Postpartum Combined Oral Contraceptive Initiation for Non-Breastfeeding Women
A postpartum woman who is not breastfeeding should wait 3 weeks (21 days) before starting combined oral contraceptives. 1, 2
Evidence-Based Timing
Combined oral contraceptives are absolutely contraindicated (U.S. MEC Category 4) during the first 3 weeks postpartum due to significantly elevated venous thromboembolism risk during this period. 1, 2 This represents the highest level of restriction in the U.S. Medical Eligibility Criteria, meaning the method should not be used because the condition represents an unacceptable health risk. 1
After 3 weeks postpartum, combined oral contraceptives can be safely initiated in women without additional VTE risk factors (U.S. MEC Category 2), meaning the advantages generally outweigh theoretical risks. 1, 2
The immediate postpartum period carries a 2- to 4-fold increase in relative risk of venous thrombosis, which is why the 3-week waiting period is critical. 3
This restriction applies to all combined hormonal contraceptives including pills, patches, and vaginal rings. 2
Risk-Stratified Approach After 3 Weeks
For women WITHOUT additional VTE risk factors: Combined oral contraceptives can be started at 3 weeks (21 days) postpartum. 1, 2
For women WITH additional VTE risk factors (such as obesity, thrombophilia, immobility, transfusion at delivery, postpartum hemorrhage, post-cesarean delivery, or preeclampsia): Combined oral contraceptives generally should not be used (U.S. MEC Category 3) until after 6 weeks postpartum. 1, 2
Common Clinical Pitfall
Waiting until the routine 6-week postpartum visit to initiate contraception in low-risk women is a common error. 2 Many women resume sexual activity before 6 weeks postpartum and are at risk for unintended pregnancy. COCs can and should be started at 3 weeks in women without VTE risk factors. 2
Backup Contraception Requirements
When starting COCs at 21 days or later, if menstrual cycles have not returned, use backup contraception or abstain from intercourse for 7 days after starting COCs. 1, 2
If menstrual cycles have returned and it has been more than 5 days since bleeding started, use backup contraception or abstain for 7 days. 1, 2
If starting within 5 days of menstrual bleeding onset, no additional contraceptive protection is needed. 2
FDA Drug Labeling Confirmation
The FDA-approved labeling for combined oral contraceptives states that "the use of [combined oral contraceptives] for contraception may be initiated 4 weeks postpartum in women who elect not to breastfeed," with explicit warning that "the increased risk of thromboembolic disease associated with the postpartum period must be considered." 3 This aligns with the guideline recommendation that COCs should not be started before 3 weeks, with careful consideration of VTE risk factors between 3-6 weeks. 1
Answer: A. 3 weeks