Randomized comparison of bleeding patterns in women using a combined contraceptive vaginal ring or a low-dose combined oral contraceptive on a menstrually signaled regimen

Abstract

Randomized comparison of bleeding patterns in women using a combined contraceptive vaginal ring or a low-dose combined oral contraceptive on a menstrually signaled regimen Study design: Women, 66 to each group, were randomized to continuous use of a CVR (15 mcg ethinyl estradiol/150 mcg etonogestrel) or a low-dose pill (20 mcg ethinyl estradiol/100 mcg levonorgestrel) for 360 days on a menstrually signaled regimen. Bleeding/spotting days, daily use of ring or pill, was recorded. Endpoint was the total number of bleeding/spotting days for each method over four 90-day reference periods (RP) plus the analysis of bleeding patterns using modified World Health Organization criteria.Results: There was a reduction in the mean (± S.D.) number of bleeding/spotting days from RP1 (CVR 14.2±10; pill 16.6±10.9) to RP4 (CVR 8.8±9.6; pill 8.8±9.1). Fifteen percent of CVR and 4% COC users experienced amenorrhea or infrequent bleeding throughout the study. Amenorrhea increased over time (RP1 vs. RP4: CVR 10% vs. 21% and COC 2% vs. 30%). Compliance with the menstrually signaled regimen was poor. Ceasing hormones for 4 days stopped a bleeding episode within 5 days in the majority of episodes and many stopped spontaneously. Conclusion:Bleeding patterns with continuous use of the CVR and COC are similar and improve over 1 year of use. The unpredictability, but short duration, of bleeding episodes should be stressed during counseling. Implication: This information for clinicians and women about breakthrough bleeding patterns with use of a CVR or combined pill over 12 months using a menstrually signaled regimen will give women an indication of what to expect with continuous use.

FSRH Guideline (January 2019, amended October 2023) Combined Hormonal Contraception

“…A recent trial in Australia65 randomised 172 women to continuous use for a year of either a CVR or 20 μg EE/LNG COC. Women were instructed to take a 4-day break if they bled for four consecutive days.…”

Case-based discussion on the implications of exogenous estrogens in hemostasis and thrombosis: the hematologist’s view

“…Delay in diagnosis, difficulty accessing treatment 21 VWF levels masked by hormones, pregnancy, comorbidities 7,8 VWF assay high variability 9,10 Iron-deficiency anemia 15 Poor cognitive, social functioning, quality-of-life [21][22][23] Malposition, expulsion of intrauterine device 26 II. Current approach to management Iron supplementation [17][18][19] Tranexamic acid 24 Levonorgestrel intrauterine device 26 Combined oral contraceptive 24 VWF concentrate 24 effect by releasing hormone into the endometrial cavity but is limited by weight gain and depression in 20% of patients, and it may be expelled as a result of large clot burden. 26 VWF concentrate replaces defective or deficient VWF protein but is limited by invasiveness and cost.…”

“…Current approach to management Iron supplementation [17][18][19] Tranexamic acid 24 Levonorgestrel intrauterine device 26 Combined oral contraceptive 24 VWF concentrate 24 effect by releasing hormone into the endometrial cavity but is limited by weight gain and depression in 20% of patients, and it may be expelled as a result of large clot burden. 26 VWF concentrate replaces defective or deficient VWF protein but is limited by invasiveness and cost. 24 A survey of hemostasis physicians regarding management of menstrual bleeding in VWD revealed that the most common first-line therapy was COCs in 70%, followed by tranexamic acid (Lysteda) in 30%, and DDAVP in 20%.…”