Ep 114: Postpartum Contraception

Ep 114: Postpartum Contraception

Nicole: In this episode, you're going to learn about the important topic of postpartum contraception. This is a little more mature content. So use your best judgment as to whether or not you want younger folks to listen.

Nicole: Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get hello. Hello. Welcome

Nicole: To another episode of the podcast. This is episode number 114. Thank you for being here with me today. In today's episode, I'm really excited to talk about postpartum contraception. This is a really important topic. So in this episode, you're going to learn why is postpartum contraception important, you'll learn how to choose contraception, I'll review all of the various contraceptive methods including sterilization, long acting reversible methods, short acting reversible methods, barrier methods, post-coital methods, how they work, the risks, the side effects, all of that stuff. And then you'll also learn about lactational amenorrhea. There is a ton of useful information in this episode. This is one you're definitely going to want to listen to, and probably come back to. Now, before we get into the episode, I have a question. Have you made your birth plan yet? A birth plan is a really great way to help communicate what you want for your birth with your birth team.

Nicole: Now there's a common misconception that a birth plan is really just like a template or a checklist or a form, but really what a birth plan is about as an opportunity to ask questions of your provider, understand your hospital, so you know that the people who are going to be with you during your birth are aware of your wishes, and they're going to support your wishes. It's also an opportunity to understand whether your unique situation in your pregnancy is compatible with the things that you want for your birth based on your unique circumstances. So it's really so much more than a template checklist or form. And in this free online class that I have, I teach you how to go through that process. Again, this class is completely free. You can register for it at drnicolerankins.com/register. You can take it on demand when you register right away, or you can register for it at specific times, this is a great class.

Nicole: And so, so, so, so so many people have written to me about how useful they have found this class. So do check it out. It's drnicolerankins.com/register. All right, let's get into the episode about postpartum contraception. Okay. So why is postpartum contraception even important? Well, it's important for a couple of reasons. Number one, you can resume fertility probably sooner than you think. If you're not breastfeeding, the average time to first ovulation varies from 45 days, so just over a month to 94 days postpartum. The earliest reported ovulation in this particular study was 25 days postpartum. So when you're not breastfeeding, you can actually ovulate pretty early. And even when you're breastfeeding, depending on if you're exclusively breastfeeding or not, you could also potentially ovulate early. Ovulation is that opportunity for you to get pregnant again. So that possibility exists fairly soon in the postpartum period.

Nicole: Now, the other issue is that it's important to space pregnancies, something called the inter pregnancy interval. And this is the interval between when you have a live birth and when you get pregnant the next time. So conception of another pregnancy, the length at that interval has implications for outcomes in that next pregnancy. So a short inter pregnancy interval, so less than six months to 18 months is considered a short inter pregnancy interval that has consequences for that next pregnancy. It increases the chances of low birth weight, what's called small for gestational age, where the baby is smaller than expected, preterm birth, and if you've had a prior cesarean birth, it increases the risk of uterine ruptures, which can be a catastrophic event where the C-section incision on your uterus, not the one on your skin, but on your uterus opens up. And that can cause bleeding issues for the baby, all kinds of things.

Nicole: Okay. So a short inter pregnancy interval, which is less than six months to 18 months has potential negative consequences. So for most women who've had a live birth, the recommended inter pregnancy interval is 18 to 24 months. This is associated with the most optimal maternal and neonatal outcomes. Now, shorter interval may be appropriate for those who have advanced maternal age, which is considered 35 or older. I, myself, my inter pregnancy interval was actually 12 months. And part of that was because by the second time I was getting pregnant, I was 34 at the time. So, um, you know, we, we just didn't want to wait and everything turned out fine. Um, but we know that reduction in fertility is a concern as you get older. So something less than 18 to 24 months may be appropriate. But in general, we recommend 18 to 24 months. And I should also say that the data on poor outcomes and subsequent pregnancies is not terribly strong, but there is some suggestion that some issues can occur.

Nicole: So that's why we recommend that interval. And an important part of spacing pregnancy is having effective contraception. We also know the inter pregnancy interval is associated with the effectiveness of the postpartum contraception method. So women who use less effective methods and we'll go through all of the methods are more likely to have shorter inter pregnancy intervals. Whereas those who use longer methods or more effective methods have longer inter pregnancy intervals. So postpartum contraception is important again, because one, you can get pregnant fairly quickly after you have a birth potentially, and two, you want to space those pregnancies as best you can ideally between 18 and 24 months, keeping in mind that that may be adjusted if you're a bit older at the time of your second pregnancy. And to say things like, you know, I always hate it when people are like, Oh, just don't have sex.

