Breakthrough Bleeding - Allbodies

Breakthrough Bleeding

Breakthrough bleeding
It’s pretty common knowledge that people with menstruating uteruses might find some period blood in their underwear every month, but what about those other times when you find blood down there and have literally no idea WTF is going on? Well, that bleeding is called breakthrough bleeding, and we’re about to tell ya all about it.

What is breakthrough bleeding, anyway?

The official definition of breakthrough bleeding is any bleeding or spotting that may occur between menstrual periods or during pregnancy (1).  Depending on the cause, breakthrough bleeding can be lumped in with a whole host of other conditions and processes, like implantation bleeding, spotting, intermenstrual bleeding, or abnormal uterine bleeding. While it’s often associated with hormonal contraception, breakthrough bleeding isn’t actually limited to people who are using birth control.

What does it look like?

Breakthrough bleeding is usually lighter in color and has less volume than bleeding experienced during menstruation, however, it can definitely resemble period blood. It’s normally light red, brown or pink, or a dark reddish brown and is similar to the blood at the beginning or end of a cycle (2).

Causes

There are lots of reasons why someone may experience off cycle-bleeding, and some of them are totes normal while others can be signs of something more serious. Here are the most common reasons: .

Your birth control

One of the most common reasons behind breakthrough bleeding is your body’s response to hormonal birth control. Breakthrough spotting in the first few months of a new B.C. is very common, particularly with methods that have little or no estrogen, like hormonal IUDs, the implant, the shot, most pills, the patch, and the ring (3). 

 

To understand why it happens, first we need to give a little background info on the hormones that regulate the menstrual cycle, aka estrogen and progesterone. In people with uteruses and ovaries, estrogen and progesterone work together to manage your reproductive processes—think periods, pregnancy, birth, and menopause. Specifically in terms of menstruation, estrogen helps stabilize the uterine lining (aka the endometrium) (3). Breakthrough bleeding on B.C. is most common either when you’re first starting a new hormonal method, or, if you’re on oral contraceptives, when you skip a pill. But those in the medical field aren’t 100% positive why new hormones introduced into the body cause irregular bleeding. One of the presiding theories is that many hormonal methods are progesterone-based and inhibit estrogen production, so when there is a significant spike in progesterone that isn’t followed by enough estrogen to regulate the endometrium, the uterine lining can shed in unpredictable patterns—cue irregular spotting and breakthrough bleeding. Skipping a pill can cause irregular bleeding because the body’s natural response to a drop in estrogen is to shed the uterine lining.  

Implantation bleeding

Twenty to forty percent of people experience bleeding during the first trimester of pregnancy (4). For a long time, doctors coined the phrase “implantation bleeding” to describe light spotting or bleeding that occurs 6-12 days after an egg is fertilized. While the exact cause of implantation bleeding has never been medically verified, prevailing theories include the breakage of tiny blood vessels as a fertilized egg travels and attaches to the uterus, and hormonal fluctuations as the body prepares for pregnancy (5). Although recent studies debate the reality of implantation bleeding (6),  you can always take a pregnancy test to rule out this potential cause. 

Miscarriage or Ectopic Pregnancy

While most light bleeding during pregnancy is normal and not a threat to you or the baby’s health, bleeding or spotting can be a sign of miscarriage or an ectopic pregnancy (an egg that implants and grows outside of the uterus). While a miscarriage is nothing to be trivialized or dismissed, it’s important to note that miscarriages are very common, with 15-20% of all pregnancies resulting in miscarriage (8). An ectopic pregnancy, on the other hand, is rarer (about 1 in 50 pregnancies) and can be a serious threat to your health (9). 

 

Irritation during vaginal sex

Bodies are built for pleasure from sex, so normally the vagina and cervix (the little canal that connects the vagina to the uterus) don’t bleed after vaginal penetration. However, sometimes irregularities in the function or form of these body parts result in post-coital bleeding or bleeding after vaginally penetrative sex. This is most common in situations where there isn’t enough lubrication and the friction from getting it on causes the vaginal walls to tear. The vagina is rife with blood vessels, so a little tear can produce a lot of blood. Additionally, irregularities in the cervix like cervical polyps or cervicitis can also cause exceptional irritation and bleeding (10).

 

Introducing a little lube into your sex life can be a fun addition AND help reduce the friction that causes vaginal tearing (#win-win). If you feel like you’re amply lubed up but still experiencing post-coital bleeding, schedule an appointment with a healthcare professional. They may want to do a pelvic exam, pap smear, or ultrasound to see if you have something in your downstairs area that’s contributing to cervical or vaginal irritation. 

STI or other infection

There are a number of reasons why various infections cause bleeding. Because infections like vaginitis inflame the vagina, they can lead to vaginal tearing and spotting. While we know the most common symptom of an STI is no symptoms at all, certain infections like chlamydia and gonorrhea can cause cervicitis, vaginitis, or pelvic inflammatory disease. The inflammation of this area isn’t just limited to STIs. Other bacterial or fungal infections (i.e. bacterial vaginosis and yeast infections) can cause bleeding in the nether regions as well. 

 

Get screened regularly and practice safe sex. As we mentioned, most STIs are asymptomatic. This means they often go undetected and can contribute to serious health problems if left untreated. STIs are extremely common—nearly 50% of sexually active people will get an STI by 25! (11)—and under-discussed in our society. This creates a level of stigma around STI testing and treatment that can delay care and contribute to larger reproductive health issues. The CDC has guidelines for STI screening, but a general rule of thumb adopted among providers is once every six months OR with every new partner. And don’t forget condoms! 

