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What Causes Breakthrough Bleeding After Taking Birth Control Pills?
Question: A year ago, at age 45, I was prescribed birth control bills to manage my monthly cycle (heavy, clotting) and random out-of-cycle bleeding. My doctor advised continuous use of birth control pills but breakthrough bleeding continued to be a problem. To try and manage this, I was changed to a higher dose estrogen pill (Sprintec, norgestimate 0.25 mg and ethinyl estradiot 0.35 mg) two months ago. Despite being very diligent about pill taking (same time ever day) and doing everything else to avoid breakthrough bleeding, at about day 23 on the pill, the spotting and breakthrough bleeding starts (dark brown spotting for 2 days, rust colored blood for two days, back to dark spotting for a day or two, then rust colored bleeding after urinating for two days) and then I stop and have 7 - 9 days of inconsistent bleeding (my "withdraw bleeding"). In the first days of spotting/breakthrough, the bleeding is made worse if I exercise or have sex. It's as if my system insists on having a monthly cycle or my lining is "too fragile" for exercise, sex, etc. I have four questions. First, if I am trying to do everything "right" to control the breakthrough bleeding and I'm not "new" to the pill nor am I a long-time user (prior to last year of starting, I hadn't used pills for 14 years), why might this problem of breakthrough bleeding persist? Second, I know my uterine lining is low (from multiple tests to try a determine cause of breakthrough bleeding to rule out cancer, fibroids, etc). Could a low lining be a part of the problem and is there anything else I can do to "stabilize it"? Third, I have heard conflicting reports on the use of Ibuprofen; some say to use to control spotting and breakthrough bleeding, some reports say that blood thinners can de-stabilize the lining and cause it. Not sure which is correct? And finally, why might not I be a good candidate for continuous use birth control pills?
Brief Answer:
Hello again! I hope I can follow up your question from last month
Detailed Answer:
I am sorry to hear that you are still having bleeding problems
Birth control pills contain both estrogen and progesterone; the estrogen in the pill builds the uterine lining and the progesterone stabilizes it and keeps it from growing too much. Normally in ovulatory menstrual cycle the beginning of the month estrogen is produced and then at the end progesterone is produced, which then withdraws at the end of the cycle to create a monthly menstrual cycle.
The problem is most birth control pills are not designed in the same way as a way your body normally works to menstruate.
The reason your uterine lining is very thin even though you are not a long-term pill user is from the effect of the Mirena IUD on your uterine lining when you had it inside. Mirena can thin the uterine lining significantly enough that the majority of patients who have it after six months to a year do not menstruate anymore. Unfortunately, in your case, a thin uterine lining is making your periods or bleeding episodes less heavy but unpredictable. Unfortunately, this would continue to happen or part probably get even worse if you took your birth control pills continuously.
The only thing, as you already know, that will help you regrow your uterine lining is estrogen. However, because all birth control pills also contain progesterone, the progesterone is working against the estrogen that is already in the pill.
So, the first thing that you can try is using a different brand of 35 µg birth control pill. Different kinds of progesterone can have different side effects on the uterine lining, so a different brand of birth control pill may help to control your breakthrough bleeding better.
In my patients with breakthrough bleeding, usually the second thing I would do is tell them to stop taking birth control pills for a while and see what happens. If your uterine lining at this point is very thin, you should not have heavy periods again until your estrogen levels increase, and your uterine lining rebuilds. Your own body makes plenty of estrogen, which is evident when you had heavy periods before. So you may do fine on your own for a little while after this treatment.
The other option I sometimes try is having the patient instead of taking birth control pills to take estrogen supplementation for certain number days each month and then progesterone separately instead of in a combination birth control pill. This I usually do with medications used as hormone replacement therapy, rather than oral contraceptives.
So I hope that perhaps you can discuss these possibilities with your doctor and see what they have to say. I also hope that my explanation makes you understand a little bit better why your breakthrough bleeding is occurring and also why continuous birth control, at this point, would probably not improve your situation.
Regarding the Motrin, there is some evidence that in people with heavy periods, the anti-inflammatory properties of NSAIDs can decrease the amount of bleeding loss during your menstrual cycle. It has to do with control prostaglandins, rather than making your blood thinner or thicker. It certainly would not be something that would probably help in your situation.
I hope that I was able to cover the issues you are asking about today, and that this information was helpful. I also want to assure you that breakthrough bleeding is something that is difficult to treat, and requires a lot of trial and error.
I hope that you and your doctor find a solution that works for you.
Sincerely,
Dr. Brown,
Hello again! I hope I can follow up your question from last month
Detailed Answer:
I am sorry to hear that you are still having bleeding problems
Birth control pills contain both estrogen and progesterone; the estrogen in the pill builds the uterine lining and the progesterone stabilizes it and keeps it from growing too much. Normally in ovulatory menstrual cycle the beginning of the month estrogen is produced and then at the end progesterone is produced, which then withdraws at the end of the cycle to create a monthly menstrual cycle.
The problem is most birth control pills are not designed in the same way as a way your body normally works to menstruate.
The reason your uterine lining is very thin even though you are not a long-term pill user is from the effect of the Mirena IUD on your uterine lining when you had it inside. Mirena can thin the uterine lining significantly enough that the majority of patients who have it after six months to a year do not menstruate anymore. Unfortunately, in your case, a thin uterine lining is making your periods or bleeding episodes less heavy but unpredictable. Unfortunately, this would continue to happen or part probably get even worse if you took your birth control pills continuously.
The only thing, as you already know, that will help you regrow your uterine lining is estrogen. However, because all birth control pills also contain progesterone, the progesterone is working against the estrogen that is already in the pill.
