You just had a baby. And maybe, you’re thinking “I am definitely not ready for another one!” (These tiny humans are a lot of work after all.) While there doesn’t seem to be a magic amount of time that suits all women, most people would agree that spacing out pregnancies is a good idea for the health and well being of both the baby and mom. Therefore, doctors often push for women to get on LARCs (long acting reversible contraceptives) such as IUDS, the implant, and the Depo-Provera birth control shot directly following birth, often beginning the conversation towards the end of a pregnancy before a woman has given birth. The appeal of the LARC to a provider is that perfect and user effectiveness are nearly identical—largely because the user has very little involvement with the LARC. By definition, LARCs may be the “easiest” form of birth control (in that they require no continued action on the part of the user), but they also give women the least amount of control over their birth control.
The idea behind the particular push to get women who’ve just had a baby on a LARC, is that a postpartum woman is busy with her new baby and may not have the time or bandwidth to remember a method that requires daily action. It is certainly true that postpartum women are very busy! But there are risks to using LARCs postpartum, which might have some women wondering: Are they worth it? And are there alternatives?
While each LARC carries a somewhat unique set of risks, each comes with the risk that if (or when) side effects are encountered, the “reversibility” may not be readily available. For example, this was a phenomenon faced by many women when routine care appointments were impossible to schedule at the outset of the pandemic, leaving some women with unwanted, expiring, or expired LARCs in their bodies, which they could not remove themselves. Under normal circumstances, a woman must make an appointment to have her IUD removed (and sometimes women even face pushback from providers who are reluctant to remove the device for various reasons—hence the recent trend in IUD self-removals). Likewise, birth control implants have to be removed by a healthcare provider. Perhaps the least “reversible” of all is the Depo-Provera birth control shot, which, as a shot (and not a device) is virtually impossible to reverse without simply waiting the 3 month period it takes to wear off.
LARCs and their effects on milk supply and mood disorders
The two reasons to reconsider hormonal contraceptives of any type during the postpartum period, and particularly LARCs, are their potential to negatively impact milk supply and their increased risk of mood disorders.
Milk supply
As an International Board Certified Lactation Consultant (IBCLC), I find the evidence that certain forms of hormonal birth control are “safe for breastfeeding” (i.e., that they won’t negatively impact milk supply) lackluster to say the least. Across many trials examining a relationship between breastfeeding success and birth control use, results are inconsistent:
“Two of eight trials noted less breastfeeding among women using hormonal birth control. One was a combined pill with few results and the other a hormonal IUD. In one study, the implant group infants gained more weight than those in the no-method group but less weight than infants in the ‘Depo’ group. Two trials noted that a combined pill had a negative effect on breast milk volume or content. One report did not have much data. The other showed lower volume for combined pill users than for women taking pills with only progestin” [1].
If hormonal contraception affects milk supply, it can sometimes be seen nearly instantaneously. A baby will suddenly reject the breast. Or, signs of diminished milk will show up, like baby’s dissatisfaction after feeds, more frequent feeding, or fussiness in between feeds. In my own experience of working with breastfeeding women as a lactation consultant, I frequently experience the reality of hormonal contraception affecting breastfeeding. When a mom comes to me with a sudden plummet in her milk supply, one of the first questions I ask is “Did you recently start hormonal contraception?” Many times, the woman responds, “Now that you mention it… I just got on the [mini-pill, IUD, Depo shot, implant, etc].” Sometimes, they get right off it, and the problem corrects itself. But because there is a virtually unquestioned belief among healthcare providers that hormonal contraception is “safe for breastfeeding,” patients often overlook it completely as a possible source of their breastfeeding difficulties.
Other times, signs of a dwindling supply can be more hidden. It doesn’t happen overnight, but rather over time. A baby might start to fall off their growth curve. It might coincide with the onset of crawling, or introduction of solids. A mom may think it’s just normal, so she increases her baby’s caloric intake from solid foods, which in turn may further decrease her milk supply.
Mood disorders
Even if you aren’t breastfeeding and concerns about milk supply do not pertain to you, birth control-related mood disorders can affect women across the board—breastfeeding or not. Thanks to a landmark Danish study, the relationship between depression and hormonal contraceptive use has been fairly well established [2]. Similar to a slowly diminishing milk supply, hormonal contraception can cause a similarly slow, but steady decline into depression. Stressed or anxious new moms, in particular, may not attribute their anxiety or depression to their birth control even though the connection is well-known. If they (or their provider) do make the connection, they can simply stop taking their birth control pills. But with a LARC, they may encounter more obstacles when it comes to reversing their “long acting reversible contraceptive.”
One recent study found that 1 in 7 women may experience postpartum depression in the year after giving birth. In the US, this equates to almost 600,000 postpartum depression diagnoses each year. I could write a whole other piece on why postpartum depression rates are so high in such a wealthy and developed nation, but some of the presumed reasons include lack of care or support, a lack of education for new moms, new parents living far from communities and family, and a striking lack of national paid family leave.
No matter the reason for the United States’ high rates of postpartum depression, it’s clear that there’s little reason to expose a new mom, who is already in a hormonally (and otherwise) fraught time, to an increased risk of depression.
We’ll now break down the particular risks of each of the most popularly-prescribed postpartum LARCs in greater detail.
