Birth control pill and breastfeeding
QUESTION (submitted 1/09/2022):
"When prescribing a birth control for a breastfeeding mom who is breastfeeding at least 4x day but who has experienced breakthrough bleeding, ie got a period, and now wants to start on an oral birth control (wants something easy reversible so she can get pregnant again in about a year if she wants) but doesn’t want her milk supply to diminish and doesn’t want to deal with staining/spotting as she would not be able to go to the mikvah (ritual bath in orthodox Jewish woman after 7 clean days so that she can resume marital relations) what would be your best choice?"
Thank you for your question.
Without knowing how long ago you had your baby or your health history, here is some information. You are correct that any birth control pill you choose will be easily reversible to plan your next pregnancy.
For breastfeeding women, a progestin only birth control pill may be started immediately after birth, and it is not believed to affect milk supply. But this type of pill is associated with more spotting and unpredictable bleeding.
Regarding choice of birth control and breastfeeding, the CDC states: “Certain women might be at risk for breastfeeding difficulties, such as women with previous breastfeeding difficulties, certain medical conditions, and certain perinatal complications and those who deliver preterm. For these women, as for all women, discussions about contraception for breastfeeding women should include information about risks, benefits, and alternatives.”
The type of pill that would be associated with a better bleeding pattern is a combined birth control pill (has estrogen and progestin). After milk supply is well established, this type of pill is generally not believed to affect supply either. But this pill may not be used immediately postpartum because of an increased risk for blood clots.
A combined pill in breastfeeding women may be started between 30-42 days postpartum, according to the CDC, only if a woman has no other risk factors for blood clots. Risk factors include age > 35 years old, had a blood clot in the past, has a clotting disorder that increases risk of clots, is immobile for some reason, has peripartum cardiomyopathy, received a transfusion at delivery, has a BMI > 30, had a postpartum hemorrhage, had a cesarean section, preeclampsia or smoking.
This is because, as CDC states: “VTE risk is increased during pregnancy and the postpartum period; this risk is most pronounced in the first 3 weeks after delivery, decreasing to near baseline levels by 42 days postpartum.”
If you have any of those conditions that increase risk for blood clots, the CDC recommends waiting to start a combination birth control pill (or vaginal ring or patch) until 42 days postpartum, when they have determined benefits to outweigh risks. Some data suggest waiting even longer until 13 weeks have passed when any effect of the postpartum condition on blood clots is gone.
If you want more specifics of which combined pill will give you the best bleeding pattern, in general, a pill with 30 -35 micrograms of estrogen in each pill usually has less spotting than low dose pills with 10-25 micrograms of estrogen.
The option that gives you the least periods is to take hormonal pills continuously, skipping the placebo pills, and therefore not getting a “pill period.” But this would space out your monthly bleeds to longer intervals e.g., you would get a period every two months or every three months or longer (whenever you schedule one). There would be fewer mikvah visits but if you must attend the mikvah monthly then this would not be an option.
DISCLAIMER: This information is for educational purposes only and not intended to guide individual therapy. Answers should never substitute for consultation with a healthcare provider or counselor who can make decisions based on an individual’s history, desires, and circumstances. Always seek the advice of a clinician for any questions regarding health, medical condition, birth control method or other family planning or social issues. Under no circumstances should an individual use this information in lieu of, or to override, the judgment of a treating clinician. Dr. Zieman, or SageMed LLC, is not responsible, or liable, for errors, omissions, or any damage or loss incurred as a result of use of any birth control method or use or reliance on any material or information provided through this website.