* In the text ‘Pill’ refers to all hormonal contraception, whether taken orally, by injection, by patch or by pessary.
WHAT IS THE ‘PILL’ ?
Hormonal contraception, (the Pill), consists of synthetic steroid sex hormones, (synthetic oestrogen or progesterone), which interfere with the normal functioning of the menstrual cycle. When a woman is on the Pill* the apparent menstrual period is not a true** menstruation, but consists only of a withdrawal bleed brought on by an abrupt drop in hormone levels during the Pill-free days.
(**true menstruation is the bleeding that occurs at the end of a normal ovulatory cycle when pregnancy does not occur and during which the endometrium was primed first by oestrogen and then by progesterone.)
Does fertility return immediately on stopping the ‘Pill’?
After stopping the Pill, the woman can use the symptothermal method of NFP to help her to identify the return of her fertility. In many women normal cycles return immediately. However for many others the return of fertility is delayed and it is impossible to predict when ovulation will return, it may vary from one month to eighteen months or more. After charting for six cycles the woman can determine if her cycles have bcome normal.
What causes the delay in the return in fertility, and is it the same for everybody?
The delay in return of normal cycles may be due to the residual synthetic steroid hormones stored in the body which interfere with the normal functioning of the hypothalamic-pituitary-ovarian axis (HPO axis), and it may take three months or more for these hormonesito be excreted. Even when all synthetic hormones are excreted it may take some time for the HPO axis to readjust to normal hormone levels. This occurs quicker in the woman who had already been pregnant, or whose cycles were regular prior to starting the Pill.
Therefore the time required for the return of fertility after stopping the Pill depends on:
The type of contraceptive medication used.
The age of the woman, the age of starting the contraceptive.
The duration of taking the contraceptive medication.
The pattern of cycles before taking the contraceptive.
Whether the woman had or had not a previous pregnancy.
The Fertility Indicators, (i.e. temperature, mucus, palpation of the cervix) in the Post-Pill situation:
Temperature (BBT) post-Pill: The thermal shift is the only sign of ovulation in the post-pill situation.
Cervical mucus post-pill: The cervical mucus indicator is less reliable after stopping the Pill because:
(a) The cervical erosion, which is found in about 25% of women who have used the Pill for more than three months weeps copious amounts of fertile-type mucus once the woman stops ingesting progestins making the mucus symptom difficult to interpret. (ref.1) (LINK to page 11j)
(b) After stopping the Pill there may be cycle irregularities due to the effects of the residual synthetic steroid stored in the body on the hypothalamic-pituitary-ovarian axis (HPO axis). These cycle irregularities may cause difficulty in the interpretation of the mucus symptom e.g. with anovular cycles there is no oestrogenic ‘build-up to peak’ mucus pattern. Even when ovulatory cycles occur, the cycles may be long due to delayed ovulation following a long follicular phase. Cycles may also be short due to a short luteal phase. The cycle irregularities caused by the Pill usually disappear by the sixth cycle after stopping the Pill. If the mucus symptom is unclear, a fertility monitor to predict ovulation may be helpful. (LINK to page 21, ovulation monitors).
(c) Contraceptive medication causes a depletion of the S-crypts in the cervix and causes premature aging of the cervix. (LINK to page 11j, effects of the Pill on the cervix).
Palpation of the cervix post-pill: Palpation of the cervix is less reliable in the post-pill situation.
Women who wish to conceive after coming of the Pill: Women are advised to defer pregnancy for three months after stopping the Pill, as it may take three months or more for all the synthetic steroid hormone to be excreted from the body. Women who are trying to conceive and are not pregnant after three or four cycles ot timed intercourse in apparently normal cycles should consult their doctor.
What if cycle irregularities persist after stopping the Pill: Women with amenorrhoea (absence of periods), persistent irregular cycles, recurrent short luteal phases or very long cycles should consult their doctor if these cycle irregularities have a duration of four months or more.
NOTE: In a review article in the March 2009 issue of the medical journal, ‘Fertility and Sterility’, (see reference 2 below), Drs Barnhart and Schreiber state that ” the overall birth rates seen in previous users of oral contraception (OC) are comparable to those seen in the general population after 12 months of attempting to conceive.” Their review of the available literature indicates “that although OC users may experience a slight delay in the return to fertility compared to those who did not use contraception or those discontinuing nonhormonal contraceptive methods, fertility impairment is not sustained in the long term.” In addition the authors state “that both DMPA injections and Norplant have a more pronounced effect on the return to fertility, (i.e. a greater delay in conception), than progestin-only oral contraceptives.” (DMPA is depot medroxyprogesterone; Norplant is levonorgestrel implant; progestin-only contraceptives is the ‘mini-pill’).
After stopping the Pill, special rules apply in the symptothermal double-check method of natural family planning, and the woman must be taught these rules by a qualified NFP teacher.
To be most effective, the woman must be taught the symptothermal double-check method of natural family planning by a qualified NFP teacher.
1. Klaus, H; ‘Natural family planning - is it scientific? is it effective/ Newman Lecture Series,1; May 21, 2000; (internet: google ‘natural family planning, Dr Hanna Klaus).
2. Barnhart, Kurt, Schreiber, Courtney; ‘Return to fertility following discontinuation of oral contraceptives’; Fertil & Steril’ vol. 91; No. 3; March 2009. This is a review of the medical literature on this topic for the years 1960 to 2007.