It might sound crazy, but chances are your obstetrician or midwife will ask you about birth control while you’re still pregnant. They might follow up as you hold your newborn in your arms in the hospital or at home. And they will probably ask you yet again at your first post-partum provider visit.
Seeing as how having another baby is probably not top of mind on any of these occasions, we felt like this topic deserved more than a minute or two of attention during what is so often a fast and furious office visit (maybe even with your little one in tow).
Leading OBGYN Kurt Wharton took an hour out of his frenetic schedule to talk candidly with us about birth control options post-partum. Below are his thoughts.
Spoiler alert: he favors an IUD for most women, especially those who have just given birth.
Disclaimer: these are but one provider’s recommendations.
On the Pill…
We have been using oral contraception post-partum for [decades]. Early pills were 20-30x stronger [in terms of estrogen levels] than the low dose Lo Loestrin we use today.
Over the years there have been a lot of side effects to the Pill, but healthcare companies have been able to markedly reduce estrogen levels. Some women worry that the Pill will negatively affect their milk supply. The majority [of my patients] do not have milk supply issues with any of the low dose pills. For those who do see a milk production drop from with the estrogen in low dose pills, I recommend the “mini pill,” which has no estrogen, but progesterone only.
Most birth control pills have 1 mg of progesterone. The mini pill has .45, so less than half of the normal amount. Taking the mini pill while breastfeeding is considered an effective form of birth control. However, once you stop breastfeeding, the mini pill’s success rate drops to about 90%. So when someone weans, I recommend she go back on a combination pill.
The mini pill does have positives. Some women have severe endometriosis [a condition where uterine tissue grows outside of the uterus] and don’t want estrogen in their blood at all. Women with blood clots may not want estrogen. And women who smoke shouldn't take estrogen. For me, if I have a patient who is 35 and older and a smoker, I take her off birth control pills completely.
Progesterone can promote acne, but estrogen is often good at controlling it. For women who want acne control, I’d recommend something like Femcon, which has 35 mcg of estrogen, but only has .40 mg of progesterone.
The Seasonique pill [where you only get period every quarter] is great. It’s actually not healthy to have a period every month - there is no biological reason for it. With Seasonique, you get a box with three months of pills in it. It definitely makes it easier for patients to not have to go back to the pharmacy as often. But you can actually do what Seasonique does with any birth control pill. Just throw your placebo pills out and go to the new pack. Then every several months, take four to seven days off to have a period. This is actually more natural.
On the IUD…
Right now we are seeing a huge push from the American Congress of Obstetricians and Gynecologists (AGOG) to encourage the long-acting intrauterine device (IUD). And that shouldn’t impact lactation because the hormones (progesterone only) are localized.
With IUD insertion, there’s tremendous variability among providers – technique is so important. Wrong technique can cause pain and also problems with migration of the device. I personally use [local anesthesia] to make the process more comfortable, depending on the age of my patients and whether or not they’ve had kids. The procedure is generally much less painful for women who have given birth.
The IUD isn’t just used for birth control. It can be for women whose periods are very heavy and they can’t or won’t take birth control pills.
A few insurance providers still won’t pay for IUDs because they’re considered medical devices. Their reasoning is that they’d then have to pay for all medical devices, some of which are much more expensive.
IUDs today are longer lasting than in previous decades. At the beginning, there was Progestasert, which you had to replace every year. Now we have longer-lasting options like Mirena [launched in 2000], which is guaranteed for five years and can actually be trusted for six years.
A newer IUD is called Skyla [launched in 2014], which looks like Mirena but only lasts for three years and is nice for women who are in between kids.
Another very new one is Liletta [approved in 2015]. This one works like Mirena in that it’s a progesterone-releasing device. It’s different because it’s more affordable with the hope of attracting those whose insurance companies won’t cover Mirena or who don’t have insurance. Right now Liletta is approved for three years.
To me, it’s silly that some women won’t take hormonal birth control because they don’t want hormones in their bodies. I think you probably get more hormones than birth control eating a Thanksgiving turkey – just my opinion.
The beauty of the IUD is that it doesn’t get systemic, meaning it doesn’t circulate through the blood. In this way, it only impacts cervical mucus and the lining of the uterus.
ParaGard [which releases copper instead of hormones] is also available and can last 10 years. I don't like it because it can make periods longer, heavier, and crampier. But it was very popular decades ago because it was the only one available and some women couldn’t or wouldn’t take the pill, or they didn’t like condoms or other alternatives.
The IUD generally slips right out in doctor’s office when you’re ready to move on or it’s time for a new one. You’ll have your period at different points afterward, depending on what part of cycle you’re in naturally. If it’s removed when the lining is beginning to grow, you’ll get one in a month. If it’s removed mid-cycle, not much will happen for a while because not much lining has built up. To get pregnant, remember that you have to have ovulation and a prepared lining of the uterus, so don’t consider yourself eligible to get pregnant after your IUD is removed until you have had a period.
It’s very uncommon for the IUD to be expelled, or for it to penetrate through the uterus. Considering how many are put in, the complication rate is extremely low.
IUD OPTIONS CURRENTLY ON THE U.S. MARKET:
Sources: FDA.gov, NCBI, clinicaltrials.gov, Bedsider.com, corporate websites
Implants [like Nexplanon] have been around a long time and require a surgical procedure to put in. For women with slender arms, you can often see the implant under the skin. In my experience, they have unpredictable bleeding patterns. They may also adversely affect your cholesterol to a not insignificant degree. Other side effects include mood changes, PMS, and headaches. A progesterone shot [like Depo Provera] does the same thing.
What’s in the future for birth control?
At this point, I don’t think there’s really anything new they’re going to come up with in terms of birth control pills. Go lower than 10 mcg of estrogen, and you’ll just get more breakthrough bleeding. So we’re maxed out about as low as we can go already with the estrogen in Lo Loestrin.
For me, now it’s all in the IUD technology – how small we can make them and how long can they last.