use of contraception, speculum examination is warranted:
      • For persistent bleeding beyond the first 3 months of use.
      • For new symptoms or a change in bleeding after at least 3 months of use.
      • If the woman has not participated in a National Cervical Screening programme.
      • If requested by the woman.
      • After a failed trial of modification of POP treatment (at least 6–8 weeks).
      • If there are other symptoms such as pain, dyspareunia, or post coital bleeding. (Note that these symptoms also warrant pelvic examination.)
  • If the above causes of menstrual irregularities have been excluded, the irregularity can be assumed to be caused by the POP.
  • Although bleeding may settle with time, there is no evidence to indicated which women may become amenorrhoeic or which women may experience irregular bleeding, or for how long. As a general guide:
      • 2 in 10 women will become amenorrhoeic; this is most likely in older women.
      • 4 in 10 women will have regular bleeding.
      • 4 in 10 women will have irregular bleeding.
  • Frequent or prolonged bleeding may be managed by trying another POP or by changing to another contraceptive method.
  • If amenorrhoea does occur, the woman can continue with the POP, once pregnancy has been excluded.
Basis for recommendation
  • These recommendations are based on guidelines from the Faculty of Sexual and Reproductive Healthcare, the Royal College of Obstetricians and Gynaecologists, and the Department of Health [FSRH, 2008b; FSRH and RCOG, 2009; DH, 2010].
  • The advice on early recognition of genito-urinary cancer is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2005].

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