Combined Hormonal Contraceptives Should Not Be Used for First 21 Days Post Partum

Regardless of their breastfeeding status, women who are less than 21 days post partum should not use combined hormonal contraception because of the high risk for venous thromboembolism, according to an update to the Centers for Disease Control and Prevention’s U.S. Medical Eligibility Criteria for Contraceptive Use 2010.

Previously, the guidelines recommended that women less than 21 days post partum "generally should not use combined hormonal contraceptives." After 21 days, combined hormonal contraceptives could be used with no restrictions.

The revised guidelines now recommend that nonbreastfeeding women who are 21-42 days post partum and have other risk factors for venous thromboembolism (VTE) generally not use combined hormonal contraceptives. These risk factors include age of 35 years or more, previous VTE, thrombophilia, immobility, transfusion at delivery, body mass index of 30 kg/m² or more, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking.

There are no restrictions for combined hormonal contraceptive use in women who are more than 42 days post partum (MMWR 2011;60:878-83).

Recommendations for breastfeeding women have not been changed. Recommendations for use of other contraceptives, including progestin-only hormonal contraceptive and IUDs, remain unchanged, according to the report.

"We do really want providers to know that progestin-only methods are safe [immediately post partum], and that it’s important for them to talk to their patients about postpartum contraception," said Dr. Naomi Tepper, an ob.gyn. at the CDC’s Division of Reproductive Health, and the lead author of the report.

Although it is important for physicians to use the recommendations, the updates "won’t be a huge change in practice in terms of what’s already being done," Dr. Eve Espey, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, commented in an interview. Dr. Espey was not involved in the MMWR report.

In a survey of roughly 400 New Mexico physicians and midwives, she and her colleagues showed that "the majority (70%) of providers prescribe progestin-only contraceptive methods to breastfeeding women within the first 6 weeks [post partum]" (Contraception 2006;74:389-93).

Dr. Espey, who chairs the Long-Acting Reversible Contraception (LARC) Working Group at the American College of Obstetricians and Gynecologists, added that the updated recommendations are consistent with the college’s guidelines. Those guidelines recommend no estrogen-containing hormonal contraception during the first 4 weeks post partum, and that breastfeeding women wait until their breastfeeding is well established before they use combined hormonal contraceptives ("ACOG Practice Bulletin No. 73," in Obstet. Gynecol. 2006;107:1453-73).

Current research suggests that women wait 18-24 months between pregnancies, said Dr. Tepper. Meanwhile, studies have shown that short birth intervals can lead to negative health outcomes for mother and baby, highlighting the importance of using contraception during the postpartum period. However, the safety of various forms of contraceptives also needs to be considered, because of an increased risk of VTE among postpartum women.

The CDC published the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) for the first time in 2010, adapting some of the World Health Organization’s Medical Eligibility Criteria for Contraceptive Use guidelines.

The current updates follow WHO’s 2010 updated guidance, which recommended that use of combined hormonal contraceptives among nonbreastfeeding postpartum women be more restrictive during the first 42 days, especially in women who are at a high risk for VTE.

To make the revisions, the CDC recruited 13 experts who reviewed WHO’s revised recommendations. "A key issue identified was that immediate postpartum use of combined hormonal contraceptives would impose a high risk for VTE without any substantial benefit in pregnancy prevention, because most nonlactating women will not have a fertile ovulation until at least 42 days post partum," the authors wrote in MMWR.

As in the 2010 U.S. MEC, the updated recommendations use categories 1 to 4, with 1 representing a safe contraceptive method with no restrictions and 4 representing an unacceptable health risk. The use of combined hormonal contraceptives during the first 21 days post partum was upgraded from category 3 to category 4.

"Our goal with these entire sets of guidelines is to keep them up to date and based on the latest evidence," said Dr. Tepper.

Dr. Tepper and Dr. Espey reported no relevant financial disclosures.

Regardless of their breastfeeding status, women who are less than 21 days post partum should not use combined hormonal contraception because of the high risk for venous thromboembolism, according to an update to the Centers for Disease Control and Prevention’s U.S. Medical Eligibility Criteria for Contraceptive Use 2010.

Previously, the guidelines recommended that women less than 21 days post partum "generally should not use combined hormonal contraceptives." After 21 days, combined hormonal contraceptives could be used with no restrictions.

The revised guidelines now recommend that nonbreastfeeding women who are 21-42 days post partum and have other risk factors for venous thromboembolism (VTE) generally not use combined hormonal contraceptives. These risk factors include age of 35 years or more, previous VTE, thrombophilia, immobility, transfusion at delivery, body mass index of 30 kg/m² or more, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking.

There are no restrictions for combined hormonal contraceptive use in women who are more than 42 days post partum (MMWR 2011;60:878-83).

Recommendations for breastfeeding women have not been changed. Recommendations for use of other contraceptives, including progestin-only hormonal contraceptive and IUDs, remain unchanged, according to the report.

"We do really want providers to know that progestin-only methods are safe [immediately post partum], and that it’s important for them to talk to their patients about postpartum contraception," said Dr. Naomi Tepper, an ob.gyn. at the CDC’s Division of Reproductive Health, and the lead author of the report.

Although it is important for physicians to use the recommendations, the updates "won’t be a huge change in practice in terms of what’s already being done," Dr. Eve Espey, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, commented in an interview. Dr. Espey was not involved in the MMWR report.

In a survey of roughly 400 New Mexico physicians and midwives, she and her colleagues showed that "the majority (70%) of providers prescribe progestin-only contraceptive methods to breastfeeding women within the first 6 weeks [post partum]" (Contraception 2006;74:389-93).