Nicole: Like, that's ridiculous. It having sex is a normal part of being a human being. So, and you don't always have to have sex associated with having children. So it's a normal part of like enjoying being a human being. So it's perfectly reasonable to take an active approach in preventing pregnancy and just telling people not to enjoy this thing that is enjoyable, does not make sense to me. Okay. I'll get off my horse about that. All right. So let's move on to talk about how to choose contraception. So this really should be, what's called a patient-centered and shared decision making approach and shared decision making means that you work with your doctor or healthcare provider to make those decisions together, taking into account evidence, as well as your own values, as well as your own preferences. There's no one size fits all for the use of contraception.

Nicole: So when you do this process, it gives you the support that you need to make the best decision for your self. Okay? So it really should be a shared decision-making and individualized approach. And those decisions are influenced by a number of things like how large you want your family to be, what your beliefs are about contraception. Maternal age is another one. Uh, your health conditions influence it, whether or not you're breastfeeding influence it. There are also some system factors. For example, some women have insurance, uh, for a limited time after delivery, that's very common with Medicaid insurance. So you have to make a decision based on how long you have insurance available, or maybe you're changing jobs, and you're going to lose insurance, those kinds of things. Also certain hospital systems, particularly religious hospital systems like Catholic systems, that's what I work in, actually restrict access to contraceptive methods because of religious restrictions.

Nicole: So you have to take all of those things into account and then come up with an individualized approach to how you deal with postpartum contraception. Now, this is a conversation that actually should start during prenatal care in the third trimester. So you have an idea of what to expect. You can be thinking about it. You can be planning for it accordingly. Okay. And that can start off with as simple as a conversation is, you know, after you give birth, are you interested in having more children? So for some people and something, a question we ask after two or three children, you know, whether or not you want to talk about sterilization as an option. I think it's a little bit, I don't think any of us typically ask, like, are you interested in having more children after one child? Although there are plenty of people who want to just have one child.

Nicole: I have a good friend who only wanted to have one child and actually she could not get her tubes tied for a long time because people kept saying she was so young. Um, but you have that discussion of how many more children do you want to have. And when do you think that might be? And that can start off a discussion about spacing pregnancies and based on your age and kind of jump off the discussion from there. This is something that I don't think I did a very good job of when I was doing prenatal care. So this is something that you may have to bring up to your doctor yourself. Like, what do you want to do about contraception postpartum? I think it's reasonable to bring it up anytime in the third trimester, so you can plan appropriately. And then when you have that discussion, you want to discuss the different options for contraception based on your unique characteristics, review any medical issues that you may have that may contribute to the choices of contraception.

Nicole: The centers for disease control and prevention, the CDC, has this lovely chart. It's called US medical eligibility, eligibility criteria. And it's a chart that lists many different health conditions. And then it categorizes whether or not a particular contraceptive method is base it rates it based on a one to four. One means no restriction. The method can be used and all the way to four, when it's unacceptable, the methods should not be used. For example, if you have, if you're who has a history of migraines with aura, then combined oral contraceptive pills, that means pills that have estrogen and progestin in them. That's a four, that's an unacceptable health risk. The method should not be used if you have migraines with aura. Another example is if you have lupus, for example, and you have antiphospholipid antibody in addition to lupus, and that is also a, for most of the fours are around hormonal contraception, specifically estrogen. And I'll talk about how estrogen increases risk of issues as I go through the various methods. But this is a great chart to look in any conditions. I mean, it has things like bariatric surgery, uh, heart disease, liver disease, to help you understand what method may be good for you. Also need to discuss your plans for breastfeeding because different methods have different implications for breastfeeding. And I will go through those as well.

Nicole: Now, after baby is, is here in order to kind of address and finalize the plans for contraception, ideally we should really follow up sooner than six weeks. It really should be two to three weeks. We're getting better about doing sooner follow-up, but I don't think we're there yet. In fact, I know we're not there yet. Um, there's a wide variation in people who will attend that six week visit and then also a significant proportion of people studies show up to 50% of women in one study will resume sexual activity before the six weeks postpartum visit. So it happens, no judgment TMI full disclosure after my first daughter was, was born a Falcon and I resumed activity before six weeks because I mean, she was in the NICU, she was in the hospital, we were at home, you know, what were we supposed to do? So, so it does happen. It did not happen after the second one, things were a little bit different than, so it does happen that folks resume activity before six weeks. So I D and you could be ovulating by then potentially. So you definitely want to have a plan in place around, you know, a two to three weeks postpartum. So you don't find yourself unintentionally pregnant. All right.

