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Acute Uncomplicated UTIs in Adults: Rapid Evidence Review

Abnormal Uterine Bleeding Associated With Hormonal Contraception

This article was corrected on March 12, 2026.

Sarina Schrager, MD, MS
Kelita Fox, MD
Rachel Lee, MD

American Family Physician. 2024;109(2):161-166.

Author disclosure: Dr. Schrager has disclosed serving as a Nexplanon trainer for Organon. All relevant financial relationships have been mitigated. Dr. Fox and Dr. Lee have no relevant financial relationships. [corrected]

Abnormal uterine bleeding is a common and bothersome symptom in people using hormonal contraception, and it can lead to discontinuation of reliable methods of contraception and unintended pregnancies. Clinicians should counsel individuals about the potential for abnormal bleeding at initiation of the contraceptive method. After considering and excluding other potential causes of abnormal uterine bleeding, clinicians can offer treatment options specific to each hormonal contraceptive method. This article includes algorithms to help clinicians treat abnormal uterine bleeding in people using levonorgestrel intrauterine devices, depo-medroxyprogesterone acetate, progestin implant, progestin-only pills, and combined hormonal contraception. For patients with levonorgestrel intrauterine devices, physicians should first ensure that the device is correctly placed within the uterus, then consider nonsteroidal anti-inflammatory drugs as a first-line treatment for abnormal uterine bleeding; estradiol can be used if nonsteroidal anti-inflammatory drugs are ineffective. For depo-medroxyprogesterone acetate or progestin implant users, combined oral contraceptives or nonsteroidal anti-inflammatory drugs may be considered. For patients using norethindrone progestin-only pills, changing to drospirenone progesterone-only pills may help reduce the bleeding. In people using combined hormonal contraception, it may be helpful to increase estrogen content from 20 mcg to 35 mcg per day, decrease the hormone-free interval (from seven to four or five days) in people using cyclic contraception, or start a trial of low-dose doxycycline. For continuous combined contraception users, adding a hormone-free interval of four or five days can help regulate bleeding patterns.

Abnormal uterine bleeding (AUB) is a common concern in individuals using hormonal contraception. However, before assuming AUB is due to hormonal contraception, alternative causes should be considered. The PALM-COEIN classification system is a helpful tool for evaluating potential underlying causes (Table 1).1 AUB caused by hormonal contraception falls under the iatrogenic category (i.e., the “I” in PALM-COEIN). Table 2 describes steps for further evaluation of AUB.1,2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Counsel patients with levonorgestrel intrauterine devices that most individuals will experience a reduction in bleeding within 12 months.3,5 B Systematic review of observational studies and clinical review
Counsel patients using depo-medroxyprogesterone acetate that most individuals will experience amenorrhea and lighter menses with continued use after six to 12 months.7,8,16 B Two prospective cohort studies
Prescribe naproxen, 500 mg twice per day for five days, to reduce abnormal uterine bleeding related to levonorgestrel intrauterine devices.13 B Small RCT
Consider prescribing daily oral contraceptives to resolve abnormal uterine bleeding associated with the progestin implant, but inform patients they may require continued use.21–23 B Small RCTs showing cessation of bleeding in those randomized to oral contraceptives for 14 days or more
Add a short (four- or five-day) hormone-free interval for patients experiencing abnormal uterine bleeding with continuous use of combined hormonal contraception.36–38 B Small RCTs and systematic review

RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SARINA SCHRAGER, MD, MS, is a professor in the Department of Family Medicine and Community Health at the University of Wisconsin, Madison.

KELITA FOX, MD, is faculty at Henry Ford Family Medicine Residency Program, Detroit, Mich.

RACHEL LEE, MD, is the associate program director of the Henry Ford Family Residency Program.

Address correspondence to Sarina Schrager, MD, MS, University of Wisconsin, 1100 Delaplaine Ct., Madison, WI 53715 (sbschrag@wisc.edu). Reprints are not available from the authors.

Author disclosure: Dr. Schrager has disclosed serving as a Nexplanon trainer for Organon. All relevant financial relationships have been mitigated. Dr. Fox and Dr. Lee have no relevant financial relationships. [corrected]

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