Illustration by Emma Günther
Bleeding on the pill when you shouldn't be? What to know
Why breakthrough bleeding happens and how to manage it
Top things to know:
Breakthrough bleeding is unexpected spotting or light bleeding that can occur while using hormonal birth control.
It’s especially common in the first 3-6 months of starting or switching hormonal birth control, as the body adjusts to new hormone levels.
Different types and doses of birth control affect breakthrough bleeding.
Missing or taking pills inconsistently is a major cause of breakthrough bleeding.
Tracking your missed pills in Clue can help you learn whether this is causing your breakthrough bleeding.
The basics of breakthrough bleeding
Breakthrough bleeding is unscheduled bleeding that happens while taking hormonal birth control—any spotting or light bleeding outside of your regular “period” (1). But before diving in, let’s clarify what we mean by "period."
When you’re on hormonal birth control, you might have regular withdrawal bleeding. This bleeding happens during the days you take placebo pills or take a break from your hormonal method (like during a pill-free week). During this time, hormone levels drop and your body responds. This leads to vaginal bleeding that seems like a period (2).
Breakthrough bleeding, on the other hand, can happen at any time while using hormonal birth control, whether you're expecting to bleed or not. It’s a common (and understandably frustrating!) side effect, especially in the first few months of starting a new birth control method or switching methods (3). Breakthrough bleeding rarely signals a health issue––and it doesn't mean your birth control isn’t preventing pregnancy (1).
Here’s what we know about breakthrough bleeding and what you can do about it:
What causes breakthrough bleeding?
Breakthrough bleeding happens due to changes in how the endometrium, or the uterine lining, reacts to hormones. In a typical menstrual cycle, the hormones estradiol and progesterone work together to change the lining of the uterus. It grows thicker to prepare the lining for a potential fertilized egg to implant there. When pregnancy doesn’t happen, these hormone levels drop, causing the endometrial lining to shed, leading to menstrual bleeding (1).
Birth control pills come in a variety of hormone dosages, so the type of pill you’re taking impacts how your endometrium will react (1). Some birth control might make the blood vessels in the uterus more sensitive than usual, so they bleed more easily and cause unexpected vaginal bleeding (1). Some people have increased blood flow to the uterus or respond more to hormones than others, both of which can cause vaginal bleeding (1). In most cases, though, breakthrough bleeding is usually a sign that the body is adjusting to the new hormone levels, and it will get better over time (3).
Types of hormonal birth control and breakthrough bleeding
Breakthrough bleeding can happen with any hormonal birth control, but it’s more common with certain types. Here’s an overview of how breakthrough bleeding might vary based on the type and dose of hormonal birth control:
Combined hormonal contraceptives (pill, patch, and ring)
Combined hormonal contraceptives are popular birth control methods that contain both estrogen and progestin (the synthetic version of progesterone). While breakthrough bleeding is possible with any of these methods, it usually gets better a few months after starting a new method.
Combined oral contraceptive pill (“the pill”)
About 2 in 10 people may experience irregular bleeding within the first three months of starting the pill, but this usually gets better over time (1). Pills with a low dose of estrogen (called ethinylestradiol or EE) cause unpredictable bleeding more often than higher-dose options (4). Most people start on a lower dose of estrogen. If your healthcare provider recommends starting with low dose birth control pills, let them know if you’re experiencing breakthrough bleeding (3).
If you take the pill continuously (without any hormone-free days), you’ll likely have some breakthrough bleeding in the first three to six months (3,4). Occasionally taking a three to four-day hormone break every 30 days or more might reduce breakthrough bleeding. If you’re still having breakthrough bleeding after a few months, you can talk to your provider about switching to a pill containing the progestin norethindrone acetate, or a slightly higher dose of estrogen (3).
The patch
There isn’t much difference in breakthrough bleeding between the combined pill and the patch during the first three months of use (1).
The ring (NuvaRing)
Breakthrough bleeding is most common during the first few months of using the ring, but it usually decreases by the end of the first year (3). Several studies have shown that breakthrough bleeding is less common with the ring compared to the combined pill (4). Continuous use (without hormone-free breaks) might make breakthrough bleeding more common (3).