Nicole: So let's get into the various methods of contraception. The first one I'm going to talk about, because this is one that I think people hear a lot about, and this is lactational amenorrhea. Lactation, amenorrhea is defined as using breastfeeding as a contraceptive method. If a woman is amenorrheic, amenorrhea means having no periods and you can't be using supplementary feedings and you cannot be using breast pumps, and you can do this for up to six months after delivery. Okay? So if you are exclusively breastfeeding, not using any supplementary feeding, not using breast pumps, that is not a bad form of contraception in the first six months after the delivery, the rates of pregnancy for lactational amenorrhea at six months range from 0.45 to 7.5%. Okay. So not a bad form. Now, and the reason that we think that this works, it's thought that the infant suckling in particular, so specifically having the infant at your breast reduces the secretion of something called gonadotropin-releasing hormone and luteinizing hormone, which in turn suppresses ovarian activity. Okay. So again, it has to be within the first six months, no supplements with food or formula and no breast pump use. That can be a little bit challenging, especially if you are going back to work. Okay.

Nicole: Now, once you start adding any supplemental feedings, once you are menstruating, your period has started again, or your baby is older than six months, then you need to transition to other contraceptive methods. All right. So after six months, your period starts, or you start supplementing or using a breast pump, then you need to use some other contraceptive method in order to be sure that you are definitely, definitely protected against getting pregnant unintentionally. Okay. So let's go through the more traditional contraceptive methods and we're going to go through from most effective to least effective. So let's start with sterilization, permanent sterilization of either the female or male partner is an option. If you don't want to have any more children, it works very well. The efficacy rates are greater than 99%. Meaning that per 100 women who have a permanent sterilization or poor per 100 I should say sterilized people, there will be less than one pregnancy, okay.

Nicole: Less than one pregnancy per 100 women. Um, who've had a permanent sterilization or the partner has been permanently sterilized. Now for the female postpartum sterilization can be performed after a vaginal birth. And that can be done either with what's called a bilateral partial salpingectomy. So that is removing a portion of the tubes. We don't actually, I don't even the expression tie tying tubes. We don't actually like tie the tubes. We tie, we actually cut a piece out of the tubes. So that's what a partial salpingectomy is, or a bilateral complete salpingectomy, we, which is completely removing the entire fallopian tube. So you can do that after a vaginal delivery, through a tiny incision, right underneath the belly button that can be done between 24 and 48 hours postpartum. And we can do that typically for full term birth, because the uterus is still big enough that it's, it's reaching right underneath the belly button.

Nicole: So you make this tiny incision under the belly button, and then you can kind of find the tubes because they're right there because the uterus is bigger. Now at the time of cesarean, you're wide open and sterilization can be done either by a complete salpingectomy. So removing the tubes all together. And these days, we actually recommend that if possible, you have your tubes completely removed, there is much, much, much evidence that shows that that will reduce the risk of certain types of ovarian cancer. So ideally you want to get your tubes completely removed. At a cesarean, they can either be completely removed or a partial salpingectomy, but again, I highly stress that they should be completely removed if possible, to reduce that risk of ovarian cancer. Now, unfortunately, studies show that up to one third to one half of women who want a postpartum sterilization do not get the procedure.

Nicole: And typically that's going to happen after a vaginal delivery. And the reasons that that can happen are if you have extra tissues, if you carry extra body weight, remember I said that in order to feel the uterus after a vaginal birth, so you can reach the tubes, it has to be right at about the level of the belly button in, and you have to be able to feel it and see it. So if you have extra fat tissue that gets in the way or increases the distance to get to the tubes, it's very difficult to do it after a vaginal birth. Also, if you had a baby born preterm, your uterus is going to be smaller. So we're not going to be able to reach it from that tiny incision under, underneath your belly button. Otherwise at a cesarean you should be able to get a sterilization unless you are having a baby at a Catholic hospital. Uh, and at that, at those facilities, sterilization is not permitted only under very rare circumstances. And you have to get approval first to do so. Now, if you want sterilization, and for whatever reason, it can't be performed right after birth, then typically what we do is do another form of contraception and then schedule you for what's called an interval, laparoscopic sterilization, anywhere from six to eight weeks later, I personally had a laparoscopic sterilization. I mean, this was years after my last one was born, and this is a outpatient procedure. You go home the same day. You recover in a few days, it's tiny incisions, one around your belly button and one or two in the lower part of your abdomen. And typically you can have your tubes removed. It's a very straightforward procedure. So if you don't get it done in the hospital, you can typically get it done within six to eight weeks afterwards or longer.

