About Follow Up Exams
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.)
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.
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
A less common, but still normal, recovery goes
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
A recovery that should be monitored looks like this:
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.
cycle that indicates a serious problem looks like this:
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
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
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
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
If you have start and stop bleeding for several months, I have
a more complex description of the relationship between progesterone and bleeding
About follow up exams:
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.
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.
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.
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.
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
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