Dr. Espey, who chairs the Long-Acting Reversible Contraception (LARC) Working Group at the American College of Obstetricians and Gynecologists, added that the updated recommendations are consistent with the college’s guidelines. Those guidelines recommend no estrogen-containing hormonal contraception during the first 4 weeks post partum, and that breastfeeding women wait until their breastfeeding is well established before they use combined hormonal contraceptives ("ACOG Practice Bulletin No. 73," in Obstet. Gynecol. 2006;107:1453-73).

Current research suggests that women wait 18-24 months between pregnancies, said Dr. Tepper. Meanwhile, studies have shown that short birth intervals can lead to negative health outcomes for mother and baby, highlighting the importance of using contraception during the postpartum period. However, the safety of various forms of contraceptives also needs to be considered, because of an increased risk of VTE among postpartum women.

The CDC published the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) for the first time in 2010, adapting some of the World Health Organization’s Medical Eligibility Criteria for Contraceptive Use guidelines.

The current updates follow WHO’s 2010 updated guidance, which recommended that use of combined hormonal contraceptives among nonbreastfeeding postpartum women be more restrictive during the first 42 days, especially in women who are at a high risk for VTE.

To make the revisions, the CDC recruited 13 experts who reviewed WHO’s revised recommendations. "A key issue identified was that immediate postpartum use of combined hormonal contraceptives would impose a high risk for VTE without any substantial benefit in pregnancy prevention, because most nonlactating women will not have a fertile ovulation until at least 42 days post partum," the authors wrote in MMWR.

As in the 2010 U.S. MEC, the updated recommendations use categories 1 to 4, with 1 representing a safe contraceptive method with no restrictions and 4 representing an unacceptable health risk. The use of combined hormonal contraceptives during the first 21 days post partum was upgraded from category 3 to category 4.

"Our goal with these entire sets of guidelines is to keep them up to date and based on the latest evidence," said Dr. Tepper.

Dr. Tepper and Dr. Espey reported no relevant financial disclosures.

Regardless of their breastfeeding status, women who are less than 21 days post partum should not use combined hormonal contraception because of the high risk for venous thromboembolism, according to an update to the Centers for Disease Control and Prevention’s U.S. Medical Eligibility Criteria for Contraceptive Use 2010.

Previously, the guidelines recommended that women less than 21 days post partum "generally should not use combined hormonal contraceptives." After 21 days, combined hormonal contraceptives could be used with no restrictions.

The revised guidelines now recommend that nonbreastfeeding women who are 21-42 days post partum and have other risk factors for venous thromboembolism (VTE) generally not use combined hormonal contraceptives. These risk factors include age of 35 years or more, previous VTE, thrombophilia, immobility, transfusion at delivery, body mass index of 30 kg/m² or more, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking.

There are no restrictions for combined hormonal contraceptive use in women who are more than 42 days post partum (MMWR 2011;60:878-83).

Recommendations for breastfeeding women have not been changed. Recommendations for use of other contraceptives, including progestin-only hormonal contraceptive and IUDs, remain unchanged, according to the report.

"We do really want providers to know that progestin-only methods are safe [immediately post partum], and that it’s important for them to talk to their patients about postpartum contraception," said Dr. Naomi Tepper, an ob.gyn. at the CDC’s Division of Reproductive Health, and the lead author of the report.

Although it is important for physicians to use the recommendations, the updates "won’t be a huge change in practice in terms of what’s already being done," Dr. Eve Espey, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, commented in an interview. Dr. Espey was not involved in the MMWR report.

In a survey of roughly 400 New Mexico physicians and midwives, she and her colleagues showed that "the majority (70%) of providers prescribe progestin-only contraceptive methods to breastfeeding women within the first 6 weeks [post partum]" (Contraception 2006;74:389-93).

Dr. Espey, who chairs the Long-Acting Reversible Contraception (LARC) Working Group at the American College of Obstetricians and Gynecologists, added that the updated recommendations are consistent with the college’s guidelines. Those guidelines recommend no estrogen-containing hormonal contraception during the first 4 weeks post partum, and that breastfeeding women wait until their breastfeeding is well established before they use combined hormonal contraceptives ("ACOG Practice Bulletin No. 73," in Obstet. Gynecol. 2006;107:1453-73).

Current research suggests that women wait 18-24 months between pregnancies, said Dr. Tepper. Meanwhile, studies have shown that short birth intervals can lead to negative health outcomes for mother and baby, highlighting the importance of using contraception during the postpartum period. However, the safety of various forms of contraceptives also needs to be considered, because of an increased risk of VTE among postpartum women.

The CDC published the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) for the first time in 2010, adapting some of the World Health Organization’s Medical Eligibility Criteria for Contraceptive Use guidelines.

The current updates follow WHO’s 2010 updated guidance, which recommended that use of combined hormonal contraceptives among nonbreastfeeding postpartum women be more restrictive during the first 42 days, especially in women who are at a high risk for VTE.

To make the revisions, the CDC recruited 13 experts who reviewed WHO’s revised recommendations. "A key issue identified was that immediate postpartum use of combined hormonal contraceptives would impose a high risk for VTE without any substantial benefit in pregnancy prevention, because most nonlactating women will not have a fertile ovulation until at least 42 days post partum," the authors wrote in MMWR.

As in the 2010 U.S. MEC, the updated recommendations use categories 1 to 4, with 1 representing a safe contraceptive method with no restrictions and 4 representing an unacceptable health risk. The use of combined hormonal contraceptives during the first 21 days post partum was upgraded from category 3 to category 4.

"Our goal with these entire sets of guidelines is to keep them up to date and based on the latest evidence," said Dr. Tepper.

Dr. Tepper and Dr. Espey reported no relevant financial disclosures.