Q&A: charting for birth control while nursing

Susan writes:

"I've got one for you.  Is there a way to chart or do any other kind of natural birth control while breastfeeding?  I really don't want to go back on hormones (swore them off after I went off of them last time), and we both hate condoms.  That leaves the diaphragm, but I tend to get UTIs so I'd really like to only have to use it during my fertile period.  This worked great before we got pregnant with our now-9 month old (which was planned).  I'd like to do it again.  We didn't do any sort of birth control before my period returned, 7 months after giving birth.  I'm now only breastfeeding about 5 times a day and none at night, so I know I can't rely on breastfeeding to prevent ovulation (as evidenced by the return of my period).  I tried charting, but it's now been 2 months and still no second period.  Is there any way I can predict when I may be fertile again?  Does temping work?  She's still awake a lot at night (not feeding) so I violate all kinds of temping rules even aside from the breastfeeding.  Are we doomed to a roll of the dice if I don't want to use the diaphragm every time?  We really like the spontaneity of not using anything, so suggestions of alternative forms of birth control are only of limited usefulness.  (We plan on having another baby eventually, so the old snip-snip isn't in the cards yet.)

Thanks for any advice you've got."

This is a tough one. I never came up with a good solution for it in the netherworld between having my period come back and having my cycle be regular again. And I was never able to find anything online or in any books about using NFP/FAM addressing this, either.

My feeling is that you're stuck with the usual suspects (condoms, diaphragm/foam/sponge/etc., or abstinence) if you're only going for the short-term until your cycle becomes regular again and you can temp. If you want to hold off on pregnancy for another year or more, you could look into getting an IUD put in. There are two on the market right now. Mirena has a hormonal compenent, and the copper IUD does not (so if you're off hormonal birth control, you'd want to go with the copper). You have to have it inserted and taken out by your provider, and it's kind of expensive, so it's better for longer-term birth control. If it sounds like something you'd be interested in, call your provider and ask about it.

Is there anyone out there who knows more about NFP/FAM than I do who can address the issue of knowing if you're fertile when your cycles aren't regular again?

(Those of you out there scratching your heads because you have no idea what we're talking about with "temping" and NFP/FAM and knowing when you're fertile, welcome to the wide world of learning your body's signals that tell you when you're ovulating and when you're not. If you know when you can get pregnant, you can act accordingly to prevent or initiate pregnancy. NFP stands for Natural Family Planning, which is the family planning method of choice for Roman Catholics*, and involves abstaining from sex during the woman's fertile times. FAM is Fertility Awareness Method and is the same thing, only it allows for using other forms of birth control [such as condoms] during the woman's fertile times. NFP/FAM works best for couples in committed relationships, obviously provides no protection against STDs, and takes a couple of months to ramp up into, during which you'll have to either abstain or use backup birth control methods to avoid pregancy.

To get started, check out the book Taking Charge of Your Fertility by Toni Weschler, M.P.H. or check out this site on FAM or this site on NFP.

* NFP is NOT "the rhythm method." The rhythm method involves assuming a woman is fertile on day 14 of her cycle and just abstaining right around then. NFP has you watch your own body's signals to figure out on any given day whether you're fertile or not, and acting accordingly. The rhythm method has a low rate of effectiveness, while NFP has a rate of between 80-99% effectiveness depending on  how strictly the couple sticks to the guidelines.)

Comments

[Erin]

It might be helpful to check out the rules for the Billings and Creighton Methods, which require monitoring of cervical mucus only. I'm pretty sure the rules are somewhere online, but I'll have to look into it later for you.

As an aside, I wrote my master's thesis on NFP/FAM and got to meet with one of the top NFP researchers. He thinks sympto-thermal method makes things far too complicated and prefers the methods I mention above.

[Moxie]

Erin, ITA with that from my own experience. But I also noticed that when my cycle was still irregular I also had irregular cervical fluid. So that was no help either. To me, at least.

[Charisse]

FWIW, once you pay for it an IUD is a heck of a lot less hassle than temping etc. As far as spontaneity, you don't have to remember to check anything or record anything...it's just there. And the copper one is good for 10 years.

