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Contraceptives in the postpartum and breastfeeding: the keys to knowing when and what method to use

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He postpartum period It constitutes a new situation for women, which forces them to rethink contraceptive options and adapt them to the circumstances, being a good time to advise both patients who were already using it previously, and those who did not, taking into account that The minimum recommended period before seeking a new pregnancy is 12 months.

Contraception in this period will depend on both the usual criteria and breastfeeding. In the lactating women, the first ovulation usually occurs around 6 months after giving birth, but this period is very variable, and depends, above all, on the duration of breastfeeding and the use of supplements, in case of artificial or mixed breastfeeding (it usually takes longer the more exclusive is breastfeeding). In fact, patients who do not exclusively breastfeed can become pregnant even before the return of menstruation.

In general, the hormonal contraceptives can be classified into 2 groups: those of mixed hormonal compositionthat is, estrogens and gestagens and others gestagenic-only composition. Both have high contraceptive efficacy and, in general, have no or minimal side effects and are well tolerated. However, the use of hormonal contraception during breastfeeding has special connotations since, although it can be used, not all types of contraceptives are recommended.

Which ones to use in this period?

Progestin-only methods: they contain only one type of hormone, progestogens, which exert their main contraceptive effect by blocking ovulation. They do not affect the establishment of lactationdo not alter the quality or quantity of breast milk and no adverse effects have been observed due to exposure in infants, being, therefore, the choice in this period.

Progestin-only pill or minipill (Cerazet®, Azalia®, Nacrez®): it can generally be prescribed immediately after delivery. Its use is oral, daily and its contraceptive effectiveness begins after 48 hours. Efficacy: high.

Implant (IMPLANON NXT®): This is a thin vinyl rod, which is placed on the inner side of the non-dominant arm and produces a continuous release of hormones for a maximum period of 3 years. It can be placed immediately after delivery. Its insertion method is ambulatory and protects from 7 days after placement. It is recommended that the patient come to the clinic for a follow-up visit after 3 months and occasionally palpate the implant area to ensure its location. Efficiency: very high.

hormonal iud (Mirena®;Kyleena®): this is an intrauterine device that continuously releases levonorgestrel for a maximum period of 5 years. It can be safely placed within the first 24 hours of postpartum, or after 4 weeks, as long as there is no suspicion of puerperal infection. It can also be used in patients with cesarean section. The insertion of the device is outpatient and it is recommended to perform an ultrasound control one month after insertion. Efficiency: very high.

These methods can be withdrawn whenever the patient wishes and the recovery of fertility is immediate with all of them. They can alter the patient’s usual bleeding pattern, generally decreasing menstrual quantity and duration, without altering the effectiveness of the method.

There are other hormonal contraceptive options that can be used safely during breastfeeding, although not in the immediate postpartum period:

From 6 weeks: Medroxyprogesterone (Depo-progevera®): it is a progesterone-only method, with the same functioning, however, due to its special formulation, its use is not recommended during the first weeks since there is a risk of exposure of the neonate to steroids. Recovery of fertility after discontinuation is slower, it can take up to 6 months. Its administration is intramuscular every 3 months. Efficacy: high.

From 6 months: Combined hormonal contraceptives (oral, vaginal or patches). Their use is not recommended before 6 months as they increase the risk of thrombosis during the first weeks postpartum and can reduce the amount of breast milk. Efficacy: high. Recovery of fertility is immediate after suspension.

Emergency contraception (“morning after pill”) and breastfeeding:

Levonorgestrel 1500 μg (Norlevo ®, Postinor ®) is safe for use during breastfeeding. It is useful for up to a maximum of 72 hours after risky sexual relations, although its effectiveness decreases as time passes.

The requirements for prescribing hormonal contraceptives are simple, with a detailed medical history and basic physical examination being sufficient.

*Dr. Olga Redrado is a gynecologist in the Women’s Unit of the Quirónsalud Zaragoza Hospital.

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