| Progestin-Only OCs for Breastfeeding Women For breastfeeding women who have resumed menstruation, progestin-only pills, or "minipills," are a good option if they want to use a hormonal method.* In contrast to combined pills, there is no risk that progestin-only pills will reduce milk production.
Why Progestin-Only Pills?Postpartum women often want to delay another pregnancy, and, indeed, birth intervals of at least two years are healthiest for both siblings (31). Intrauterine and barrier methods offer good postpartum contraception with no effect on lactation. Many women, however, prefer to use OCs. Because combined pills may inhibit milk production, some providers are reluctant to give them to breastfeeding women. If providers will not give OCs to breastfeeding women, however, some women may stop breastfeeding in order to obtain them (21).Progestin-only pills are a good alternative. They have no adverse effects on lactation. Most research has found either that they have positive effects—increasing milk quantity or improving its nutritional quality—or that they have no effect (72, 145, 211, 296, 530, 531). Women who choose progestin-only pills can use them and continue to breastfeed until lactation naturally stops. The main comparative disadvantage of progestin-only pills—higher pregnancy rates than combined pills—is offset by the protection against pregnancy that breastfeeding itself provides; during breastfeeding ovulation is uncommon before menstruation resumes and may be irregular even after menstruation has resumed (70). Also, the bleeding irregularities associated with progestin-only pills may not bother postpartum women because they may be amenorrheic or expect irregular bleeding postpartum (297). Progestin-only OCs may not be the best method, however, for women with a history of gestational diabetes (temporary diabetes that develops only during pregnancy). A recent study of women with a history of gestational diabetes found that those who used progestin-only OCs during breastfeeding were almost three times more likely to develop chronic non-insulin-dependent diabetes than women who used nonhormonal methods. Use of combined OCs did not increase the risk of diabetes for women with a history of gestational diabetes (246). Although combined OCs do affect breast milk, these effects do not seem to harm infants. With combined OCs milk volume usually decreases slightly, even with low estrogen doses (21, 116, 211, 297, 452). Breast milk composition may change, too, although findings vary. Most studies report decreases in mineral content (211, 296). A number of studies have found, however, that reduced milk volume in OC users did not affect their infants' weight gain (57, 208, 452, 529). Studies in Chile reported slower infant weight gain but no other adverse effects on infant health (98, 116, 351). The longest follow-up study found no effects on the health or the physical, intellectual, or psychological development through age eight of Swedish children whose mothers used combined OCs while nursing (329). Progestin-only pills do not adversely affect a mother's milk supply, and women using progestin-only pills breastfeed as long as women using no contraception or a method other than OCs (111, 297, 520, 551). In one study 83% of progestin-only pill users breastfed for four months or longer compared with 40% of combined OC users (90).
When to Begin?When can breastfeeding women begin to use progestin-only pills? As a general rule, as soon as six weeks after childbirth, according to the World Health Organization medical eligibility criteria for contraceptive methods (538). If a woman is partially breastfeeding and her child receives much other food or drink, six weeks after childbirth is the best time to start progestin-only pills. If she waits longer, fertility may return (190, 255). In contrast, if a woman plans to breastfeed exclusively or fully for a lengthy period, some providers may advise her to wait and offer her progestin-only pills later. Of course, a program can provide any woman with pills immediately postpartum with instructions about when to start them, if contacting her later might be difficult. In all cases it is important that the woman has access to the pills before she needs them.Most family planning programs prefer not to offer any hormonal contraception in the early postpartum months. This is because trace amounts of contraceptive hormones—usually less than one-tenth of 1% of maternal doses—can reach infants in breast milk. No health risks have been linked to such exposure, however (500, 530, 531). In any case, as noted, fully or nearly fully breastfeeding women who are amenorrheic do not need OCs in the early postpartum period. Fully breastfeeding is more than 98% effective in protecting against pregnancy as long as a mother is: (1) in the first six months postpartum and (2) still amenorrheic (237). This rate—two pregnancies per 100 women in the first six months after childbirth—is about the same as typical OC effectiveness (see Chapter 2.1). Program practices about when to offer progestin-only pills to fully or nearly fully breastfeeding women can be based largely on the breastfeeding patterns of the client population. To protect herself from pregnancy, the client should begin progestin-only OCs when menstruation returns or at six months postpartum, whichever comes first (84, 237, 485). *Postpartum women have little need of contraception for up to six months after giving birth if they have not resumed menstruating and they are fully or nearly fully breastfeeding—that is, breastfeeding often, day and night, with breastfeeds accounting for at least 85% of the baby's feedings (255, 552). Recent studies have reported a high degree of pregnancy protection for at least six months postpartum and somewhat less protection up to 12 months, if menstruation has not resumed (555).
