When Babies Are Not on the Brain: Post-Partum Contraception

Babies out. Bleeding is on. Boobs are big. Belly is still large. Sounds awesome. With all of these bothersome symptoms, “bonking” is completely out of the question. Let’s face it: when you look and feel like you have been through the wringer, intimacy is probably the last thing on your mind. But before you know it, all systems will be healed, and sex will be a go. And while those days seem further away than your first full night of sleep, it will happen. We promise! And when it does, even if you are breastfeeding, you can get pregnant without contraception. To avoid that major oops, here’s how best to prevent pregnancy postpartum.

Let’s do a quick Obstetrics 101 review. In most cases, it takes at least three weeks before ovulation resumes. Prior to this, elevations in your hormones (think hCG, progesterone, and estrogen) will keep ovulation in a holding pattern. After about one month, these levels will drop, and ovulation will resume. However, in women who are breastfeeding, prolactin (the hormone that helps you produce milk) will arrive and stay on the scene until you are ready to move on to formula or milk. In high levels, prolactin can function similar to hCG and prevent ovulation for some time.

No ovulation = no egg = no embryo = no pregnancy

The sticking point is that “some time” can be anytime; how long you can use breastfeeding as contraception depends on how frequently you are feeding/pumping, how many other “things” (a.k.a. formula or food) your baby is taking in, and your own body. Women with the exact same routines can start ovulating at very different times. Bottom line: breastfeeding is not a completely reliable source of contraception. You need a back-up mechanism.

So, what are your options? While there aren’t as many choices as for non-breastfeeding women, you do still have choices. Think about the contraceptive choices for breastfeeding women as a three-choice exam. Option A = oral contraceptive pills (a.k.a. OCPs), Option B = IUD, and Option C = barrier devices (condoms or a diaphragm).

You can go with any of the three and achieve pretty good results—if they are taken correctly! Which you select really depends on what is best for you, your medical history, and your personal needs. The first few months after bringing a baby home can be exhausting and hectic, to say the least. Remembering to take a pill daily at the same time may be harder than it sounds. The OCP prescribed to breastfeeding women, a.k.a. the “mini-pill,” only includes progesterone and must be taken at the same time daily to remain effective. While the toothbrush or shower trick may help, believe it or not, some days you might not make it into the shower (or even brush your teeth)! If you go with an Option B (IUD), you won’t have to think at all. Combined with its good contraceptive benefits, this may B the right choice for you!

If you have decided to go right to the bottle (aka formula)—and trust us, there is no judgment in that statement—you need post-partum contraception ASAP. This convo will usually commence at your six-week postpartum visit. Remember: sex before six weeks is off limits anyway! The options for women who are not breastfeeding are no different than for women who are breastfeeding. Where things diverge is in the type of oral contraceptive pills (a.k.a. hormones) that one can take.

Non-breastfeeding women can take good old-fashioned estrogen + progesterone pills as well as progesterone-only pills. Usually, the former is preferred due to slightly more flexibility in how perfect your timing when it’s taken needs to be. Because milk production is not an issue, the suppressive effect of estrogen on milk production is no big deal. If OCPs are not your speed (or medically a no go), you can also go with the patch, the ring, implantable devices, Depo-Provera, the IUD, condoms, or diaphragms.

Basically, barring any underlying medical issues, the sky is the limit. Pick what’s best for you and your busy lifestyle. Just remember: fatigue will be an issue, so the less you have to think, the better. Whatever you choose, be sure to commit; otherwise you may find yourself expecting way before you were expecting!

Let’s Get the Screening Started

If your little ones have finally started to sleep through the night, eat real food, and maybe even venture onto the potty, you are probably feeling pretty good. Major milestones for your kids mean a lot to you not only as a mom (#ProudMom) but also as an individual (#HiWorldIamBack). While your schedule still somewhat revolves around your little ones’ naptime (which, let’s face it, none of us really likes to give up), the bonds of babyhood are slowly being released. (See you later, diapers and bottles!) As things settle, you are ready to get not only your house back into order but also your health. This includes sleeping, eating, exercising, and screening. While screening may conjure up an image of TSA and airport security, what we are referring to may include an X-ray machine and takes a whole lot more than 3 seconds.

