Use of progestin-only methods—including DMPA, progestin-only pills, the contraceptive implant, and the levonorgestrel IUS—is associated with relatively high rates of initial irregular and unpredictable bleeding; rates of amenorrhea vary over time and by method (142,153). Because irregular bleeding is so often present with these methods of contraception, counseling before their use is imperative. Women who do not believe that they can cope with irregular, unpredictable bleeding may not be good candidates for these methods. Hormonal implants and IUDs releasing progestins do offer significant benefits of high efficacy and ease of use (154).
The management of irregular bleeding with hormonal contraceptive use can range from reassurance and initial expectant management to recommendations for a change in the hormonal delivery system or regimen. The use of additional oral estrogen improves bleeding with both DMPA and the subdermal levonorgestrel. The use of NSAIDs results in decreased breakthrough bleeding. The development of a better understanding of the mechanisms causing irregular bleeding will likely result in more effective and acceptable management strategies (153).
Not all bleeding that occurs while an individual is using hormonal contraception is a consequence of hormonal factors. In one study, women who experienced irregular bleeding while taking oral contraceptives had a higher frequency of C. trachomatis infection (76). Thus, screening should be considered in women presenting with irregular bleeding while using hormonal contraception.
Endocrine Causes Both hypothyroidism and hyperthyroidism can be associated with abnormal bleeding. With hypothyroidism, menstrual abnormalities, including menorrhagia, are common (see Chapter 31). The most common cause of thyroid hyperfunctioning in premenopausal women is Graves disease, which occurs four to five times more often in women than men. Hyperthyroidism can result in oligomenorrhea or amenorrhea, and it can lead to elevated levels of plasma estrogen (155). Other causes of anovulation include hypothalamic dysfunction, hyperprolactinemia, premature ovarian failure, and primary pituitary disease (Table 14.6) (143). These conditions often are considered causes of amenorrhea, and they may cause irregular bleeding (see Chapter 30). The rare and unusual causes of abnormal bleeding should not be overlooked. Women with primary ovarian insufficiency (POI; previously termed premature ovarian failure [POF]) frequently see several clinicians with symptoms of oligomenorrhea or amenorrhea prior to receiving a diagnosis; the diagnosis of POI is often delayed during waning ovarian function and insufficiency (156,157). POI is thought to occur in approximately 1 of 100 women by age 40, 1 of 1,000 women by age 30, and 1 of 10,000 women by age 20. Women should be encouraged to track their menstrual cyclicity and to consider that the menstrual cycle can be a “vital sign” that reﬂects overall health (61).
Diabetes mellitus can be associated with anovulation, obesity, insulin resistance, and androgen excess. Androgen disorders are very common among women of reproductive age and should be evaluated and managed accordingly. PCOS is present in 5% to 8% of adult women and undiagnosed in many of them (158). Because androgen disorders are associated with significant cardiovascular disease, the condition should be diagnosed promptly and treated. This condition becomes of more immediate concern in older women of reproductive age. Management of bleeding disorders associated with androgen excess consists of an appropriate diagnostic evaluation followed by the use of oral contraceptives (in the absence of significant contraindications or the desire for conception) or the use of insulin-sensitizing agents, coupled with dietary and exercise modification (159–161).