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Control of postpartum breast engorgement with oral contraceptives
Control of postpartum
breast engorgement
with oral contraceptives DAVID
E.
BOOKER,
IRWIN
R.
PAHL,
Springfield,
Massachusetts
M.D. M.D.
The need for effective suppression of breast discomfort, as well as for early reliable pregnancy control, was met in this preliminary study of 100 nonnursing mothers who began taking an oral contraceptive immediately post partum. Breast Jymptoms zere absent or minimal in 86 per cent of the study group, and the medication prescribed in this manner was found to be enthusiastically accepted and extremely well tolerated.
Materials
0 v u L A T I o N-inhibiting agents have found increasingly expanding therapeutic usage in a number of conditions in addition to their revolutionary impact on conception control. Among those conditions reportedly benefitted by oral contraceptives are: dysmenorrhea, dysfunctional uterine bleeding (menorrhagia, metrorrhagia, irregular menses), amenorrhea, infertility, habitual abortion, mittelschmerz, premenstrual tension, chronic cystic nrastitis, acne, and endometriosis. A decrease in lactation, especially when not well established, has occasionally been noted in nursing mothers who have taken oral contraceptives. In our practice, many, if not most, recent parturients desire suppression of lactation and an early effective contraceptive means. Oral contraceptives have traditionally been initiated following the first postpartum menstrual period. This period generally occurs between 6 and 12 weeks following delivery and can often cause considerable consternation, especially when delayed. With this in mind, we attempted to test the feasibility of initiating an oral contraceptive immediately following delivery and at the same time made subjective and objective observations of breast symptoms, lochial discharge, time of onset of first menstrual period, and adverse side effects of the medication.
and
methods
One tablet containing 2 mg. norethindrone and 0.1 mg. mestranol” was administered daily for 20 days, starting 2 hours post parturn to 100 nonnursing mothers. Objective and subjective evaluation of breast symptoms were made by one or both of us daily at least through day 5, and at 2 weeks, 4 weeks, and 6 weeks post oartum. In each case, breast symptoms were evaluated as “none,” “slight,” “moderately, severe,” or “very severe,” and recorded as such for each day of observation. In addition, the date of the first menstrual period, the amount of lochial flow with relation to previous pregnancies in multiparas, and undesirable side effects of the medication were subjectively evaluated. If a patient wished to continue the medication for contraception, she was instructed to restart the pills in the usual cyclic manner, beginning again on the fifth day of her first period, or 7 days after her last pill if no menstrual flow was observed. She was asked to report any breast symptoms that occurred within the 6 week observation period.
*Supplied
1099
as Nolinyl,
Syntex
Laboratories,
Inc.
1100
Booker
and
Pahl Am.
Table -~
I. Breast
evaluation -
Symptoms Discomfort None Slight Moderately Very severe
(total
entries*)
/ Day2
severe
August 15. 1967 J. Obst. g: Gyner.
1 Day3
/ Day4
1 Day5
/ Day6
/ Week2
/ Week4
/ Week6
100 0 0 0
92 5 3 0
76 20 4 (I
90 7 3 0
92 8 0 0
100 0 0 IO
1 on 0 (I 0
100 0 IJ 0
99 1 0 0
91 6 3 0
73 ‘18 9 0
88 9 3 0
93 7 0 0
100 0 0 0
100 0 0 0
100 0 0 n
100 0 0 0
92 5 3 0
81 89 12 8 7 3 0 ~___-__- 0
95 5 0 0
100 100 0 0 0 0 0 __-.--____-. 0
100 I) II 0
Engorgement None Slight Moderately Very severe
severe
Tenderness NotIe Slight Moderately Very severe *Includes
Table
severe
total
daily
II. Lochial
entrks
of
100
study
flow
(multiparas)
patients.
Comparison to preuious pregnancies
%
Less Same More Total
Table III. (twentieth)
Start of menses tablet
37 21 2 60
62 35 3 100
following
last
Day I
( 2
/ 3
I 4
8
40
30
3
I 5 2
) 7
j 9
i 7nZe.r
1
1
5
I Total 90
Results
In only one instance was any breast symptom observed before the third postpartum day. There were no cases of induration, erythema, nodules, or fever due to breast engorgement observed in the 100 study patients. A minority of patients exhibited some breast discomfort, engorgement, and tenderness on days 2 through 6 with a peak incidence on day 4 (Table I). Fifty-four per cent of the patients had no breast symptoms whatsoever, and another 32 per cent had only “slight” symptoms. Fourteen patients had symptoms which could be classified as “mod-
erately severe” and no patients had symptoms evaluated as “very severe” (Table I ) . Early in the study it became apparent that the lochial flow in the majority of cases was less heavy and of shorter duration, most frequently being completely stopped by the 2 week examination. Of the 60 multiparas questioned concerning their lochial flow, 62 per cent reported “less” or “very much less” flow than previously, 35 per cent reported the “same,” and only 3 per cent thought they had “more” flow than before (Table II). All except 7 of the 90 women questioned specifically had begun a distinct menstrual period by the fifth day following their last tablet, and only 5 had no discernible flow (Table III). Over half (60 per cent) of the study patients decided to continue the medication for contraceptive purposes. The remainder discontinued for various reasons after the first or second month, but interestingly, only 2 women stopped because of adverse side effects of the medication, one because of edema and the other because of edema and rash. As a matter of fact, these were the only instances of the usual side effects frequently observed in the first few months of oral contraception except for some vaginal “spotting” and bleeding kvhich was difficult to separate from the lochial flow.
