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Perdarahan terobosan (BTB) adalah salah satu dari berbagai bentuk perdarahan vagina, biasanya
mengacu pada perdarahan pertengahan siklus pada pengguna kontrasepsi oral kombinasi, sebagai
akibat dari estrogen yang tidak mencukupi. Mungkin juga terjadi dengan kontrasepsi hormonal
lainnya. Kadang-kadang, perdarahan terobosan diklasifikasikan sebagai abnormal dan dengan
demikian sebagai bentuk metrorrhagia, dan kadang-kadang diklasifikasikan sebagai tidak
abnormal.
Perdarahan terobosan paling sering disebabkan oleh endometrium yang sangat tebal (lapisan
uterus). Ini bukan kondisi berbahaya, meskipun periode perdarahan yang tak terduga dan sering
lama tidak menyenangkan. Perdarahan terobosan juga bisa disebabkan oleh efek hormonal ovulasi.
Perdarahan terobosan juga bisa menjadi gejala kehamilan.
Perdarahan terobosan adalah yang paling umum ketika seorang wanita pertama mulai
menggunakan kontrasepsi oral, atau perubahan dari satu kontrasepsi oral tertentu ke yang lain,
meskipun mungkin terjadi perdarahan terobosan terjadi setiap saat. Perokok sangat rentan terhadap
perdarahan terobosan saat menggunakan kontrasepsi oral; meskipun banyak pengguna mengalami
perdarahan terobosan dalam tiga siklus pertama mengambil pil, non-perokok cenderung melihat
pendarahan menghilang lebih cepat daripada perokok.
Perdarahan terobosan kemungkinan karena fluktuasi hormonal. Tubuh diprogram untuk membuat
kadar estrogen tertentu setiap hari dan estrogen (dan beberapa hormon tambahan, seperti FSH, LH,
dan Progesterone) bertanggung jawab untuk mengatur penumpahan endometrium. Karena itu,
ketika level hormon baru memasuki tubuh melalui kontrasepsi oral, tubuh diberikan dua cara untuk
menerima estrogen. Tingkat estrogen berlebih ini dapat menyebabkan perdarahan pra-menstruasi
(pendarahan melalui). Ini harus diatur dalam beberapa bulan.
Menurut Lange Gynecology and Obstetrics, edisi ke-8, efek samping paling umum yang terkait
dengan penggunaan OC adalah perdarahan terobosan. Biasanya terjadi selama satu atau dua siklus
pertama dan menyelesaikan sendiri secara spontan. Masalah umum lainnya adalah amenore.
Perdarahan terus-menerus melalui perdarahan dan amenore umumnya mencerminkan
endometrium atrofi, atau tipis dan kurang berkembang.
Penggunaan gabungan estrogen dan progesteron menghilangkan siklus hormonal endogen normal
dan secara bertahap menghasilkan atrofi kelenjar endometrium. Ini karena dosis estrogen dalam
pil kontrasepsi oral jauh lebih rendah daripada jumlah yang diproduksi secara alami oleh indung
telur. Jumlah yang lebih tinggi yang dihasilkan oleh ovarium menginduksi proliferasi, tetapi
tingkat rendah yang dipasok oleh pil menghasilkan atrofi tetapi cukup untuk menghambat sekresi
endogen dari gonadotropin.
Rantai kejadian yang tepat yang mengarah dari endometrium atrofi ke bercak di antara menstruasi
tidak dijelaskan oleh teks. Kondisi ini dapat dikoreksi dengan menggunakan pil dengan estrogen
yang lebih tinggi (yang akan merangsang proliferasi lebih lanjut dari endometrium) atau
kandungan progestin yang lebih rendah (yang akan mengurangi stabilitasnya).
Breakthrough bleeding is any bleeding or spotting you may experience between your
normal menstrual periods or during pregnancy. It’s important to pay attention to any
changes in your normal bleeding patterns from month to month. Women who smoke, for
example, risk experiencing breakthrough bleeding.
Here’s more about how to identify breakthrough bleeding or spotting, what might be
causing it, and when to see your doctor.
The typical menstrual cycle is 28 days long. Some cycles may be as short as 21 days, while
others may be 35 days or more days in length.
Generally speaking, day one starts with the onset of your period and last around five days.
After that, the hormones in your body gear up to produce an egg that may or may not be
fertilized when you ovulate around day 14 of your cycle.
