For postpartum patients, early initiation of reliable contraception prevents short-interval pregnancy (ie, pregnancy within 6-18 months) and associated risks (eg, preterm delivery). The choice of method depends on future fertility plans, postpartum timing, breastfeeding status, and medical history.
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.
Non-hormonal (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. In contrast, progestin-only contraception methods help decrease menstrual bleeding while also providing contraception.
Progestin-only methods (eg, progestin-only pill, medroxyprogesterone injection, progestin-releasing intrauterine device [IUD]) are often used for breastfeeding patients because there is almost no effect on milk supply and have high efficacy (>99%). These methods can be initiated either immediately after delivery (low thromboembolism risk with progestin-only methods) or at the postpartum visit (≥4 weeks postpartum). In addition, they decrease menstrual bleeding and can cause amenorrhea, thereby reducing the risk for anemia due to blood loss from heavy menses.
Progestin-releasing IUD, which may be inserted immediately after placental delivery or at ≥4 weeks postpartum, is an ideal contraceptive option for this patient because it is primarily a locally acting contraceptive with minimal systemic absorption. Therefore, the incidence of progesterone-related adverse effects (eg, mood changes, increased appetite leading to weight gain) is low. It is highly effective at preventing pregnancy, and its efficacy is not user-dependent (ie, no daily pills). It also has the added benefit of decreasing heavy menstrual bleeding by inducing amenorrhea. In addition, the lactational amenorrhea associated with exclusively breastfeeding an infant <6 months will decrease this patient's risk of IUD expulsion from heavy menses.
