JEWISH WOMEN'S HEALTHA GUIDE FOR HEALTH PROFESSIONALS

IN MEMORY OF MINDEL BAT R'CHAIM

Progestin Only Contraception

Abstract: Progesterone only methods are often prescribed for breastfeeding women. The main halachic concern with progesterone only preparations is their propensity to cause vaginal bleeding and spotting. This often, but not always, causes the woman to become niddah. Patients should be aware of what to anticipate prior to starting this method. Patients should be counseled to consult with their rabbis before abandoning this method because of spotting, as halachic solutions can sometimes be found

Discussion:

Progestin only methods are a form of hormonal contraception that includes one of a number of artificial progesterones [1]. They are available as the various brands of oral pills (“minipill”), injections, and subdermal capsules [2]. These methods are generally prescribed for women for whom estrogen use is not desired. This includes breastfeeding women, as progesterone only preparations are less likely to have a negative impact on milk supply [3].

The main concern with this method is unanticipated bleeding. According to a 1982 randomized, double-blind trial by the World Health Organization (WHO), during the first three months of use, an average of 53% of users reported frequent bleeding, 22% reported prolonged bleeding, and 13% reported irregular bleeding. All of these patterns can lead to extended periods when the couple cannot have relations. Although the frequency of these effects decreased by cycle 12, one quarter of POP users in the study discontinued because of bleeding disturbances[4]. Halacha observant women are likely to abandon the method sooner, as these effects are more than just a nuisance.

However, sometimes this spotting may not be of halachic consequence and therefore, a woman should consult her rabbi before precipitously abandoning the method. She should also be counseled that it takes time for the body to adjust to the new hormonal environment. Spotting may improve after the first month or two of use, and she should be prepared to test the method for this period of time before abandoning it.

Care should be taken prior to recommending the depot methods of administering progesterone. Not only is spotting a concern, but this method is typically associated even more than the minipill with very irregular, erratic, and unpredictable bleeding. Furthermore, the drug remains in the woman’s body for a number of months. Therefore, there is little that can be done to help alleviate the situation. Implants under the skin do not constitute a barrier to mikveh immersion.

Implications for Patient Care:

Progesterone only contraception is a common request in the halacha observant population. Patients should be counseled by the physician as to the expected frequency of irregular bleeding and spotting. They should be advised to consult with their rabbis as how to best avoid unnecessary periods of being niddah. Depot preparations should be used with great caution in this patient population.

Medical References

[1] Grimes  DA, Lopez  LM, O’Brien  PA, Raymond  EG. Progestin only pills for contraception. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD007541.

[2] Royer PA, Jones KP. Progestins for contraception: modern delivery systems and novel formulations. Clin Obstet Gynecol. 2014 Dec;57(4):644-58.

[3] Lopez  LM, Grey  TW, Stuebe  AM, Chen  M, Truitt  ST, Gallo  MF. Combined hormonal versus nonhormonal versus progestin‐only contraception in lactation. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD003988.

[4] WHO Task Force on Oral Contraceptives. A randomized, double-blind study of two combined and two progestogen-only oral contraceptives. Contraception 1982;25:243-252.

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