The screening we are talking about includes visiting your MD for a good, old-fashioned chat, a physical exam, and probably some tests. Although most of us can barely find time to get a haircut, a checkup is kind of essential. While this meeting may include nothing more than a quick conversation along with a height, weight, and blood pressure check and focused physical (think heart, lungs, breasts, abdomen, and pelvis), if something looks or sounds off, we recommend a more detailed follow-up exam with blood tests and imaging studies (X-ray, MRI, or CT scan).

Depending on where you are in life (a.k.a., your age) and what your family’s history is like, you are probably getting teed up for a mammogram and maybe a colonoscopy. Although you should already be doing breast self-exams and clinical breast exams (by a healthcare specialist), most of us welcome the big 4-0 with our first mammograms. While there is a lot of fear and anxiety over entering the world of mammograms, for most of us (no matter what your breast size is), it’s nothing more than a few minutes of discomfort. You have endured endless sleepless nights, changed innumerable dirty diapers, and sat with a breast pump on for hours—you can tolerate a mammogram!

Although admitting this is hard (it is for us too), as our kids age, so do we. With age comes not only maturity and perspective but also disease and illness. As a result, your body needs to be “looked at” more frequently than it was in your 20s. Prevention is the key to your body’s prosperity and longevity. So, while we don’t doubt that you are a woman with a loud roar, even the strongest among us can get sick. Having a good doctor who knows you and your body is crucial. Get checked up and checked out on a regular basis (not just when you are sick). Screening may not be as “sexy” as getting your hair colored or your skin cleansed, but it will likely help you keep looking and feeling sexy.

The bottom line is that you should get a mammogram, get a Pap smear (or at the least have your OB/GYN review your cervical cancer screening history), and share your past and your family’s past with your doctor. While your kids may no longer be babies, there will be several bumps in the road for which they will need you by their side. Screening will help you stay strong!

Milk Maid: Are the Benefits of Breastfeeding Bogus or a True Bonus for Your Baby?

Ah, breastfeeding. What can we say? Just the word, the thought, and the image can engender emotions as variable as night and day, north and south, love and hate. People are very passionate (on both sides of the aisle) about this topic. Remember how much flak that lady took who was breastfeeding her 3-year-old son on the cover of Time magazine? She almost got as much press as Caitlyn Jenner!

For those who have danced the dance before, some recall the experience with fondness and affection, while others remember it with frustration and fury. For those who have not yet even tried, the thought can create both anxiety and excitement, nervousness, and anticipation. Wherever you fall on the breastfeeding spectrum, it is worth a discussion. Why is there so much buzz around this subject, including if you do it, where you do it (who knew a woman breastfeeding her baby would make its way to the floor of Congress!), and how long you do it?

The tides on breastfeeding have changed more than the Atlantic Ocean in hurricane season. In the 1950s, women were given medications that put them in a twilight state for delivery (no memory of the pain, the pushing, and the other glories of childbirth) and given formula to feed their babies when they woke up.

Today, hospitals are jockeying to receive the prestigious “Baby Friendly” recognition where Baby and Mom are never separated (the newborn nursery no longer exists). Lactation consultants occupy the hallway. Breastfeeding classes happen twice daily, and formula is hardly even mentioned. In 1971 only, about 25% of mothers left the hospital breastfeeding. In 2005, this number had risen to 72%. The change has come on the heels of extensive research, which has demonstrated the numerous benefits of breastfeeding for both Mom and Baby.

So what is so magical about that milk? Why is it liquid gold? Breast milk offers numerous benefits for both babies and mothers. The list is long, and at the top is the protection it offers against infection. Buried within the milk are antibodies that strengthen your baby’s immune system. While women are breastfeeding, their babies have a lower chance of infections, including stomach bugs, respiratory illnesses (colds and coughs), ear infections, and urinary tract infections. Additionally, breast milk has been shown to help stimulate the growth and motility of a baby’s GI tract.

And as if the carats of this gold were not high enough, breastfeeding does not just offer short-term gains but also major long-term benefits for your child. The pluses seem to persist for years after the last drop is released; a mother’s milk provides protection against illnesses for the first several years of a child’s life. Fast-forward into your child’s adolescent and adult years, and there is evidence that suggests breastfed babies have a lower incidence of chronic diseases, including obesity, cancers, allergies, diabetes, and even adult cardiovascular disease.

