How to Stop Bleeding While on Birth Control
For unscheduled bleeding while actively using birth control, start with NSAIDs (ibuprofen or naproxen) for 5-7 days during bleeding episodes, and if this fails after 3-6 months or bleeding is heavy, add short-term low-dose combined oral contraceptives (30-35 μg ethinyl estradiol) for 10-20 days. 1
Initial Assessment
Before treating bleeding, rule out these specific causes:
- Pregnancy - always exclude first 1, 2
- Missed pills or inconsistent use - the most common cause of breakthrough bleeding 3
- Drug interactions that reduce contraceptive hormone levels 1
- Sexually transmitted infections - particularly chlamydia and gonorrhea 1
- New uterine pathology - fibroids, polyps, or cervical lesions 1
- Cigarette smoking - increases breakthrough bleeding risk 1
Treatment Algorithm by Bleeding Type
For Spotting or Light Unscheduled Bleeding
First-line treatment:
- NSAIDs for 5-7 days during bleeding episodes (ibuprofen 400-800 mg three times daily or naproxen 500 mg twice daily) 1, 4
- This works by reducing prostaglandin production in the endometrium 3
If NSAIDs fail after trying for 2-3 bleeding episodes:
- Add low-dose combined oral contraceptives (30-35 μg ethinyl estradiol) for 10-20 days during bleeding, if medically eligible 1, 2
- Alternatively, use estrogen alone for 10-20 days if progestin is contraindicated 1
For Heavy or Prolonged Bleeding
Proceed directly to hormonal treatment:
- Low-dose COCs (30-35 μg ethinyl estradiol) for 10-20 days during bleeding episodes 1, 2
- This is more effective than NSAIDs alone for heavy bleeding 1, 3
For Bleeding on Extended/Continuous Combined Hormonal Methods
Expect bleeding in first 3-6 months - this is normal and decreases with time 1
If bleeding persists beyond 6 months and is bothersome:
- Take a 3-4 day hormone-free interval (pill-free break) 1
- Do NOT use this approach in the first 21 days of starting the method 1
- Do NOT use more than once per month as it reduces contraceptive effectiveness 1
For Bleeding on Progestin-Only Pills
Recent evidence shows a specific solution:
- Add norethisterone acetate 5 mg daily to the progestin-only pill regimen 5
- This significantly reduces bleeding frequency after 2,4, and 6 weeks compared to doubling the POP dose or switching formulations 5
- Alternative: try NSAIDs for 5-7 days, though less effective than with combined methods 3
For Bleeding on DMPA (Depo-Provera) Injections
- Mefenamic acid 500 mg three times daily for 5 days stops bleeding within 7 days 1
- Valdecoxib (if available) for 5 days also effective 1
- Short-term estrogen therapy can stop bleeding during treatment period 1
For Bleeding on Implants (Nexplanon)
- NSAIDs for 5-7 days during bleeding episodes 1
- Celecoxib 200 mg daily for 5 days or mefenamic acid 500 mg three times daily for 5 days both stop bleeding within 7 days 1
- Low-dose COCs for 10-20 days if NSAIDs fail 1
Critical Counseling Points
Set realistic expectations before starting treatment:
- Unscheduled bleeding is most common in the first 3-6 months of any hormonal method 1, 6
- This bleeding is generally not harmful and usually improves with time 1
- Enhanced counseling about expected bleeding patterns reduces discontinuation rates 1, 6
Important Safety Warnings
When using COCs for bleeding treatment:
- COCs increase venous thromboembolism risk 3-4 fold (up to 4 per 10,000 woman-years) 2
- Do NOT combine with hormonal contraceptives if using tranexamic acid, as this further increases clotting risk 7
- Check medical eligibility before prescribing estrogen-containing treatments 1, 2
When to Switch Methods
Consider offering an alternative contraceptive method if:
- Bleeding persists despite treatment and the woman finds it unacceptable 1
- Up to 25% of women discontinue progestin-only methods due to bleeding disturbances 8
- Bleeding is the leading cause of contraceptive discontinuation and subsequent unintended pregnancy 3, 6