LARCs commonly offered to postpartum women
IUDS
IUDs are rapidly growing in popularity for postpartum women. Broadly speaking, there are two options for the IUD: hormonal and non-hormonal. In the United States, hormonal IUDs come in 4 different brands: Mirena, Kyleena, Liletta, or Skyla, all of which contain varying amounts of levonorgestrel, a progestin. There is only one brand of non-hormonal IUD on the market, and that is the copper Paragard. For breastfeeding moms, Paragard is often touted as the “best” option, since it is non-hormonal and unlikely to affect breastfeeding. However, even hormonal IUDs are sold as “safe for breastfeeding,” since they contain progestin only (and it is largely believed that estrogen has the more significant, negative impact upon breastfeeding). However, as I noted above, in my own experience of working with breastfeeding women as a lactation consultant, I frequently experience the reality of hormonal contraception—whether progestin-only or not—affecting breastfeeding success.
Another risk with an IUD for postpartum women? Migration or expulsion of the device, and/or organ perforation (often of the uterus). Particularly for breastfeeding women, uterine perforation by an IUD is 6 times more likely [3]! This is probably due to a woman’s natural lack of estrogen during breastfeeding, and the oxytocin released during a milk letdown. The lack of estrogen is biologically normal as a result of lactation suppressing fertility (more on this later). Oxytocin contracts the uterus, which helps it go back down to its original size, and also enhances mother-baby bonding, combats depression, and helps counter sleep deprivation. But because of this combination, the endometrium wall isn’t very thick, and the uterus contracts periodically—neither of which bodes well for IUD use.
Other risks with IUD use are cramping, pain, pelvic inflammatory disease (PID), infection, mood instability, depression, headaches, weight gain, and acne. The non-hormonal copper IUD carries the same risks of PID, infection, perforation, and pain, and has also been linked to reports of IUD breakage and copper toxicity.
Implant
The Nexplanon contains Etonogestrel, another form of progestin. Rather than being housed in the uterus, the implant goes in the upper arm subcutaneously (a fancy word for under the skin), and prevents pregnancy for up to 3 years. It is another popular option for postpartum women because of its low maintenance, set-it-and-forget-it nature. The side effects from the hormones in Nexplanon are similar to the IUD; weight gain, depression, acne, nausea, stomach pain, vaginitis, and viral infections. There are also risks of pain and infection of the area of insertion.
Like the IUD, the Nexplanon implant also has the ability to migrate, especially if it is improperly placed. According to the Nexplanon site, a rare but serious complication is migration to a “blood vessel, including a blood vessel in the lung.”
In addition to these aforementioned risks, the hormones in the birth control implant may or may not affect milk supply in breastfeeding women.
Depo-Provera, the birth control “shot”
Lastly, the Depo-Provera birth control shot is an option often presented to new moms. It is an injection of Medroxyprogesterone acetate, a form of progestin, given every 3 months. This appeals to people who don’t want to have to remember anything daily, but also find a foreign material object, like an IUD or implant taking up residence in their body a bit unnerving.
One of the most concerning aspects of the Depo shot is its temporary irreversibility. If you do have a milk supply issue (or any other issue) from Depo, nothing can be done. You’ll simply have to wait out the effects for roughly three months, after which point regaining milk supply may be impossible.
Other side effects from the injection include headache, nervousness, depression, osteoporosis, weight gain, and excessive growth of facial and body hair. Depo use is well known to correlate with bone density loss, bone fractures, and greater risk of HIV contraction. Because of its effects on bone density, even the manufacturers of Depo do not recommend its use for longer than 2 years.
For the women who discontinue Depo, the withdrawal period can be devastating. Many women are also unaware that Depo-Provera’s effects on one’s fertility can extend for several months—and even years—after she has had her last injection. This can be especially troubling for the woman who wants to give her child a sibling, and finds herself unable to do so at the time of her choosing—because of the lasting effects of her birth control.
Postpartum hormones are designed to keep you temporarily infertile—and fertility awareness can help you take advantage of that
I think it’s important to keep in mind what postpartum hormones are biologically designed to do. From an anthropological point of view, a postpartum woman is designed to be infertile. From the hormonal side, lactation is biologically designed to suppress ovulation. (Although in industrialized nations, for various reasons, the suppression doesn’t last as long as in other nations.) This natural infertility often brings about a lower libido (although not for everyone.) If the hormones of lactation do not get in the way of procreation, the real life implications of having a small human just might. Frequent night wakings, the physical demands of infant care, and moms feeling “touched out.” All designed that way for a reason!
So, if you’ve decided that you want to avoid LARCs or hormonal contraception all together postpartum, the good news is that modern fertility awareness methods (FAM) can work for postpartum family planning—yes, even if you aren’t cycling again yet! You can know your real-time fertility day-by-day, anticipate and identify your first postpartum ovulation, and therefore be prepared for your first true postpartum period, too. Perhaps best of all, postpartum FAMs won’t affect your milk supply, and don’t expose you to an increased risk of mood disorders. (Note that for maximum family planning efficacy, it is highly recommended that you work with a FAM instructor during this time.)
If you are postpartum, whether you are breastfeeding or not, it’s worth reconsidering the LARC. With other effective methods out there, the LARC shouldn’t be the go-to, gold standard for new moms. With possible risks of depression, depleting your milk supply, perforation, bone fractures, delayed return to fertility, or infection—LARCs just aren’t worth it.
References:
[1] https://www.cochrane.org/CD003988/FERTILREG_hormonal-and-nonhormonal-birth-control-during-breastfeeding [2] https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552796 [3] https://lacted.org/questions/iuds-breastfeeding-uterine-perforation/Want to help us demand greater transparency from the FDA about these and other evidence-based side effects of hormonal contraception? Sign our FDA petition today.
Additional Reading:
Why the Copper IUD Is Not the Natural Birth Control You’ve Been Looking For