And if you think that’s it, think again. Select studies have shown that breastfed babies may have better vision, hearing, cognitive development, childhood behavior, and stress reduction. But while the list is long, some points deserve more press than others. While the early benefits are clear, the later ones are controversial. Don’t let the fear of what might happen to your child ten years into their life if you put the pump away after six months keep you going. Whatever you have done or will do is better than nothing! And remember, many of us have gotten to the top of the professional ladder and never consumed even one ounce of breast milk. Your child’s success is not solely based on their first diet.

Breastmilk doesn’t just do a baby’s body good; it also does your body good! Breastfeeding hastens your recovery post-delivery (the hormone that produces milk also helps the uterus to shrink back down to its normal size). It helps the weight come off faster (a magic diet pill—we’ll take that!), and it can serve as a form of birth control (at least in the first few months after your delivery).

Some data suggest that women who breastfed have a lower incidence of breast and ovarian cancer as well as a lower risk of heart disease. Lastly, it’s basically free! Formula is not cheap, and babies drink a lot of it! Take the money you saved, and buy yourself something special. You deserve it. Breastfeeding is hard work!

But while breastfeeding may not be right for every woman, it is medically not advised for some women. These include women who are HIV+, HTLV type I or type II, have active untreated tuberculosis or varicella (chicken pox), or have active herpes with breast lesions. Women who are advised to take certain chronic medications that they briefly stop during the pregnancy may also be advised to resume postpartum and not breastfeed. Additionally, women who use illicit drugs or consume excessive alcohol should not breastfeed. Lastly, babies with a condition called galactosemia (inability to break down a milk byproduct) should not be breastfed.

Let’s face it, even the best milk producers amongst us need a break every now and again. An afternoon to pamper yourself or an evening out with friends is important for your mental state and can actually help with your milk production. Making milk is hard work. You need to eat well, drink lots of fluid, take your vitamins, and try your best to get some rest (we understand how hard this is!) Continue to watch your fish intake (like you did during pregnancy), as some are loaded with mercury  (Link: A Fishy Situation). Bottom line: in order to keep the milk flowing, you need to maintain your health.

You’re not a machine, but even machines don’t work without maintenance! In fact, it is estimated that you need an extra 500kcal per day when breastfeeding. And although infant demand (how much your baby wants and needs) is the major factor determining how much milk you produce (some women breastfeed twins, triplets, plus!), maternal stress, anxiety, fatigue, illness, and smoking can all lead to a tapping out of your supply. A little pumping and dumping now and again never hurt anyone or left any baby hungry.

While we are not here to tell you not to try or to stop prematurely, we are here to say, cut yourself some slack. You are not a failure if you didn’t make milk, if you couldn’t get your baby to latch, or if you simply could not do it. Breastfeeding does offer many benefits, but it’s not right, easy, or appropriate for every mother. And that’s ok. No baby was rejected from Harvard because his or her mother did not breastfeed, quit after a few months, or didn’t make the recommended six-month mark.

In an ideal world, we would have an extended paid maternity leave—this time together would be more conducive to continued breastfeeding. But most women don’t get this; shortly after delivery, they must return to work. So we recommend you use all the resources available to you: lactation consultants, breast feeding organizations/stores, websites, and your friends. Many of them will have walked in your footsteps only months before and can be your cheering squad pushing you forward. Their knowledge can benefit you and offer you solutions to a problem that, despite the loneliness you feel, millions of women before you have faced.

It’s likely not a day will go by that you don’t blame yourself for something, feel guilty about something, or think that someone else would have done it better. It’s par for the course. Parenting is a big responsibility. We get it; the thought is overwhelming. But on this journey of motherhood, you will bogey, you will eagle, and sometimes you will even par. We all do. Breastfeeding is only the first putt on the course. Do your best, and the rest will likely take care of itself.

Got the All Clear, But Can I Really Re-Consummate This Relationship? Sex after Baby

The first six weeks after your baby is born are a major blur. Let’s be real: while there are magical moments, most of your days are filled with spit up, dirty diapers, milk stains, and sweats (don’t think we changed out of our workout clothes once!). Your home becomes a welcoming ground for friends, family, and all of those well-wishers who can’t wait to meet your little one.

