How can I stop my current breakthrough bleeding while taking Lo Loestrin Fe (ethinyl estradiol and norethindrone acetate)?

Managing Breakthrough Bleeding on Lo Loestrin Fe

For active breakthrough bleeding while taking Lo Loestrin Fe, add NSAIDs (ibuprofen 400-600mg three times daily) for 5-7 days during the bleeding episode as first-line treatment, and if this fails after one cycle, add a short course of supplemental low-dose combined oral contraceptives (30-35 μg ethinyl estradiol) for 10-20 days. 1

Immediate Management Steps

First-Line Treatment: NSAIDs

• Start ibuprofen 400-600mg three times daily for 5-7 days during active bleeding episodes 1
• NSAIDs are recommended as first-line therapy by the World Health Organization for spotting or light unscheduled bleeding 1
• This approach addresses the bleeding without altering your contraceptive regimen 1

Second-Line Treatment: Supplemental Estrogen

• If NSAIDs fail to control bleeding after one treatment cycle, add a low-dose COC (30-35 μg ethinyl estradiol) for 10-20 days during bleeding episodes 1
• This provides additional estrogen support while maintaining your current contraceptive 1
• The American College of Obstetricians and Gynecologists recommends this approach when NSAIDs are insufficient 1

Critical Exclusions Before Treatment

Before starting any treatment, rule out these causes:

• Pregnancy must be excluded first - this is the most critical step per CDC recommendations 1
• Screen for sexually transmitted infections (chlamydia and gonorrhea) - these commonly cause breakthrough bleeding 1
• Review all medications for drug interactions - rifampin, anticonvulsants (phenytoin, carbamazepine, topiramate), and St. John's Wort all reduce contraceptive hormone levels and cause breakthrough bleeding 2, 3, 4
• Assess for new uterine pathology - fibroids, polyps, or cervical lesions should be considered 1
• Smoking status - cigarette smoking significantly increases breakthrough bleeding risk 1

Important Context About Your Medication

Lo Loestrin Fe contains very low doses of hormones (10 μg ethinyl estradiol and 1 mg norethindrone acetate), making breakthrough bleeding more common than with higher-dose formulations. The FDA label for norethindrone specifically notes that breakthrough bleeding can occur with hormonal contraceptives 3.

Expected Timeline

• Breakthrough bleeding is most common in the first 3-6 months of any hormonal contraceptive 1
• Bleeding generally decreases with continued use and is not harmful 2, 1
• If bleeding persists beyond 3-6 months despite treatment, reassessment for underlying pathology is warranted 1

Safety Considerations

Before adding supplemental estrogen-containing COCs, verify you have no contraindications:

• Combined oral contraceptives increase venous thromboembolism risk 3-4 fold (up to 4 per 10,000 woman-years) 1
• Check medical eligibility before prescribing estrogen-containing treatments 1
• Active VTE, smoking over age 35, uncontrolled hypertension, and positive antiphospholipid antibodies are contraindications 5

When to Return for Follow-Up

• Return if bleeding becomes unacceptable or if you want to change contraceptive methods 1
• If bleeding persists after trying both NSAIDs and supplemental estrogen, alternative contraceptive methods should be discussed 1

Common Pitfall to Avoid

Do not stop taking Lo Loestrin Fe during breakthrough bleeding episodes - this increases pregnancy risk. The hormone-free interval should not be extended beyond what is already built into your pill pack 2. Continue taking your pills exactly as prescribed while treating the breakthrough bleeding 3.