Nicole: If you want to. Now, if you have Medicaid for your insurance, you almost certainly will have to have a signed sterilization consent, a specific Medicaid sterilization consent that was signed at least 30 days before delivery for a full-term birth or 72 hours before delivery for a preterm birth. And this came from the fact that, um, years ago, and actually in some cases, not too long ago, thirties, forties, fifties, people were sterilized in the U S against their will. Okay. So if you were intellectually disabled, if you were incarcerated, some members of minority groups were getting sterilized without their consent. You know, it was just kind of happening as sort of a, you don't need to have more babies kind of decision. So they implemented this policy that if you have Medicaid, you have to have the signed consent. There has to be this discussion. Now there is some talk today that these restrictions aren't as necessary, and they actually may create unnecessary barriers to permanent contraception for people who have Medicaid insurance.

Nicole: Um, but that's just a little bit of the history of where they came from. Now for males, males can also get permanent sterilization. That's called a vasectomy. That's a surgical procedure. It happens in the office. It is highly effective. It's minimally invasive and very widely available. Now you do have to use a backup method for three months before vasectomy is fully effective. Whereas for female sterilization, it is effective right away. Now, one thing I want you to know is that you should consider sterilization permanent, okay? Permanent, permanent, permanent. You sh you can reverse a vasectomy. You can potentially sew the tubes back together, but that can be really difficult and really challenging. So do not get a sterilization unless you are considering it permanent. Okay. So let's talk about reversible methods and we're going to first start off with reversible implants. These are extremely effective at preventing pregnancy.

Nicole: Actually, they have slightly lower failure rates than permanent sterilization, except they're reversible. We're going to first talk about the implant. The progestin only implant it's called Nexplanon. It is a single rod that goes in your upper inner arm. It has a hormone in it called progestin, in the specific progestin etonogestrel, the device itself is short. It's about one and a half inches long, and it's very thin, only two millimeters wide. So it's a tiny device, although it goes right under the skin and you can feel it while it's there. It's approved for use for three years, but data suggests that it can actually work for up to five years. Most women are candidates for the Nexplanon implant. They're not many women who cannot have it. The Nexplanon can actually be done prior to discharge from the hospital. It's not something that happens very commonly, just because mostly it's like insurance barriers and getting the right materials and all of these things, it's way more complicated than it needs to be, but it can be difficult to get it done in the hospital, but it can be done prior to discharge from the hospital.

Nicole: But if not, they can be very easily inserted in the office with just local anesthesia. They go in very, very easy. There are some potential side effects. One of the biggest ones that I see people have is a change in bleeding pattern. Okay? You may have longer periods. You may have shorter periods. You may have no periods at all. And I can't predict, or we can't predict if you're going to fall into those categories. I will say the most common side effect is unscheduled bleeding. It's irregular bleeding, which happens in about 11% of users. And it may or may not get better with continued use. We have not a very good way of predicting whether or not it will or won't get better. It doesn't necessarily have to be heavy bleeding, but it can be annoying because it's like, you never know when it's going to come.

Nicole: And in fact, this unscheduled bleeding is the primary reason that people stop using the Nexplanon or get it, get it taken out. Now treatment of this bleeding is not necessary, but because it interferes with like quality of life and things like that, there are some things that can be done to help with it. I'm not going to go into all of that here, but there is a possibility to help control the bleeding and get it regulated. Um, also this doesn't protect against sexually transmitted infections. I should say the only thing that protects against protects against sexually transmitted infections is going to be condoms. Now, as far as breastfeeding, this implant does not appear to have any negative effects on breastfeeding. Um, the data is limited. The studies are small, but there's best as best we can tell it does not affect breastfeeding. And that's why we can offer it prior to discharge from the hospital.