And while you welcome a break from the routine (feed, burp, diaper, sleep), their presence can be beyond overwhelming. It’s not only the germs you see them bringing into your Purel-ed place or the gift that now requires a thank-you note (you could write a thank-you note for that cute onesie in your sleep!), but your energy level for entertaining is at an all-time low. It is not easy.

And to top it all off, your body still does not feel like your own. You’re still bleeding, your boobs are now enormous, and your belly still looks pregnant. (We have all been there. It is not fun one month after delivering, when that friendly neighbor says, “Any day now: you must be so excited!”). Additionally, you are now on pelvic rest—a.k.a. nothing in the vagina for six weeks post-delivery (whether or not your kid came out from below or through your belly). That includes no tampons and no sex.

So you make it through the first six weeks sleepless and sexless and go to your OB for the famous post-partum visit. She or he chats about life, how you are feeling, and how you are adjusting. They weigh you (ugh, still have 15 pounds to go) and examine your incisions (both abdominally and/or vaginally). Then they begin the discussion about birth control—pills versus patch, condoms versus IUD, or for those at the end of the baby line, tying your tubes versus tying his tubes (a.k.a. a vasectomy).

This subject transitions into “YOU are all good to go”; basically, you have the green light to have sex again. At this moment, you are probably thinking, Am I really ready to turn in my postpartum hospital-grade underwear? (Gotta admit, those are the best!) for my Hanky Pankys? Given your current state, sleepless and shaveless, it’s hard to imagine being intimate again.

Let us give you a quick preview… It’s as dry as the desert in summer down there, and no matter how much lubricant you use, you will still feel like you are being set on fire. We are here to say not to worry; while completely unpleasant, it is totally normal. In a large study of post-partum women, nearly 85% of women reported sexual problems at three months’ postpartum (See, you are not alone).

Your mind and body have gone through some pretty serious changes, and it will take time for things to go back to normal. And the good news is that for most it will go back to normal. Research shows that about 50% of women reported dyspareunia (medical way to say pain with sex) at two months post-partum. By 18 months postpartum, this number decreased to 24% (See, time does heal all wounds!).

Post-delivery, your estrogen levels plummet. This drop is not only caused by the delivery of your baby and placenta, but also by the rise in prolactin (the hormone that produces breast milk). Prolactin levels remain elevated post-partum to allow for the continued production of milk. With this high comes the persistent low of estrogen.

In addition to the mood changes, the hair changes, the skin changes, and the headaches that come with low estrogen, you can also welcome vaginal dryness. And not just the mild “Oh, KY Jelly or Astroglide can fix that” vaginal dryness…it’s a dryness that requires an army of products. Medically, we call it “atrophy” or “friable.” Due to “atrophy,” you can often see bleeding post-sex. Again, we are here to say that this is not uncommon.

In addition to the discomfort experienced with sex post-partum, a significant number of women report decreased libido. Nearly 60% of women reported a decreased libido at three months post-partum. Not surprisingly, they cited fatigue, discomfort, and fear of making a bad situation worse. Women who breastfeed were even more likely to report a decrease in libido than non-breastfeeding women; this is likely because those who don’t breastfeed have a faster return of their hormones to baseline. However, the difference did not persist for the long term (again, nothing lasts forever!).

Ways to combat this problem include lubricants and vaginal estrogen creams. So even without a major makeover, in most cases, things will get better. Now, if you sustained a serious tear or had a complication with your laceration or episiotomy, the situation might be a bit more complex. It may require you to sit out on the bench for a bit longer and apply a more comprehensive armamentarium of medications and products. But don’t worry. Even in the most serious cases, with the help of an OB/GYN, a pelvic surgeon, and in most cases, physical therapists, this team can help restore the situation back to normal (although you may need to consider having a C Section for your next child to avoid a repeat event if the situation was really bad).

Bottom line is that your bottom will heal—it just takes time. If you don’t feel like you, physically and emotionally, it is totally normal. Don’t be afraid to give your body and your brain time to rest; the postpartum period is no joke! But rest assured, with a little rest and assurance, you will be back in the game in no time.