Control
Comment
Suppression of breast symptoms was found to be complete or nearly so in 86 per cent of the study group. This compares to suppression in 95.3 per cent of Roser’s study group treated by an injection of testosterone enanthate plus estradiol valerate at delivery, as against 38.2 per cent of his control patients experiencing natural suppressi0n.l In addition to the apparently very acceptable suppression of breast engorgement and the obvious advantage of initiating an early, effective contraceptive technique, omther benefits which seem to have been derived were a decrease in lochial flow and a virtual absence of adverse side effects of the medication. Neither were any of the controversial, more serious but equally more rare complications which have been attributed to the oral contraceptives observed, but these would not be expected in a small study group during the relatively short observation period. Summary
1. One hundred, nonnursing mothers were studied for the effects on control of postpartum breast engorgement by the daily administration of an oral contraceptive tablet containing 2 mg. norethindrone and 0.1 mg. mestranol, starting 2 hours post partum, and
of
postpartum
breast
engorgement
1101
then daily for a to,tal of twenty tablets. Objective and subjective observations were made daily during at least the first 5 days and then at 2, 4, and 6 weeks post partum. 2. Fifty-four per cent of the patients had no breast symptoms whatsoever, one-third had only slight discomfort, engorgement, or tenderness, while 14 per cent had moderately severe, and none had very severe symptoms. Symptoms were quite transient, lasting one or 2 days, and rarel), 3 days, and usually occurred on the third. fourth, or fifth postpartum day. 3. Lochial flow was thought to be less than previously experienced by the majority of multiparas, and a menstrual period was almost always observed within a few days of stopping medication. 4. The various adverse side effects of the medication frequently observed during the first few months of oral contraception were virtually absent in this study. 5. Over half of the study group chose to continue the medication as their method of contraception. REFERENCE
1. Roser, D. M.: Obst. & Gynec. 27: 73, 1966. 780 Chestnut Springfield,
Street Massachusetts
01107
breast engorgement
with oral contraceptives DAVID
E.
BOOKER,
IRWIN
R.
PAHL,
Springfield,
Massachusetts
M.D. M.D.
The need for effective suppression of breast discomfort, as well as for early reliable pregnancy control, was met in this preliminary study of 100 nonnursing mothers who began taking an oral contraceptive immediately post partum. Breast Jymptoms zere absent or minimal in 86 per cent of the study group, and the medication prescribed in this manner was found to be enthusiastically accepted and extremely well tolerated.
Materials
0 v u L A T I o N-inhibiting agents have found increasingly expanding therapeutic usage in a number of conditions in addition to their revolutionary impact on conception control. Among those conditions reportedly benefitted by oral contraceptives are: dysmenorrhea, dysfunctional uterine bleeding (menorrhagia, metrorrhagia, irregular menses), amenorrhea, infertility, habitual abortion, mittelschmerz, premenstrual tension, chronic cystic nrastitis, acne, and endometriosis. A decrease in lactation, especially when not well established, has occasionally been noted in nursing mothers who have taken oral contraceptives. In our practice, many, if not most, recent parturients desire suppression of lactation and an early effective contraceptive means. Oral contraceptives have traditionally been initiated following the first postpartum menstrual period. This period generally occurs between 6 and 12 weeks following delivery and can often cause considerable consternation, especially when delayed. With this in mind, we attempted to test the feasibility of initiating an oral contraceptive immediately following delivery and at the same time made subjective and objective observations of breast symptoms, lochial discharge, time of onset of first menstrual period, and adverse side effects of the medication.
and
methods
One tablet containing 2 mg. norethindrone and 0.1 mg. mestranol” was administered daily for 20 days, starting 2 hours post parturn to 100 nonnursing mothers. Objective and subjective evaluation of breast symptoms were made by one or both of us daily at least through day 5, and at 2 weeks, 4 weeks, and 6 weeks post oartum. In each case, breast symptoms were evaluated as “none,” “slight,” “moderately, severe,” or “very severe,” and recorded as such for each day of observation. In addition, the date of the first menstrual period, the amount of lochial flow with relation to previous pregnancies in multiparas, and undesirable side effects of the medication were subjectively evaluated. If a patient wished to continue the medication for contraception, she was instructed to restart the pills in the usual cyclic manner, beginning again on the fifth day of her first period, or 7 days after her last pill if no menstrual flow was observed. She was asked to report any breast symptoms that occurred within the 6 week observation period.