Nicole: The other good thing about the Nexplanon is that the hormone effects end pretty promptly after removal. So the circulating levels of the hormone are undetectable within a week. More than 90% of women will isolate within three to four weeks after removal of the Nexplanon. Okay, next up is the IUD, the intrauterine device. This is the most commonly used method of a long acting reversible contraception. It's safe. It's easy to use. It's very cost-effective again, it's a non-surgical option that is as effective, even a tiny bit more effective than surgical sterilization. Now, there are two types of IUD that are available in the United States. One is a copper IUD. It's called paraguard. They're both T-shaped, uh, copper IUD called paraguard. It can be left in place for up to 10 years. And then, um, the levonorgestrel IUD, there are actually four different types.

Nicole: Mirena is the most popular or most well-known one. I should say the one that's been around a long, the longest. So there are four different, um, variations in terms of how much hormone is there. And they can stay in for three to five years. The way IUD's work is that just having that foreign body there. So having just the IUD sitting there in and of itself causes what is referred to as a sterile inflammatory response. Okay. So your body knows is this foreign thing is there, it produces a little bit of an inflammatory action, but it's sterile. Meaning it's not an infection and there's no bacteria, but that inflammatory environment is toxic to sperm. It's toxic to eggs, so nothing can implant there also, it can, um, the release of something called cytotoxins, inhibit sperm, motility, it kills sperm. So that's how it works.

Nicole: And then the hormones in the progestin IUD have additional effects on your menstrual cycle. Now what a lot of people may not know is that these can actually be inserted immediately after birth. And by that, I mean, right after the placenta is out, you can insert either a copper or, um, the levonorgestrel IUD. That doesn't happen very common. Oh, it can also happen at vaginal and cesarean birth. So either one, now this doesn't happen frequently and it is largely related to insurance and who's going to pay for it. It's silly, but it's something about it being in the hospital that makes it difficult to get insurance to pay for it. Now, inserting it right after birth does increase the risk of expulsion. So there is that risk there. It does not however, increase the risk of uterine perforation, which is where you can poke a hole through the uterus with the IUD itself.

Nicole: It is also associated with an abnormal position. Normally it's going to sit like a straight up T in the uterus. It's more likely to get twisted or turned when it's inserted postpartum. However, the significance of that isn't really known. And for the most part we assume is if you're not having pain, as long as it's in the uterus, if it's not bothering you, even if it's a little bit twisted, it's still doing what it's supposed to do. Now, as far as side effects for the copper IUD, your periods may be heavier, longer or more painful, particularly in the first several cycles after the IUD is inserted. For the levonorgestrel IUD's like Mirena the most common, um, changes and bleeding patterns are prolonged. Bleeding is not necessarily heavy, but it's just like persistent. And there can be spotting. That happens for up to 60% of folks, followed very closely by unscheduled bleeding up to 50% of people.

Nicole: And then 20% of folks will have no periods at all. They will become amenorrheic. Now those changes are just a side effect of the hormone. They're not dangerous. Um, it's very, very common. Typically these issues with bleeding will improve by six months of use. So I always say give the Mirena six months before you decide whether or not you like it or not. If you can stick it out for six months and give it a chance it's typically going to settle down at that time. Now the copper IUD does not affect milk or breastfeeding at all. And then the levonorgestrel IUD is generally have reported either no effects on breastfeeding or very minimal effects on breastfeeding. So that is why they too are both considered safe to start immediately postpartum. Okay, let's go to the next tier in terms of effectiveness.

Nicole: And these are short acting reversible contraception, and these are going to be your progestin injections that's Depo-Provera, oral progestin pills, also known as the mini pill, and then combine estrogen and progestin products, which are either birth control pills, the patch, or the vaginal ring. These are all also effective, just not as effective as the long-term reversible methods. They have effectiveness rates in the range of 93 to 96%. So four to seven pregnancies per 100 women. These are all easy to use, low cost, very common methods of contraception. So let's first talk about the progestin only injectable. This is depo medroxyprogesterone acetate also known as Depo-Provera. It is a single injection that lasts for 12 weeks. Okay. This can be given during the hospital admission, all of this, a little bit controversial depending on what organization you go with. And I'll talk about it in just a minute, but it can be administered during the hospitalization.

Nicole: It also works as a nice bridge for someone, for instance, who wants to get a sterilization down the line, you can get a shot of the Depo, and that's going to keep you protected for 12 weeks until you can get your sterilization scheduled, or you'll get a shot of the Depo until you can get your office appointments scheduled to get an IUD. Or if you want to just continue the Depo, you can do that as well. Now, as far as side effects, menstrual changes, again are the most common reason that people will discontinue using depo, unpredictable, bleeding, and spotting are quite common. It's also difficult to tell who is going to have that unpredictable bleeding. So it's really a little bit of a gamble in the sense that you're getting this medication it's in your system for 12 weeks. You can't reverse it. Whereas like the IUD, when those cause abnormal bleeding, you know, if you get sick of it, you can ultimately, like, I just want this thing out.

