Cervical cancer is also rare in thispopulation, especially in women who comply with National Cervical Screening Programmes.A management plan is outlined and can be tailored tothe individual woman (Figure 1).
This Guidance is notintended to serve alone as a standard of medical care, asthis should be determined individually based on availableclinical information.
This Guidance has beensystematically developed using the standard methodologyoutlined in the Appendix to this document.
The management of women with unscheduledbleeding in the initial months (i.e.
3–6 months) afterstarting a new method of hormonal contraception maydiffer from that of women who continue to haveunscheduled bleeding in the longer term or who presentwith a change in bleeding pattern.
A clinical history (Box 2)should highlight possible underlying causes (an examplebeing Chlamydia trachomatis) and provide a guide to themost appropriate examination, investigation and treatmentoptions required.
Reassuringly in community populations,endometrial cancer is very rare in women of reproductiveage who are using hormonal contraception or who do nothave risk factors for endometrial cancer (such as obesity,polycystic ovarian syndrome, tamoxifen use or unopposedestrogen therapy).combined oralcontraceptive pill (COC), transdermal patch, progestogen-only pill (POP), injectable, implant or intrauterine system(IUS)].The term unscheduled bleeding in this Guidancerefers to breakthrough bleeding, spotting, prolonged orfrequent bleeding (Box 1).1The management of women who present withunscheduled bleeding while using hormonal contraceptionis challenging.Bleeding may not settle with time and ovarian activity isincompletely suppressed.Approximately 10–15% are amenorrhoeic; up to 50%have a regular bleed; 30–40% have irregular bleeding.10Up to 70% are amenorrhoeic at 1 year.6After 6 months use, 30% have infrequent bleeding;10–20% have prolonged bleeding.6,12Long-acting reversible contraceptive (LARC) guidancesuggests: 20% are amenorrhoeic; 50% have infrequent,frequent or prolonged bleeding, which may not settle withtime.665% have amenorrhoea or reduced bleeding at1 year.6A 90% reduction in menstrual blood loss has beendemonstrated over 12 months of use.11,13A pregnancy test should be performed if there hasbeen incorrect method use (such as missed pills, lateinjection or expelled IUS), drug interactions or illness,which may alter absorption of oral methods.Exposure toprogesterone in the luteal phase results in secretorydifferentiation.