Expensive if you're looking to another kid soon...if not it's worth looking into.

[Erin]

Moxie, IIRC, there are rules related to the fact that the cervical mucus patterns are irregular. Of course, if one is not having any cervical mucus, then it will feel like a big game of Russian roulette. I'll have to refresh my memory, though.

[Moxie]

Hmmm...I am intrigued by rules for irregularity (in general and also for charting cycles).

[Erin]

Here is a link to the page on the Billings website that discussion breastfeeding: http://www.woomb.org/bom/breastfeeding.html You can find the basic rules on the website as well.

Their rule is that if you see a change in the basic infertile pattern, then you wait 3 days before having intercourse again. You can see examples in the charts. So, for example, if you have one day of slippery cervical mucus, you'd need to wait three days. If you were back to your BIP for those three days, then you'd be safe to resume intercourse again. I'm sure the Billings people would say that if you use a barrier, you're interfering with your signs. I've never really found that to be an issue with condoms, but I don't know anything about using a diaphragm.

Also, I've only ever used sympto-thermal method, so I can't speak from personal experience. My baby is 6.5 months old, and I'm still waiting for something to happen (and still stuck using condoms). It's fun reporting that my last LMP was in October 2005 when I see a doctor, though.

[pnuts mama]

moxie, the person online that i know is an expert in this area is jamie selkie- she used to write tons about temps and monitoring and i know she is an extended bf'er as well.

you made me laugh out loud when you said NFP is the birth control method of choice used by roman catholics. our bishops wish!! NFP is the method *approved* by the Church to help couples decide how many children they wish to have in their families, but statistics show that the majority of RC couples in this country who are in their childbearing years don't use NFP, mainly because it isn't taught very well (brief mention during pre-cana) and is widely misunderstood as rhythm, having a high fail rate or ruining spontaneity. there are, however, some very good classes and resources on NFP (again i would differ to jamie on those, but you could start at http://www.ccli.org/nfp ), and I recommend it especially for couples who are trying to conceive, as you truly do learn to understand your bodies clues as to where you are in your cycle.

[anon]

Wow - looks like there are some real charting experts out there. I don't have anything so official to say, except that my hunch is it really depends on the person, on what your fertility signs are. I got pregnant (on purpose) while nursing about as much as you are, and I had a pretty good sense of when I might be ovulating, just based on mucus, etc., with no temping, even though my cycles were very irregular (35 to 65 days, and I have PCOS). But I can see how for some it could be much less clear (and I was only sure I knew what I was seeing after 3-4 cycles). I think if I were you, and if I were totally averse to "rolling the dice" I would use some annoying birth control method (diaphragm or whatever) while charting and trying to determine what the pattern is for you. But then, I tend to be really risk averse and to not believe theories as much as my own observations.

[Melissa]

I know IUD doesn't sound like the choice for you if you want to have a baby again soon but my insurance paid for mine and I love not having to take the pill or worry about hormones (I have the copper one). It is so teeny you don't know it's there so it's nice to forget about it without worrying about "forgetting" about it!

So if it seems like something you'd consider but cost is an issue check with your insurance carrier.

[Beth]

Just chiming in to say that I LOVE LOVE LOVE my copper IUD. I too despise hormones - they make me insane and depressed and I've tried several different types with no success. I had heavy periods and bad cramps so I was scared; the copper is known to make periods worse, while Mirena is known for making them lighter and less painful. But my experience has been wonderful. Periods are fine, maybe even slightly better than before. Insertion was mildly painful, but compared to my 38 week cervical check - it was nothing!

[Amy]

Adding my 2 cents to Moxie and Erin's exchange... I'm an experienced charter (charted to get pg with first two and then used it to avoid pg after #2 for over 2 years)... so I know all my signs, etc. Stopped temping because, well, I knew all the other signs. Cervical mucus was always my first tip off... so in the absence of any tell-tale cervical mucus one wine soaked evening, we had unprotected sex. Uh oh, woke up the next morning with tell-tale sign #2... the ovarian pain. I'm now 30 weeks pregnant! (Happily, I should add as we were about to start trying.) So, my point is, cervical mucus is a great indicator... but it doesn't always tell the whole story! (Hence, I guess, why the plan isn't 100% effective!)

