Q Ask the Experts

How to start mini-pills in a breast-feeding mom

How do you initiate mini-pills in a lactating woman who specifies such pill use for contraception? The following experts weigh in on the subject: Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta, and Sharon Schnare, RN, FNP, CNM, MSN, clinician at South Kitsap Family Care Clinic, Port Orchard, WA.

Question: If a breast-feeding mother wants to start oral contraception six months postpartum rather than the initial three to six weeks, can you start mini-pills at any time? If she has not had a period yet, we don’t know where she may be in her cycle. Do you just pick a random Sunday start date, or have to do any labs, etc.?

Hatcher: Your breast-feeding mom has not had a period yet. But she is in a period of time when it is quite likely that she will ovulate before her first period. The probability that ovulation will precede the first menstrual period in a lactating woman increases from 33%-45% during the first three months to 64%-71% during months four to 12 and 87% after 12 months.1-3 She may have ovulated already.

You may start her on mini-pills immediately if she have been using condoms for the past two weeks and has a negative pregnancy test. If she has not had intercourse for the past two weeks and has a negative pregnancy test, she also may start mini-pills. If she has a period, then start mini-pills immediately (on the first day of bleeding).

Schnare: This postpartum woman may start mini-pills at any time, irrespective of her cycle. I would assess whether she has had unprotected intercourse. I would do a pregnancy test and offer her Plan B and condoms. If she is not pregnant, I would start progestin-only pills immediately with a seven-day backup. Have her keep a menstrual calendar, and encourage her to return for more effective contraception if she is interested. It is important that she know to take the mini-pill every day within a two-hour window. This may be most challenging for a mother with a 6-month-old baby.

Starting combination hormonal contraception

When do you start combination hormonal contraceptives in women who are not regularly menstruating? Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville, offers this approach:

Kaunitz: This question comes up frequently. The question refers to a woman with lactational amenorrhea. Another example when this question arises is in the patient with amenorrhea/ oligomenorrhea associated with polycystic ovarian syndrome: She will benefit from starting combination hormonal contraception but because she does not regularly menstruate, clinicians query when to initiate birth control.

The answer is straightforward. Combination methods can be initiated any time the clinician can be sure the patient is not pregnant.

Sometimes the history is sufficient (the patient indicates she has never been sexually active or has not been active for an extended period of time); other times it is important to perform a sensitive urine pregnancy test to rule out pregnancy.

If the patient would benefit from a Sunday start (or a start day any other day of the week), the method can be started on that particular day. Otherwise, the contraceptive should be started as soon as pregnancy can be excluded.

References

  1. Campbell OMR, Gray RH. Characteristics and determinants of postpartum ovarian function in women in the United States. Am J Obstet Gynecol 1993; 169:55-60.
  2. Lewis PR, Brown JB, Renfree MB, et al. The resumption of ovulation and menstruation in a well-nourished population of women breast-feeding for an extended period of time. Fertil Steril 1991; 55:529-536.
  3. Kennedy KI, Trussell J. "Postpartum contraception and lactation." In: Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology: 18th revised edition. New York City: Ardent Media; 2004.