Taking a four-day hormone-free interval can help with breakthrough bleeding. Another option is to keep the ring in for four or more consecutive days of bleeding, then remove it for a four-day break before inserting a new ring. This method is called the “bleeding-signaled” approach. It has been shown to stop bleeding within four days for about half of users, and within seven days for more than 90% (3).
Progestin-only contraceptives (mini-pill, shot, implant, and IUD)
Progestin-only contraceptives are more likely to cause breakthrough bleeding compared to combined contraceptives containing just estrogen and progestin (4).
Here’s how breakthrough bleeding can vary by method:
The mini-pill
The mini-pill can cause changes in bleeding duration, frequency, and predictability (5). People who use the mini-pill are more likely to experience unpredictable bleeding compared to users of the combined pill (5). In the first three months of using the mini-pill, about one-third of users notice changes in their bleeding, and around 1 in 10 experience frequent bleeding (more than five episodes) (3). Although it’s unclear if these patterns stabilize over time, research on the drospirenone-containing mini-pill suggests that breakthrough bleeding and spotting tend to decrease the longer you use it (3). Taking the mini-pill at the same time daily can reduce breakthrough bleeding (5).
The shot (Depo-Provera/DMPA)
Bleeding often becomes lighter or stops altogether over time when using the shot. After the first shot, up to 3 in 10 users experience no bleeding at all (amenorrhea). After one year, about half of people who use it don’t have any bleeding. Infrequent, prolonged, or unpredictable bleeding is still possible, though. This is a common reason some people stop using the shot. Nonsteroidal anti-inflammatory drugs (NSAIDS), estrogen, or combined birth control pills can help manage bothersome bleeding (3).
The implant
Unscheduled light bleeding or spotting is common with implant use. After three months of using the birth control implant, about one-third of users have only a few episodes of bleeding (3). After six months of use, an additional one-third may notice improvements. Even after six months, some users still aren’t happy with how often or how much they are bleeding (3). NSAIDs, tamoxifen, estrogen, or combined birth control pills can help manage bothersome bleeding (5-8).
The hormonal intrauterine device (IUD)
Unpredictable bleeding and spotting are common in the first few months of using hormonal IUDs (3). Bleeding and spotting days usually decrease after the first three months. As with the shot and implant, NSAIDs, estrogen, or combined birth control pills can help manage bothersome bleeding (3). Some things to look out for are bleeding after sex, heavy bleeding, or unpredictable bleeding that happens often. Let your healthcare provider know as soon as possible if you notice any of this on the IUD (3).
Factors that can influence breakthrough bleeding
Missed or late pills
When you miss a pill or take it late, your body’s hormone levels drop suddenly. This can cause breakthrough bleeding (4). Vomiting or diarrhea before your body can fully absorb the pill can also reduce hormone levels and cause breakthrough bleeding. Tracking your pills in Clue can help you stay on schedule. This way you’ll know if missed pills are to blame for unexpected bleeding. It’s a good idea to take your pills every day (and at the same time every day if you’re taking progestin-only pills) to make sure you’re protected from pregnancy.
Did you know that Saturdays and Sundays are the most common days for tracking missed or late pills in Clue?
Interactions with other medications
Some medications can interfere with how your body absorbs hormones––like the antibiotic rifamycin, anti-seizure drugs, and herbal supplements such as St. John’s Wort. These can interfere with hormonal birth control, making breakthrough bleeding more likely (4,9). If you’re starting a new medication, it’s a good idea to check with your healthcare provider or pharmacist to make sure it doesn’t impact your birth control’s effectiveness.
Other medical factors
If breakthrough bleeding lasts longer than six months, call your healthcare provider. They will want to rule out a few things including infection, uterine polyps, fibroids, and some reproductive growths or cancers (4,10).
Lifestyle influences
Certain factors about your life can impact when and how much you bleed. If you’re feeling stressed, have recently lost or gained weight, or are exercising a lot, you may notice changes in your bleeding. People who smoke are also more likely to experience breakthrough bleeding (4). Sexually transmitted infections (STIs) like chlamydia or gonorrhea can contribute to irregular bleeding too (1,4).
