• Identify and manage causes for bleeding irregularities such as missed pills, drug interactions, vomiting, severe diarrhoea.
• 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 COC 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.)
• After potential causes have been excluded:
• Encourage persevering for up to three months for new users.
• Consider stopping the COC for up to 7 days and then restarting (and using an alternative method while protection is lost).
• Changing to a different COC (with a higher dose of oestrogen, or higher dose of progestogen or different type of progestogen).
• Changing to another form of contraception.

In depth