We don’t see any issue with progestin methods,” says Isabel Sausjord, MD, lead author of the paper and a resident physician at the University of Massachusetts Chan Medical School. “The birth control pill is one of the most popular forms of contraception in the United States. There is some evidence it could decrease milk supply, so make sure the milk supply is well established before starting the combination pill.” But other studies have shown the use of the pill has increased milk supply, and most studies show no difference, she adds.
Contraceptives with estrogen are not recommended in the first few weeks postpartum because of the risk of deep vein thrombosis, according to the American College of Obstetricians and Gynecologists.2 The over-the-counter (OTC) progestin-only pill, Opill, was approved by the Food and Drug Administration for OTC use after the paper was submitted.
In general studies of oral norgestrel pills, this contraceptive has been like other progestins and has not significantly affected milk supply. “In the immediate postpartum setting, it depends on the patient and their goals,” Sausjord says. “Many don’t want to think about birth control until the postpartum visit, so don’t push them.”
Clinicians should provide contraceptive counseling to postpartum patients who are interested in finding a safe method in those early weeks and months after giving birth.
“If they want something [more] reliable, we have long-lasting methods. If they want to use condoms and emergency contraception, that’s another option,” Sausjord says. “A nonhormonal method like the copper IUD is very effective.”
Levonorgestrel emergency contraception is considered safe while breastfeeding. The prescription emergency contraceptive pill, ulipristal, also is considered safe by the World Health Organization.3
It is important for clinicians to remember that finding the right contraceptive for postpartum patients is all about the patients’ personal goals. It also is about finding a safe option.
“We can leave estrogen contraception to a future visit because we don’t use it immediately postpartum,” Sausjord explains. “They can come back at the six-week visit and transition to the estrogen-containing combined pill.”
Breastfeeding as contraception is the choice some people may prefer because it fits in with their philosophy of natural family planning. “If a woman exclusively breastfeeds and hasn’t gotten her period in the first six months of the baby’s life, that’s pretty reliable,” Sausjord says. “Once the baby reaches six months, and if the period has returned, or if they’re no longer exclusively breastfeeding, there’s a higher chance of getting pregnant.”
It is important for reproductive health providers to be aware of all the effective hormonal contraceptive methods that are both effective and safe for postpartum patients. “We want these effective hormonal options available to the patients who want it, and we want them to know what their options are so they will be able to make that choice,” Sausjord explains.
The next step is to make more contraceptive methods available to American women. “There are methods available [in other nations] that we don’t have in the U.S., like combined injectables,” Sausjord says. “The hope is to develop new contraceptive options and bring these other options into the U.S. if they’re proven to be safe and effective, so women have more choices.”
REFERENCES
- Sausjord IK, Acton LW, White KO, et al. Breastfeeding and hormonal contraception: A scoping review of clinical guidelines, professional association recommendations, and the literature. Breastfeed Med 2023;18:645-665.
- The American College of Obstetricians and Gynecologists. Postpartum birth control: Frequently asked questions. Last updated April 2023.
- The Breastfeeding Network. Emergency hormonal contraception and breastfeeding. September 2019.
Reproductive health organizations should consider updating contraceptive counseling guidelines for patients who are breastfeeding to reflect that it is safe for them to use progestin-only contraceptive methods, according to the authors of a recent paper.
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