"I started taking Ortho-Tricyclen® about
2 years ago. I would have my normal period for 5-7
days, and then the following year I started continual
bleeding for 2-4 weeks out of each month in addition
to my normal week period. Last year, I had my period
for five weeks straight, and was rushed to the hospital,
where I was put on highest estrogen pill (beige w/
butterflies) and taken off Ortho-Tricyclen® ,
until about 8 months ago. I experienced the same irregular
bleeding with this pill, so they put me on the lowest
estrogen pill for the next several months. No results
from this pill either, they next tried Depo. "
" I've been on Depo since then, and have experienced
continual bleeding for 9 months, until recently I
was put on another low dose pill (could be Ortho Novum
777®, not sure), while still on Depo. The bleeding
stopped within a day after taking the pill. I don't
know whether to get off Depo or the pill? My doctors
can't tell me what's wrong, and I am getting no answers
where ever I go. I have a history of cancer in my
family, and am afraid that this might be a factor?
Please help me out with any answers, suggestions,
or advice. "
Anonymous
You can either discontinue the pill and take some
periodic added estrogen along with your DepoProvera®
or you can discontinue the DepoProvera® and switch
to a pill regimen that raises the estrogen component
or gives you added estrogen in the week you are off
of active pills.
The bleeding you are experiencing is most likely
atrophic bleeding due to low estrogen. The only question
in the history you give is why the bleeding did not
improve when they gave you a higher estrogen pill
for several months. The progestin in that pill (Ovral)
is also a very potent one and probably counteracted
the higher estrogen. When you were given estrogen
again in the form of a low dose birth control pill
while the DepoProvera was 'onboard', your bleeding
stopped.
What causes the prolonged bleeding when a woman is
on birth control pills or Depo Provera® ?
Assuming a woman is not just missing her pills every
couple of days, the most common cause of continuous
bleeding is due to low estrogens which make the endometrium
atrophic (1). A small amount of estrogen is needed
to make the lining of the uterus repair the open blood
vessels that result from a menstrual slough. After
a menses, estrogen alone in a normally ovulating woman
not taking birth control starts the tissue growing
again and in effect seals off the bleeding blood vessels.
This makes bleeding stop. With birth control pills
that have both estrogen (very small doses) and progestin
in each pill, the progestin component works opposite
the the estrogen and does not allow the endometrial
tissue to grow and repair itself. If a woman is on
a progestin only birth control pill, or using DepoProvera®
which is pure progestin only, the same effect takes
place, i.e., the endometrium may not totally repair
its entire surface inside the uterus because of a
lack of estrogen or the antagonism of the progestin
working against any small amount of estrogen present
in the woman's body.
If you are a smoker, that lowers your body's estrogen
levels and may explain why you are having a problem
with this low estrogen level when many others on the
same contraceptives may not. If you are thinner and
have less body fat than other women your age, that
may also play a role in having less estrogens.
If I want to continue taking birth control pills,
how do I get around all this bleeding?
If you have this continuous spotting on the pills,
the estrogen level needs to be raised. This can be
done in one of two ways. A very small dose of estrogen
can be given during the week when you are not taking
active hormone pills. One pill that comes packaged
this way is Mircette®. It has 10 mcgm of ethinyl
estradiol in 5 of the 7 days of pills in between the
21 days of estrogen with progestin pills. The cycle
control of bleeding with Mircette especially in the
first two months of use is better than other low estrogen
dose (20 mcgm) pills such as Alesse® (2). Instead
of using Mircette, a supplemental estrogen of 1 mg
estradiol could be given during that week off active
pills or even a transdermal patch such as those used
for menopausal estrogen replacement therapy.
In addition to being given a supplemental estrogen
in between active pills, another solution might be
to change to a pill with higher estrogen levels of
30 or 35 mcgm but combined with a progestin that is
not as strong as the one you were given in Ovral®.
Ovcon 1-35® or Ortho Novum 1-35® or their
generics are pills that come to mind and might eliminate
the continuous spotting you are having.
If I want to stay on DepoProvera® but not have
all the continuous spotting, what can I do?
The principle here is the same as that needed with
oral contraceptive pills. Estrogen needs to be added
to the DepoProvera® regimen. Added estradiol of
1 mg per day by mouth for about two weeks each 3 months
may be enough to stop the bleeding pattern. There
are not good studies on this right now so the doctor
will need to work with you to try to stop the bleeding
problem. It would probably be better to used the estradiol
than one of the other estrogens such as conjugated
estrogens (Premarin®), estrone or estriol which
do not stimulate the endometrium as well as estradiol.
Again, using an estradiol transdermal skin patch of
0.1 mg/day for 1-2 weeks might also be enough to stop
the continuous spotting.
Another choice might be an injectable contraceptive
called Lunelle®. It is a shot that has both estrogen
and progestin so there should be less problems with
breakthrough bleeding. Ask your doctor about it.
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