Menstruation and Birth Control
The return of menstruation after childbirth is quite variable and may take up to six months. Most breastfeeding mothers will resume menses about four weeks after breastfeeding has stopped, though some will menstruate while breastfeeding. Non-breastfeeding mothers usually start to menstruate in about six to twelve weeks. Your first period is usually different and may be very heavy with clots. It may stop and start again. It may take a few months for a regular cycle to re-establish, and it may differ somewhat in length from previous cycles.
Though bleeding may be irregular and sporadic, the possibility of pregnancy exists at any time after childbirth, regardless of whether your period has reappeared or if you are breastfeeding.
Discuss the contraceptive preferences of you and your partner with your obstetric care provider, weighing the positive and negative aspects of each method. If you plan to use birth control pills, you can begin taking them when you leave the hospital. Birth control pills are not generally recommended for breastfeeding mothers.
You may be fitted/refitted for a diaphragm at your six-week checkup. Until then, you may consider using a condom with contraceptive foam or vaginal sponge. You must follow the directions for all birth control methods in order to insure protection from pregnancy. Latex condoms are the only method that protects you against sexually transmitted diseases (STDs), if used properly.
You will need to be examined by your obstetric care provider, including a breast exam and Pap test before birth control can be prescribed.
Birth Control Pills
When used correctly, the birth control pill is more than 97 percent effective in preventing pregnancy. Birth control pills do not protect against sexually transmitted diseases including HIV. Be sure your partner(s) uses condoms when you are taking the birth control pill.
The hormones in the pill - estrogen and progestin - inhibit ovulation, which is the monthly occurrence of a woman’s ovaries releasing an egg. When you take the pill, there is no egg with which a man’s sperm can join, so a pregnancy cannot occur. The pill is a medication. Be sure to tell your doctor and other caregivers you are taking it when questioned about your medical and prescription history. For women who smoke, there is an increased risk for blood clots and heart disease. Be sure to tell your health care provider if you smoke.
Guidelines for Taking Birth Control Pills
Take ONE pill at the same time every day. Most birth control packages have 28 pills: 21 pills with hormones and seven different-colored pills that contain no hormones, just to keep you in the habit of taking the pill daily.
Other birth control packages have only 21 hormone pills. The birth control pill works best if you keep a constant level of the hormone in your body. Choose a time that is easiest for you to remember, like first thing in the morning, lunch or bedtime. Depending on the type of pill prescribed, your obstetric care provider will instruct you on when to begin taking your first package of pills.
Keep track of how many packages of pills your prescription covers. Before you start your last package, make an appointment with your doctor for an examination and a new prescription. You should have a gynecological examination, including a Pap test, once a year.
If You Forget a Pill
IF YOU MISS ONE PILL, take the forgotten one as soon as you remember and take the next pill at the time you normally would.
IF YOU MISS TWO PILLS in a row, take those two pills as soon as you remember and two pills the following day. For example, you realize Monday morning you have forgotten to take your pill Saturday and Sunday. Take two pills Monday and two on Tuesday. You may have slight spotting at this time.
IF YOU MISS THREE PILLS in a row, throw the package away. Start a new package the following Sunday, even if you are bleeding, and use a second form of birth control until you have taken two weeks of pills from the new package. Any time you miss taking a pill, use a second form of birth control until you start a new package.
IF YOU OFTEN FORGET your pills, consider another method of birth control as you are more likely to become pregnant on the pill.
IF YOU MISSED one or more pills, have a pregnancy test done.
If You Skip a Period
IF YOU HAVE NOT missed any pills, you probably are not pregnant. Continue taking your pills regularly and have a pregnancy test if you are worried. If you want to get pregnant, stop the pill at the end of the pack and use another form of birth control for two to three normal periods before you try to become pregnant.
As one of the best-studied medications prescribed, the pill is a safe method of contraception for most women. If you experience any minor side effects, stay on the pill. They will usually disappear by the time you have finished your third pack of pills. If they persist, call your doctor.
Common side effects of the pill include:
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Spotting (bleeding) between periods;
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Nausea (try taking the pill at bedtime to decrease this problem);
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Weight gain from fluid retention;
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Weight gain or loss due to appetite change (should not be more than 5 pounds);
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Breast tenderness;
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Mild headaches;
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Missed periods;
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Mood changes, tiredness;
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Decreased sex drive (usually the opposite is true);
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Acne (usually there is a decrease in acne problems);
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Increased risk of heart disease and blood clots in women who smoke and take the pill.
Notify your doctor immediately if you have any of the following symptoms:
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Severe abdominal pain;
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Severe chest pain or shortness of breath;
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Severe headaches;
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Eye problems, blurred vision;
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Severe leg pain (in calves).