[Jess]

I'm 39.5 half weeks pregnant with my first child (and I've been having contractions for the past week and am about to go out of my mind waiting for real labor to start, but that's another story). I too hate the pill and have vowed not to ever go back on it! My question is: what about the sponge? You can put them in hours before sex and leave them in hours after, if I remember correctly. They recently came back on the market and I was thinking of using them while b'fing. Does anyone know any reason not to medically or health-wise?

[Gretchen]

My IUD was paid for by insurance, I think I just paid the $10 copay.

[Maura]

Delurking to say:

You can only use temperature as a SECONDARY indicator that ovulation has already occurred, so your first indication is always going to be cervical mucus. That being said, sympto-thermal method with no barriers while breastfeeding can be extremely challenging.

We use NFP, and I have an almost 1-yr old son whom I breastfed exclusively until about 5 mo when I started vet school. Like with yours, I was not nursing at all overnight, and only about 4 times a day, and my cycles were still not semi-normal until about a month after I started suplementing with formula for half his feedings, and not regular until after he weaned at around 9 mo.

If you're open to using barrier methods, then I'd second what previous posters mentioned and say use them until you have a better idea of what's happening with your own body. Chart using the sympto-thermal method, that way you'll know when you ARE actually ovulating again. It will also help you see what are actually patterns, even if they don't seem like it at first.

I second Moxie on Taking Charge of Your Fertility, and will add a personal plug for the software that they have available. It's called OvuSoft, and it actually gets my husband actively involved in the whole process, since it's on the almighty computer.

[Amy F]

We used NFP to prevent pregnancy for 2 years (40 cycles) and briefly between my two pregnancies and we're planning to become teaching instructors through CCLI in the near future.

For those saying that CCLI's sympto-thermal method is too complicated -- they're in the midst of revamping it to simplify it considerably. It'll still use temps and mucus, but only one rule to follow instead of choosing between a bunch.

Anyway--for those who nurse at night and don't really get out of bed, temping should still be accurate. That doesn't help the original poster, but it might be useful to others. Peter was still nursing 3 or 4 times at night when my period returned and I could still see the temp shift. I'd recommend using mucus as the primary indicator with temps as a cross-check for someone who's waking at night with a baby.

I had all-the-time mucus after Peter was born, but when my cycles returned, there was an obvious shift to EWCM and the more fertile mucus. It's also normal to have one period and then not have the next for awhile as cycles adjust. I had luteal phases of 5-8 days for the first three cycles postpartum.

The Art of Natural Family Planning goes into a lot of detail about postpartum charting and cycles -- it's the only book on the sympto-thermal method that gives a lot of help for that phase. The patch rules that Erin mentioned above are what CCLI suggests too -- if you see a change from the basic infertile pattern, wait 2 days (or maybe 3).

The good news is that the wonky cycles won't last all that long -- I think most people's sort themselves out within 3 months or so.

I'm almost a year postpartum and have been having all-the-time mucus for the past couple months but no cycles yet.

[KAMI]

I'm not sure of the cost in the US (assuming that's where you live), but my IUD (hormone-less) cost about $70 - so not that expensive at all. It's as simple to insert and remove as having a PAP, so I don't see why it can't be for short term prevention as well as long term. I loved, loved, loved the freedom from even thinking about getting pregnant and will have another inserted 6 weeks after the delivery of my current load!

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The best form of birth control is graduate school.

[Susan]

Thanks so much for all the advice, girls. I knew about the Mirena IUD (hormones) but I didn't know about the copper one. I will definitely look into it. My cervical mucus has been all over the map but I will start to pay more attention. I guess I was under the misguided notion that once my cycles returned, I'd be regular again. Not even remotely the case (still waiting for period #2, 2+ months later). I like the cervical mucus only idea and I think we'll go with that for now. Ideally I'd like to not get pregnant again until at least August, but the world won't end if I do now.

Moxie and posters, you're the best!

[Rachel H.]

