Breastfeeding as a Contraceptive Method (Lactational Amenorrhoea Method)

Breastfeeding is a temporary contraceptive method which takes advantage of the way in which breastfeeding naturally makes a woman much less likely to conceive. Health professionals often refer to this as the lactational amenorrhoea contraception method.

Whilst breastfeeding, the amount of oestrogen produced by a woman's body is reduced. Ovulation (the release of an egg from the ovaries into the fallopian tubes) only occurs when a woman produces high levels of oestrogen, because high levels of oestrogen trigger ovulation. Because a breastfeeding woman produces less oestrogen than normally, she does not ovulate and cannot become pregnant.

If a woman breastfeeds exclusively and does not give her baby any supplementary foods in the first six months after childbirth, the lactational amenorrhoea method is highly effective (98%) as long as the woman's menstrual cycle has not returned. The method requires no special devices or procedures, and is easy to use. However, it can only be used effectively in the first six months after childbirth.

Lactation (the production of breast milk) is controlled primarily by two hormones, prolactin and oxytocin. Prolactin stimulates milk production, while oxytocin is responsible for transporting milk into the ducts which connect to the nipple.

Prolactin increases throughout pregnancy, causing the breasts to enlarge. While a woman remains pregnant she does not produce milk. This is because levels of another hormone, progesterone, also rise during pregnancy. Progesterone is produced by the placenta and so during pregnancy while the placenta remains in the woman's womb, breast milk is not produced. Following childbirth, when the placenta is expelled, progesterone levels decrease and milk production is stimulated. The infant's suckling at the mother's nipple also stimulates the production of breast milk.

The infant's suckling continues to regulate the amount of milk produced because the suckling action stimulates production of prolactin, which in turn stimulates milk production. The amount of milk produced by a lactating woman is equal to the amount consumed by the infant. When an infant stops suckling, breast milk production will quickly cease. When an infant is suckling frequently and heavily, prolactin levels will increase so that more milk can be produced.

More information on breastfeeding

The contraceptive effect of the lactational amenorrhoea method is a result of increased levels of prolactin. When prolactin levels increase, the production and secretion of another hormone, gonadotrophin releasing hormone are inhibited. When gonadotrophin releasing hormone levels reduce, the woman's body also reduces the amount of oestrogen it produces. Ovulation cannot occur without a surge in oestrogen levels, and if a woman does not ovulate, pregnancy is prevented.

Lactational amenorrhoea can be used by women who wish to prevent pregnancy and meet the following criteria:

They have given birth in the previous six months;They are breastfeeding their infant exclusively or almost exclusively; andThey have not experienced menstrual bleeding since childbirth.

The method is contraindicated in women who do not meet all of the above criteria. While non-exclusive breastfeeding can exert some contraceptive effect, the risk of pregnancy is increased.

The risk of pregnancy is also increased for women who breastfeed exclusively but express milk, either by hand or pump. Women who express milk (e.g. while they are at work) should use an additional contraceptive methods and there are numerous other methods which are safe for use during breastfeeding.

Lactational amenorrhoea is also unsuitable for women using some medications, including mood altering medications. Women using medications should check with their doctor about whether the medications will interfere with effective use of lactational amenorrhoea.

The effectiveness of lactational amenorrhoea is highly dependent on correct use. In particular, it is important that breastfeeding must:

Occur at regular intervals (i.e. on demand and at least every four hours during the day and every six hours at night); and Be exclusive, or almost exclusive (i.e. supplemental foods should not exceed 5-10% of the infant's nutritional intake).

It is also important to begin taking another contraceptive method after six months or earlier if the menstrual cycle returns before six months after childbirth. Individuals using lactational amenorrhoea should inquire about and obtain an additional method when they are visiting a health facility, so that they are ready to commence that method at the return of menstrual bleeding. Alternatively breastfeeding women can commence using progesterone-only hormonal contraceptive methods before the return of the menstrual cycle.