Non-contraceptive benefits of birth control pills include:
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Shorter periods with less bleeding and cramping;
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Protection against PID (pelvic inflammatory disease);
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Protection against non-cancerous breast disease;
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Protection against formation of ovarian cysts;
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Protection against endometriosis;
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Protection against uterine and ovarian cancer;
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Possible protection against rheumatoid arthritis;
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Reduced risk of iron deficiency anemia;
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Decreased bleeding from and growth of fibroids.
Progestin-Only Pills ("Mini-Pill")
Progestin-only pills (“mini-pills”) contain just one hormone, unlike conventional birth control pills that contain two hormones – estrogen and progestin. The “mini-pill” works by making cervical mucus thicker so sperm cannot reach the egg, and by making the lining of the uterus thinner. Sometimes they stop ovulation.
The advantages of taking the “mini-pill” includes:
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No estrogen side-effects;
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Can be taken by breastfeeding mothers (preferably after the baby is six weeks old);
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Decreased cramps and pain during periods;
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Can be taken by women who have had thrombophlebitis (inflamed veins);
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Can be taken by women who smoke and are over 35 years old.
The disadvantages of taking the “mini-pill” include:
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Menstrual irregularity;
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The progestin-only pill MUST be taken at the same time every single day since it causes cervical mucus to thicken for only 22-24 hours;
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Higher failure rate;
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Not regularly available at pharmacies;
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Similar to the “regular” birth control pill, mini-pills do not offer protection against sexually transmitted diseases (STDs). Latex condoms, when used properly, are the only method that protects you against STDs.
The Diaphragm (with Contraceptive Cream)
A diaphragm is a soft, flexible, dome-shaped rubber cup that is inserted into the vagina before sexual intercourse to block sperm from entering the uterus. If you follow the guidelines given below, the diaphragm is 82-94 percent effective.
To effectively prevent pregnancy, a diaphragm must be:
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used with spermicidal cream or jelly, which kills the sperm in the vagina;
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used every time you have intercourse – even during menstrual periods;
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inserted immediately before intercourse or no earlier than six hours prior to intercourse;
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kept in place for at least six hours after intercourse (because sperm can live in the vagina) and no longer than 24 hours (because of the risk of Toxic Shock Syndrome).
How to Use Your Diaphragm:
Wash your hands. Hold the diaphragm up to the light to check for holes and cracks. With proper care, they can last up to two years.
Hold the diaphragm with the open side up, as you would a cup. Squeeze one tablespoon of contraceptive cream into the dome. With your fingers, spread the cream throughout the inside of the diaphragm and evenly around the rim.
Lie on your back with your legs bent or stand with one foot on the toilet lid or a chair. Use your thumb and middle finger of the hand holding the diaphragm to squeeze together the opposite sides of the rim.
With your free hand, spread the lips covering your vagina. Then insert the folded diaphragm (rim up) into your vagina (as you would a tampon), pushing back as far as it will go and up to cover your cervix, the opening to your uterus.
Use your index finger to check if the diaphragm is correctly in place. The last part of the rim that entered your body should fit snugly up behind your pubic bone, which feels like a small shelf, and the cream inside the diaphragm should be against your cervix, which feels like the tip of your nose. If the diaphragm does not feel comfortable, take it out and try again.
To remove your diaphragm, use your index finger to hook the part of the rim closest to you. Then, pull down and out. Be careful not to puncture the diaphragm with your fingernail.
After removing the diaphragm, wash it with mild soap and water, rinse well and pat dry with a towel. Do not use soaps containing deodorants, talcum, perfumed powders or oil-based products. They may damage the diaphragm or harm your vagina and cervix. Store the diaphragm away from heat.
If you want to have intercourse more than once in a six-hour period, leave your diaphragm in and use an applicator to insert additional spermicidal cream into your vagina before you have intercourse. Wait six hours after you last had intercourse before removing the diaphragm.
If you have a bowel movement while the diaphragm is in place, wash your hands afterward and check if the diaphragm is still in place.
Some women who wear diaphragms feel that it is necessary to douche, however, douching is not recommended at any time for any woman.
If your diaphragm is never comfortable, you may need to have the size checked. You will need your diaphragm refitted if you gain or lose 15 or more pounds, have lower abdominal surgery or have a pregnancy of any length. It is a good practice to bring your diaphragm with you to your routine annual pelvic exam so your doctor can check it for you.
If a contraceptive cream irritates your skin, switch to a different brand. If you have a latex allergy, ask your doctor to prescribe a latex-free diaphragm.
Non-contraceptive Benefits of the Diaphragm
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During menstruation, the diaphragm holds back flow – making intercourse more comfortable.
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Diaphragms may provide some protection against sexually transmitted infections, but not complete protection.
Depo-Provera® (hormone injection)
A hormone injection administered starting within the first five days of your period, then every 12 weeks thereafter, Depo-Provera® is 99 percent effective in preventing pregnancy.
