Put contraceptive pearls to work in your practice

Unscheduled spotting and bleeding occurs in 30% to 50% of women in the first few months of combined oral contraceptive (OC) use.1 How can you help patients “stay the course”?

Use contraceptive “pearls” gleaned from the 20th revised edition of Contraceptive Technology, advises Deborah Kowal, MA, PA, chief executive officer and president of Contraceptive Technology Communications in Atlanta.2 Kowal presented highlights from the recently revised family planning handbook at the Contraceptive Technology: Quest for Excellence conference in Atlanta.

Page 313 in the new edition offers handy tips for dealing with spotting and bleeding, Kowal says. If spotting or bleeding occurs before a patient completes active pills, more endometrial support might be needed, according to the tips. Increase the progestin content of her pills, by changing to a different monophasic formulation or by switching to a triphasic formation that boosts the progestin levels in the last active pills.

If a patient continues to have spotting or bleeding following the scheduled bleeding, more estrogen might be need to proliferate the endometrium. Consider increasing the estrogen in the first pills in the pack or decrease the progestin content of those first pills, the book advises.

How about mid-cycle bleeding? One approach for this relatively uncommon bleeding pattern is to prescribe a triphasic formulation that increases the estrogen and progestin levels in the middle pills.

Be prepared to deal with unscheduled spotting and bleeding in women who use extended cycle pills, especially after week number 5 in the first cycle, the book advises. Be sure to inform women that as with all other pills, they will have more spotting when they begin taking extended OCs and that this unscheduled bleeding will decrease rapidly over time. However, if having completed 21 days of pills a patient still finds this bothersome, she can stop taking pills for two to three days to allow a withdrawal bleed to start. Then she should restart taking the active pills, taking at least three weeks of pills before she stops again. As she takes pills in this flexible pattern, the length of time between unscheduled spotting and bleeding episodes will increase. Instruct the patient that eventually she will be able to take pills for 3-12 months at a time with little or no unscheduled bleeding or spotting.1

How about missed pills?

Missed pills happen, notes Michael Rosenberg, MD, MPH, clinical professor of obstetrics and gynecology and adjunct professor of epidemiology at the University of North Carolina at Chapel Hill and chief executive officer of Health Decisions, a Durham, NC, private research firm with expertise in reproductive health. Rosenberg points to a prospective cohort study of 943 U.S. women who began or switched to a new OC brand at study enrollment. At follow up two months after enrollment, 47% of pill users reported missing one or more pills per cycle, and 22% missed two or more pills in each cycle.3 Those who missed one or more pills were significantly more likely than those who did not to lack an established pill-taking routine, not to have read or understood the informational material accompanying the pill, and to have experienced spotting or heavy bleeding.3

The issues are the same today as when the study was conducted, says Rosenberg. They perhaps might be a bit more important, because the trends to prescribed lower estrogen pills means that consistent use and anticipating spotting and bleeding problems is more important, he notes.

Want a simple way to approach missed pills? Kowal directs readers to page 322 of Contraceptive Technology for simplified recommendations. First, ask the patient if she had intercourse without extra protection before she missed her pill. If she did, provide her with emergency contraception.

If the woman is less than 12 hours late taking her pill, advise her to take it now and take her next pills at the time she usually would.

If the patient is more than 12 hours late in taking her pill, advise her to take her missed pill now and any other pill she is supposed to take today. Instruct her to finish taking all the other pills in her pack on time.

Counsel that abstinence or condoms should be used with every act of sex until the woman has taken seven active pills.1 All of these steps might overtreat the situation, but they are easy to follow, the book advises.1


  1. Nelson AL, Cwiak C. Combined oral contraceptives (COCs). In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
  2. Kowal D. Clinical pearls: diving into the new 20th edition of Contraceptive Technology. Presented at the Contraceptive Technology: Quest for Excellence conference. Atlanta; November 2012.
  3. Rosenberg MJ, Waugh MS, Burnhill MS. Compliance, counseling and satisfaction with oral contraceptives: a prospective evaluation. Fam Plann Perspect 1998; 30(2):89-92,104.