When used by women who meet all three criteria for the method (i.e. no menstrual bleeding, exclusive breastfeeding and less than six months since childbirth) lactational amenorrhoea is effective in preventing pregnancy in 98% of cases.

Menstruation is the key factor which signals the return of fertility, and women who have returned to menses (defined as two consecutive days of bleeding or spotting) cannot use lactational amenorrhoea.

In women who do not experience menstrual bleeding and continue to breastfeed exclusively, lactational amenorrhoea provides contraceptive protection which is 94% effective, one year postpartum.

However, the effectiveness of the method is dependent of the frequency and intensity of breastfeeding. Fertility will increase as the frequency of breastfeeding and the quantity of breast milk decrease.

Women who express milk from their breasts also have a higher risk of pregnancy, even if their infant is feeding exclusively on breast milk. The limited available research suggests that effectiveness is around 95% in women who express milk.

Lactational amenorrhoea encourages exclusive breastfeeding, which has health benefits for both the mother and infant. These include:

Decreased bleeding after childbirth (mother);The uterus returns to its normal size more quickly after childbirth (mother);Improved nutrition (infant);Reduced risk of infectious disease (infant).

There are also many health benefits associated with the increased birth intervals which arise from use of contraceptives.

Other benefits of lactational amenorrhoea include:

It does not cost anything;No special supplies are needed; andIt has no side effects.

There are no health risks associated with the use of lactational amenorrhoea.

The use of lactational amenorrhoea is highly limited, as it is effective only in the first six months postpartum, for women that are not having menstrual periods and breastfeeding exclusively.

In Australia only 54% of women breastfeed their babies exclusively in the first three months of life and an even lower proportion (32%) manage to breastfeed exclusively for the following three months. This means that using lactational ammenorrhoea is not an option for the majority of women in Australia, and is of limited duration for those who can use it.

Lactational amenorrhoea provides no protection against sexually transmitted infections (STIs). Patients who have sexual partners of unknown STI status should be advised to use condoms to prevent STI transmission.

Lactational amenorrhoea is a highly effective contraceptive method for some women, however it is only suitable for women who:

Breast feed exclusively;Do not experience menstrual periods; andHave had a child in the previous six months

For more information on different types of contraception, male and female anatomy and?related health issues, see?Contraception.

King, J. Contraception and Lactation. J Midwifery Women's Health. 2007;52(6):614-20World Health Organisation. Family Planning: A global handbook for providers. 2007. [cited 2009, June 20] Available from:? www.who.int/entity/reproductivehealth/publications/family_planning/en/World Health Organisation Department of Reproductive Health and Research. Progesterone-only contraceptive use during lactation and its effects on the neonate. 2009 [cited 2009, June 20], Available from: http://www.who.int/reproductivehealth/publications/family_planning/en/Labbock, M.H. Hight-Laukaran, V. Peterson, A.E. et al. A multicenter study of the lactational amenerrhea method (LAM): I Efficacy, duration and implications for clinical application. Contraception. 1997;5:327-36World Health Organisation. Health benefits of family planning. 1995 [cited 2009, June 24]. Available from: http://www.who.int/reproductivehealth/publications/family_planning/HRP_FHE_FPP_95_15/en/index.htmlFamily Health International. Lactational Amenorrhoea. 2009. [cited 2009, July 1] Available from: http://www.fhi.org/en/rh/faqs/lam_faq.htm Australian Bureau of Statistics. 4810.0.55.001- Breastfeeding in Australia 2001. Issued 17/9/2003. [cited 2009, July 29]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4810.0.55.001

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Fertility Awareness Contraceptive Methods

Fertility awareness contraceptive methods are methods of preventing pregnancy which rely on a woman monitoring her fertility throughout the menstrual cycle and avoiding sex on days of the cycle in which she is fertile. These methods are also known as periodic abstinence methods and natural contraceptive methods. Methods for monitoring fertility are either:

Calendar based, that is, based on keeping a menstrual cycle calendar (which commences on the first day of menstrual bleeding) and determining fertility according to the number of days which have passed since last menstrual bleeding; orSymptom based, that is, monitoring body changes which indicate changing levels of hormones and determining fertility based on these changes.