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Facts About Pill Use: Did You Know...?
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Preventing Cervical CancerCervical infection with some types of human papillomavirus (HPV) appears to cause most, if not all, cases of cervical cancer (126, 372). A recent analysis of 1,000 cervical cancer specimens collected worldwide found evidence of HPV infection in 99.7% of the samples (502). Many women develop HPV infections, but few go on to develop cervical neoplasia. HPV infection usually is transient and clears without treatment (199). Apparently, cancer arises from infections that persist—perhaps those lasting six months or more (203, 383).
Avoiding HPVPrimary prevention of cervical cancer is the ideal, and that means minimizing exposure to HPV. A woman can reduce her exposure to HPV and other sexually transmitted disease organisms by using a barrier method of contraception—preferably condoms, but perhaps also diaphragms and spermicides—whether or not she also uses another family planning method such as OCs. Abstinence and delaying first sexual intercourse also reduce the risk (173). The behavior of women's sexual partners is important. Men who were young when they first had sexual intercourse, who have multiple sexual partners, or who visit prostitutes regularly increase their partners' risk of cervical cancer significantly (107, 317, 462).It may be particularly difficult for a sexually active woman to avoid HPV. Identifying an uninfected sexual partner—and knowing one's own status—is not possible without testing. Moreover, the types of HPV that cause cervical cancer do not cause warts (235) or any other obvious symptom. At the same time, the virus is very common. Condoms are helpful, but HPV can spread through contact between areas of the body near the anus or genitals that a condom does not cover (423). HPV vaccines are being developed, but the availability of a safe and effective vaccine is probably over a decade away (215, 372). While HPV infection may initiate most or all cervical cancers, cigarette smoking poses an increased risk (523, 527), and avoiding smoking will limit risk. A diet rich in vitamin C may also help (173).
ScreeningSince most women cannot eliminate all chances of exposure to HPV, where feasible, women should be screened for cervical lesions. The Papanicolaou (Pap) smear is the current standard screening method. Pap smears can identify cervical neoplasia at early stages, when treatment is almost always effective. Countries that have instituted national screening programs have seen deaths from cervical cancer decline to one-third or less of previous levels (384). Unfor-tunately, comprehensive Pap screening is practically non-existent in developing countries, where cervical cancer is the most common type of cancer among women.A more feasible screening technique appears to be on the horizon. Visual inspection of the cervix after an acetic acid (vinegar) wash—also known as cervicoscopy, or VIA—offers a low-cost, low-tech alternative to the Pap smear. Lesions appear white after application of vinegar and can be seen with a flashlight (220). In Zimbabwe nurse-midwives using this method accurately detected more than 75% of pre-invasive lesions compared with 44% with Pap smears (479). Similarly, in India paramedical personnel could accurately detect pre-invasive and invasive lesions using VIA (402). In India, VIA was as specific—able to detect accurately women who do not have pre-invasive or invasive lesions—as a Pap smear (402), while in Zimbabwe VIA was less specific than a Pap smear (479). Early detection allows for early treatment with low-cost, easy methods such as cryotherapy—freezing the cervix with a liquid coolant to destroy abnormal tissue—that nurse-midwives and many other health care providers can administer (220).
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