Nicole: Whereas with the depo, you have to stick with it for 12 weeks. Also, the Nexplanon can be removed as well, but the depo is in your system for 12 weeks. There's no way to reverse it. Now on the flip side, almost half of women will stop having periods after one year of the depo. So it's a good chance that your periods will actually stop all together. And I should say, when periods stop, when you're on hormonal contraception, it's not because like, things are building up inside your uterus or anything like that. It's that the hormones are making it so that nothing builds up inside your uterus. So there's nothing that's there to come out. So don't have to, you don't have to worry that like all of this stuff is accumulating inside of your uterus because you're not having a period when you're using hormonal contraception.

Nicole: Now that's different if you're not on hormonal contraception or, and you don't have a period after four months, and that is a concern, but when you're on hormonal contraception is not a concern. Okay. So back to the depo, um, other side effects other than the irregular bleeding are that there is a bit of a tendency and this data's a little bit mixed that you can gain weight on depo. Okay? So if you already have a tendency to gain weight easily, you may struggle with weight gain while using Depo-Provera. We think that that may be related to how the progestin affects your appetite. Also for people who are susceptible depo can trigger headaches as a side effect in some folks also can trigger mood changes and people who are, um, prone to things like pre-menstrual syndrome. If you have mood disorders underlying like depression or anxiety, depo can potentially make those depression symptoms worse.

Nicole: And if you have depression, it doesn't mean that you can't start depo, but we have to watch you a little bit more carefully to make sure it's not worsening your depression. There's also some concern that depo may increase your risk for postpartum depression studies are conflicting. So we have to be careful about that as well. Depo will also reduce your bone mineral density. So you have to be very careful about making sure you have adequate intake of calcium and vitamin D of course, do things that we should all do, like regular exercise, avoid cigarette smoking. We have gone back and forth about how we monitor it. Like, Oh, you can only be on depo for three years before you have to switch to something else because of the effects on the bone mineral density, or you have to get a scan to make sure your bone mineral density is okay if you want to stay on it for longer than three years.

Nicole: So we've kind of gone back and forth on that. The latest I believe is we don't have to do any special monitoring or anything. Um, we do have to be careful in people who are, for some reason at an increased risk of having weaker bones to start with. So it will affect your bone mineral density. It also is associated with the increased risk of diabetes in women who already have an increased risk of diabetes. If you gain weight while on it, it can increase your risk of diabetes. Now, as far as how it affects breastfeeding, most studies have reported either no change or actually better breastfeeding outcomes, um, and no harmful effects on babies growth or health or development. However, there are some animal studies that have reported a possible effect of Depo-Provera on the developing rat brain. So the World Health Organization actually recommends delaying depo in lactating women until six weeks postpartum.

Nicole: Okay. So if you're breastfeeding, they recommend delaying it until six weeks postpartum. If you're not breastfeeding, then you can get it right away. They do provide a caveat that the benefits may outweigh, outweigh the risks. So if you want to do it, then do it. Um, and the CDC says you can do it right away. So there is that caveat there, but it may affect breastfeeding theoretically, or I'm sorry. It may affect infants, theoretically, that has not been proven. That is just based on those rat studies. The biggest issue with me for depo is how it can affect your return of fertility. There is a small proportion of women who even after the last depo shot happens, your fertility will not be reestablished until eight, 18 months after the last injection. Yes. I said that right, 18 months after the last injection. And we don't have a way of knowing if you will fall into that category, there tends to be a higher risk of this happening from women who have higher body weights.

Nicole: But again, we don't know exactly who this happens to. Okay. So if you want to become pregnant within the next one or two years, do not use depo because it can have that negative effect on your fertility that lasts way after the last shot. Okay. Let's move on to talk about the progestin only pills. They are also called the mini pill. And I don't know why they're called the mini pill, I guess, cause they're like a mini version of traditional birth control pills. These pills only have progestin. Standard or typical birth control pills have progestin and estrogen. These only have progestin. These can be started anytime after delivery. Okay. That's the benefit of those? Their efficacy though, their effectiveness is a little bit lower than combined hormonal contraception because you really have to be careful to take them at just about the same time every day.

