Experience with Oral Contraceptives in the Immediate Puerperium: Effect on Breast Engorgement and Menstrual Flow*

21

lar led ces e111

Vol. 21, No. I, January 1070 Printed in U.S.A.

FERTILITY AND STERILITY

Copyright © 1970 by The Williams & Wilkins Co.

EXPERIENCE WITH ORAL CONTRACEPTIVES IN THE IMMEDIATE PUERPERIUM: EFFECT ON BREAST ENGORGEMENT AND MENSTRUAL FLOW* JAMEB A. BOWMAN, JR., M.j).

W .. uathe Jll-

and lent

3

of

Jrld , p.

:urr

Brit ned ma. ogy :29, the 735,

ent. mw

I, p.

Department of Reproductive Biology, The School of Medicine, Case Western Reserve University, Cleveland, Ohio

Oral contraceptives provide an accep- uate the effectivene::;s of norethindrone and table method of family planning for many mestranol in suppressing postpartum breast postpartum patients. The desirability of engorgement and to determine the effect, establishing the postpartum patient on oral if any, on involution of the uteruti and escontraceptives stems from the patient's tablitihment of menses. desires as well as the physician's to achieve MATERIAL::; AXD METHOD::; early acceptable tiafe contraception. Oral Patients who showed an interest moral contraception started 3-4 days after decontraception and who were willing to livery has been reported previously.1 It has been shown that the use of oral come to The Family Planning Clinic contraceptives early in the postpartum for three visits during the 1O-week postperiod does not change the involution of partum period were selected from the obthe pelvic organs, but docs delay the res- stetrical service of University Hospitals of titution of the endometrium from the post- Cleveland. Evaluations of breast symptoms partum titate in compari::;on with patient::; were made on the third day postpartum not under the influence of the oral pro- and at 3 weeks, 6 weeks, and 10 weeks postpartum. In each case breast discomgestins.:l Initiating the program before the patient fort, engorgement, erythema, and milk seis discharged from the hospital and while cretion were evaluated as nOlle, mild, modpregnancy is uppermost in her thoughts erate, and marked. At the time of the 3-, 6-, and 1O-week seems to offer the most feasible approach visits a bimanual examination of the pelvic to family planning." The enlarged tender breast of the non- structures was made to evaluate the involunursing mother in the puerperium has been tion of the uterus, and the cervix was exa concern of the obstetrician for decades. posed with a speculum. The onset and duSince the reported use of estrogens in ration of the first two menstrual cycles were recorded and the incidence of break1938,~ there have been a myriad of hormone combinations suggested to decrease through bleeding was noted. Approximately 300 patients were folpostpartum breast engorgement. Consistlowed during the course of the study. The ently good rewlts were rarely achieved patients were divided into three groups. with anyone medication and, furthermore, Groujl A, consisting of 102 patients, rethe majority of oral medications required ceived norethindrone, 2 mg., and mestranol, daily administration for prolonged periods 0.1 mg. (Norinyl, 2 mg.), in a single daily of time. In many instances rebound phedose for 20 days starting 24 hr. postpartum. 4 nomenon negated any therapeutic effect. Group B consisted of 98 patients who reThe present study was planned to evalceived the same dosage of norethindrone * This study was supported b~' a grant from and mestranol 21 days postpartum. Group Syntex Luboratorirs.

39

40

BOWMAN

C consisted of 98 patients who received the same dosage starting the fifth day following onset of their first menses. None of the patients (in the study) received any other hormone preparation which might have affected the breasts or pelvic structures. RESULTS

Breast Discomfort. There appeared to be no difference in the breast evaluations of women who had received norethindrone and mestranol 24 hr. postpartum and those women who had not received the drug. Two patients in the entire group requested analgesia because of breast discomfort. One patient was in the group receiving norethindrone and mestranol 24 hr. postpartum and 1 patient was from the group who received the contraceptive at the time of the first menses, Group C. Mild or no breast discomfort was reported by 75.5% of the group receiving the oral contraceptive 24 hr. postpartum, as opposed to 81.5% of the patients who did not receive the drug. Moderate to marked pain was reported by 24.5% of the patients receiving the oral contraceptive and 18.5% of the patients not receiving the drug. Among patients receiving oral contraceptives 51% were observed to have mild or no breast engorgement compared to 63% of patients not receiving the drug. Of the patients on oral contraceptives 29.4% had moderate engorgement at the third day postpartum compared to 30.6% of patients not receiving the drug. TABLE 1. Onset of Menses Postpartum Group A Days Patients Group B Days Patients Group C Days Patients