If the egg is fertilized, it may result in pregnancy. If not, your hormones will again adjust
to shed the lining of your uterus and result in another period for around five days. Women
generally lose around 2 to 3 tablespoons of blood during a menstrual period.
Periods tend to be longerand heavier in teens and women nearing menopause.
Breakthrough bleeding is any bleeding that occurs outside of the normal menstrual
period. This could be full-on bleeding — blood loss that’s enough to warrant a tampon
or pad — or spotting.
There are many different reasons why you might experience bleeding between periods. It
can be caused by anything from your body’s adjustment to hormonal
contraception to miscarriage. Although some cases of bleeding may resolve on their own
without treatment, it’s a good idea to report any changes to your doctor.
With extended or continuous birth control pills, you take active pills throughout the entire
month to effectively skip your period. This method is done either in an extended use
pattern for two to three months or in a continuous use pattern for an entire year. The
most common side effect of using birth control pills in this way is breakthrough bleeding
in the first several months. You may even notice that the blood you see is dark brown,
which may mean that it’s old blood.
With IUDs, you may experience changes in your menstrual flow until your body adjusts to
influx of new hormones. With the copper IUD, there are no new hormones, but you could
still experience changes in your menstrual flow. Bleeding between periods is also a
common side effect for both kinds of IUDs. It’s important to tell your doctor if your
bleeding is particularly heavy or if you notice spotting or bleeding after sex.
While breakthrough bleeding may be normal and go away on its own over time, you
should call your doctor if you’re also experiencing:
abdominal pain
chest pain
heavy bleeding
eyesight or vision changes
severe leg pain
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.
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.
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.
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.
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 three 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 to 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
Withdrawal bleeding, also called a “fake period”, is the bleeding you experience in the
placebo pill week of a conventional course of birth control pills. It also occurs with other
forms of hormonal birth control that affect a menstrual cycle, like contraceptive patches
or vaginal rings. To understand why this happens, it might help to consider how birth
control pills work.
Hormonal birth controls dose you up commonly with estrogen and progesterone. This
stops you from ovulating (releasing eggs), and prevents any further thickening of the
uterine lining.
However, when you take the dummy pills, those hormone levels drop down. The bleeding
you experience is just the uterus’ way of responding to the decrease in estrogen and
progesterone.
Though it may look like a period, what you get in a withdrawal bleed is a little different.
What you shed naturally in a period is the thickened uterine lining, but when you take birth
control pills, this lining stays thin. Withdrawal bleeding may look and feel like a period, but
it’s just a response to a drop in hormones.
Withdrawal bleeding is also different from “breakthrough bleeding”, which refers to the
unscheduled period-like blood and spotting you may experience as your body is still
getting used to the hormones in the pill.
If you’re taking birth control, there’s no physiological reason you need to have withdrawal
bleeding every month. There’s no evidence that going longer than a month without
withdrawal bleeding has any negative impact on your health.
However, it’s been included in most hormonal birth control methods for a psychological
reason. For starters, many of us rely on getting periods as a sign that we’re not pregnant,
so a withdrawal bleeding provides some much-needed reassurance.
On the other hand, there are many reasons someone may want to “skip” their period from
time to time. With this in mind, some extended cycle formulations of birth control let you
go longer between withdrawal bleedings. Instead of having 12 fake periods each year,
you only have 4 per year with these methods.
Assuming that you’re taking all your pills correctly as directed, you haven’t had any
vomiting or diarrhea that could interfere with absorption, and you’re not taking any other
drugs that could interfere with them? Then no. You’re not at any increased risk of getting
pregnant during the placebo week when withdrawal bleeding occurs.
This is because the days of “active pills” have already prevented your body from releasing
an egg, or from thickening the uterine lining. Just make sure you take all your pills as
directed, and you can have confidence that you’re not putting yourself at risk of an
unplanned pregnancy.
However, if you go more than a week without active pills – as could happen, say, if you
got the stomach flu, or skipped a few doses and then moved straight onto the placebo
week – there is a chance your body could restart the ovulation process. Play it safe and
use condoms if you’re not sure.
Whether you’re using to prevent pregnancy, get on top of a painful menstrual cycle, or
both, hormonal birth control can often make life a bit easier. Withdrawal bleeding is a
quirk of the dosing schedule of many hormonal birth control methods – not a “real” period.
But just as with regular menstrual periods, if your withdrawal bleeding is painful or
interfering with your daily life, you don’t need to put up with it. Speak to your doctor about
your options for avoiding excessive withdrawal bleeding, or improving the symptoms.