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Recommendations for Contraceptive Use |
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Combined Oral Contraceptives (COCs) |
Q.2. When can COCs be started
postpartum?
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| For Breastfeeding Women:
(These restrictions do not apply to women who are only doing token, i.e., minimal,
breastfeeding.) |
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| a) COCs should not be used in
the first 6 weeks postpartum. COCs are considered by many experts to be the method
of LAST choice during any state of lactation, especially in the first 6 weeks to 6 months. b) After 6 to 8 weeks postpartum, breastfeeding women desiring
hormonal contraception should be encouraged to use progestin-only pills (POPs) or
injectables or NORPLANT® Implants. (Before 6 to 8 weeks postpartum, there is no risk of
conception for a fully or nearly fully breastfeeding woman - see How
to Be Reasonably Sure the Woman Is Not Pregnant.) |
a-b) Even low dose (30 to 35
mcg) COCs decrease breastmilk production.
- WHO Task Force on Oral Contraceptives.
Effects of hormonal contraceptives on milk volume and infant growth. Contraception 1984;30(6):505-521.
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| c) If COCs remain the method of
choice, but the woman chooses to rely on the Lactational Amenorrhea Method (LAM)
initially, start COCs when her menses return,** or when the woman is no longer fully or
nearly fully breastfeeding or at 6 months postpartum, whichever comes first. COC packets
may be given to the woman before this time to ensure that she is able to start the method
when she needs to. **In breastfeeding women,
bleeding in the first 56 days (8weeks) postpartum is NOT considered "menstrual"
bleeding, because it is not preceded by ovulation. |
c) For fully breastfeeding
women, there is no known advantage to initiating COCs during LAM or while the LAM criteria
apply.
- Kennedy KI. Breastfeeding and the
double protection dilemma. Family Health International, September 1991.
- Labbok M, Cooney K, Coly S.
Guidelines: Breastfeeding, Family Planning, and the Lactational Amenorrhea Method - LAM.
Washington, DC: Institute for Reproductive Health, 1994.
In fact, initiating COCs before they are necessary may be
a disadvantage because COCs have a detrimental effect on breastmilk volume and
composition, which may affect the infant's health and growth.
- WHO Task Force on Oral Contraceptives.
Effects of hormonal contraceptives on milk volume and infant growth. Contraception 1984;
30(6):505-521.
- WHO Task Force on Oral Contraceptives.
Special Programme of Research, Development, and Research Training in Human Reproduction.
Effects of hormonal contraceptives on breast milk composition and infant growth. Studies
in Family Planning 1988; 19(6):361-369.
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| d) If she does not want
to rely on LAM but is breastfeeding, she should be advised to choose a non-estrogenic
method. If she still makes an informed choice to use COCs, they can be started anytime
after the first 8 to 12 weeks postpartum if she is still amenorrheic, or whenever the
service provider can be reasonably sure that the woman is not
pregnant. |
d) Even low dose (30 to 35 mcg)
COCs decrease breastmilk production. Waiting at least 8 to 12 weeks postpartum permits
breastfeeding to be better established. Whether exposure of the neonate (in the first 8
weeks) to exogenous estrogens and progestins may, in theory, affect neonatal growth and
development is a question under study. |
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| For Non-Breastfeeding Women: |
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| a) If not breastfeeding, a woman
can begin COCs after the second to third postpartum week. |
a) Blood coagulation and
fibrinolysis are essentially normalized by 3 weeks postpartum (and are close to normal at
2 weeks postpartum).
- Dahlman T, Hellgren M, Blombäck M.
Changes in blood coagulation and fibrinolysis in the normal puerperium. Gynecologic and
Obstetric Investigation 1985;20(1):37-44.
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