Treatment for bleeding disorders

The use of progesterone preparations often causes breakthrough bleeding and spotting. Usually these are transitory and do not require treatment. After a first Mirena® is fitted this too often results in irregular bleeding for the first 3-6 months, becoming significantly less frequent. So by the end of the first year most women have only 1-2 days of bleeding per month and almost half have no periods at all. It is vital that this aspect in particular is discussed fully in a consultation before the fitting. (If a Mirena® is removed after five years and a new one is fitted straight away, the existing pattern of bleeding continues i.e. it doesn’t lead to increased bleeding again).

Generally however after a first Mirena® is fitted for the first time, bleeding gets heavier and/or lasts longer. It is not possible to predict invidivual risk for longer or heavier bleeding because there are no known risk factors. A treatment should be offered if the quality of life of the patient is restricted or if there are medical grounds for doing so, due to the sustained bloodloss. There is currently no standard treatment for this scenario, but the following options may be considered:

  • Ruling out myoma or incorrect positioning of the IUD/IUS using either ultrasound or hysteroscopy (the Mirena® can also be left in place after the hysteroscopy).
  • Additional use of a combined oral contraceptive or the administration of oral or transdermal oestradiol or ethinylestradiol for three months.
  • Mifepriston (progesterone receptor antagonist) blocks the progesterone receptor and induces the formation of oestrogen receptors in the endometrium. This can be strengthened by additional oestrogen of 20 mcg Ethinylestradiol on day 2-5. The endometrium can proliferate again and the bleeding is stemmed.
  • 100mg doxycyclin, twice a day for five days. The effect of doxycyclin or tetrazycline is to restrict the  effect of the matrix metalloproteinasen on the matrix degeneration in the fibrous tissue. Matrix metalloproteinasen are important in the endometrium for the thickening of the mucous membrane. It has been shown that the model for matrix-metallproteinasen is altered in users of long-term progesterone preparations.
  • Non-steroidal anti-inflammatory drugs (NSAID)
  • Tranexamic acid

A comprehensive procedure in the event of bleeding with progesterone-only contraceptives can be found in:

– Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Abdel-Aleem H, d’Arcangues C, Vogelsong KM, Gülmezoglu AM. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003449.

– Bleeding pattern changes with progestogen-only long-acting reversible contraceptives, Sexual Health & Family Planning Australia

– Blutungsstörungen unter reiner Gestagen-Langzeitkontrazeption mit subdermalen Implantaten Teil 2: Management von Zusatzblutungen unter subdermalen Implantaten, Der Frauenarzt, 2011, Hans-Joachim Ahrendt, Christian Egarter

– M. Ludwig: Hormonelle Kontrazeption – ein Handbuch für die Praxis, 2009