What You Should Know About Breakthrough Bleeding With Birth Control

Breakthrough bleeding is a common concern among women using hormonal birth control. It’s usually a small amount of spotting at a time when you’re not expecting your period, though some women have heavier bleeding. Most often, my patients come in saying they feel fine, but are noticing a little spotting when they use the bathroom. Should they be worried?

I reassure them that breakthrough bleeding rarely signals a health problem. And it doesn’t mean your birth control isn’t effective at preventing pregnancy. But there are ways we can try to fix it.

Here’s what I tell my patients about birth control and breakthrough bleeding.

It can happen with any type of hormonal birth control.

All these methods work by delivering hormones that prevent pregnancy. These methods include

• birth control pills

• the birth control implant, a small plastic rod that’s placed under the skin of the upper arm

• hormonal IUDs (intrauterine devices)

• the birth control shot given by a health care professional

• the vaginal ring that women can place and remove on their own

• the skin patch that contains hormones

But it’s more common with certain types of birth control.

Breakthrough bleeding happens more often with low-dose and ultra-low-dose birth control pills, the implant, and hormonal IUDs.

With IUDs, women often have spotting and irregular bleeding in the first months after placement. This usually gets better in 2 to 6 months. With the implant, though, the bleeding pattern women have in the first 3 months is usually their pattern going forward.

Some women are more likely to experience it.

Breakthrough bleeding happens more often in women who smoke cigarettes and in women who don’t take their birth control pills consistently. Some medications, like emergency contraception pills, also can cause irregular bleeding. Having certain infections, such as chlamydia or gonorrhea, also can increase risk.

It’s also more common when women who use birth control pills or the ring take a continuous dose of hormones to skip their periods altogether. One more factor: Benign (not cancerous) growths such as uterine fibroids can cause irregular bleeding that’s unrelated to birth control.

Some women can improve breakthrough bleeding on their own.

Quitting smoking can help. So can taking birth control pills at the same time each day.

If you’re getting continuous hormones with birth control pills or the ring, try scheduling a period every few months. This gives the uterus a chance to shed any built-up lining. It can help reduce irregular spotting and bleeding.

Your ob-gyn can help.

Although breakthrough bleeding with birth control isn’t physically harmful, it can be really annoying. When a patient says they’re having spotting or irregular bleeding, we first chat about the factors that might be causing the bleeding. Then we may do a physical exam as well.

After we confirm the bleeding is related to birth control, there are usually a number of options. For example, we can switch from an ultra-low-dose birth control pill to a low-dose pill. We also can change the number of placebo (or pill-free) days. Or we can explore other methods of birth control. With IUDs, implants, or the birth control shot, taking ibuprofen can be helpful, or we can add short-term treatment with estrogen pills.

No matter the situation, talk with your ob-gyn if you’re unhappy with your bleeding. We don’t want women to struggle with breakthrough bleeding, and we definitely have options to improve it.

Published: January 2021

Last reviewed: February 2023

Copyright 2023 by the American College of Obstetricians and Gynecologists. All rights reserved. Read copyright and permissions information.

This information is designed as an educational aid for the public. It offers current information and opinions related to women’s health. It is not intended as a statement of the standard of care. It does not explain all of the proper treatments or methods of care. It is not a substitute for the advice of a physician. Read ACOG’s complete disclaimer.

Why Does Birth Control Cause Spotting?

Written by Hallie Levine

Medically Reviewed by Nivin Todd, MD on June 21, 2022

• Which Types of Birth Control Can Cause Breakthrough Bleeding?
• How Can I Stop Breakthrough Bleeding?
• When Should You Call Your Doctor?

If you go on a hormonal form of birth control, you might expect it to help with pesky bleeding. But breakthrough bleeding is a common side effect of contraceptive use.

It might just be some light spotting when you’re not expecting your period. Or the bleeding might be heavier. That can be surprising, especially if you went on birth control to try to regulate your period.

The good news is breakthrough bleeding isn’t harmful. And it usually can be stopped. Here’s what you need to know.

All forms of hormonal birth control can trigger breakthrough bleeding, including:

Pills. Up to 50% of people who start estrogen-progestin birth control pills have spotting, but this number goes down to less than 10% by the third month of use. You’re more likely to have unscheduled bleeding if you use a low-dose or ultra-low dose birth control pill.

Implants. This is a small rod placed in your upper arm. Almost 80% of users report breakthrough bleeding during the first 3 months.

Intrauterine devices (IUDs). Unscheduled bleeding can happen with both hormonal and copper IUDs.