Effective use of either calendar or symptom based methods is highly dependent on both the woman using them and her partner's willingness and ability to avoid penetrative vaginal sex, or use another contraceptive method during fertile periods of the cycle. Periodic abstinence or alternative contraceptive methods are an important part of the method.

Fertility awareness methods work by preventing fertilisation, that is, a sperm and egg coming into contact with each other in a woman's uterus or fallopian tubes. Each menstrual cycle an egg is released from the ovaries, and travels through the fallopian tubes and into the uterus. If it is not fertilised by a sperm, it is expelled from the uterus, along with the lining of the uterus (i.e. menstrual blood) within 24 hours. In order for sperm to fertilise the egg, it must be alive in the uterus at the same time as an egg, that is, it must be alive in the uterus just after ovulation. Sperm can stay alive in the uterus for up to five days, and so a woman can become pregnant if she has sex in the five days prior to ovulation, or the 24 hour period in which ovulation takes place.

Ovulation occurs at roughly the same time in each menstrual cycle (around the middle of the cycle), and a number of observable changes take place in a woman's body in the lead up to and following ovulation. These include changes to the texture and quantity of her cervical mucus and body temperature changes. By monitoring these changes, or by tracking the days of her menstrual cycle to identify the mid point, a woman can work out when she is and is not fertile.

The woman must then abstain from penetrative sex or use another contraceptive method during the fertile period, to ensure that sperm does not enter her uterus while she is fertile.

Fertility based awareness methods are suitable for most women although some women may have difficulty using some of the methods (e.g. women with irregular length menstrual cycles). Some women may also need to wait a short while before they can use fertility awareness methods (e.g. those who have recently given birth).

Calendar based methods

For calendar methods, women who may not be able to use the methods or may have to wait to use them include:

Young women who have just started menstruating and who may not yet have established a regular cycle. These women should only use calendar based methods with caution;Women who are approaching menopause and experiencing irregular menstrual cycles as a result. These women should also use calendar based methods with caution;Women who have recently given birth. These women should wait until they are once again experiencing regular menstrual cycles before using calendar based methods. The methods should be used with caution for the first three menstrual cycles;Women who are breastfeeding. These women should wait until their menstrual cycle returns and use calendar based methods with caution for the first three cycles;Women who have experienced miscarriage or have terminated a pregnancy. These women should wait until the start of their next menstrual cycle to begin using calendar based methods;Women using any form of mood altering drug (e.g. anti-depressants). These women should delay using calendar based methods until they finish the medication, or use with caution if necessary;Women on long-term antibiotic or non steroidal anti-inflammatory drugs. These women should also delay using calendar based methods until they finish the medication, or use with caution if necessary;Women who have been using the hormonal contraceptive. These women should wait until their next menstrual cycle to begin using calendar methods.

Women who would like to use calendar based methods but must wait for a period of time to do so, and should therefore abstain from sex or use another contraceptive method while they are waiting, for example male or female condoms.

For more information, see Calendar Based Methods of Contraception

Symptom based methods

For symptom based methods, women who should delay use or use the methods cautiously include:

Women who have just experienced a miscarriage or pregnancy termination - symptom based methods should be used with caution;Women who experience irregular menstrual cycles, for example those approaching menopause - symptom based methods should be used with caution;Women who have a health condition which raises their body temperature should ideally wait until the condition has been treated to use symptom based methods;Women who have recently given birth should delay using symptom based methods until regular menstrual cycles return, typically six months for breastfeeding women and four weeks for non-breastfeeding women. The methods should then be used with caution for the first three months;Women with irregular vaginal bleeding should delay until regular vaginal bleeding returns;Women with unusual vaginal discharge should delay use of these methods until the discharge is treated and goes away;Women using mood altering drugs, some antibiotics or non-sterioidal anti-inflammatory drugs should use symptom based methods with caution or delay until drug use ceases).

