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14 Causes of Spotting and Breakthrough Bleeding

Often, bleeding between periods is just a minor inconvenience. Other times, it can signal a serious health issue.
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If you feel like you can usually predict your period with military precision—or at least generally know when you can expect it to begin and end—breakthrough bleeding might throw you for a loop. Allow us to help you out if you’re now staring at your screen like, Wait, what is breakthrough bleeding, exactly? Breakthrough bleeding is spotting that happens between your regular periods. It can be pretty common and is often nothing to worry about, Jacques Moritz, M.D., an ob-gyn at New York-Presbyterian and Weill Cornell Medicine, tells SELF. Sometimes, though, breakthrough bleeding may be a sign of a medical issue that requires evaluation and treatment.

That’s why we’re going to make the blanket recommendation that if you are seeing bleeding between periods and aren’t sure why—especially if it’s new or accompanied by pain or other symptoms—you should get in touch with your primary care physician or ob-gyn so they can help you figure out what’s going on. In any case, here are some of the most common breakthrough bleeding causes that people experience. They might give you an idea of what’s up before you go in to see the doctor.

1. You recently started a new birth control pill.

Spotting during the first three months after going on a new birth control pill is considered fairly normal, Dr. Moritz says. “It may take three months for your body to get used to the medicine and the lining of your uterus to adjust to it.”

Spotting can also occur when you switch from a brand name to a generic, Dr. Moritz says. Some gynecologists think that generics may not perfectly match brand-name formulations and that the slight difference may be enough to cause breakthrough bleeding. The United States Food and Drug Administration (FDA) says all generic drugs work the same as their brand-name counterparts but allow for a slight, natural variability that won’t change the main function of the drug. If after three months on a new pill you’re still spotting, or you suddenly start spotting on a pill you’ve taken for longer than that, ask your ob-gyn about switching medications if it’s really bothering you.

2. You’re taking a very low-dose birth control pill.

Many of the newer generations of lower-hormone birth control pills have either very little estrogen or no estrogen at all, relying instead on progestin to regulate your cycle. While many people like these formulations because they experience fewer side effects overall, the super-low hormone dosage makes breakthrough bleeding more likely, even when you’ve been using the same pill for a while. “The pill is making the lining of the uterus so thin that the little blood vessels are fragile and just break because they don’t have enough hormones for support,” Dr. Moritz explains. If the spotting bothers you, ask your ob-gyn about switching to a higher-dose pill and what side effects you can expect if you make the jump.

3. You have an IUD.

Similarly to the pill, a hormonal IUD can cause breakthrough bleeding at first, usually for up to three to six months after insertion. When it comes to the copper IUD, irregular bleeding (and heavier, more painful periods) is relatively common and can go on for quite a while. As SELF previously reported, this is because the device can irritate and inflame the uterus. Although doctors generally recommend giving your body six months or so to adjust, talk to your ob-gyn if you’re miserable.

4. You’re ovulating.

Some people spot during ovulation because the downswing in hormones can cause a little uterine lining to break down too early, causing light bleeding. If your mid-cycle bleeding is accompanied by one-sided pain, you might be dealing with mittelschmerz. This type of ovulation pain occurs when the follicle ruptures and releases its egg, according to the Mayo Clinic.

5. You’re perimenopausal.

Depending on your age, changes in your menstrual cycle are likely to indicate that your body is nearing menopause, which usually begins between ages 45 and 55. The phase before menopause, called perimenopause, can last for several years as hormone levels begin gradually shifting, according to the American College of Obstetricians and Gynecologists (ACOG). Along with periods that are lighter or heavier, shorter or longer, more or less frequent, you may experience breakthrough bleeding during hormone dips.

6. You’ve recently had sex.

Friction from vaginal intercourse can also cause breakthrough bleeding, especially if your vagina wasn’t lubricated enough (because there wasn’t enough foreplay, enough lube, et cetera). If you experience persistent vaginal dryness, it can compound this issue. Vaginal dryness can occur for lots of reasons, including childbirth, taking certain cold medications, and being in perimenopause or menopause. Perimenopause and menopause make you more likely to experience vulvovaginal atrophy, which is a reduction in estrogen that causes symptoms including irritation, soreness, urinary frequency, incontinence, and vaginal dryness. In the event that vaginal dryness during sex is the cause of your spotting, there are over-the-counter vaginal moisturizers that might help you find some relief, and you can always try to find a lubricant that works for you. If nothing is helping, your doctor might be able to offer more guidance.

7. You’re about to become pregnant.

Implantation bleeding is one of the earliest signs of pregnancy, occurring in up to 25% of pregnant people, according to ACOG. One to two weeks after fertilization, when the fertilized egg implants in the uterine lining, a very small amount of blood may flow from the uterus and out the vagina. “It’s just a little spot, not a lot,” Dr. Moritz says.

