Withdrawal Bleeding

Is Withdrawal Bleeding the Same as a Regular Menstrual Period?

Sex During Period
Withdrawal Bleeding. Photo Nancy R. Cohen/Getty Images

Definition of Withdrawal Bleeding

Withdrawal bleeding, also known as a hormonal period or fake period, is the monthly bleeding women experience while using a hormonal birth control method, such as the Pill, the patch, or the NuvaRing. During the placebo week of these methods, women will typically have withdrawal bleeding, which often feels like a regular period. Monthly withdrawal bleeding is not the same thing, though, as having a real menstrual period.

When Does Withdrawal Bleeding Occur?

If you use combination hormonal contraception, you should be expecting your withdrawal bleeding to come when you are not taking any hormones from your birth control method. This is usually during the fourth week of your cycle:

  • Combination Pill Users: expect your withdrawal bleeding to take place during Week 4 (your placebo week) if you are using a 28-day pill pack brand.
  • Patch Users: you should be expecting your withdrawal bleeding during the week you keep your patch off (Week 4).
  • NuvaRing Users: expect your withdrawal bleeding to occur during the week when you take out your NuvaRing (Week 4). 
  • Extended Cycle Pill Users: if you are you a 91-day extended cycle pill (like Seasonique), don't be expecting your withdrawal bleeding for three months. It should come sometime during Week 13.
  • Progestin-Only Pill Users: things are a little different for you since you do not have a placebo week. If you start your pills on the first day of your actual period, you can expect your monthly withdrawal bleed sometime during the first week of your next pack.
  • 21-Day Birth Control Pill Pack Users: some of you use pill brands that only contain 21 pills (like Loestrin 1/20 or Loestrin 1.5/30), so when should you expect your withdrawal bleeding? Well, take all 21 pills (Weeks 1-3). Then, during Week 4 when you don't take any pills you can expect your withdrawal bleeding.

    What Causes Withdrawal Bleeding?

    Withdrawal bleeding usually takes place during the last week of your birth control cycle because there is a change in the hormone dosage that your body is used to. Not having any hormones during Week 4 can cause the lining of your uterus to weaken just enough to allow for some bleeding to occur. It is important to point out that withdrawal bleeding is due to the change in hormone levels, and is not a true period.

    A withdrawal bleed can also occur after a course of progesterone therapy.

    If It's Not Real, Why Have Withdrawal Bleeding?

    When you use hormonal birth control, you are "overriding" your natural menstrual cycle. In a way, these methods make your body think that it's pregnant. Back when Margaret Sanger, Katharine McCormick, John Rock, and Gregory Pincus first developed the pill, they felt that women may not like the idea of not have a monthly period -- especially since women usually rely on their regular period as "proof" that they are not pregnant. There's no biological or medical reason to have this period.

    But again, the pill developers thought that women would feel more comfortable still having a monthly withdrawal bleed, and they also thought that since the pill mimicked a woman's natural cycle, then perhaps there would be less religious objection to pill use.

    So the pill developers made the decision to build a withdrawal bleed into the pill. How did they do this? Well, they designed the pill to only have 3 weeks ( 21 days of active, hormone pills). Then, in Week 4, they included a hormone-free interval of seven days by using only placebo pills. The hormone decline that takes place during this pill-free/patch-free/NuvaRing-free interval results in your withdrawal bleeding.  

    So How Does Withdrawal Bleeding Differ from a Real Period?

    Withdrawal bleeding is a somewhat similar to your menstrual period (and is often referred to as being on your period). But, you need to remember that it is not the same thing as having a true menstrual period. To understand why these are different, we need to take a quick look inside your body to understand what causes you to have a period. In real simple terms:

    • Fluctuations (changes) in hormone levels can cause changes in your uterine lining.
    • If your hormone levels don't fluctuate, then the lining of your uterus will not thicken.
    • Because it is not thick, it does not need to shed off -- which is what happens during a regular period. 
    • The only biological reason for these changes in your uterine lining is to prepare the uterus for a possible pregnancy. 

    BUT, when you use the Pill, the Patch, or NuvaRing, your body hormone levels stay low, and they don't seesaw -- they actually stay fairly steady. Not having hormone fluctuations will keep your uterus lining thin. This is important to point out, it doesn't just stay thin for the 3 weeks you are using hormone contraception, it is still thin during Week 4, and will continue to stay thin for all the time you are using this method.

    • This thinness means that there is no tissue building up in your uterine lining.
    • No thickening of the lining means that there is no build-up that needs to be shed off.
    • No shedding means that you do not need to have a regular menstrual period.

    This is how these hormonal methods stop you from having a "real" monthly period. Instead, each month you have withdrawal bleeding (or a "fake" period). Not adding hormones into your system during week 4, basically softens your thin uterine lining just enough to cause some bleeding. This bleeding is your withdrawal bleeding. Because your uterine lining hasn't been thickened, withdrawal bleeding tends to be shorter and lighter than a regular period.

    Withdrawal Bleeding and Sex

    Last, but certainly not least,you may be wondering about having sex during Week 4, and whether or not the pill, patch, or NuvaRing still offers pregnancy protection during the placebo week. The answer is YES! Even though you are not taking any hormones during Week 4 (or Week 13 for extended cycle pill users) and even if you are having withdrawal bleeding, your hormonal birth control has got you covered.

    Source:

    Kaunitz AM. "Menstruation: Choosing whether...and when." Contraception. 2002; 62:277-284.

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