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Writer's pictureKarolina Manns

Why we shouldn’t rush into taking The Pill for abnormal bleeding.



No, I’m not going to talk about the side effects of the OCP (oral contraceptive pill). There are tonnes of books written on this subject.


I’m going to backtrack and talk about the different reasons why you might have abnormal bleeding and how taking the pill might only mask the problem or maybe even make it worse in the long-term.

 

Whether you then choose to take it or not, that’s another story. But best to make that decision with your eyes wide open.

 

Let’s start with a little biology recap. Technically speaking the day 1 of your menstrual cycle is the first day of your bleed. But let’s look at the time that is leading to your bleed and what potentially could go wrong.

 

Once you finish your previous bleed, the new cycle starts again. The first hormone on the scene is FSH (Follicle Stimulating Hormone) and as the name suggests: it stimulates the follicles so that ONE (leading) follicle is selected.


Once this is done, FSH stands down. The follicle itself starts to produce estrogen.

 



In a couple of days there is enough estrogen (remember, the body functions based on many feedback loops that signal whether there is enough of something, or ‘we need some more please’).


So once there is enough estrogen secreted, FSH comes back on the scene with a little bit of help from the luteinizing hormone and testosterone. This is to nudge the egg to ovulate which basically means forcing the egg out of its follicle into the fallopian tube for roughly 24 hours where it awaits implantation.

 



The follicle itself is left behind on the surface of the ovary and turns itself into a temporary gland called corpus luteum. That gland is then responsible for producing progesterone.

 

If there is any distraction in signalling between any of the above-mentioned hormones, ovulation might not happen. And if ovulation doesn’t happen, we don’t produce progesterone which nicely sets the scene for an abnormal bleeding (usually shorter cycles and often heavier and more painful as well).

 

As you can see, a cascade of things can potentially go wrong leading to menstruation. Not necessarily because there could be some signalling problems along the way (although that too could be an issue), but because the signal itself might not be strong enough. If the hypothalamus (the commanding general) which stands at the top of the HPO axis perceives some uncertainties coming from the outside world (think: lifestyle), it will turn down the signal or turn it all off. And there could be a multitude of reasons why the hypothalamus might do that. Let’s name just a few:

 

  • Stress

  • Calorific restriction

  • Weight loss

  • Over-exercise

  • Sleep disturbances

  • Physical illness

  • Psychosocial threat

 

But this is only part of the story. And in fact, a very small fraction of the story.


Anything to do with ovulation or the lack of it is one of the non-structural causes of abnormal bleeding. The name non-structural causes from the fact that they have nothing to do with the physical structure of the uterus. Instead, something is acting upon the uterus.

For example, thyroid issues, PCOS, insulin resistance, and certain medications will influence ovulation or the lack of it. There are also blood clotting issues which will influence the heaviness of the menstrual flow.

 

Let's not forget that age is an important factor. For example, in puberty, whilst the whole HPO axis is developing, there often are hiccups and irregularities. These are expected to happen. Likewise in perimenopause, we might expect the unexpected.

 

Also, one or two late / early periods or one skipped period during your reproductive years is almost never medically concerning (assuming no pregnancy). [1]

 

But non-structural causes of abnormal bleeding are only half of the story.

There are also structural (physical) causes of abnormal bleeding, meaning: the uterus itself has some abnormalities.

These can be:

 

  • Polyps (overgrowth of endometrium)

  • Adenomyosis (endometrium grows into the lining of the uterus)

  • Fibroids (benign tumors of the uterus)

  • Malignancy (cancer)

 

I don’t know about you but if you look at the last point, popping a pill without investigating properly the reasons why you have abnormal bleeding would be a bit scary, don’t you think?

 

Looking at endometrial cancer (which is often caused by exposure to estrogen when there is insufficient progesterone) the associated bleeding patterns are periods less than twenty-one days apart, heavy bleeding or bleeding for eight days or longer; and breakthrough bleeding. [2]



It’s important not to dismiss a change in pattern or breakthrough bleeding as ‘just a thing’ especially when these abnormalities are persistent.

 

Structural issues can lead to heavy periods and/or bleeding between periods but they won’t change the regularity of the menstrual cycle.

 

Irregular cycles most likely derive from any ovulatory changes as the frequency of menstruation depends on ovulation.

 

However, it’s possible to have two medical conditions at the same time...

 

It also sometimes might be difficult to say whether you have regular cycles if you have breakthrough bleeds in between.

 

So yes, the oral contraceptive pill or the hormonal IUD are usually the most conventional methods for ‘regulating’ your menstrual cycle, but I don’t believe they should be prescribed without thorough investigation first.

 

What’s your take and experience on this? Let me know in comments below.



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