Women who need to delay use of symptom based methods should use an alternative contraceptive method or abstain from sex while they are waiting.

For more information, see Cervical Mucus Monitoring Methods of Birth Control

The Sex in Australia survey, a nationally representative survey of sexual practices, reported that 4.4% of Australian women use fertility awareness methods for contraception.

Women from non-English speaking backgrounds and those who live with regular partners are more likely to use this method than their English speaking and non-cohabiting counterparts.

Women from remote areas were less likely to use fertility awareness methods than women from regional or urban areas.

There are numerous ways in which a woman can monitor her fertility. Each is a different contraceptive method, which use very different systems for tracking fertile and infertile times in the cycle. The most common include:

Symptom based methods: Cervical mucus monitoring methods (including the Billings or ovulation method and the two days method) - these methods rely on the woman examining her cervical mucus on a daily basis in order to identify when she is and is not fertile; Basal body temperature monitoring method - is a contraceptive method which relies on the woman measuring her basal body temperature everyday, in order to identify the end of the fertile phase of her menstrual cycle;Symptothermal method - is a method in which both basal body temperature and cervical secretions are monitored simultaneously to determine fertility;Calendar based methods; Standard days method - is a method in which a woman with standard length cycles counts the days from the commencement of menstrual bleeding. Fertile and infertile periods are calculated based on a standard length menstrual cycle and the number of days elapsed;Calendar rhythm method?- a method in which a woman with non-standard length cycles counts the days from the commencement of bleeding. Fertile and infertile periods are calculated based on the average length of her menstrual cycle in the previous six months.

Women who wish to use fertility awareness methods must ensure that they are properly informed regarding the use of these methods. They may wish to visit a family planning clinic or their doctor to discuss the benefits and limitations of each method, which include:

Need for periodic abstinence or alternative contraception: fertility awareness methods only work if the woman abstains or uses alternative contraceptives during the fertile period. This means fairly long periods of sexual abstinence or the need to use an alternative contraceptive method. As sexual abstinence and the use of some barrier methods are highly dependent on the cooperation of the woman's sexual partner, women should discuss how the method works with their partner or take them to the family planning clinic or doctor so they can also receive information about fertility awareness methods from a health professional.Need for accurate monitoring: fertility awareness methods require daily monitoring or recording. Unless this is performed accurately, the effectiveness of the method will decline.Risk of sexually transmitted infection: women should be aware that fertility awareness methods do not protect against sexually transmitted infections (STIs).

Women who use fertility awareness methods and wish to have sex during the fertile periods of their cycle should discuss alternative methods of contraception with their healthcare provider. They should be aware that emergency contraceptives?can reduce the chance of pregnancy for up to five days after unprotected intercourse in the fertile period and are available over the counter in Australian pharmacies.

Fertility awareness methods can be highly effective methods of family planning. When used correctly they prevent pregnancy in 91-99% of cases, depending on the method of fertility monitoring chosen. Basal body temperature monitoring is the most effective (99%) fertility awareness method when used correctly, while the calendar rhythm method is the least effective (91%). Women using these methods should also be aware that the methods are more effective for users who abstain from sex during their fertile periods, compared to those who use alternative contraceptive methods at this time.

They should also be aware that in practice, fertility awareness methods are far less effective. An estimated one in four women become pregnant in the first year of using fertility awareness methods (i.e. these methods are 75% effective in preventing pregnancy). The main reason this is because women using them do not avoid sex or use alternative contraceptive methods during the fertile period of their menstrual cycle.

Fertility awareness methods are natural methods of family planning and therefore do not have any adverse health effects for women. Women also report liking fertility awareness methods as using the methods increases their awareness about their bodies and fertility throughout the menstrual cycle.