*Supplied
1099
as Nolinyl,
Syntex
Laboratories,
Inc.
1100
Booker
and
Pahl Am.
Table -~
I. Breast
evaluation -
Symptoms Discomfort None Slight Moderately Very severe
(total
entries*)
/ Day2
severe
August 15. 1967 J. Obst. g: Gyner.
1 Day3
/ Day4
1 Day5
/ Day6
/ Week2
/ Week4
/ Week6
100 0 0 0
92 5 3 0
76 20 4 (I
90 7 3 0
92 8 0 0
100 0 0 IO
1 on 0 (I 0
100 0 IJ 0
99 1 0 0
91 6 3 0
73 ‘18 9 0
88 9 3 0
93 7 0 0
100 0 0 0
100 0 0 0
100 0 0 n
100 0 0 0
92 5 3 0
81 89 12 8 7 3 0 ~___-__- 0
95 5 0 0
100 100 0 0 0 0 0 __-.--____-. 0
100 I) II 0
Engorgement None Slight Moderately Very severe
severe
Tenderness NotIe Slight Moderately Very severe *Includes
Table
severe
total
daily
II. Lochial
entrks
of
100
study
flow
(multiparas)
patients.
Comparison to preuious pregnancies
%
Less Same More Total
Table III. (twentieth)
Start of menses tablet
37 21 2 60
62 35 3 100
following
last
Day I
( 2
/ 3
I 4
8
40
30
3
I 5 2
) 7
j 9
i 7nZe.r
1
1
5
I Total 90
Results
In only one instance was any breast symptom observed before the third postpartum day. There were no cases of induration, erythema, nodules, or fever due to breast engorgement observed in the 100 study patients. A minority of patients exhibited some breast discomfort, engorgement, and tenderness on days 2 through 6 with a peak incidence on day 4 (Table I). Fifty-four per cent of the patients had no breast symptoms whatsoever, and another 32 per cent had only “slight” symptoms. Fourteen patients had symptoms which could be classified as “mod-
erately severe” and no patients had symptoms evaluated as “very severe” (Table I ) . Early in the study it became apparent that the lochial flow in the majority of cases was less heavy and of shorter duration, most frequently being completely stopped by the 2 week examination. Of the 60 multiparas questioned concerning their lochial flow, 62 per cent reported “less” or “very much less” flow than previously, 35 per cent reported the “same,” and only 3 per cent thought they had “more” flow than before (Table II). All except 7 of the 90 women questioned specifically had begun a distinct menstrual period by the fifth day following their last tablet, and only 5 had no discernible flow (Table III). Over half (60 per cent) of the study patients decided to continue the medication for contraceptive purposes. The remainder discontinued for various reasons after the first or second month, but interestingly, only 2 women stopped because of adverse side effects of the medication, one because of edema and the other because of edema and rash. As a matter of fact, these were the only instances of the usual side effects frequently observed in the first few months of oral contraception except for some vaginal “spotting” and bleeding kvhich was difficult to separate from the lochial flow.
Control
Comment
Suppression of breast symptoms was found to be complete or nearly so in 86 per cent of the study group. This compares to suppression in 95.3 per cent of Roser’s study group treated by an injection of testosterone enanthate plus estradiol valerate at delivery, as against 38.2 per cent of his control patients experiencing natural suppressi0n.l In addition to the apparently very acceptable suppression of breast engorgement and the obvious advantage of initiating an early, effective contraceptive technique, omther benefits which seem to have been derived were a decrease in lochial flow and a virtual absence of adverse side effects of the medication. Neither were any of the controversial, more serious but equally more rare complications which have been attributed to the oral contraceptives observed, but these would not be expected in a small study group during the relatively short observation period. Summary
1. One hundred, nonnursing mothers were studied for the effects on control of postpartum breast engorgement by the daily administration of an oral contraceptive tablet containing 2 mg. norethindrone and 0.1 mg. mestranol, starting 2 hours post partum, and
of
postpartum
breast
engorgement
1101
then daily for a to,tal of twenty tablets. Objective and subjective observations were made daily during at least the first 5 days and then at 2, 4, and 6 weeks post partum. 2. Fifty-four per cent of the patients had no breast symptoms whatsoever, one-third had only slight discomfort, engorgement, or tenderness, while 14 per cent had moderately severe, and none had very severe symptoms. Symptoms were quite transient, lasting one or 2 days, and rarel), 3 days, and usually occurred on the third. fourth, or fifth postpartum day. 3. Lochial flow was thought to be less than previously experienced by the majority of multiparas, and a menstrual period was almost always observed within a few days of stopping medication. 4. The various adverse side effects of the medication frequently observed during the first few months of oral contraception were virtually absent in this study. 5. Over half of the study group chose to continue the medication as their method of contraception. REFERENCE
1. Roser, D. M.: Obst. & Gynec. 27: 73, 1966. 780 Chestnut Springfield,
Street Massachusetts
01107