The birth control shot. Most people who get depot medroxyprogesterone acetate (Depo-Provera) have breakthrough bleeding. But it usually gets better over time.

Hormonal skin patches. Unscheduled bleeding with this form of birth control occurs at about the same rate as hormonal birth control pills.

Breakthrough bleeding is most common with:

• Low-dose birth control pills
• The implant
• Hormonal IUDs

You’re more likely to see breakthrough bleeding if you:

• Smoke
• Don’t take your birth control pills consistently
• Take an emergency contraception pill (Plan B)
• Have an STD like chlamydia or gonorrhea

Using birth control pills or the vaginal ring continuously (meaning you don’t stop for a week each month), may also trigger bleeding.

Give it time. If you’re on a hormonal IUD, oftentimes it will go away on its own within 6 months of insertion. The same is true for birth control pills. It may take time for your body to get used to the hormones in the pill and for the lining of your uterus to become thinner.

However, if you have breakthrough bleeding for the first 3 months on the implant, you can expect it to continue.

Other steps you can take include:

If you smoke, work on quitting. Ask your doctor for help if you need it.

Stay on schedule. Take your birth control pills at the same time every day.

Consider NSAIDs. If you want some type of treatment, your doctor might recommend an over-the-counter or prescription nonsteroidal anti-inflammatory such as ibuprofen. The usual dose is 400–800 milligrams three times a day for 5-10 days. But there’s not a lot of research to support this.

Take a break. Talk to your doctor about scheduling a period every few months if you take birth control pills or use the vaginal ring without stopping for a week. An occasional period allows your uterus to shed any built-up lining, which stops breakthrough bleeding.

Switch your birth control pill. For example, if you’re taking an ultra-low-dose birth control pill, your doctor can prescribe one with a slightly higher dose. Your doctor also might change the number of placebo days. That’s when you take a pill that doesn’t contain hormones to keep you on schedule.

Try another option. If you’re on the birth control pill, your doctor might recommend that you try the vaginal ring instead. Because the ring has more consistent hormone levels than the pill, you are less likely to have spotting. Also, you won’t have bleeding due to a missed pill.

Add another form of birth control. For some methods, like the birth control shot, your doctor might also prescribe a low-dose combination birth control pill for 10-20 days. Some doctors also give shots more often, but it’s not recommended, as there’s no data that shows this practice works.

Let your doctor know if your breakthrough bleeding becomes heavy. That means less spotting and more like an actual period. Or if the bleeding lasts for more than 7 days in a row. In these situations, there may be another cause, such as an infection or fibroids.

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Third extra: why China should have eased birth control long ago

Apparently, by the end of the year, Chinese couples will be allowed to have three children. But the new policy is unlikely to solve China’s aging population and shrinking workforce, says Igor Denisov, a senior fellow at the Institute for International Studies at Moscow State Institute of International Relations (MGIMO). Nevertheless, it is not canceled, but only consistently adjusted. Officially, this is presented as the ability of the party to adapt to changing conditions. However, it is no secret that these conditions themselves were largely created by the previous administrative measures. Especially a lot of complaints are expressed against the rigid policy of “one family – one child”, which was proclaimed in 1980 year. Since 1982, planned childbearing has become a constitutional norm, it is mentioned four times in the Basic Law, and fertility planning is in the first place among the duties of both spouses.

The adoption of the relevant law is ahead, but the Politburo of the Central Committee of the Communist Party of China has already approved changes in the birth control policy.

Unnecessary rigidity

Today, the authorities are trying to achieve balanced economic growth and overcome the progressive decline in the working population. However, the critically low population growth, distortions in the gender and age structure, and even such social problems as the selfishness and infantilism of the generation of “little emperors” – the only children in families – are largely related to the “one family – one child” policy.

The reports of supporters of this course claim that as a result, 400 million new citizens were not born in China, but in fact, the decline in the birth rate was due to 75% of natural social factors: urbanization, increased employment and education of women, the growth of the middle class, who is not so bound by the traditional ideals of a large multi-generational family. These trends are so strong that even allowing all couples to have two children since 2016 has not helped to cope with the demographic collapse.