Nicole: Otherwise they don't work as well. These are an option that are good for women who can't use estrogen for whatever reason, maybe they have a history of blood clots or they prefer not to use estrogen for another reason, but still want to take a pill. As with many of the other contraceptive methods, unscheduled bleeding, changes in period, most common side effect that's going to be associated with that and actually fairly common. Also the most frequent cause for stopping the contraception. Okay. They don't cause significant weight gain though, which is great. They also don't cause an increase in headaches, but they may cause acne to get a little bit worse. As far as the effects on breastfeeding, the data suggests that progestin only pills do not have a negative effect on breastfeeding. So both the World Health Organization and the CDC agree that breastfeeding women can use progestin only pills any time during the postpartum period.

Nicole: Okay. So let's talk about combined hormonal contraception and that comes in three forms: pills, the patch or the vaginal ring. And these are combined hormonal contraception because they can include both estrogen and a progestin. Okay. They have both. Now the big thing about combined hormonal contraception is that it is not recommended until at a minimum three weeks postpartum. That's the earliest you can start it. So three to six weeks postpartum because of the effect that estrogen has on increasing the risk of venous thromboembolism disease or blood clots that can form in your legs that can travel to your lungs for a pulmonary embolism, which can be catastrophic. Now, pregnancy in and of itself, including the postpartum period, just being pregnant and postpartum increases your risk of having venous thromboembolism disease. And we don't want to add the risk of estrogen on top of that.

Nicole: So we do not start combined hormonal contraception until three to six weeks postpartum at the earliest. Then when we talk about the various method, birth control pills, combined oral contraceptive pills contain a similar estrogen component, but in varying quantities, whether it's a low dose amount of estrogen or higher dose, and then one of a dozen different progestins. So it's all the same estrogen, different progestins. They can also be monophasic where you take the same pill every single day. Multi-phase where you take different amounts of the hormone at different points in the cycle. You can do birth control pills cyclically, where you have a menstrual period or continuously where you don't. So there are a lot of permutations that can happen with birth control pills, if you definitely want to do birth control pills, you like birth control pills. I took birth control pills for many years. I also had an IUD for a little bit as well. Um, you can start if you really want to do birth control pills, you can start the progestin only pills immediately after birth, and then use those for six weeks and then transition to the combined pills, which are a bit more effective after six weeks. And then the difference between the pills, the pills you have to take every day, roughly around the same time every day. Whereas the patch is delivered through a patch on your skin and you have to change that weekly. And the ring is absorbed through your vaginal walls and you leave that in for up to three weeks, take it out, either have a period or put in a new one right away for another three weeks. Now, common side effects of these methods of having estrogen and progestin. And a lot of this is related to the estrogen, breast tenderness, nausea, bloating are common and they tend to be worse with higher doses of estrogen. They typically resolve very quickly though. Occasionally you may have unscheduled bleeding that typically resolves with within three months. It may also impact your mood. It may decrease your sexual desire. That data is mixed. There's definitely no evidence that it causes weight gain though. And definitely overall, it doesn't appear that it increases your risk of cancer. We do know that combined contraception, estrogen and progestin is associated with the increased risk of high blood pressure. So you have to be careful there also heart attack and stroke in certain populations. And we also know that there's an increased risk of venous thromboembolism disease. Um, it varies based on age, your weight, whether or not you smoke, the risk is higher if you smoke and it can be even the relative risk can be very high meaning like if look at people who aren't on birth control pills, and then you compare them to people who are depending on certain populations, the risks can be seven to eight times greater, but the absolute number is still very low.

Nicole: Meaning that when you, it may be like just an example, these aren't exact numbers. It may be like seven in a thousand versus one in a thousand. So that's going to look like a seven times different risk, but still the overall number even seven in a thousand is still low. So the absolute risk of developing blood clots with contraception is low. Now the impact of combined hormonal contraception, whether it's pills, patch, the vaginal ring on breastfeeding is mixed. Like the data is, is not very consistent. The World Health Organization, because of that actually recommends delaying the use of any estrogen containing methods until six months postpartum for women who are, who are primarily breastfeeding, because breastfeeding is very important and they want to be sure that women are able to have everything in the best possible setup and not have this potential negative impact from combined hormonal contraception.

