What are the best contraceptive options for a 35-year-old postpartum woman?

Best Postpartum Contraceptives for a 35-Year-Old Woman

For a 35-year-old postpartum woman, long-acting reversible contraception (LARC)—specifically the etonogestrel implant or levonorgestrel IUD—represents the optimal first-line choice, as these methods can be inserted immediately postpartum, have failure rates below 1% per year, and carry no restrictions regardless of breastfeeding status or VTE risk factors associated with age ≥35 years. 1, 2

Recommended Contraceptive Algorithm by Priority

First-Line: Long-Acting Reversible Contraception (LARC)

Etonogestrel Implant (Nexplanon)

• Can be inserted at any time postpartum, including immediately after delivery, with U.S. MEC Category 1 (no restrictions) for non-breastfeeding women and Category 2 (advantages generally outweigh risks) if <1 month postpartum for breastfeeding women 1, 2
• Failure rate <0.05% with typical use, making it one of the most effective contraceptive methods available 2
• No backup contraception needed if inserted within 6 months postpartum in amenorrheic, fully breastfeeding women (≥85% of feeds); otherwise requires 7 days of backup contraception 1, 2
• No negative effects on milk volume, composition, or infant development have been demonstrated 2, 3

Levonorgestrel IUD (Mirena) or Copper IUD (Paragard)

• Can be inserted immediately postpartum (within 10 minutes of placental delivery) or at any time thereafter, with U.S. MEC Category 2 if <10 minutes to <4 weeks postpartum, and Category 1 if ≥4 weeks postpartum 1
• Levonorgestrel IUD has a failure rate of 0.2% with typical use; copper IUD has a failure rate of 0.8% with typical use 2
• No backup contraception needed at insertion 2
• Immediate postpartum insertion (before hospital discharge) is safe, effective, and strongly recommended by CDC and AAP, though expulsion rates are higher (5-10% within 5 years) compared to interval insertion 2, 4, 5
• Optimal timing for interval IUD insertion is either immediate postplacental or delayed until ≥4-6 weeks postpartum to minimize expulsion risk 3

Second-Line: Progestin-Only Pills (POP)

• Can be started immediately postpartum at any time, with U.S. MEC Category 1 for non-breastfeeding women and Category 2 if <1 month postpartum for breastfeeding women 1, 2, 3
• Requires only 2 days of backup contraception if started ≥21 days postpartum when amenorrheic, or if started >5 days after menstrual bleeding onset 2, 3
• No negative effects on milk production or infant development 2, 3
• Failure rate approximately 4-7% per year with typical use (higher than LARC methods) 6

Third-Line: Depot Medroxyprogesterone Acetate (DMPA/Depo-Provera)

• Can be initiated immediately postpartum, with U.S. MEC Category 1 for non-breastfeeding women and Category 2 if <1 month postpartum for breastfeeding women 1, 2
• Ideal timing is 6 weeks postpartum to minimize infant hormone exposure and decrease irregular bleeding while lactational amenorrhea still provides protection 3
• No backup contraception needed at initiation 2
• Failure rate approximately 6% with typical use 2

Fourth-Line (Delayed): Combined Hormonal Contraceptives (CHC)

Critical Age-Related Restriction for 35-Year-Old Women:

Combined hormonal contraceptives (pills, patch, ring) are absolutely contraindicated (U.S. MEC Category 4) during the first 3 weeks postpartum due to significantly elevated venous thromboembolism risk 1, 2, 7

Timing Based on Breastfeeding Status and VTE Risk:

• Non-breastfeeding women WITHOUT additional VTE risk factors: Can start at 21 days postpartum (U.S. MEC Category 2 at 21-42 days, Category 1 after 42 days) 1, 2

• Non-breastfeeding women WITH additional VTE risk factors (including age ≥35 years): Generally should not use (U.S. MEC Category 3) at 21-42 days postpartum; can use after 42 days (U.S. MEC Category 2) 1, 2

• Breastfeeding women: Generally should not use (U.S. MEC Category 3) at 21-42 days postpartum due to potential negative effects on milk production; can use after 42 days (U.S. MEC Category 2) 1, 2, 8

• Requires 7 days of backup contraception if started when menses has not returned or if >5 days since menstrual bleeding started 2, 8

• FDA labeling specifically warns that COCs should not be used by women who are over 35 years of age and smoke 7

Critical Clinical Considerations for Age 35

VTE Risk Factors to Assess: Age ≥35 years itself is a VTE risk factor that elevates the U.S. MEC category for combined hormonal contraceptives in the postpartum period 1, 2. Additional VTE risk factors include: previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ≥30 kg/m², postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking 1

Why LARC is Optimal for This Age Group:

• Copper IUD is specifically recommended as a first-line contraceptive method for women with a history of deep venous thrombosis, pulmonary embolism, or coronary events 5
• LARC methods have no age-related restrictions and no increased cardiovascular risks 1, 9, 10
• Effectiveness does not depend on user adherence, which is particularly important given that oral contraceptive failure rates increase with typical (vs. perfect) use 6

Common Pitfalls to Avoid

• Do not delay contraception until the 6-week postpartum visit when safe and effective options (LARC, progestin-only methods) are available immediately 2, 3
• Do not prescribe combined hormonal contraceptives before 3 weeks postpartum under any circumstances due to VTE risk 2, 3, 7
• Do not assume all hormonal methods affect breastfeeding equally—progestin-only methods have no negative effects on lactation, while combined hormonal methods may reduce milk production if started before 6 weeks 2, 3
• Do not overlook immediate postpartum LARC insertion (before hospital discharge) as this removes barriers to contraceptive access and is supported by CDC and AAP 2