For 10 girls, 12 guys: how birth control in China led to a shortage of women

The decision on strict birth control was not the only option, and no “demographic catastrophe” most likely threatened China. Since the late 1960s, the birth rate in China has already begun to decline. According to Chinese demographers, if, with the beginning of Deng Xiaoping’s reforms, the former soft course of “later – less often – less” (marry later, take at least a four-year break between births, have two or three children in families) continued, then it would be possible to achieve harmony between the growing number of Chinese and the needs of economic development. However, for this it would not be necessary to concentrate huge state power and bring down exorbitant fines on the families of violators, interfere in the personal lives of millions of people and, most importantly, create a very costly bureaucracy. Probably, Chinese leaders and some of their advisers were strongly impressed by the predictions of the Club of Rome about the danger of uncontrolled population growth, projecting the conclusions of futurologists onto a weak and poor China.

This is a vivid example of how the consequences of a political decision are multiplied by bureaucratic inertia. Even according to fragmentary data, it is clear that not only a self-sufficient control apparatus was formed around the “planned childbearing”, but also serious financial interests arose. Chinese statistics do not take into account the corrupt side of demographic policy, but according to expert estimates, only from 1980 to 2011, up to 2 trillion yuan of fines were officially collected from citizens for “extra” children (about $312.7 billion at the current exchange rate). The budgets of the less developed provinces of the PRC were highly dependent on revenues from this item. Now that Chinese families are almost allowed to have a third child, the story of famous film director Zhang Yimou, who in 2014 had to pay a fine of $1.2 million for three “illegal” children, looks like a bitter irony.

The burden of demography

It is possible that soon the government will have to pay extra for the birth of children. The Politburo’s decision came less than a month after the seventh general population census in China’s history was summed up. The results were more alarming than expected. Firstly, the planned baby boom did not take place. Immediately after the permission for two children in the family, some scientists predicted a sharp rise in the birth rate, but it turned out that after a short-term surge, it fell again. If in 2000 (that is, at the height of the “one-child” policy), the number of births in China was 17.71 million, then in 2020 only 12 million children were born. Secondly, the census showed that China is confidently turning into a “country of gray hair” and can grow old faster than it gets rich.

The combination of these two factors is extremely unfavorable for the country’s development prospects. If, in the interests of stability, the authorities try to maintain an increase in living standards (and the population is already accustomed to prosperity and does not expect the situation to worsen), then by 2050 state spending on the social sphere may amount to about a third of GDP. Apparently, we will have to raise the retirement age (now it is 50-55 years for women and 60 years for men). The decline in the working-age population leads to higher wages, which reduces the competitiveness of Chinese exports. The “demographic dividend” is no longer relevant for China, and it is becoming increasingly difficult to hope for an increase in the birth rate.

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Barriers are the rising cost of housing and the cost of quality education. So the decision on the “three-child policy” cannot be called populist. The government’s Xinhua News Agency had to stop and remove a poll about the party’s new appeal from social media. Less than 5% of respondents said they were ready to have a third child even now, and 92% do not consider such a prospect at all.

It is possible that in order to encourage the birth rate, the state will have to turn to business: the pioneers of this approach have already appeared. Some companies have announced big bonuses for employees who decide to have a third child. The whole question is how many employees of private companies will take this step, because business owners are unlikely to support a child until adulthood.

The decline in the birth rate and the aging of society are visible manifestations of changes in the value orientations of the Chinese, who are less and less following the old traditions. Calls here are unlikely to change anything, in order to eliminate disparities, the state will have to strengthen its social role and begin to actively invest in human capital, confirming that citizens are more than just a denominator in the formula for calculating GDP per capita.

The opinion of the author may not coincide with the point of view of the editors

Chinese lessons: how China became a unicorn sanctuary

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where and how is birth control done?

From childhood we are told that a family is good. A big family is even better. They say that a family should have at least two children. Otherwise, there will be no natural reproduction, and the nation will gradually die out. Such horror stories are part of a large state program for birth control. In this case, by increasing it. Tax breaks, payments to mothers and promotion of the image of a happy family encourage people to live longer and give birth more.

However, there are also reverse examples. Humanity has made a “demographic transition”, when both the birth rate and the death rate have decreased several times in the 20th century – it has reached self-reproduction, but then it suddenly turned out that there are no more places. In the countries with the most rapidly developing economies, human capital was not appreciated and gently asked not to create an even greater population density in a small area.

Where are they fined and where are they rewarded for having a large family? On International Children’s Day, WORLD 24 found out which countries actively use birth control.

China

Perhaps the most famous and egregious case of birth control was and still exists in a truncated form in the PRC. Communist regimes, in principle, have never been particularly philanthropic. Everything was according to plans, calculated in a notebook. It is necessary to reduce the population by several million people in order to meet the brilliant calculations of the top of the CCP – that means they will reduce it. And in what way – it does not matter.

