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What to do when birth control pills are not controlling your cycle

At Women's Health Practice we have conducted over 100 clinical research trials in many aspects of women's health. Contraceptive advances and helping women control irregular menstrual cycles is one of our most important issues we have helped study. Women expect effective cycle control as well as effective contraception on their birth control pills. A common question every gyno gets is what should I do and: why did I have unusual bleeding on my pills. Sometimes it’s a few spots after intercourse, and that is unlikely to be a problem with the pill. Sometimes it’s just an early or late period, which we call “unscheduled bleeding,” you will probably call it 'not controlling your period.' Most often it is what your physician calls Breakthrough Bleeding or BTB.

Spotting is common: and if it's up to 8 times a year, it's pretty normal. If it’s not enough to need to use a pad we just call this bleeding during your pill pack spotting.

Unscheduled menstrual bleeding is common as well.

Irregular bleeding requiring protection (BTB) and spotting are common during the first few months of taking oral contraceptives. If you have BTB you are not at risk for pregnancy.

Pregnancy protection doesn't depend upon bleeding or spotting or regular periods, and women should not stop their contracetive pills if they get BTB or spotting. BTB usually is caused by shedding of the lining tissue as your uterus adjusts to a new thin state in which it is fragile and thin.

Lower dosage pills are probably the safest, however breakthrough bleeding is a bit more common with the current, extremely safe, and lower dose birth control pills. BTB on birth control pills is annoying but almost always resolves without any treatment within two to three months.

Longer cycle pills designed to have 4 periods a year are nice, but may cause cycle problems for some. If you are on a pill that takes few or no breaks in hormone use during the year, BTB is more common.

If hormone levels fluctuate at all you may see BTB. There may be interference by smoking, antibiotics or herbals like St. John's Wort, causing a theoretical drop in blood hormone levels that translates into an irregular period. Forgetting a pill can also cause breakthrough bleeding, and is more common than other reasons of BTB. It’s less common for consistent pill users who have been on their birth control longer and often will only happen if you miss pills or take a medication that interacts with your pill. So if you miss a pill take it the next day with that days pills. If you take two pills together like that you should be covered against pregnancy. But if you miss more than two pills most physicians will tell you to use back up.

Although the World Health Organization (WHO) states that no back-up or emergency contraception is needed unless three or more 30 to 35 mcg ethinyl estradiol pills have been forgotten (or two or more 20 to 25 mcg pills), condoms are good STD protection and should always be considered. And if you use back-up contraception be sure to take it for full seven days after two missed active hormonal pills, regardless of dose. If the missed pills are in your first week of the cycle and unprotected intercourse occurs during this week, use of emergency contraception (morning after pills) could decrease the risk of pregnancy.

Your own hormones can affect BTB on the pills. Some women on very low hormone birth control pills will sometimes have their own ovarian estrogen still produced, this is called follicular development. It probably still doesn’t increase risk of pregnancy, but should be discussed with your health care provider.

If you have a bit of BTB, keep track of it, notify your provider, but most likely you will be told to just monitor it for a bit. After 2 cycles of unusual bleeding you should be seen by your doctor to have both your cervix and uterus checked. You may be given tests for pregnancy, for infection and/or an ultrasound. But most likely it's not something serious that needs to be treated, just something you need a bit of patience for.


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