Is breakthrough bleeding a common occurrence when initiating hormonal birth control (contraception)?

From the Guidelines

Breakthrough bleeding is a common occurrence when starting birth control, and it is essential to continue taking the prescribed birth control, even if bleeding occurs, as it usually resolves within 3-6 months. Many women experience spotting or light bleeding between periods during the first few months of using hormonal contraceptives, such as pills, patches, rings, implants, hormonal IUDs, and injections like Depo-Provera 1. This side effect typically occurs due to the thinning of the uterine lining caused by hormonal contraceptives, leading to irregular shedding of the endometrium and resulting in unexpected bleeding.

According to the most recent guidelines, the management of bleeding irregularities while using contraception should prioritize patient goals, including continued method use or method discontinuation 1. If the patient wants to continue use, providing reassurance and advising the patient to contact their provider at any time to discuss bleeding irregularities or other side effects is recommended. For patients experiencing spotting or light bleeding, treatment options such as NSAIDs for 5-7 days may be considered, depending on the patient's preferences, treatment goals, and medical history.

Key points to consider when managing breakthrough bleeding include:

• Continuing to take the prescribed birth control, even if bleeding occurs, as it usually resolves within 3-6 months
• Taking pills at the same time each day to help minimize breakthrough bleeding
• Consulting a healthcare provider if the bleeding is heavy, persists beyond 6 months, or causes significant discomfort
• Considering switching to a different formulation with different hormone levels or a different type of contraceptive altogether if breakthrough bleeding persists
• Exploring patient goals, including continued method use or method discontinuation, and providing reassurance and advice on managing bleeding irregularities.

It is crucial to prioritize the patient's goals and preferences when managing breakthrough bleeding, and to consider the most recent guidelines and evidence-based recommendations, such as those outlined in the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1.

From the FDA Drug Label

Breakthrough bleeding and spotting are sometimes encountered in patients on oral contraceptives, especially during the first three months of use Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. Breakthrough bleeding is a common occurrence when starting birth control, especially during the first three months of use.

• It is recommended to consider non-hormonal causes and rule out malignancy or pregnancy in the event of breakthrough bleeding.
• If pathology has been excluded, time or a change to another formulation may solve the problem 2, 2.

From the Research

Breakthrough Bleeding and Birth Control

• Breakthrough bleeding is a common side effect of hormonal contraception, particularly when starting birth control 3, 4.
• Studies have shown that breakthrough bleeding typically subsides over time, with the time needed to return to baseline depending on the dose of ethinyl estradiol (EE) and the type of progestin used 3.
• The dose-response relationships established for breakthrough bleeding across different progestin/EE combinations can be used to support the selection of optimal birth control dosing regimens 3.

Factors Affecting Breakthrough Bleeding

• The dose of EE and the type of progestin used can affect the incidence of breakthrough bleeding 3, 4.
• Higher estrogen doses may be associated with less breakthrough bleeding, while progestins can also contribute to bleeding problems 4.
• The combination of estrogens and progestins may help alleviate breakthrough bleeding, but the solution may need to be found empirically for each woman 4.

Management of Breakthrough Bleeding

• Several therapies have been evaluated to manage unscheduled bleeding associated with progestin-containing contraceptives, but the exact etiology of irregular bleeding is not fully understood 5.
• A novel oral contraceptive composed of estradiol valerate/dienogest has been shown to have an acceptable bleeding profile comparable to that of an ethinyl estradiol-containing oral contraceptive 6.