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A Select Issue in the Postpartum Period: Contraception Proceedings in Obstetrics and Gynecology, 2013; 3(2):1 A select issue in the postpartum period: contraception The importance of providing postpartum contraception counseling Whitney Cowman, MD,1 Abbey Hardy-Fairbanks, MD,1 Jill Endres, MD,2 Colleen K. 1 Stockdale, MS, MD Keywords: postpartum, contraception, guidelines, counseling Abstract Data from the United States reveals that of the approximately 6.6 million One half of pregnancies in the United States are pregnancies per year, one-half are unintended and associated with adverse unintended.1-3 Of the approximately 61 pregnancy outcomes. The postpartum period is million women of reproductive age in an important, yet underutilized, time to initiate 2006-2010, 62% were using some form contraception. The U.S. Medical Eligibility 4 Criteria for Contraceptive Use, 2010 provides of contraception. 7.7% of those not evidence-based guidelines for choosing a using contraception had intercourse in contraceptive method and an update in 2011 the previous 3 months, and represent specifically addresses contraceptive method use those at highest risk for unintended in the puerperium. The variety of contraceptive 5 pregnancy. Unintended pregnancies methods include hormonal contraception, lactational amenorrhea, barrier contraception, are associated with adverse pregnancy natural family planning, and sterilization. Ideally, outcomes and behaviors, including late counseling about contraceptive choice should entry into prenatal care, decreased begin early in pregnancy care and continue breastfeeding, and low birth weight.6 postpartum; it should also include a variety of Also, short interval pregnancies are at teaching modalities. Specifically we recommend LARC options such as intrauterine devices and increased risk for obstetric etonorgestrel implants, postpartum tubal complications, including low birth sterilization, and progestin-only pills for those weight, preterm birth and neonatal 7-9 desiring an oral method. mortality. The optimal interval 1Department of Obstetrics and Gynecology, between pregnancies is debated, but Carver College of Medicine, University of Iowa greater than 11-18 months has been Hospitals and Clinics, Iowa City, IA, 522422 suggested as reducing complications in 7,8 2 the subsequent pregnancy. Department of Family Medicine, University of Postpartum contraception is vital to the Iowa Hospitals and Clinics, Iowa City, IA, 52242 reduction of short interval pregnancies, which is a significant source of neonatal Please cite this paper as: Cowman W, Hardy-Fairbanks A , Endres J. Stockdale CK. A select issue in the postpartum period: contraception. Proc Obstet Gynecol. 2013;3(2):Article 1 [15 p.]. Available from: http://ir.uiowa.edu/pog/. Free full text article. Corresponding author: Whitney Cowman, Department of Obstetrics and Gynecology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 42242. [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 Proceedings in Obstetrics and Gynecology, 2013; 3(2):1 morbidity and medical care costs. criteria can be used to evaluate options for women in the postpartum period with The immediate puerperium is an and without chronic medical conditions. important period to initiate Updates to the CDC-MEC 10 contraception. Women are often recommendations specific for motivated to prevent or delay another postpartum women were released in pregnancy, they have immediate access 2011 and will be reviewed here. to health care providers, and they are known not be pregnant.10,11 Because Hormonal contraception ovulation may occur as early as 25 days postpartum among women not Combined estrogen and progestin breastfeeding, providing an effective hormonal contraceptive agents (oral contraceptive method during the combined hormonal contraceptive puerperium is vitally important in pills, transdermal patch, vaginal ring) reducing unintended pregnancy.12 Hormonal contraceptives are among the The puerperium is a unique time period most used methods of contraception in in a woman’s life, resulting in unique the United States. In fact, according to contraception needs. Understanding the most recent data from the National and communicating the risks and Center for Health Statistics, the oral benefits of the various contraceptive contraceptive pill is used by 17.1% of all methods is vital, as some contraceptive reproductive age women (28% of forms are better suited than others for women using some form of use during this time period. contraception), 1.3% use the contraceptive ring, and 0.9%, the In 2010, the Centers for Disease Control implant or transdermal patch.5 These (CDC) published