From the Guidelines
Initiating Oral Contraceptive Pills (OCPs) in the postpartum period should be done with caution, considering the risks of venous thromboembolism and effects on breastfeeding.
Guidelines for Postpartum Women
- For breastfeeding women, combined hormonal contraceptives should not be started until at least 3-4 weeks postpartum, and ideally 4-6 weeks postpartum if there are other risk factors for venous thromboembolism 1.
- For non-breastfeeding women, progestin-only pills can be started at any time postpartum, while combined hormonal contraceptives can be started 21 days postpartum, with caution in women with other risk factors for venous thromboembolism 2, 3.
Need for Back-up Contraception
- Women who are less than 6 months postpartum, amenorrheic, and fully or nearly fully breastfeeding do not need additional contraceptive protection 1.
- Otherwise, women who are 21 days postpartum and have not experienced return of their menstrual cycle need to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days 1, 2.
Important Considerations
- Venous thromboembolism risk factors, such as age ≥ 35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, body mass index ≥ 30 kg per m², postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking, should be taken into account when initiating OCPs in the postpartum period 3.
- Breastfeeding performance may be affected by combined hormonal contraceptives, and progestin-only methods may be a safer alternative 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. When the tablets are administered during the postpartum period, the increased risk of thromboembolic disease associated with the postpartum period must be considered If the patient starts on Kariva postpartum, and has not yet had a period, she should be instructed to use another method of contraception until a white tablet has been taken daily for 7 days.
The guidelines for initiating Oral Contraceptive Pills (OCPs) in the postpartum period are to start 4 weeks postpartum in women who do not breastfeed. It is also recommended to use an additional method of contraception for the first 7 days of OCP use if the patient has not yet had a period. The increased risk of thromboembolic disease during the postpartum period should be considered when initiating OCPs 4. Key considerations include:
- Starting OCPs 4 weeks postpartum in non-breastfeeding women
- Using an additional method of contraception for the first 7 days
- Considering the increased risk of thromboembolic disease during the postpartum period
From the Research
Guidelines for Initiating Oral Contraceptive Pills (OCPs) in the Postpartum Period
- In breastfeeding women, combined hormonal pills are not recommended prior to 6 weeks postpartum due to effects on milk production 5.
- Progestogen-only pills can be used in breastfeeding women, but the timing of initiation is controversial due to lack of data on possible effects on infants exposed to progestogens in breastmilk 5.
- In non-breastfeeding women, the use of combined hormonal pills is restricted prior to 21 days postpartum due to elevated risk of venous thromboembolism 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 5.
- After 42 days postpartum, there is no restriction on the use of combined hormonal pills for otherwise healthy women 5.
- Non-breastfeeding women can safely use progestogen-only pills at any time during the postpartum period 5.
Considerations for Contraceptive Selection
- Optimal contraceptive selection requires patient and clinician discussion of the patient's tolerance for risk of pregnancy, menstrual bleeding changes, other risks, and personal values and preferences 6.
- Oral contraceptive pills are the most commonly used reversible contraceptives, but intrauterine devices and subdermal implants have the highest effectiveness 6.
- Progestin-only and nonhormonal methods have the lowest risks, and hormonal contraceptives can improve medical conditions associated with hormonal changes related to the menstrual cycle 6.
Provider Practices and Guidelines
- National and international contraceptive guidelines recommend against the use of estrogen-containing hormonal contraception in the early postpartum period 7.
- Most providers follow expert recommendations regarding the initiation of hormonal contraception for breastfeeding women, but a sizable minority prescribe combined pills in the early postpartum period 7.
- The combined oral contraceptive pill is an effective contraceptive method that can also offer other benefits, and pills containing levonorgestrel or norethisterone in combination with ethinyloestradiol 35 microgram or less are considered first-line 8.