Q        My regular period stopped about 12 days ago and I then started bleeding again. No pain at first, but now after 3 days I am bleeding constantly and cramping. What’s up? I am 36 years old and consider myself very healthy.Â
A:       You indicate that your period stopped 12 days ago. Then you started bleeding again, at first with no pain, but now after 3 days, with constant bleeding and cramping. Otherwise you are a healthy 36 year-old woman.
| As a woman approaching menopause, periods do become far less predictable. While there are some important problems that could cause your recent pain and bleeding, it may be nothing but the approach of the perimenopause. See your clinician about this. |
Below is a long list of causes of bleeding or spotting at a time other than your regular period:
BREAKTHROUGH BLEEDING
When a woman experiences BTB, the usual approach is to increase the strength of the progestin, the estrogen or both. If your BTB returns, other causes of BTB must be considered. Professor John Guillebaud, of London and Oxford, England, suggests 12 causes of bleeding other than pill-induced BTB. They all begin with the letter D. Here they are [Guillebaud – 1999; Sapire – 1990]:
 Disease –Consider EXAMINING the cervix. It is not unknown for bleeding from an invasive cancer to be wrongly attributed to BTB on the pill. Chlamydia often causes a blood-stained discharge due to endometriosis. Or a polyp might be present.
Disorder of pregnancy causing bleeding (e.g. because of recent abortion, trophoblastic tumor)
Default – missed pill(s). Remember that the BTB may start 2 or 3 days later and be very persistent thereafter
Drugs – especially enzyme-inducers (see Qs 5.36, 5.40) – cigarettes also relevant. Drugs (see Q 5.171)
Diarrhea with VOMITING – diarrhea alone has to be very severe to impair absorption significantly (see Q 5.26)
Disturbance of absorption – likewise has to be very marked to be relevant, e.g. after massive gut resection
Diet – gut flora involved in recycling ethinylestradiol might be reduced in vegetarians. An entirely theoretical factor, no obvious increase in BTB risk in vegetarians has ever been reported
Duration too short - BTB that the woman can tolerable might resolve if she can persevere for-3 months with any new formulation (see Q 5,174). See also Q 5.33 regarding management of BTB during tricyling (possible need to take a bleeding-triggered break in continuous tablet-taking).
Finally, after the above have been excluded: Â Â Â Â Â Â Â
Dose (1) if she is taking a monophasic; try a phasic pill (Qs 5.174, 5.181 -5.184) if possible.          (2) Increase the progestogen or estrogen component (see 5.174, 5.175) if possible. (3) Try a different progestogen. (4) Try a different route to ensure absorption (e.g. contraceptive patch or ring, see Qs 6.81-6.84).
More causes of BTB:
D for Doctor-caused (poor instruction/advice)
D for Dud pills: iatrogenic causes (which have really happened) include wrong prescriptions for POPs and HRT products instead of the COC. Overdue Date (time-expired product) or other cause of Damaged product is another possibility!
D for Diathesis/Dyscrasia: a coincidental bleeding disease could first manifest itself this way.
D for Drink: alcohol and other non-therapeutic substances, i.e. drugs, chiefly because their abuse is a likely cause of default (liver enzyme induction by alcohol is not thought to be important.)
What is your status today, May 27, 2015? Â Please do let us know.
Robert A. Hatcher MD, MPH
Emeritus Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, GA
To learn more about the advantages and disadvantages of birth control pills, go to: www.managingcontraception.com.  You can order all of these books listed below from our website or by calling 404-875-5001.Â
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