Waiting for Period

Technically, when things go perfectly, your first period will not arrive until four weeks after your hCG levels reach zero. Since most women will not be tested all the way to zero (which on your forms would show as "less than 5"), you will not know exactly when this will happen. In a normal recovery, it can take three weeks for the hormone chain to fire up again, and it will not be marked by bleeding or any physical symptom. You will only know that the new cycle worked by having a period at the end of it, between five and seven weeks after your miscarriage.

Here are the most common scenarios and symptoms that go with them. They come from a decade's worth of collecting women's experiences, from the easiest and quickest recoveries to the most elongated and complicated ones.

Remember that the day you found out about the loss is not a benchmark, nor is the day you began bleeding. The actual hormone change begins to take place either during the D&C or when the placenta pulls away from the uterus during the natural miscarriage, which is usually when the cramps and bleeding are at their worst. That is Day 1 of the recovery (but not Day 1 of a new cycle, as you will see.)

Here are the scenarios:

The most common recovery goes like this:

Your bleeding will taper off to spotting within a week, and maybe random spotting will continue for another week. Your hCG drops steadily, usually hitting zero during the end of the spotting, or about 10 days after the miscarriage or D&C. When the spotting ends, you will get strange symptoms. If you use a fertility monitor, it may say you are ovulating, but you are not. You may see lots of cervical mucus coming out, sometimes still brown or yellow, but it is not a fertility sign either. In fact, most of the time, you will not ovulate in this cycle. You should not be trying to get pregnant, either. For why, visit the trying again section.

Some women find they have mild pregnancy symptoms, or little ovulation cramps. Many many women think they could be pregnant, because strange things are happening and their period is "late" (although almost every post-miscarriage period is late.) These symptoms are due to the body's attempts to regulate its hormones again. It may kick into gear right away, and you will get a new period in four to five weeks, or it may struggle a bit, and the period will not come for seven weeks. If you chart your temperatures, they will be all over the place. This is all perfectly normal and expected. Eventually your period arrives and can be either light or heavy. There is no "normal" right now. For more on this, or to spot trouble, see the next section on Your First Period.

A less common, but still normal, recovery goes like this:

Your bleeding tapers off quickly, but with some spotting. You think it is over. Perhaps a week or even two will pass, and you begin to wait for your period. Then suddenly, it begins again. Strong cramping, heavy bleeding, and pain. You are scared and shocked and sad all over again. You hope it is just your period, but it is not. (You must not bleed at all for about 20 days for it to be a real period, otherwise you have not gone through the hormone chain properly.) You call your doctor, who may or may not be responsive. Most will just tell you to call them in a few days if it doesn't stop. You hang up very upset, and don't know why they don't care more about you and your predicament.

That's because within a few days, it does stop, and you are just spotting again. Here is what happened, some tissue was missed during your D&C or natural miscarriage. A bit of placenta clung to the wall of the uterus. It continued to draw a little blood, and the body continued to create very small amounts of pregnancy hormone. Eventually the body realized no baby was there and turned loose of this last bit of tissue. The miscarriage process begins again. Only now will your levels drop to zero and a new cycle begin. You cannot expect a normal period any sooner than four weeks from this, and up to seven weeks could still be normal. Your total wait time from original miscarriage to first period can creep up to nine or ten weeks and still be normal.

A recovery that should be monitored looks like this:

The main bleeding seems to have ended, and you are spotting. And spotting, and spotting. Three weeks pass and you are still wearing panty liners. (You call your doctor, and they said give it another week.) Spotting ends. You are relieved. A few days later it begins again. You are crushed. Sometimes you get slightly heavier bleeding. You hope it is your period, then read that you have to have NO bleeding for almost three weeks first. You are crushed again. Your ordeal seems like it will never end.

You should go in for an hCG blood test. If your doctor won't do it, take a home pregnancy test. If it is still positive, call them back. Your levels should be at zero by now.

Your levels may come back at 100, or even higher. It may be zero. Your doctor still wants you to wait and see. If your levels were high and things go well, you will suddenly get another big passage of blood and tissue, and it will be over. You will still have a good case for requesting one more blood test to be sure. If this pattern continues, you may need a D&C, or in some cases, a drug called Cytotec, to induce cramping to push out left tissue.

If your levels were zero or not very high, and you still just keep spotting and spotting, you should be able to request a shot of provera or some other form of progesterone. This big dose will put your body into thinking it is nearing the end of a cycle. When the dose is done, the sudden drop in progesterone should trick your body into thinking it is time for a period, and you will bleed. This period can be terribly heavy or light, but it counts. If this has happened, it is still a good idea to wait one more cycle before trying to conceive. If it doesn't work, your doctor may put you on birth control pills for a couple of months to get your cycle regulated.

A cycle that indicates a serious problem looks like this:

The bleeding tapered off, but then got heavy again. You are going through several pads a day. After two weeks of this you call the doctor. They tell you to see what happens. You may get a little reprieve of no bleeding or just spotting, then it begins again, as heavy as ever. You call and insist on being seen. You are feeling exhausted from the constant loss of blood and the sad ordeal just going on and on.