In fact, China has almost never been a country where incredibly many children were born. The average family had fewer offspring than Indians or Africans. Sociologists note a significant increase in the birth rate only in 1960s. Then, thanks to the “Great Leap Forward” policy, the communists starved several tens of millions of people. The society reacted with a momentary attempt to replace the lost population and showed some of the most “productive” years in Chinese history. You can compare it with the post-war baby boom.

However, the valiant party elite immediately arrived in time with new calculations in notebooks. It turned out that the people were starving because too many Chinese were born on Chinese soil. And we decided to do something about it. For starters, by means of propaganda. But it turned out, not surprisingly, to be absolutely ineffective for the inhabitants of rural areas. Then the government decided to allow cheap and even free abortions, distribute a large number of contraceptives and, finally, prohibit having more than a certain number of children. First we settled on the number three, by 1979 was reduced to one.

In some periods of time the ban was strict, in others it was possible to pay off with several annual salaries and have a second child. One way or another, for 35 years in China, a rare couple went beyond the firstborn. This led to disastrous consequences for the state. Yes, the goal of reducing the birth rate to the level of reproduction has been achieved. But at the same time, sociologists noted the rapid aging of the population. In the 2010s, there are dozens of times more unemployable people in China than working youth. In addition, due to affordable abortions and the limitation on the number of children, the Chinese sought to have exclusively sons – heirs. Normally around 970 girls born per 1000 boys, in China this figure was about 855 girls per 1000 boys. Natural causes did not have time to take enough representatives of the male population, so many of them could not find a mate and became homosexuals. This is still happening. In the end, social ties were broken, traditionally large Chinese families lost numerous brothers and sisters, aunts, uncles, relatives of grandparents. Every cell of society became nuclear, which brought about irreversible changes in Chinese society.

In 2016, the one-child policy was abolished. Now any family in China can have two children.

India

India was one of the first countries to be concerned about high birth rates in general. At some point, the state began to grow even faster than China, and something had to be done about it. To begin with, they tried to get by not with repressive, but with encouraging measures. Free abortions, free condoms – the birth rate was halved thanks to social programs.

But this did not help completely. As of 2015, every second pregnancy in India is unplanned. And every third ends with an abortion. Under such conditions, it is clear that incentives alone, such as benefits for citizens who have voluntarily undergone sterilization, will not be limited. Otherwise, India runs the risk of finding itself with a population of two billion by the middle of the century, unable to provide for it.

It should be noted here that the Indian society, unlike the Chinese, is hostile to any control over the number of children in a family. Traditionalist sentiments are extremely strong there: people believe that they should give birth a lot, and this is not only an economic calculation with the number of helpers on earth in the future, but also a cultural aspect.

The most recent decision by local authorities is to ban people with two or more children from holding public office. Considering that in many areas the civil service is the highest paid job, this is a significant argument.

Iran

The Islamic Republic of Iran has shown one of the most effective birth control programs. There, in an amazing way, citizens listened to their government, expanding families when it was necessary to restore the population after the Iran-Iraq war, and narrowing families when Iran wanted to reduce the birth rate.

Over the past 20 years, Iran’s birth rate has fallen faster than any other country in the world. By the beginning of the 1990s, this figure was in the region of six, now it is less than two.

Attitudes towards family planning in the republic changed on an ongoing basis. Even before the Islamic revolution, contraceptives and abortions were quite common. However, Ruhollah Khomeini, who came to power, decided that Iran and Islam needed more children. In the first ten years after the revolution, such laws were adopted as: lowering the age of consent to nine years for girls, allowing polygamous marriages, artificially increasing the cost of contraceptives, creating a special fund that was supposed to help newlyweds with money.

With the death of Khomeini and the arrival of Ali Khamenei, who replaced him, the pendulum swung the other way. It turned out that 100 million Iranians by the year 2000 – where everything was heading – would be a disaster for the state. All the media suddenly began to promote birth control, in mosques they said that “Islam encourages families with two children”, people were forbidden to marry before they had passed special birth control courses. It got to the point that the government began to conduct free sterilization for everyone.

The next reversal took place only about six or seven years ago. Top leaders of the state, including Khamenei and President Mahmoud Ahmadinejad, have begun to openly say that birth control is no longer relevant. Politicians noted that Iran’s population growth is what the “enemy west is afraid of.” Since then, the more anti-American sentiments in society, the higher the birth rate in the country.

Other countries

Much milder and more unremarkable measures to increase or decrease the birth rate can be found in other countries.