Nicole: So they recommend no estrogen containing products until six months postpartum. And that you only do non-hormonal methods or progestin only methods. Okay. Now the CDC recommends delaying till at least 30 days postpartum due to the increased risk of the venous thromboembolism disease and breastfeeding women maybe can even delay it up to 42 days or six weeks postpartum before they start combined contraception. So that is one that you really need to be mindful for in terms of the impact of breastfeeding is any estrogen containing birth control and how that, that may have an negative impact on breastfeeding. So keep that in mind. All right. And let's end with what are considered the most or the least effective methods. Uh, and these are pericoital methods and barrier methods. They have rates of roughly about 13 pregnancies out of a hundred women. Okay. So 13 pregnancies out of a hundred women with these methods and pericoital methods are diaphragm, cervical caps, which I have never in my 19 years, since I graduated from medical school, seen or prescribed either one of these are not very common.

Nicole: They can't be used for the first six weeks postpartum because the uterus is still undergoing changes. You can however, use spermicides or the contraceptive sponge within the first weeks postpartum. Although you may have some vaginal irritation, you can use both male and female condoms without restrictions in the first six weeks after delivery. And neither one of those peri-coital methods or barrier methods impact your milk supply or breastfeeding. And finally, I do want to say a word about emergency contraception. Um, emergency contraception is still out there and can be used in the postpartum period. You can access it in the pharmacy. You don't need a prescription. Um, also the copper IUD is considered a form of emergency contraception as well. There's also oral evonorgestrel that's plan B. There is something else called oral. Um, Ulipristal I'm, you know what I'm saying? That right? That one you may need a prescription for, but these are all safe to use in the postpartum period and breastfeeding.

Nicole: So remember that emergency contraception is available okay. For the Ulipristal, you have to not breastfeed for 24 hours after that, but otherwise it is considered safe. And then the final thing I want to talk about is fertility awareness based methods. That's also called natural family planning. And what that involves is identifying fertile days of your menstrual cycle using, um, the cycle length, physical manifestations of ovulation, like change in cervical secretions, basal body temperature. And then you avoid sexual intercourse on the days that you know that you are fertile or you use barrier methods on those days, you can also use these methods in reverse in order to try improve the chances of conception by, um, having sex on the days that you know, that you're most fertile, this is going to be tricky if you're breastfeeding and you can't really do it until your periods resume.

Nicole: Okay? So this isn't something that you're going to be able to do, like right away after birth, but it is something that you can think about in the future. If you want to not have any type of hormonal method of contraception, pregnancy rates are reported as high as 25% using a fertility awareness based methods. But some of that is like people who weren't really paying attention, it's actually lower. If you're really diligent about paying attention to all of the things, and it does require some diligence in order to do that. Okay. Whew. That was a lot. So just to recap, postpartum contraception is important to help with pregnancy spacing also because your ovulation can resume as soon as 25 days after birth. So you can get pregnant fairly quickly and you have no way of knowing whether or not you're going to be that person who ovulates sooner or who ovulates later.

Nicole: This is something that needs to be discussed during pregnancy, and then have that visit at two to three weeks um, uh, afterbirth as up to half a women will resume sexual activity before six, six weeks. As far as the effectiveness of methods, the most effective methods are permanent sterilization and then reversible methods like the Norplant not Norplant nor plain is what it used to be called way back in the day. I just dated myself like Nexplanon or the intrauterine device. Those are great. You don't have to think about those or anything like that. And then next level of effectiveness are the depo injection and then oral contraceptive pills, whether it's progestin only pills or combination pills, you cannot do combination pills, the patch or the ring for at a minimum three weeks, potentially longer six weeks, because it increases the risk of blood clots in the postpartum period.

Nicole: And then the least effective methods are condoms or even withdrawal or sponge. You have to be careful about using those every single time. Um, you definitely have to think about it. You can also do fertility awareness based methods. Once your period comes back a spermicide, you can use fairly quickly. You can't use a diaphragm until after six weeks. Okay. That was a lot of information. There you have it. Now be sure to subscribe to the podcast in Apple Podcast or wherever you're listening to me right now. And I would love it if you leave an honest review in Apple Podcast, it helps other women to find the show and it helps the show to grow. I do shout outs from those reviews from time to time. And I just love to hear what you say about the show. Also be sure to check out my free online class on How To Make A Birth Plan That Works. You do not want to go into your birth without this. It is completely free register at drnicolerankins.com/register. And that is it for this episode, do come on back next week. And until then, I wish you a beautiful pregnancy and birth.

Nicole: Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast, head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain in labor and warning signs to look out for after birth. You'll also find information on my free online class, on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.