Postpartum Combined Oral Contraceptive Initiation
A healthy postpartum woman who is not breastfeeding should start combined oral contraceptive pills at 3 weeks (21 days) postpartum—the correct answer is A. 1, 2
Evidence-Based Timing Framework
The 3-Week Rule for Non-Breastfeeding Women
Combined oral contraceptives are absolutely contraindicated (U.S. MEC Category 4) during the first 3 weeks postpartum due to significantly elevated venous thromboembolism risk. 1, 2 This restriction applies universally to all combined hormonal contraceptives including pills, patches, and rings. 2
At exactly 3 weeks postpartum, COCs become appropriate (U.S. MEC Category 2) for women without additional VTE risk factors, meaning the advantages generally outweigh theoretical risks. 1, 2 The CDC explicitly states that postpartum women should not use combined hormonal contraceptives during the first 3 weeks after delivery because of concerns about increased risk for venous thromboembolism. 1
Risk Stratification Beyond 3 Weeks
Women without additional VTE risk factors can safely start COCs at 3 weeks postpartum. 1, 2
Women with additional VTE risk factors (age ≥35 years, previous VTE, thrombophilia, BMI ≥30 kg/m², smoking) generally should not use COCs (U.S. MEC Category 3) until after 6 weeks postpartum. 1, 2, 3
After 6 weeks postpartum, there are no restrictions on COC use for otherwise healthy non-breastfeeding women. 4
Backup Contraception Requirements
When initiating COCs at 21 days or later postpartum: 1, 2
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 >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
Common Clinical Pitfall
Waiting until the 6-week postpartum visit to initiate contraception in low-risk women is a common error. 2 The CDC and ACOG emphasize that COCs can safely be started at 3 weeks in women without VTE risk factors, and delaying contraception unnecessarily increases the risk of unintended pregnancy. 2 Many women ovulate as early as 25 days postpartum, making timely contraceptive initiation critical. 5
Alternative Immediate Options
For women desiring contraception before 3 weeks postpartum: 2, 3
Progestin-only pills can be started immediately postpartum (U.S. MEC Category 1) with only 2 days of backup contraception needed 1, 2
Etonogestrel implant can be inserted immediately postpartum with a failure rate <0.05% and no restrictions 2, 3
Levonorgestrel or copper IUDs can be inserted immediately postpartum with no backup contraception needed 2, 3