Don't forget about a cervical cap! Much smaller than a diaphram. I had an IUD and liked it ok -- I may go that route again.

[Hilary]

This is my favorite website for birth control method information:

http://www.fwhc.org/birth-control/index.htm

The sponge has higher than a 25% failure rate, if I am not mistaken. The IUD has less than 1%. If someone is planning on having another child soon, this may be acceptable. If someone is not, I think this would be significant.

[Hilary]

Sorry, it looks like the failure rate is now reported at about one in seven, lower than I had read previously.

http://www.walgreens.com/store/product.jsp?CATID=100267&navAction=jump&navCount=0&id=prod1509039

[Sheila Kippley]

For a free, short, easy-to-read "How To" NFP online manual, go to www.nfpandmore.org. This manual covers all one needs to know about the Seven Standards of eco-breastfeeding and the fertility signs for systematic NFP in 84 pages. People are using this manual to learn the natural methods and to teach it.
Sheila Kippley
volunteer, NFP International

[just a thought]

waiting for a period for 2+ months? any chance you're already pregnant again? just a thought, especially before you do anything invasive....

[Steph]

I'll second that "just a thought" comment above, I got pregnant after one period but didn't realize it because I had spotting that I mistook for menstrual bleeding. Didn't figure out what was going on until I was 14 weeks pregnant.

[Purple_Kangaroo]

I'm nursing a 19-month-old, and just finished my first month of charting again after a few years of not charting.

It's quite a change going from the textbook-perfect 28-day cycles I had before children to the wonky really strange cycles I've been having for about a year now. Charting is turning out to be really helpful for me already in figuring out WHY my cycles are so irregular, why I'm so hormonal at certain times, etc.

It's also very revealing about how hugely things like not getting enough sleep affect my body . . . I can clearly see in my temperature and other signs that staying up too late is really messing with me.

With the sleep thing, give it a try . . . you may find that you don't actually need 3 hours of consecutive sleep to get an accurate temperature. For me, the overall amount and quality of sleep affects my temps more than a few brief wakings or even getting out of bed for a few minutes before temping does.

Also, some people find that taking their temperature by one of the methods other than orally helps to stabilize some of the temperature variations.

Whatever method you use, like others have said, it takes a few months to learn it and get familiar with what your body is doing. During that time you'll need to use barrier methods or (usually recommended, so it doesn't mess up your cervical fluid signs) abstain for most of the month while you're learning the method.

If you do end up using the Ovusoft software or something similar, PLEASE be sure to ask questions on the discussion forums before you try to count on it too much.

The Ovusoft/Taking Charge of your Fertility method, for instance, requires only a 2-degree shift for a thermal shift, as opposed to The Art of Natural Family Planning (CCLI) method, which requires (in general, though there are exceptions) a 4-degree shift. It makes a big difference.

Especially since in this last cycle I had a 2-degree shift around day 18, which sort of cross-checked with the other fertility signs, but wasn't completely clear when taking all the signs together (although if I'd been following a cervical-fluid-only method it also might have looked like ovulation, taking that alone).

I then had a full 6-degree shift that clearly cross-checked with the other signs on day 36. If we had taken the advice of the software, we would have assumed I ovulated on day 18 and would have thought we were safe long before I actually ovulated. In fact, I would most likely have gotten pregnant if I had trusted the software's analysis.

It was giving me the "congratulations--you're pregnant!" message starting the day I actually ovulated.

Thankfully, the people in the forums were able to look at my chart and say, "nope, it looks like you ovulated on day 38, not day 18." And the two pregnancy tests were negative, too. :)

Seriously, though, I think every woman should try it or at least learn a bit about it even if you're using other birth control methods. It's just so useful in helping you understand what's going on with your body, and can be a great diagnostic tool for your health, too.

BTW, my cycles have not yet normalized, and it's been WAAY more than 3 months. I never get amenorrhea even with ecological breastfeeding, and this is the first time (with 3 kids) that I haven't immediately gone back to something pretty close to normal cycles within a month or two after giving birth. But I'm also underweight and having other health issues, so that could be why. Hopefully the charting will help us figure some of this out.

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