What type of oral birth control pill is recommended for a 33-year-old lactating woman, 2 months postpartum, with a history of cesarean section (C/S)?

Progestin-Only Pills are Recommended for a Lactating Woman 2 Months Postpartum with History of C-Section

For a 33-year-old lactating woman who is 2 months postpartum with a history of cesarean section, progestin-only pills (POPs) are the recommended oral contraceptive option. 1

Rationale for Progestin-Only Pills in Lactating Women

• POPs are classified as Category 1 (no restriction for use) for women who are ≥4 weeks postpartum and breastfeeding 1
• Combined hormonal contraceptives (CHCs) containing estrogen are classified as Category 2 (advantages generally outweigh risks) for women who are >42 days (6 weeks) postpartum and breastfeeding 1
• POPs do not adversely affect milk production or composition, unlike estrogen-containing pills which may reduce milk volume 2, 3
• POPs have no demonstrated deleterious effects on infant growth or development when used during breastfeeding 2

Timing Considerations

• At 2 months postpartum, the patient is well beyond the initial high-risk period for venous thromboembolism (VTE) that occurs in the first 3 weeks postpartum 1
• POPs can be safely started at any time during the postpartum period for breastfeeding women 1, 4
• Ideally, POPs should be started at 6 weeks postpartum if the woman is fully breastfeeding to decrease infant exposure to exogenous hormones 2
• Since the patient is already 2 months (approximately 8 weeks) postpartum, POPs can be started immediately 1

Efficacy of Progestin-Only Pills

• With perfect use, the first-year failure rate for POPs is 0.5% 5
• With typical use, the failure rate is estimated to be closer to 5%, due to late or missed pills 5
• POPs must be taken at the same time each day for maximum effectiveness, with a narrow window of only 3 hours for late pills 1

Important Counseling Points

• POPs should be taken at the same time every day; a pill is considered missed if taken >3 hours late 1

• If a pill is missed (>3 hours late), the woman should:

  • Take one pill as soon as possible 1
  • Continue taking pills daily at the same time 1
  • Use backup contraception (e.g., condoms) or avoid sexual intercourse for 2 consecutive days of correct pill-taking 1
  • Consider emergency contraception if unprotected intercourse occurred 1

• The most common side effect with POPs is irregular bleeding patterns, which may affect compliance 3

• Proper counseling about expected bleeding patterns can improve acceptance and continuation 3

Why Not Combined Hormonal Contraceptives?

• While CHCs are Category 2 (advantages generally outweigh risks) for women >42 days postpartum who are breastfeeding, they may reduce milk production 1, 3
• This reduction in milk volume could lead to earlier discontinuation of breastfeeding or necessitate supplementation 2
• CHCs should be used with caution by women who are not able to obtain supplemental milk 2
• POPs are preferred over CHCs during lactation to maintain optimal breastfeeding 6, 7

Other Contraceptive Options to Consider

• Other progestin-only methods that are safe during breastfeeding include:
  • Implants (Category 1 for women ≥4 weeks postpartum) 1
  • Injectable contraceptives like DMPA (Category 1 for women ≥4 weeks postpartum) 1
  • Intrauterine devices (both copper and levonorgestrel) are Category 1 for women ≥4 weeks postpartum 1

Remember that any hormonal contraceptive method does not protect against sexually transmitted infections (STIs), and consistent and correct use of condoms is recommended if STI protection is needed 1.