In addition they do not rely on any special devices or medications, so women who have concerns about introducing foreign substances or devices to their bodies may like this method more than other methods of family planning. Women who are unable to use other forms of contraception for religious or cultural reasons may also find these methods highly acceptable.

Fertility awareness methods also provide women with a contraceptive method which they do not depend on a health professional to provide, and thus they can commence using the method at any time once they have been instructed about how to monitor their fertility.

Fertility awareness methods rely on the cooperation of the woman's partner and his willingness to either avoid sex or use an alternative contraceptive method at fertile times in the cycle. This often means long periods of abstinence.

To be used effectively the methods also rely on women accurately monitoring the stage of their menstrual cycle or body changes. Some women may be uncomfortable with monitoring methods which require them to touch their genitals (e.g. cervical mucus monitoring). Other women may find it difficult to monitor their cycle or body changes on a daily basis (e.g. because they are forgetful).

Fertility awareness based methods provide no protection against sexually transmitted infections (STIs). Women who are at risk of STI as well as pregnancy should, if possible, use male or female condoms in addition to fertility awareness methods.

For more information on different types of contraception, male and female anatomy and?related health issues, see?Contraception.

World Health Organisation. Family Planning: A global handbook for providers. 2007. [cited 2009, June 20] Available from:? www.who.int/entity/reproductivehealth/publications/family_planning/en/ Germano, E. Jenning, V. New approaches to fertility awareness based methods: incorporating the standard days and two days methods into practice. J Midwifery Women's Health. 2006;51:471-7.Richters, J. Grulich, A.E. de Visser, R.O. et al. Sex in Australia: Contraceptive Practices in a representative sample of women. Aust NZ J Pub Health. 2003;27:210-6.International Planned Parenting Federation. Fertility Awareness. 2009. [coted 2009, November 5] Available from: http://www.plannedparenthood.org/health-topics/birth-control/fertility-awareness-4217.htm

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Withdrawal Contraceptive Method

Withdrawal is a contraceptive method in which the male partner interrupts intercourse, so that he can withdraw his penis from his partner's vagina prior to ejaculation. It is also known as coitus interruptus or simply as "pulling out". Withdrawal is a natural family planning method which can be used as a primary or back up method (e.g. couples using fertility awareness methods of family planning may use withdrawal as a back up method during fertile times of the menstrual cycle).

Withdrawal has been used for centuries, in most societies of the world. While it is much less effective than many modern contraceptive methods, it provides considerable contraceptive protection compared to not using contraceptives at all.

The withdrawal contraceptive method works by preventing sperm?entering the woman's uterus. It therefore prevents sperm coming into contact with an oocyte and thus prevents fertilisation.

All women who have a willing partner can use withdrawal as a contraceptive method. There are no medical conditions which contraindicate use of this method by men, although there are some men who may find the method more difficult to use than others. These include:

Men who experience premature ejaculation; andMen who find it difficult to identify when they are about to ejaculate (for example, sexually inexperienced men).

The Sex in Australia survey, a national survey of sexual behaviours and experiences, reported that 4.5% of Australian women rely on withdrawal for contraceptive protection. This is lower than the global prevalence of withdrawal use (6%), and the prevalence in other developed countries (e.g. in Canada 9% of all women and 22% of 15-17 year olds use withdrawal for contraceptive protection).

In Australia, women from non-English speaking backgrounds, and those with a non-cohabiting, regular sexual partner were significantly more likely to use the withdrawal method than English speaking women, or those in other types of sexual partnerships. Use was less common amongst those living in regional, compared to those living in urban and remote areas. Use of withdrawal amongst Australian women was not significantly associated with their age, level of education, income, or occupational type.

Individuals considering using the withdrawal method should be aware of other, more effective contraceptive methods including hormonal (e.g. the hormonal contraceptive pill?or injection), barrier (e.g. male condoms?and female condoms) and other natural family planning (e.g. Basal body temperature monitoring). A general practitioner or family planning clinic will be able to provide the necessary information about the benefits and limitations of each of these methods.