A blood hCG comes out high, 500 or more. The doctor tells you to wait and see, or maybe schedules another test. Your bleeding is still heavy, and sometimes you see big black gunk or tissue coming out. You feel panicky every time you go to the bathroom.

A second hCG test comes out only slightly lower than before or even higher than before. The doctor asks a few questions to rule out a new pregnancy and may do a sonogram.

The cause of this can be one of two things:

1. Leftover tissue that refuses to budge. You may need a D&C or methotrexate to kill the tissue and make it come away. If left untreated, you could hemorrhage badly, eventually losing consciousness or becoming seriously iron-deficient. Scar tissue can also form should the left tissue become infected.

2. Molar or partial molar pregnancy. It is very important to follow up on this and get a concrete diagnosis. Molar pregnancy can persist for months, and you absolutely cannot attempt another pregnancy until you have been without any hCG in your system for several months. Read more about molar pregnancy.

If you have start and stop bleeding for several months, I have a more complex description of the relationship between progesterone and bleeding down below.

About follow up exams:

If you had a D&C, you will usually be called back in two weeks for a follow up exam. If you miscarried naturally, you may not need a follow up, or it could be at two or six weeks.

This exam is most likely going to hurt some. The cervix has been open and will be very tender for a while. Taking a couple of ibuprofen before you go can help. If you are able, having sex the night prior to the exam will help "break things in." You can control penetration with sex, and do it slowly, rather than have a metal speculum suddenly open you up.

This exam is your chance to ask questions. Don't be surprised if it is quick, your doctor does not have many answers, or you do not get any tests. This is pretty normal after a first miscarriage, where it is assumed you will be in the category whose next pregnancy will go perfectly (about 80%). For more on testing, see the diagnosing section.

The hardest part of the exam will be seeing other pregnant women around you, and perhaps returning to the room where you learned you lost the baby. Be prepared for this, and if you have an option (particularly in bigger practices), ask if you can be seen in the Gynecology slots, rather than the OB slots, where you should be waiting with women getting mammograms or annual exams, rather than prenatal visits. These are scheduled differently in most practices, as OB visits are short-notice slots, and annuals are set slots done in advance.

About sex:

You should probably avoid sex while you are actively miscarrying, and certainly use a condom if you have sex within two weeks of the loss. This is because your cervix is slightly open and you are very susceptible to infection.

Sex will often hurt for a few weeks after the loss, although it often gets progressively better, because your cervix will be tender from being open and closed through the miscarriage. Sex can also be very emotionally difficult, as it will remind you of the whole process of pregnancy and conception. It is pretty important not to try again until you get a regular period. You can read why at the trying again section.

[ First Few Days ]

[ Waiting for a Period ]

[ The First Period ]

[ New Cycles ]

Why do I start and stop bleeding and the hCG refuse to fall? It's been several months now!

Let's start with why we bleed at all. Our body, during our cycle, makes progesterone. This causes the lining in our uterus to thicken and prepare for pregnancy. When we do not get pregnant, the body cuts the progesterone level suddenly, and this dramatic loss of hormone makes us bleed.

When we are pregnant, we make even MORE progesterones, levels that go from an ordinary 12 in a cycle to 30 or more. Some get even way way higher. It varies from woman to woman. While you are pregnant, if you get any sort of hormone flux, let's say it drops temporarily from 30 to 25, you will bleed a little. This often happens when you would have expected your period. Your pregnancy can be fine as the body goes OOPS and makes more progesterone to cover the loss and baby goes along happily growing as the part of the lining he or she is using is not affected.

When the baby dies, or the body figures out it is a blighted ovum and no baby is growing, in some people it will cut off the flow of progesterone immediately. These women suddenly cramp and bleed and the body gets it all out in one shot. This is a complete miscarriage.

Other times, the body turns the tissue loose slowly, and the progesterone drops a bit, and some bleeding occurs, maybe even part of the chorion comes out as tissue, but then the body senses hCG still, so it says OOPS and boosts that progesterone again, and you stop bleeding. This is a missed miscarriage.

After a few days or a week or more, once again the body realizes no baby is growing, so it drops it again. More tissue comes out, but if the hCG is still high enough, the cycle of correcting itself continues.

Most women will get a D&C at this point, and the scraping of the uterus gets rid of all placenta, which is putting out the hCG, and so the body gets no more baby signals and you have your period.

If any placenta is left, though, the body is going to get fooled again.

At this point, usually the woman, if she has already had a D&C, will be given either:

1. a shot of progesterone, to create a false "drop" so the body will start cramping and bleeding and pushing out whatever might be in there.

2. birth control pills, to do the same thing when she stops taking them

In one special case, hCG's failure to drop can be caused by a molar or partial molar pregnancy. If your hCG ever goes UP after a loss, this is very likely the case. If your hCG stalls out, it might be the case and your blood hCG should be monitored by your doctor. It is unusual for molars to fall below 100, however.