A 25-year-old woman, gravida 2 para 2, comes to the office for a postpartum visit and contraception. Two weeks ago, the patient had a vaginal delivery at 36 weeks gestation. She is breastfeeding exclusively with no issues. Lochia has decreased, and she has no pelvic pain. The patient would like to start reliable contraception as soon as possible because she conceived while breastfeeding after her first pregnancy. She takes daily iron supplementation for iron deficiency anemia due to heavy menstrual bleeding. The patient has no other chronic medical conditions and takes no other medications. Vital signs are normal. Pelvic examination is deferred. Which of the following is the best contraceptive option for this patient?
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The choice of postpartum contraception is based on time from delivery, breastfeeding status, patient-specific risk factors, and desire for future fertility. In patients who are <1 month postpartum, estrogen-containing contraceptives are avoided because they increase the risk for thromboembolism (due to estrogen-induced hypercoagulability) and can negatively affect breastfeeding (Choice A).
Nonhormonal (eg, copper-containing intrauterine device [IUD]) and progestin-only contraception methods are preferred in patients <1 month postpartum and breastfeeding. However, in this patient with heavy menstrual bleeding complicated by anemia, the copper-containing IUD may increase menstrual bleeding and worsen the preexisting anemia (Choice B). In contrast, progestin-only contraception methods help decrease menstrual bleeding while also providing contraception.
In this patient who desires reliable contraception to avoid another short-interval pregnancy, the best contraceptive option is a progesterone-based, long-acting, reversible contraceptive such as the subdermal progestin-releasing implant or the progestin-releasing IUD. These methods have high efficacy (>99%) for pregnancy prevention and do not increase thromboembolic risk or affect breastfeeding. They can be inserted immediately postpartum and kept in place for up to 3-7 years. In addition, they decrease menstrual bleeding and can cause amenorrhea, thereby reducing the risk for anemia due to blood loss from heavy menses.
(Choice C) Condoms and the diaphragm are barrier methods of contraception that do not affect thromboembolic risk or breastfeeding. However, they have poor contraceptive efficacy (82%).
(Choice D) Progestin-only oral contraceptives do not affect breastfeeding or thromboembolic risk. However, they are less effective (91%) for pregnancy prevention than the subdermal progestin-releasing implant due to high rates of user error and short medication half-life, which requires that the pill be taken at the same time daily to be effective.
Educational objective:
In postpartum patients who are breastfeeding, progestin-only contraception methods (eg, subdermal progestin-releasing implant, progestin-releasing IUD) are preferred and may be initiated immediately because they do not increase thromboembolism risk or affect breastfeeding.