COC Use at 6 Months Postpartum
Yes, combined oral contraceptives (COCs) can be safely used at 6 months postpartum in both breastfeeding and non-breastfeeding women, as the critical early postpartum risks have resolved by this timepoint. 1
Breastfeeding Women at 6 Months
COCs are medically eligible (U.S. MEC Category 2) for breastfeeding women at 6 months postpartum, meaning the advantages generally outweigh any theoretical risks. 2, 1
The primary concerns that restrict COC use earlier in the postpartum period—venous thromboembolism risk (first 3 weeks) and potential effects on milk production (first 6 weeks to 6 months)—are no longer relevant at 6 months. 1
After 6 months postpartum, restrictions related to breastfeeding performance and infant hormone exposure are effectively resolved, making COCs a reasonable contraceptive choice. 1
The CDC guidelines specifically note that from 1 month to less than 6 months postpartum, COCs carry a Category 2 classification, and at ≥6 months postpartum, this classification continues, indicating safety for use. 2
Non-Breastfeeding Women at 6 Months
For non-breastfeeding women, COCs can be used without restriction at 6 months postpartum (U.S. MEC Category 1 after 21 days for women without additional VTE risk factors). 2
The elevated venous thromboembolism risk that contraindicates COC use in the first 3 weeks postpartum (U.S. MEC 4) has completely resolved by 6 months. 2, 3
Women with additional VTE risk factors should generally avoid COCs only during the 3-6 week window postpartum (U.S. MEC 3), but these restrictions do not apply at 6 months. 2
Practical Initiation Guidelines
COCs can be started at any time after 6 months if it is reasonably certain the woman is not pregnant. 1
Backup Contraception Requirements:
If menstrual cycles have returned and it has been >5 days since menstrual bleeding started: Use backup contraception for 7 days after starting COCs. 2, 1
If the woman is still amenorrheic at 6 months and fully/nearly fully breastfeeding (≥85% of feeds are breastfeeds): No additional backup contraception is needed when starting COCs. 2, 1
If menstrual cycles have returned and COCs are started within the first 5 days of menstrual bleeding: No additional contraceptive protection is needed. 2
Important Caveats
While COCs are safe at 6 months postpartum, progestin-only pills remain the preferred first-line oral contraceptive option for breastfeeding women because they have no negative effect on lactation and can be started at any time. 4
The evidence on COC effects on breastfeeding is inconsistent, with some studies showing decreased milk production and earlier supplementation when COCs are initiated before 6 weeks postpartum, though no consistent negative effects on infant growth have been demonstrated. 5
Standard cardiovascular risk assessment still applies: Women who smoke (especially ≥35 years old), have hypertension, diabetes, or other cardiovascular risk factors should be counseled about increased risks with COC use regardless of postpartum timing. 6