As the withdrawal method is highly dependent on the male partner's ability and willingness to interrupt intercourse and withdraw his penis prior to ejaculation, women considering using this method should discuss their choice with their partner. Wherever possible, both partners should attend a family planning clinic or GP's office together, to jointly discuss their contraceptive options. The couple should consider realistically their ability to use the method, in particular whether or not the male partner has the capacity to withdraw prior to ejaculation during every act of intercourse. Couples may wish to consider using another form of contraception in the early stages to allow the man to practice and become more used to withdrawing prior to ejaculation.

It is important to understand the following points on how to use the withdrawal method:

The male sexual partner should withdraw his penis from the female partner's vagina when he feels like he is about to ejaculate;He should also ensure that his penis is away from the woman's external genital area before ejaculating;After ejaculation, the man should urinate before having sex again. Urinating helps wash away any sperm which may remain in his penis;Emergency contraceptives?should be used if the method fails (i.e. if the male partner does not withdraw his penis prior to ejaculation). Emergency contraceptives are available over the counter from Australian pharmacies, and can be used effectively for several days, and not just the morning after unprotected intercourse. Couples who do not have easy access to a pharmacy (e.g. those living in remote areas) may which to keep emergency contraceptives on hand, just in case they are needed;Patients wishing to protect themselves against sexually transmitted infections (STI)?should use male or female condoms as the withdrawal method does not protect against STIs.

When used properly, the withdrawal method is 96% effective. It is however highly user-dependent, that is, it is highly dependent on the ability of the male partner to correctly identify when he is about to ejaculate, so that he can withdraw his penis prior to ejaculation. This may be difficult for some men, for example young men with limited sexual experience and men who experience premature ejaculation. In practice withdrawal protects women against pregnancy in 73% of cases.

While this is considerably lower than highly effective modern methods of contraception (e.g. combined oral contraceptive pills?are >99% effective), withdrawal offers considerable contraceptive protection when compared to no contraceptive use at all. An estimated 85% of women will become pregnant within a year when no contraception is used, compared to only 27% of women who use withdrawal.

The benefits of the withdrawal method include:

It is a natural method which has no side effects;It is available to all couples, all the time, as either a primary or backup method;It doesn't cost anything;It promotes male responsibility for contraceptive protection and may encourage couples to communicate; andLearning to control ejaculation may make men more aware of their sexual sensations and help them to manage premature ejaculation.

The limitations of the withdrawal method include:

It is one of the least effective contraceptive methods;It requires high levels of self control from the male partner; andIt may interfere with sexual pleasure.

For more information on different types of contraception, male and female anatomy and?related health issues, see?Contraception.

World Health Organisation. Family Planning: A global handbook for providers. 2007. [cited 2009, June 20] Available from:? www.who.int/entity/reproductivehealth/publications/family_planning/en/ Bissell, M. Withdrawal: historical, current and cultural perspectives on its use. Canadian J Human Sexuality. 2003;12. [cited 2009, July 29], available from: http://www.accessmylibrary.com/coms2/summary_0286-12839304_ITM Germano, E. Jenning, V. New approaches to fertility awareness based methods: incorporating the standard days and two days methods into practice. J Midwifery Women's Health. 2006;51:471-7.Richters, J. Grulich, A.E. de Visser, R.O. et al. Sex in Australia: Contraceptive Practices in a representative sample of women. Aust NZ J Pub Health. 2003;27:210-6.Callabretto, H. Emergency contraception- knowledge and attitudes in a group of Australian university students. Aust NZ J Public Health. 2009;33(3):234-9.International Planned Parenting Federation. Withdrawal. 2009. [cited 2009, July 4]. Available from: http://www.ippf.org/en/Resources/Contraception/Contraception.htm

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