Is It Normal to Have Breakthrough Bleeding?

I am 42 and am on the birth control pill Sprintec to help manage late-reproductive-stage symptoms (I have lots of perimenopause-seeming symptoms but a very regular period when not on birth control), and it’s been very helpful. However, despite continuously taking the pill, I will start spotting/bleeding by week 5 or 6, and the bleeding will not stop until I stop taking the pill and seem to have a period. Prior to the bleeding starting, I will still have some PMS-like symptoms, such as constipation, swollen/very sore breasts, worse-than-usual body dysmorphia, and migraines. Why is this happening? What should I be asking my OB-GYN?

—Bleeding and over it

Not all birth control pills are created equal. They all have ethinyl estradiol (but the doses vary) and progestin, of which there are several types. Modern pills have anywhere from 35 to 10 micrograms of ethinyl estradiol. The first birth control pills had more than 50 mcg. Progestins vary in how androgenic they are — that is, how much they act like testosterone in the body. The estrogen builds the uterine lining, and progesterone and progestins stabilize it.

However, as with any woman taking a birth control pill, the bleeding you are having is not a true period, in that it is not bleeding that occurs after ovulation, because your birth control pill very effectively prevents ovulation. Instead, what you are having is called breakthrough bleeding. Essentially, the balance between the estrogen and progestin in your birth control is working for you in some ways, by managing many of your symptoms. But at times the balance is not quite right, causing breakthrough bleeding, sore breasts, and migraines.

When my patients struggle with similar issues, I consider a few possible solutions. A birth control pill with less estrogen might cause less buildup of the uterine lining. As a result, it might cause less breakthrough bleeding. Sometimes it takes some time on the pill for the uterine lining to thin out. Since the birth control pill is relatively new for you, giving your body a little break of three or four days when the breakthrough bleeding starts might result in longer stretches between breakthrough bleeding that would eventually result in no significant breakthrough bleeding at all.

Both of these strategies have allowed my patients to take birth control pills continuously to control their perimenopausal symptoms. As for which strategy might work best for you, that is where a conversation with your doctor will be helpful. You might ask if either switching your pill or taking brief breaks in taking the active pills when you get breakthrough bleeding might work for you. You might also ask if she recommends other strategies for breakthrough bleeding on birth control pills.

If your doctor recommends trying this pill for a little longer — which she might, depending on how long you have been taking it — be clear on how much longer she would want you to try it before you touch base again. Lastly, make sure you and your doctor are on the same page regarding what success will look like. Of the side effects you are having, like breakthrough bleeding, sore breasts, and headaches, decide which are tolerable and which are deal-breakers for you.

Ultimately, every treatment option is a tradeoff between reducing your symptoms and side effects. The goal in choosing the right birth control pill and regimen for taking it is to find out which best treats your symptoms with the fewest side effects.