When is it generally safe to start combination oral contraceptive pills (COCs) postpartum?

From the Guidelines

For non-breastfeeding women, it is generally safe to start combination oral contraceptive pills (COCs) 21 days after delivery, while for breastfeeding women, it's recommended to delay starting COCs until at least 6 weeks postpartum. This recommendation is based on the increased risk of venous thromboembolism (VTE) in the early postpartum period, as pregnancy creates a hypercoagulable state that gradually resolves over the first few weeks after delivery 1. COCs contain estrogen, which further increases clotting risk, making this timing crucial for safety. Women with additional risk factors for VTE (such as obesity, history of thrombosis, or cesarean delivery) may need to wait longer or consider progestin-only methods instead.

Some key considerations for starting COCs postpartum include:

• The woman's medical eligibility to use the method
• The certainty that she is not pregnant
• The need for backup contraception during the initial waiting period
• The importance of daily adherence to the COC regimen for maximum effectiveness
• The potential effects on breastfeeding performance, particularly in the first few weeks postpartum 1.

It's also important to note that ovulation can return as early as 4 weeks postpartum in non-breastfeeding women, highlighting the need for alternative contraception during the waiting period to prevent unintended pregnancy 1. Once started, COCs should be taken daily at approximately the same time for maximum effectiveness.

In terms of specific guidance, the U.S. Selected Practice Recommendations for Contraceptive Use, 2013, adapted from the World Health Organization, provide detailed advice on the timing of COC initiation postpartum, including considerations for breastfeeding and non-breastfeeding women 1. These recommendations emphasize the importance of balancing the risks and benefits of COC use in the postpartum period, particularly with regard to VTE risk and breastfeeding performance.

Ultimately, the decision to start COCs postpartum should be individualized, taking into account the woman's unique medical history, breastfeeding status, and personal preferences, with the goal of minimizing risks while maximizing benefits in terms of contraception and overall health 1.

From the FDA Drug Label

The use of Kariva for contraception may be initiated 4 weeks postpartum in women who elect not to breastfeed.

It is generally safe to start combination oral contraceptive pills 4 weeks postpartum in women who do not breastfeed 2.

• The patient should be aware of the increased risk of thromboembolic disease associated with the postpartum period.
• If the patient starts on combination oral contraceptive pills postpartum and has not yet had a period, she should be instructed to use another method of contraception until a tablet has been taken daily for 7 days.

From the Research

General Safety Guidelines for Starting Combination Oral Contraceptive Pills Postpartum

• The safety of starting combination oral contraceptive pills (COCs) postpartum depends on whether the woman is breastfeeding or not 3.
• For breastfeeding women, combined hormonal pills are not recommended prior to 6 weeks postpartum due to their effects on milk production 3, 4.
• In non-breastfeeding women, the elevated risk of venous thromboembolism restricts the use of combined hormonal pills prior to 21 days postpartum 3, 5.
• From 21 to 42 days postpartum, the use of combined hormonal pills should be assessed based on a woman's personal venous thromboembolism risk profile 3.
• After 42 days postpartum, there is no restriction on the use of combined hormonal pills for otherwise healthy women 3.

Considerations for Breastfeeding Women

• Progestogen-only pills do not adversely affect milk production, but there is a lack of data regarding possible effects on infants exposed to progestogens in breastmilk, making the timing of initiation of this method controversial 3.
• Breastfeeding women may safely use progestogen-only pills at any time during the postpartum, but it is recommended to postpone their use until 6 weeks postpartum 6.
• Combined hormonal contraceptives may affect breastfeeding performance and infant health outcomes, and their use among breastfeeding women should be carefully considered 4.

Considerations for Non-Breastfeeding Women

• Non-breastfeeding women may safely use progestogen-only pills at any time during the postpartum 3.
• The risk of venous thromboembolism is a significant consideration for non-breastfeeding women, and the use of combined hormonal pills should be carefully assessed based on individual risk factors 3, 5.
• Women with a history of venous thromboembolism or thrombophilia should be carefully evaluated before starting hormonal contraception, and alternative methods may be recommended 5, 7.