Hormonal Imbalance

As we mentioned earlier, menstruation and uterine bleeding are closely linked to the hormones that regulate reproductive health. If any of the hormones that manage your sexual or reproductive health processes are out of whack or missing this can create abnormal patterns in menstruation and intermenstrual bleeding. There are a variety of causes that can contribute to a hormonal imbalance such as chronic stress, disorders that affect the pituitary gland or adrenal cortex (areas of the brain that secrete and govern these hormones), and of course, menopause (the mother of all hormone imbalances!). 

 

If you feel like you could have a potential hormonal imbalance, schedule an appointment with your provider. You may get referred to an endocrinologist (a medical professional who specializes in hormones) who can perform a series of tests and exams to confirm. Treatment for hormonal imbalances varies depending on the hormones that are affected, but could include medication, hormonal therapy, or nutritional supplements. 

Fibroisis

Another common cause of breakthrough bleeding is uterine fibroids—benign growths that emerge from the muscle tissue of the uterus. Also called leiomyomas or myomas, uterine fibroids can vary in size, shape, and location. While they can occur at any age, they are most common in vagina-havers between ages 30-40. Symptoms of fibroids include pelvic or abdominal pain, problems with urination, swelling or the abdomen and—you guessed it—irregular bleeding.

When to see a doctor or midwife?

If at any point you experience breakthrough bleeding and have concern, it is a good idea to check in with your practitioner. It is possible that there is nothing wrong at all, and otherwise, teatment plans will depend on your diagnosis.  Here’s a little break down of each of the aforementioned for reference.  But please remember we are NOT diagnoising you! Don’t get ahead of yourself and let this scare you. Remember you are not a statistic so it’s important to discuss your concerns with your personal health team. Use this to simply help guide the convo! 

Treatment

Birth control

If you’re experiencing breakthrough bleeding and you’re new to hormonal contraception, know that it could take a few months for your body to get used to the new amounts of hormones that are affecting your cycle. However, if you’re spotting with a method you’ve been on for more than 3 months OR just deciding the #spottinglyfe isn’t for you, you have options. Talk to your provider about your other B.C. options. Your body may respond better to a pill with higher estrogen or a multiphasic pill that delivers different levels of estrogen at certain times during your cycle. There are also several non-hormonal options to explore (i.e. the non-hormonal IUD, traditional barrier methods and the good ol’ fertility awareness method) if you decide you’d like to ditch hormones altogether. 

Implantation bleeding

Studies suggest that most light bleeding during early pregnancy is not a cause for concern and that most folks who experience light spotting or bleeding in the first 8-12 weeks of pregnancy go on to have a perfectly healthy pregnancy and baby (6). In most cases, this spotting will go away on its own and doesn’t require additional treatment or medical attention (7). However, if you do get that double line of positivity, and are worried that this bleeding could indicate problems with your pregnancy, schedule an appointment with your doctor or midwife just to check it out—that’s what they’re there for! 

Miscarriage or ectopic pregnancy

So you may be thinking, “Okay, so bleeding during pregnancy is either completely normal OR could be a huge dangerous red flag? Whaaa?” The bleeding that accompanies miscarriages and ectopic pregnancies is normally heavier and lasts longer than common prenatal spotting. If you’re pregnant and experience breakthrough bleeding that lasts longer than 2-3 days or gets increasingly heavy in flow, seek medical attention. Even if it ends up being nothing to worry about, a visit or call to your doctor or midwife can help ease your mind (unnecessary stress during pregnancy = no bueno). 

Irritation during vaginal sex

Introducing a little lube into your sex life can be a fun addition AND help reduce the friction that causes vaginal tearing (#win-win). If you feel like you’re amply lubed up but still experiencing post-coital bleeding, schedule an appointment with a healthcare professional. They may want to do a pelvic exam, pap smear, or ultrasound to see if you have something in your downstairs area that’s contributing to cervical or vaginal irritation. 

STI or other infection

Get screened regularly and practice safe sex. As we mentioned, most STIs are asymptomatic. This means they often go undetected and can contribute to serious health problems if left untreated. STIs are extremely common—nearly 50% of sexually active people will get an STI by 25! (11)—and under-discussed in our society. This creates a level of stigma around STI testing and treatment that can delay care and contribute to larger reproductive health issues. The CDC has guidelines for STI screening, but a general rule of thumb adopted among providers is once every six months OR with every new partner. And don’t forget condoms! 

Hormonal imbalance

As we mentioned earlier, menstruation and uterine bleeding are closely linked to the hormones that regulate reproductive health. If any of the hormones that manage your sexual or reproductive health processes are out of whack or missing this can create abnormal patterns in menstruation and intermenstrual bleeding. There are a variety of causes that can contribute to a hormonal imbalance such as chronic stress, disorders that affect the pituitary gland or adrenal cortex (areas of the brain that secrete and govern these hormones), and of course, menopause (the mother of all hormone imbalances!). 

 

If you feel like you could have a potential hormonal imbalance, schedule an appointment with your provider. You may get referred to an endocrinologist (a medical professional who specializes in hormones) who can perform a series of tests and exams to confirm. Treatment for hormonal imbalances varies depending on the hormones that are affected, but could include medication, hormonal therapy, or nutritional supplements. 

Fibrosis

Although fibroids are non-cancerous, they are still incredibly painful and can cause issues with fertility, which is why it’s important to get your doc or midwife involved. They may have you undergo a series of tests including an ultrasound, hysteroscopy and/or a hysterosalpingography (tests that allow health care professionals to visualize the uterus and any contents). Treatment ranges depending on the type of fibroids and can include hormone-based medication to control bleeding and maintain or reduce the size of the fibroid and surgery. 

Written by: Jaclyn Chavira, MPH and Health Educator at the UCLA OBGYN clinic 

Medically Reviewed by: Danielle LeBlanc, RN

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