U.S. Medical Eligibility methods prevent ovulation by Criteria for Contraceptive Use, 2010 (US suppressing hypothalamic 13 MEC), providing evidence-based gonadotropin-releasing factors, which guidelines for choosing a contraceptive then prevents pituitary secretion of FSH method based on the relative safety for and LH. Estrogens prevent ovulation by women with certain suppressing FSH release, and also characteristics/conditions, including stabilize the endometrium. Progestins those who are postpartum. A category suppress LH, thicken cervical mucus, 1 distinction indicates that there are no and render the endometrium restrictions for the use of a particular unfavorable for implantation.14 Oral contraceptive method. Category 2 progestin-only options can provide designates that the method may be contraceptive efficacy, although the used but that individualization and estrogen component improves cycle careful follow-up may be required. control, unfortunately at the expense of Category 3 indicates that a certain estrogenic side effects such as nausea, method is generally not recommended breast tenderness and thromboembolic unless other methods are unavailable or events.15 Progestins produce unacceptable. Category 4 notes an androgenic side effects such as acne, 15 unacceptable health risk may be hirsutism and lipid changes. The 13 conferred with use. The CDC-MEC overall side effect profile, therefore, is Postpartum contraception 2 Proceedings in Obstetrics and Gynecology, 2013; 3(2):1 dependent upon the concentration of suppressive effect on lactation. Those each hormone and specific type of with 35 mcg or less, still have some progestin.15 suppressive effects, and low-dose combination oral contraceptives Combined hormonal contraceptive pills containing 0.03 mg ethinyl estradiol and have many benefits, including familiarity 0.15 mg levonorgestrel in women who with the method, effectiveness, safety, had been nursing for one month, had a reversibility, cycle control, decrease in small but significant decrease in dysmenorrhea, decrease in days of lactation performance and in weight gain 17 bleeding and amount of blood loss and of their infants or cause maternal 16 other, non-contraceptive benefits. anxiety about milk supply. This slight Non-oral delivery methods such as the inhibition of lactation induced by transdermal patch or vaginal ring have combined oral contraceptive agents may the additional advantage of eliminating be sufficient enough to discourage the need for daily compliance, as well as women from continuing breastfeeding, offering a different pharmacokinetic particularly in those whose desire to 15 profile. Daily intake of oral combined nurse is marginal.17 On the other hand, hormonal contraceptives creates peaks a 2003 Cochrane review concluded that and troughs in ethinyl estradiol there was insufficient evidence to concentrations, whereas the ring and establish the effect of combined patch deliver more constant levels. hormonal contraceptives, if any, on milk Exposure is lowest with the ring, while quality or quantity18 and a systematic the patch is associated with the greatest review confirmed an inconsistent effect 15 overall exposure. Intermenstrual of combined oral contraceptives on bleeding, amenorrhea, breast breastfeeding duration and success, tenderness, abdominal bloating, and found that infant outcomes were not headache and nausea are a few of the affected.19 common side effects of combined oral contraceptives. The transdermal patch An update to the US MEC, specifically has similar side effects, though breast regarding use of contraceptive methods discomfort and dysmenorrhea are during the postpartum period, was significantly more common. The most published in 2011.11 These updated frequent side effects associated with the recommendations describe specific vaginal ring are headache, leukorrhea, guidelines stating that all postpartum vaginitis, weight gain and nausea.15 women should not use combined hormonal contraceptives during the first Despite the advantages, there are 21 days postpartum due to significant several reasons why combined increased risk of venous hormonal contraceptives are not thromboembolism (VTE) (category 4). typically used in the puerperium. The During days 21-42, non-breastfeeding safety and timing of contraceptive women with risk factors for VTE (e.g. initiation during lactation are subject to prior VTE, recent cesarean delivery, or debate. Studies of hormonal smoking), should not use these methods contraceptive agents with doses of for the same reason of increased VTE ethinyl estradiol or mestranol of 50 mcg risk (category 3). Without additional risk or more have demonstrated
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