Ever had period-like bleeding while using hormonal contraception? That’s withdrawal bleeding, and (take a sigh of relief) it is pretty normal. Withdrawal bleeding, also known as breakthrough bleeding, is a common occurrence while using hormonal contraception. This condition occurs when a woman discontinues taking active hormone tablets, usually during the placebo or inactive pill week of their contraceptive pack. An abrupt drop in hormone levels causes the uterine lining to shed, resulting in menstrual-like bleeding. However, withdrawal bleeding is not considered an actual period, but rather a response to hormonal changes caused by the contraceptive regimen. It happens regularly during the hormone-free phase and is usually lighter and shorter in duration than a normal period of menstruation. Here is everything you need to know about withdrawal bleeding.

What is withdrawal bleeding?

Withdrawal bleeding is a type of bleeding that occurs when there is an abrupt decline in hormone levels following a period of constant hormone delivery. “This is most commonly experienced by women using hormonal contraceptives such as birth control pills, patches, or vaginal rings, which include a cycle of active hormone intake followed by a hormone-free interval,” says obstetrician and gynaecologist Dr Sukirti Jain.

During the active phase of these contraceptives, synthetic hormones (estrogen and progestin) are taken regularly, which prevents ovulation and maintains a stable uterine lining (endometrium). The hormone-free interval, typically lasting a week, allows the body to shed the endometrial lining, resulting in withdrawal bleeding. This bleeding mimics a menstrual period but is usually lighter and shorter because the endometrial lining is thinner due to the effect of hormonal contraceptives, as per a 2016 research published in Pharmacology, Toxicology, and Pharmaceutical Science.

What causes withdrawal bleeding?

The primary cause of withdrawal bleeding is the sudden cessation of hormonal contraceptives during the hormone-free interval. “This drop in synthetic hormone levels causes the endometrial lining, which had been stabilised and maintained by these hormones, to shed,” says the expert. Other factors that can influence withdrawal bleeding are:

• Hormone dosage and type: Different hormonal formulations can affect the frequency and intensity of withdrawal bleeding.
• Adherence to contraceptive schedule: Inconsistent use of birth control can lead to unscheduled bleeding or spotting.
• Individual response: Each woman’s body can respond differently to hormonal contraceptives, influencing bleeding patterns.

What are the common symptoms of withdrawal bleeding?

Symptoms of withdrawal bleeding may be similar to those of regular periods:

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• Light to moderate bleeding: Withdrawal, spotting, or implantation bleeding is usually lighter than a regular period, but the amount of bleeding varies.
• Abdominal cramps: Some people may experience minor cramping or discomfort during withdrawal bleeding.
• Breast soreness: Hormonal fluctuations might result in breast soreness or sensitivity.
• Mood changes: Fluctuating hormone levels can also affect mood, causing irritation or mood swings.

Withdrawal bleeding is sometimes confused with a regular monthly period, although there are some key differences. A period is the natural shedding of the uterine lining in response to hormonal changes, according to a June 2024 research published in StatPearls. On the other hand, withdrawal bleeding is the outcome of hormonal fluctuations produced by the discontinuation of hormonal birth control treatments.

Types of birth control that may cause withdrawal bleeding

According to a 2016 study published in the Journal of Contraception, some common birth control methods that may cause withdrawal bleeding symptoms include:

• Combination oral contraceptives: These pills, which include both oestrogen and progestin, are used once a day. When inactive tablets are administered for a placebo week, withdrawal bleeding is commonly seen.
• Progesterone-only pills: These tablets, sometimes known as “mini-pills,” contain solely progestin. Withdrawal bleeding may occur irregularly or during hormone-free time.
• Contraceptive patches: These patches are placed on the skin and release hormones into the bloodstream. Withdrawal bleeding may occur during the patch-free week.
• Contraceptive implants: These small, flexible rods are placed beneath the skin to release progestin. Withdrawal bleeding may occur irregularly.
• Intrauterine devices (IUDs): Both hormonal and non-hormonal IUDs can produce withdrawal bleeding, although the frequency and length differ.

Withdrawal bleeding is a designed feature of certain contraceptive regimens rather than a biological necessity. “Women have the option to use hormonal contraceptives continuously to avoid withdrawal bleeding, provided they consult with a healthcare provider to ensure it is appropriate for their individual health needs. This flexibility allows for a more tailored approach to contraception, enhancing comfort and quality of life,” shares the expert.

How to prevent withdrawal bleeding?

Here are some easy ways to prevent withdrawal bleeding:

1. Continuous use of hormonal contraceptives

Using combination birth control pills, patches, or rings continuously without a hormone-free interval can prevent withdrawal bleeding. This method involves skipping the placebo pills or starting a new pack immediately after finishing the active pills.

2. Extended-cycle contraceptives

Some birth control pills are designed for extended use, with a hormone-free interval every three months instead of monthly. This results in fewer withdrawal bleeds per year.

3. Long-acting reversible contraceptives (LARCs)

Methods such as hormonal IUDs, contraceptive implants, and progestin-only injections (Depo-Provera) can reduce the frequency or even eliminate bleeding altogether for some women.

It’s essential to discuss any plans to modify your contraceptive use with a healthcare provider. They can guide the safest and most effective methods based on your health needs and preferences. Preventing withdrawal bleeding through these methods can improve the quality of life for women who experience significant menstrual discomfort or those who prefer the convenience of fewer or no periods. However, individual responses to hormonal contraception can vary, and some women may still experience breakthrough bleeding or spotting, particularly in the initial months of continuous use.

Frequently Asked Questions (FAQs)

1. Is it okay to skip withdrawal bleeding?

Yes, it is generally considered safe to skip withdrawal bleeding by continuously using hormonal contraceptives without the hormone-free interval. This practice, known as continuous or extended-cycle contraception, can be beneficial for women who experience severe menstrual symptoms, such as painful cramps, heavy bleeding, or menstrual migraines. However, it’s important to consult with a healthcare provider before making changes to your contraceptive regimen.

2. Can you have withdrawal bleeding after stopping birth control?

Yes, after stopping hormonal birth control, withdrawal bleeding can occur as the body’s hormone levels adjust. This bleeding usually happens within a few days to a week after the last dose of hormones. Following withdrawal bleeding, the body’s natural menstrual cycle should resume, but it may take a few months for cycles to regularise, especially if the contraceptive was used for a long time.

3. Can you have sex during withdrawal bleeding?

It is safe to have sex during withdrawal bleeding though some women may find it messy or uncomfortable. It is important to continue using contraception consistently if you wish to prevent pregnancy, as fertility can return quickly after stopping hormonal birth control. Additionally, using barrier methods such as condoms can provide extra protection and reduce the risk of sexually transmitted infections (STIs).