Working much like the birth control pill, the hormone progestin in Depo-Provera® keeps you from releasing an egg each month, so pregnancy cannot occur. It also changes the lining of your uterus, making it difficult for sperm to fertilize any egg that is released.
A Depo-Provera® shot is given during the first five days of your normal menstrual cycle. For use following childbirth, the injection is given within five days to bottle-feeding mothers. Breastfeeding mothers should discuss this option with their pediatric care provider.
Advantages
During the 12 weeks between hormone shots, you do not have to bother with oral or other contraceptive methods, which all require consistent use. Depo-Provera® does not protect you against sexually transmitted diseases including HIV. Be sure your partner uses condoms.
Precautions
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Do not use Depo-Provera® if you know or suspect that you are pregnant.
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Use Depo-Provera® with caution if you have unexplained vaginal bleeding, a history of breast cancer, stroke, blood clots or liver problems.
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Use only with your doctor’s permission if you have high blood pressure, migraines, asthma, epilepsy, an abnormal mammogram or diabetes.
Side Effects
Some women may experience some of these side effects:
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irregular or no menstrual bleeding;
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vaginal discharge;
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acne;
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bloating, swelling of the hands and feet;
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weight gain (eat a well-balanced diet and avoid excessive calories);
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insomnia;
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nervousness;
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hot flashes;
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depression;
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headaches, dizziness;
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cramps, backaches, leg cramps;
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breast tenderness;
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fatigue.
Depo-Provera® does not offer protection against sexually transmitted diseases (STDs). Latex condoms, when used properly, are the only method that protects you against STDs.
Ortho Evra™ Patch
Ortho Evra™, an alternative to birth control pills, is a one-and-three-quarter inch square patch containing hormones that get released into the body to prevent pregnancy. Similar to birth control pills, Ortho Evra™ is 99 percent effective in preventing pregnancy.
Women who choose to use the product should apply it to the lower abdomen, buttocks or upper body, but not to the breasts. Each patch should be worn every day for one week and should then be replaced with a new patch on the same day of the week for a total of three weeks of patch wear. The fourth week, which is patch-free, allows a woman to have her menstrual period – similar to the process for birth control pills.
Like birth control pills, Ortho Evra™ is effective for preventing pregnancy when used as directed. The risks of using this product are similar to the risks of using birth control pills including an increased risk of blood clots, heart attack, and stroke. In clinical trials, about five percent of women had at least one patch that did not stay attached to their skin and two percent found the patch to irritate the skin.
Packages of a single replacement patch are available if a patch comes off before it is due to be changed. Ortho Evra™ does not offer protection against sexually transmitted diseases (STDs). Latex condoms, when used properly, are the only method that protects you against STDs.
Rhythm/Fertility Awareness Method
The rhythm, or fertility awareness method, consists of avoiding sex during the woman’s fertile period, the time when the egg leaves the ovary and enters the fallopian tube. Three methods can be used together to determine the fertile period: calendar, basal body temperature, and cervical mucous.
The calendar method is based on determining when you ovulate, which is approximately two weeks before your period begins every month.
The basal body temperature method involves taking your temperature every morning and charting it. A small rise in temperature occurs after the ovary releases the egg.
The cervical mucous method uses the quality of the mucous in your vagina to determine the fertile period. When the mucous is clear and thin, instead of thick and sticky, sexual intercourse must be avoided. To avoid pregnancy a couple can abstain (not have sex) or use another contraceptive method during this fertile time.
Who might prefer rhythm methods?
Who should not use rhythm methods?
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Women who cannot interpret their fertility signs correctly.
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Women with irregular periods.
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Women with frequent pelvic infections.
The rhythm or fertility awareness method does not offer protection against sexually transmitted diseases (STDs). Latex condoms, when used properly, are the only method that protects you against STDs.
Sterilization
Sterilization can be performed in both women and men. In women it is called tubal ligation, which consists of sealing off the fallopian tubes that carry the egg from the ovary to the uterus. Tubal ligation can be performed after giving birth while still in the hospital or you may choose to return to the hospital at another time. In men, sterilization is called a vasectomy in which the ducts (vas deferens) are cut and burned so they cannot carry the sperm from the testicles to the penis. Both methods prevent the egg and the sperm from meeting.
Who might prefer sterilization?
Who should not use sterilization?
This is major surgery that is not always reversible, so unless you are absolutely certain that you do not want children, we do not recommend sterilization as a method of birth control. As with any surgical procedure, there may be discomfort and pain for a short period after sterilization. Other complications include bleeding, infection, damage to other organs in women and swelling and tenderness near the testicles in men.
Sterilization does not protect against sexually transmitted diseases. Latex condoms, when used properly, are the only method that protects you against STDs.