-20 9

21 14

22 38

23 17

24 6

25 3

26 1

27 28+ 3 10

-38 4

39 4

40 8

41 15

42 22

43 14

44 9

45 46+ 5 10

-29 30-34 35-39 40-44 45-49 50-54 55-59 60+ 9 10 19 15 15 7 2 14

Vol. 21

Marked engorgement was noted in 19.6% of the patients receiving norethindronemestranol 24 hr. postpartum compared to 5.2% in the group not receiving the oral contraceptives in the immediate puerperium. Since most of the breast examinations on the third postpartum day were made by the same observer, this marked difference between the two groups is difficult to explain. The subsequent examinations of the breasts at 3, 6, and 10 weeks postpartum were essentially the same among the three groups. Onset 0 f Menses. Table 1 details the great variance in onset of menses among the three groups. In Group A, patients were given norethindrone-mestranol 24 hr after delivery; the average date of onset of flow was 22 days with a range of 19-30 days or more. Group B received norethindronemestranol 21 days postpartum for 20 days and the average onset of flow was 42 days with a range of 29-49 days. Group C patients had the widest range of onset of menses, from 22 to'more than 73 days. Two patients became so concerned about their menses that withdrawal bleeding was induced at 70 and 79 days respectively following the administration .of norethindrone-mestranol for 5 days. Duration and amount of menstrual flow did not differ appreciably among the three groups. Five patients in Group A did not have withdrawal bleeding after the first cycle of norethindrone-mestranol but had withdrawal bleeding following the second cycle. The second menstrual cycle was more uniform, as one might expect. Groups A and B had an average onset of menses at 26-27 days following the first cycle. Since there was a marked range in onset of first cycle bleeding in Group C, only a few patients had a second cycle at the time of the 1O-week examination. The amount and

21

January 1970

>% leto ral erlasre

duration of the second menses did not vary among the three groups. Involution. There was no difference in size of the uterus reported among the three groups at the time of examination at 3, 6, and 10 weeks respectively. One patient became pregnant during the study. The patient was a 16-year-old primipara in group B. She completed the course of norethindrone-mestranol 41 days postpartum but did not have withdrawal bleeding until 46 days postpartum. The patient did not start the second course of tablets on time, a lapse of medication for some 10 days.

~ed

ffi-

the

1m

ree

Ghe mg ere ter ow or netys tys )aof 'wo leir lll-

'01-

.lll-

.ow ree not lrst lad md ore A

at nce lrst pathe md

EXPERIENCE WITH ORAL CONTRACEPTIVES

DISCUSSION

This study of 298 women during the postpartum period indicates the need and value of early use of the oral contraceptives. The repeated comment of the patients who had received norethindronemestranol 24 hr. postpartum was the relief of anxiety and the peace of mind in resuming the marital role. Patient education is an important part of the early use of the oral contraceptives. We found that small classes conducted by a nurse trained in family planning technics were extremely effective. The classes were given on the postpartum floor. Visual aids were used and patients were given an opportunity to vent their anxieties. Many women find the time between the first postpartum coitus and the first menses a worrisome interval. The most impressive result of norethindrone-mestranol administration was the predictable onset of menses in Groups A and B. Patients had to be taught, however, to differentiate between lochia and the first cycle. Ninetytwo per cent of the patients in Group A had menstruated within 4 weeks of delivery. More than 500 women had breast examinations on the third postpartum day

41

during the course of the study in order to obtain sufficient patients to follow in the subsequent 10 weeks. We were impressed by the relatively few women who complained of severe breast discomfort, and how the maj ority had little or no symptoms. Those patients with mild to moderate discomfort had relief with simple breast support. In conclusion, norethindrone-mestranol does not appear to suppress postpartum breast engorgement when given in the usual contraceptive dosages in the early puerperium. It would also appear that breast discomfort is not a great problem for the majority of women. The oral contraceptives may be safely used in the early puerperium, and with high patient acceptance. There were no problems related to nausea, bleeding, or subinvolution of the uterus. SUMMARY

1. Three groups of postpartum patients were studied to determine the effect of suppression of breast engorgement, onset of menses, and involution of the uterus by the administration of 2 mg. of norethindrone and 0.1 mg. of mestranol in the puerperium. 2. In Group A, the medication was given 24 hr after delivery; in Group B, 21 days after delivery; and in Group C, on the fifth day following the first day of menstruation. 3. The average onset of menses occurred 22 days postpartum in Group A and 42 days postpartum in Group B. 4. No discernible difference was observed in breast symptoms between the treated groups and the untreated groups. 5. No discernible difference was noted in the three groups with involution of the uterus at 3, 6, or 10 weeks postpartum. 6. Oral contraceptives can be safely given during the immediate puerperium with excellent patient acceptance.

42

BOWMAN

REFERENCES 1. CURTIS. E. M .. NEWSml. N. R .. A:\"D GRA:\"T. R. P. Oral contracepti\"(~s in the immediate puerperium. J M ed Ass Georgi({ 52 :425. 1963. 2. Foss. G. L .. A:\"D PHILIPS, P. The suppression of lactation by oral oestrogen therapy. Brit Mer! J 2 :887. 1938. 3. FRA:\"K. R.. ALPER:\". W. B .. A:\"D ESHBAUGH, D. E. "Observations on the Use of Onilen in the

Vol. 21

Early Postpartum Period." In Advances in Planned P({renthood (Vo!. 2), Excerpta Medica Foundation. 1967, p. 66. 4. GOLD. J. J .. A:\"D COHEN, M. R. Sex-steroid therapy for postpartum breast symptoms: A revie\\'. Ob,tet GYllec 13 :413, 1959. 5. RECH. F. M., A:\"D SCHWARZ, R. R. Postpartum oral contraception: A clinical evaluation. Fertil Steri! 17 :556, 1966.