What should I do if I don't experience withdrawal bleeding after taking Ethinylestradiol (Ethinyloestradiol)/Cyproterone acetate (Cyproterone) for 21 days, followed by a 7-day break?

From the Guidelines

If you've completed a 21-day course of Ethinylestradiol/cyproterone acetate and didn't experience withdrawal bleeding during your 7-day break, you should start your next pack as scheduled and consider taking a pregnancy test if you do not have a withdrawal bleed within 3 weeks, as advised by the U.S. selected practice recommendations for contraceptive use, 2013 1. When considering the management of Ethinylestradiol/cyproterone acetate treatment without withdrawal bleeding, several factors come into play, including the potential for pregnancy, the effects of hormonal contraception on the menstrual cycle, and the guidelines for contraceptive use.

• The primary concern with the absence of withdrawal bleeding after a cycle of hormonal contraception is the possibility of pregnancy, especially if the medication was not taken as directed or if there was unprotected intercourse during the cycle.
• According to the U.S. selected practice recommendations for contraceptive use, 2013 1, if a woman does not have a withdrawal bleed within 3 weeks after using a contraceptive method, she should have a pregnancy test.
• It's also important to note that not having a withdrawal bleed does not necessarily indicate a problem or pregnancy, as factors like stress, weight changes, or hormonal fluctuations can affect withdrawal bleeding.
• The medication works by suppressing ovulation and thinning the uterine lining, which can sometimes result in minimal or no withdrawal bleeding during the break.
• If this pattern of no withdrawal bleeding continues for multiple cycles or if you experience other concerning symptoms like severe abdominal pain, you should consult your healthcare provider for further evaluation and guidance.
• In terms of managing the situation, the key steps include continuing the medication as prescribed unless directed otherwise by a healthcare provider and being vigilant about potential pregnancy, especially if there have been any deviations from the prescribed regimen or if unprotected intercourse has occurred.

From the FDA Drug Label

If scheduled bleeding does not occur, consider the possibility of pregnancy. If the patient has not adhered to the prescribed dosing schedule (missed one or two active tablets or started taking them on a day later than she should have), consider the possibility of pregnancy at the time of the first missed period and perform appropriate diagnostic measures If the patient has adhered to the prescribed dosing schedule and misses two consecutive periods, rule out pregnancy.

If you have taken Ethinylestradiol/cyproterone acetate for 21 days and had a 7-day break without withdrawal bleeding, consider the possibility of pregnancy. Since you have only missed one period, perform appropriate diagnostic measures to rule out pregnancy, such as a pregnancy test 2.

From the Research

Absence of Withdrawal Bleeding

• The absence of withdrawal bleeding after taking Ethinylestradiol/cyproterone acetate for 21 days and a 7-day break may be a concern, but it is not uncommon in users of oral contraceptives 3.
• A study on the pharmacokinetics of cyproterone acetate and ethinylestradiol found that trough levels of cyproterone acetate in the serum increased during a treatment cycle, reaching a steady-state around day 16, which may affect bleeding patterns 4.
• Another study on bleeding patterns of oral contraceptives with a cyclic dosing regimen found that each type of oral contraceptive has its own specific bleeding pattern, and that the estrogen component plays a crucial role in maintaining a regular bleeding pattern 5.

Possible Causes and Next Steps

• The absence of withdrawal bleeding may be due to the hormonal effects of the oral contraceptive, particularly the balance between estrogen and progestin components 5.
• It is recommended to consult a healthcare provider to discuss the absence of withdrawal bleeding and to rule out any underlying medical conditions that may be contributing to this issue.
• The healthcare provider may recommend continuing the oral contraceptive for another cycle to see if the bleeding pattern regulates itself, or may consider alternative oral contraceptives with different hormonal components 3.

Importance of Medical Consultation

• It is essential to consult a healthcare provider to discuss the absence of withdrawal bleeding and to determine the best course of action 6, 7.
• The healthcare provider can assess individual factors, such as medical history and hormonal balance, to provide personalized guidance and recommendations.