Why am I experiencing heavier periods while taking birth control pills, such as Loestrin (ethinyl estradiol and norethindrone), and what are my treatment options?

Heavier Periods with Birth Control Pills: Causes and Treatment

If you are experiencing heavier periods on Loestrin (ethinyl estradiol and norethindrone), this is paradoxical since combined oral contraceptives typically reduce menstrual blood loss, and you should first rule out incorrect pill use, missed pills, or underlying pathology before considering treatment with NSAIDs for 5-7 days or switching to a higher estrogen formulation. 1

Understanding the Problem

Combined hormonal contraceptives (CHCs) like Loestrin are actually designed to reduce menstrual bleeding by thinning the endometrium and regulating cycles. 2 When heavier bleeding occurs on CHCs, this represents either:

• Breakthrough bleeding during the adjustment period (first 3-6 months), which is common and generally not harmful 1
• Incorrect or inconsistent pill use, which is the most common cause of unscheduled bleeding 1
• Underlying pathology that needs evaluation 1

Initial Assessment Steps

Before treating the bleeding, you must:

• Verify consistent pill timing: Missed pills or inconsistent timing is the primary cause of breakthrough bleeding with CHCs 1
• Rule out pregnancy 1
• Consider underlying conditions: sexually transmitted infections, thyroid disorders, new uterine pathology (polyps, fibroids), or medication interactions 1
• Determine timing: If this is within the first 3-6 months of starting the pill, reassurance may be all that's needed 1

Treatment Options

First-Line: NSAIDs

Start with NSAIDs (ibuprofen, naproxen, or mefenamic acid) for 5-7 days during bleeding episodes, which reduce menstrual blood loss by 20-60%. 1, 3, 4

• Do NOT use aspirin, as it may paradoxically increase bleeding 3
• NSAIDs can be repeated as needed with subsequent bleeding episodes 1

Second-Line: Increase Estrogen Content

If NSAIDs fail and you want to continue with oral contraceptives:

Switch from your current 20 mcg ethinyl estradiol formulation to a 35 mcg ethinyl estradiol pill, which may better stabilize the endometrium and reduce breakthrough bleeding. 5

Third-Line: Modify Pill Regimen

For women using extended or continuous CHC regimens with persistent bleeding:

Consider a hormone-free interval of 3-4 consecutive days, which can help regulate bleeding patterns. 1, 5

• This should NOT be done during the first 21 days of extended/continuous use 1
• This should NOT be done more than once per month as it may reduce contraceptive effectiveness 1

Alternative: Consider Different Contraceptive Methods

If bleeding persists despite these interventions:

The levonorgestrel-releasing intrauterine system (LNG-IUD) is superior to combined oral contraceptives for reducing menstrual blood loss, decreasing bleeding by 71-95% compared to CHCs. 3, 2

• Evidence shows LNG-IUD is more effective than COCP for heavy menstrual bleeding 2
• This option provides both contraception and dramatic reduction in menstrual blood loss 3

Important Caveats

Timing matters: If you've been on this pill for less than 3-6 months, the bleeding irregularities are expected and usually resolve with continued consistent use. 1 Enhanced counseling and reassurance during this period reduces discontinuation rates. 1

Doxycycline does NOT work: Despite being tried in some studies, oral doxycycline (100 mg twice daily for 5 days) showed no benefit for unscheduled bleeding in CHC users. 1

Tranexamic acid is an option but expensive: This antifibrinolytic agent reduces bleeding by 40-60%, but is contraindicated if you have any history of blood clots or thromboembolism. 3, 4

When to Seek Further Evaluation

If bleeding persists after 3-6 months of consistent pill use and despite treatment with NSAIDs, you require re-evaluation for underlying pathology and should consider switching to an alternative contraceptive method entirely. 1, 3