So, the first thing that you can try is using a different brand of 35 µg birth control pill. Different kinds of progesterone can have different side effects on the uterine lining, so a different brand of birth control pill may help to control your breakthrough bleeding better.
In my patients with breakthrough bleeding, usually the second thing I would do is tell them to stop taking birth control pills for a while and see what happens. If your uterine lining at this point is very thin, you should not have heavy periods again until your estrogen levels increase, and your uterine lining rebuilds. Your own body makes plenty of estrogen, which is evident when you had heavy periods before. So you may do fine on your own for a little while after this treatment.
The other option I sometimes try is having the patient instead of taking birth control pills to take estrogen supplementation for certain number days each month and then progesterone separately instead of in a combination birth control pill. This I usually do with medications used as hormone replacement therapy, rather than oral contraceptives.
So I hope that perhaps you can discuss these possibilities with your doctor and see what they have to say. I also hope that my explanation makes you understand a little bit better why your breakthrough bleeding is occurring and also why continuous birth control, at this point, would probably not improve your situation.
Regarding the Motrin, there is some evidence that in people with heavy periods, the anti-inflammatory properties of NSAIDs can decrease the amount of bleeding loss during your menstrual cycle. It has to do with control prostaglandins, rather than making your blood thinner or thicker. It certainly would not be something that would probably help in your situation.
I hope that I was able to cover the issues you are asking about today, and that this information was helpful. I also want to assure you that breakthrough bleeding is something that is difficult to treat, and requires a lot of trial and error.
I hope that you and your doctor find a solution that works for you.
Sincerely,
Dr. Brown,
Above answer was peer-reviewed by :
Dr. Raju A.T
Thank you. Since I just changed birth control pills (on advice of doctor, due to this situation), I want to give this type a bit more time. My frustration is not understanding why this is happening; if my uterine lining is so thin, why do I have such a cycle (less bleeding than before but still significant). What is triggering the breakthrough bleeding at day 23 if I'm not stopping the pill? That seems to be consistent over past 4 months. Can I take an estrogen supplement for a duration to stabilize the lining? I'm trying to stick to one course of action before I give up and go back to original problems. Thanks again.
Brief Answer:
Unfortunately there is no "why" you are prone to breakthrough bleeding
Detailed Answer:
No problem. Sometimes it can take a few months for your body to get used to a new pill. At least you are able to get 21 days a month without bleeding.
But you are correct... Taking supplemental estrogen along with the pill for about a week a month may also help. It will take trial and error to figure out when in your pill pack to take it- but considering you bleed usually around day 23 maybe the last week of the pack would be a good time to take extra estrogen.
So give it time and see what happens. I hope your symptoms improve but you are welcome to consult with me again for any further advice.
Take care,
Dr. Brown
Unfortunately there is no "why" you are prone to breakthrough bleeding
Detailed Answer:
No problem. Sometimes it can take a few months for your body to get used to a new pill. At least you are able to get 21 days a month without bleeding.
But you are correct... Taking supplemental estrogen along with the pill for about a week a month may also help. It will take trial and error to figure out when in your pill pack to take it- but considering you bleed usually around day 23 maybe the last week of the pack would be a good time to take extra estrogen.
So give it time and see what happens. I hope your symptoms improve but you are welcome to consult with me again for any further advice.
Take care,
Dr. Brown
Above answer was peer-reviewed by :
Dr. Arnab Banerjee
Thank you (again). Ok - this is my last question/clarification before I either wait and see or go back to my doctor (for the estrogen supplement). If my uterine lining is low, why do I still have a good amount of bleeding? I thought low lining often meant less or light bleeding. Granted, there is less than before but my heaviest days off the pill (days 3 and 4) still have a lot of clotting and bleeding and the duration of my cycle is still 7+ days.
Brief Answer:
Not all of what comes out of your uterus when you bleed is endometrial
Detailed Answer:
When you bleed from your uterus, the blood you see is a combination of endometrial lining tissue and blood, which is produced by the veins of the uterine wall. When there is estrogen present, there is more endometrial tissue lost, but when you have breakthrough bleeding, it is mostly pure blood coming from the unprotected uterine wall. Think of your skin- when it is very dry and thin it may crack and bleed. It may all look like blood, but it is coming from a different process than heavy menstruation. In order to re-cover the raw, thin skin inside your uterus, estrogen needs to build a new lining. Estrogen rebuilds a uterine lining so fast that IV estrogen is used to treat uncontrollable bleeding from almost any gynecologic cause.
Check out this link it gives a good summary of dysfunctional uterine bleeding (DUB) it's causes and some treatments:
XXXX
I hope this helps
Take care,
Dr. Brown
Not all of what comes out of your uterus when you bleed is endometrial
Detailed Answer:
When you bleed from your uterus, the blood you see is a combination of endometrial lining tissue and blood, which is produced by the veins of the uterine wall. When there is estrogen present, there is more endometrial tissue lost, but when you have breakthrough bleeding, it is mostly pure blood coming from the unprotected uterine wall. Think of your skin- when it is very dry and thin it may crack and bleed. It may all look like blood, but it is coming from a different process than heavy menstruation. In order to re-cover the raw, thin skin inside your uterus, estrogen needs to build a new lining. Estrogen rebuilds a uterine lining so fast that IV estrogen is used to treat uncontrollable bleeding from almost any gynecologic cause.
Check out this link it gives a good summary of dysfunctional uterine bleeding (DUB) it's causes and some treatments:
XXXX
I hope this helps
Take care,
Dr. Brown
Above answer was peer-reviewed by :
Dr. Arnab Banerjee
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