8. You had vaginal intercourse while pregnant.

During pregnancy, the cervix gets very sensitive, and if it’s irritated during penetrative sex, it can bleed a lot, Dr. Moritz says. Additional blood vessels are developing there, according to ACOG, so bleeding a little after intercourse is no big deal. “It’s totally fine,” he says. It doesn’t mean anything has happened to the baby—having penetrative sex doesn’t harm the fetus.

9. You’re pregnant and have a subchorionic hematoma.

A subchorionic hematoma is essentially a blood clot that can occur when the outermost membrane surrounding the embryo (the chorion) separates a little from the uterine wall, allowing some blood to pool in that space between the two. Sometimes that blood flows out of the vagina, but sometimes it doesn’t. In any case, it’s painless and very common, Dr. Moritz says. These usually aren’t a major cause for concern, and research isn’t really conclusive about whether or not subchorionic hematomas definitively increase a person’s risk of miscarriage or how factors like the size of the hematoma and when it occurs may influence that risk.

10. You have noncancerous growths on your ovaries, uterus, or cervix.

There are a number of abnormal but typically benign growths that can occur on your reproductive organs, including ovarian cysts, uterine fibroids, uterine polyps, and cervical polyps. Localized pain to varying degrees may come along with all of these, along with other symptoms, but it really depends on what you’re dealing with. Bleeding doesn’t necessarily occur with all of them. For example, it’s much more common to see bleeding with uterine polyps than with ovarian cysts, Dr. Moritz says.

Although bleeding from any of these growths is pretty normal, your doctor may want to run tests or remove them even if they’re benign, because in addition to pain and other symptoms, they may cause complications like fertility issues.

11. You’ve recently had an abortion.

Bleeding is a side effect of both medication and surgical abortion, the Mayo Clinic says, so depending on when you got one, it could be causing breakthrough bleeding. In most cases, your provider will let you know how much bleeding to expect, the Mayo Clinic explains. For instance, it’s totally normal to have bleeding for days or weeks after your abortion (it’s also normal to have cramps), ACOG explains. But if you have abdominal pain, fever, or you’re dealing with heavy bleeding (which typically means you’re soaking two or more maxi pads for two hours straight), reach out to your provider to discuss your symptoms.

12. You’re having a miscarriage or ectopic pregnancy.

Though bleeding during pregnancy is common and usually harmless, especially in early pregnancy, there are a few worst-case scenarios you should be aware of. Bleeding is the first sign of a miscarriage, Dr. Moritz says, which occurs in about 10% of known pregnancies, according to ACOG. Cramping may also occur.

Bleeding is also the first sign of an ectopic pregnancy, as ACOG explains, which is when a fertilized egg implants somewhere other than inside the uterus, almost always in the fallopian tubes. While ectopic pregnancies are rare, they can become life-threatening if a tube ruptures. Sometimes bleeding is the only sign of ectopic pregnancy, but other signs can include abdominal, pelvic, and shoulder pain, according to ACOG. If you think you might be experiencing an ectopic pregnancy, call your ob-gyn to talk through your symptoms and figure out any potential next steps.

13. You have a sexually transmitted infection (STI).

While gonorrhea and chlamydia are usually asymptomatic—one of the reasons regular STI screening is so important—they can both cause vaginal bleeding (along with other symptoms). Endometritis (inflammation of the endometrium) and cervicitis (inflammation of the cervix) can occur, as well as pelvic inflammatory disease (PID), which happens when bacteria infect the reproductive organs. This can cause complications like permanent damage to the fallopian tubes that leads to fertility issues. (Although gonorrhea and chlamydia are the most common infections associated with PID, according to the Mayo Clinic, other types of bacteria can cause it too.)

14. You have a gynecological cancer.

We put this last on the list to reiterate that there are many, many less worrisome breakthrough bleeding causes that are more likely to be behind your spotting. With that said, we’d be remiss not to mention gynecological cancer as a potential cause behind random breakthrough bleeding.

Although many people with gynecological cancer don’t experience any symptoms, especially early on, abnormal vaginal bleeding is often one of the first signs of cervical, ovarian, uterine, vaginal, or vulvar cancer, according to the Centers for Disease Control and Prevention (CDC). Although cancer is unlikely, it’s a good idea to see your doctor to rule it out. This is especially true if you are postmenopausal, Dr. Moritz says, because common causes of bleeding like the pill or pregnancy are off the table. “Any time after menopause, any spotting, even a drop, has to be investigated,” he says.

How to manage breakthrough bleeding and when to see a doctor

Hopefully the reasons above helped you parse through when spotting is simply a passing occurrence and when it might need a bit more investigation. But as we said above, if you’re experiencing spotting along with other symptoms like pain or fever, it’s a good idea to check in with your doctor. This is especially important because breakthrough bleeding is a common symptom, but different conditions require different treatments.

Even if you think you know what’s wrong but you’re still worried, it’s totally fine to talk to your provider to address your concerns. While you’re working to figure out the underlying cause, you can try to manage your breakthrough bleeding with whichever products—tampons, pads, pantyliners, menstrual cups—normally work for your period.

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