If any of this sounds familiar, you can track your stress, weight, exercise, STIs, and breakthrough bleeding in Clue to see if any patterns emerge.
Other common situations and breakthrough bleeding
Bleeding during the placebo or hormone-free phase
Some people have light bleeding that’s less than an average period during the days they are taking placebo pills. It’s also possible to experience only light spotting or no bleeding at all. This is more common if you’re on a higher-dose estrogen pill or a pack with a shorter hormone-free interval (fewer than seven days) (11,12). This doesn’t mean there’s an issue with your birth control’s effectiveness (12).
Bleeding after stopping birth control
When you stop using hormonal birth control, some unpredictable bleeding can occur as your body readjusts. Hormonal changes and other stressors can contribute to this, but it should settle down after a few cycles (13,14). Check in with your healthcare provider if it’s been more than three months and your bleeding is still unpredictable.
Bleeding on birth control after years of stability
Spotting or breakthrough bleeding after years of knowing what to expect on the pill can be unsettling. In most of these cases, the bleeding can be linked to stress, smoking, certain medications, illness, or even a missed pill (1,15). Spotting in these cases is temporary and should settle as things return to normal. If you’re experiencing new or unusual bleeding after long-term use of the pill, it’s a good idea to reach out to your healthcare provider so they can pinpoint what is causing it (1,15).
Managing breakthrough bleeding on your own
If you’re experiencing breakthrough bleeding, there are a few steps you can take to manage it on your own:
Take a look at what’s going on in your life: Could something like stress, weight changes, or smoking be to blame? Small adjustments, like finding ways to manage stress or making gradual changes to food habits and exercise, may help stabilize breakthrough bleeding.
Track in Clue: Keeping an eye on your bleeding patterns and other changes in Clue can help you notice any triggers and make it easier to track trends over time. You can also bring this data to your healthcare provider to help them better understand what’s going on.
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Managing breakthrough bleeding with your OB-GYN’s help
If breakthrough bleeding is affecting your work, school, or relationships, it’s worth telling your healthcare provider. They might suggest:
Adjusting your pill dose or progestin type: Your healthcare provider might recommend switching to a pill with a higher dose of estrogen or a different type of progestin to reduce bleeding (4). (See our article on Progestins 101 to learn more.)
Planning hormone “breaks”: Periodic breaks from hormones can help stabilize bleeding patterns (3,4). Your healthcare provider can guide you on how to schedule these breaks.
Switching to the ring: If you’d like to continue a combined method, your healthcare provider may suggest trying the vaginal ring (4).
When to speak to your healthcare provider
In some cases, breakthrough bleeding may indicate an underlying medical issue. See your healthcare provider if: (3,10,16-18):
Your bleeding lasts longer than eight days in a row
Your bleeding increases or is severe
You have intense pain in your abdomen or pelvis
You have pain or bleeding during sex
You think you might be pregnant
You have been, or might have been, exposed to an STI
You have unexplained fever or chills
FAQs
When should I be concerned about bleeding on the pill?
If you’re experiencing heavy or prolonged bleeding that doesn’t improve over time, it’s a good idea to consult your healthcare provider (16). They can help determine if everything is okay or if a different type of birth control might work better for you.
Should I stop birth control if I'm bleeding?
In most cases, bleeding doesn’t mean you need to stop your birth control. Many people experience breakthrough bleeding, especially when starting or adjusting their method, and it typically improves over time. However, if bleeding is disrupting your quality of life, speak to your healthcare provider about other options (19).
Does bleeding on birth control mean pregnancy?
Spotting can happen for various reasons and is rarely a sign of pregnancy. That being said, missed pills can increase the risk of pregnancy, so staying consistent with your birth control routine is essential (1). For more details, see our article: Why does hormonal birth control fail?
Does spotting mean the pill is not working?
No, spotting doesn’t necessarily mean your pill is ineffective. If spotting occurs alongside missed pills or certain medications, however, it’s wise to consult a provider to ensure continued protection (1).