Condoms
A condom is a latex or synthetic sheath worn over the penis. When used correctly, condoms prevent pregnancy by prohibiting sperm from entering the vagina and uterus; only two in 100 women (two percent) will get pregnant in a year. For even greater protection, spermkilling lubricants can be used along with a condom. Latex condoms also protect against diseases, including the virus that causes AIDS. For disease protection, you should use a condom every time you have vaginal intercourse, and when you have anal or oral sex.
Proper Steps to Follow
Check the expiration date on the package to make sure the condom is not too old. Never use a condom if the package or the condom is discolored, sticky or brittle. Do not keep condoms that have been kept in a wallet or car because heat can damage the condom.
After you carefully unwrap the condom, while the penis is erect, put on the condom - unrolling it down the shaft, all the way to the base. (Unrolling a condom before putting it on can cause a condom to break.) If the penis is uncircumcised, pull back the foreskin before putting on the condom.
Pinch the tip of the condom, leaving about a half inch of space for semen to fill. If you do not leave space, the condom could break. If a condom breaks during intercourse, withdraw and put on a new condom before ejaculation. After ejaculation, and while the penis is still erect, hold the condom firmly onto the base of the penis while pulling out of the vagina.
What to Know About Lubricants
Some condoms are lubricated–look for the informaion on their package. Use only water-based lubricants like K-Y jelly®, Gyne-Moistrin®, Astroglide® or lubricating gel. Never use petroleum jelly, hand lotion, lipstick or lip balm with or on condoms because this causes them to break. In only 60 seconds, any oil-based lubricant can destroy a condom’s strength. Foams or jellies that prevent pregnancy by killing sperm can be good lubricants.
Female Condoms
A female condom is a plastic sheath with plastic rings at both ends. The closed end of the sheath is inserted into the vagina, where one ring holds it in place. The ring at the open end is left outside the woman’s body. Female condoms help prevent pregnancy. Their effectiveness in disease protection is still being studied. Both male and female condoms are one-use only, so throw away after a single use.
Foam (Spermicidal Contraceptive)
Contraceptive foam is a spermicidal, or sperm-killing, substance inserted into the vagina within 30 minutes before intercourse. Protection is immediate and lasts one hour. When used properly and with a condom, foam is almost 100 percent effective in preventing pregnancy.
A condom, a latex or synthetic sheath worn over the penis, is necessary for proper protection because it prevents any sperm not killed by the foam from entering the vagina and uterus. Foam used with condoms also protects against sexually transmitted diseases, including the virus that causes AIDS.
You can buy foam and condoms without a prescription at any drug store. Foam comes in a small aerosol container. When buying foam for the first time, be sure to buy a package with an applicator included. Also, you might want to keep an extra container of foam on hand because it is difficult to tell when a container is almost empty. Be sure the label reads contraceptive foam and/or spermicidal. (Make sure you do not buy a feminine deodorant or douching product instead of foam.)
Do not use foam with a diaphragm; use only spermicidal cream or jelly.
How to Use Foam
Shake the foam container 20 times before using so that the spermicidal substance mixes with the foam. To fill the applicator, place it on the nozzle of the open container. Following packaging directions for the brand you are using, either tilt the container or press down on the applicator. This dispenses foam into the applicator tube, pushing up the plunger.
While lying on your back, use one hand to spread the lips covering your vagina. With the other hand, insert the applicator as far as you can into your vagina (like you would a tampon). Your partner can also assist with this.
Push in the plunger of the applicator. Foam will flow out of the applicator into your vagina. Remove the applicator without pulling on the plunger to avoid sucking foam back into the applicator. Insert another applicator of foam before you have intercourse again, and if you stand or go to the bathroom after inserting the foam. After use, wash the foam applicator with soap and warm water.
What if...
If a condom slips off, tears or spills sperm, insert more foam immediately. If following intercourse, foam drips out of your vagina, wipe it off and wear a panty liner to protect your panties. Douching is NOT recommended. It may even force sperm into your uterus.
NuvaRing®
NuvaRing® is a flexible, transparent, odorless combined contraceptive vaginal ring used to prevent pregnancy. About the size of a silver dollar, it contains a combination of progestin and estrogen. NuvaRing® is inserted into the vagina for three weeks and removed for a one week ring-free period. NuvaRing® may have the same side effects as the conventional birth control pill.
As with any combination (progestin and estrogen) contraceptive, cigarette smoking increases the risk of serious cardiovascular side effects. The risk increases even more if you are over the age of 35 and if you smoke 15 or more cigarettes a day.
Women who are breastfeeding should not use NuvaRing®.
NuvaRing® does not offer protection against sexually transmitted diseases (STDs). Latex condoms, when used properly, are the only method that protects you against STDs.
