Breastfeeding and the first post-pregnancy menstrual period - By Lactation Consultant Niyati Naik




The human body undergoes incredible transformations during the various phases of life. From preparing to become pregnant, maintaining pregnancy and even the return to fertility. Menstruation is a pivotal component of these processes. Most women usually welcome the 9-month break that pregnancy provides: of not having a menstrual period. However, many women may wonder about the return of their period and their menstrual cycle once their baby has been born.


The purpose of this information article is therefore, to shed some light on this topic, in helping you to understand a new mother’s return to fertility, and to describe the role that breastfeeding plays in this process.

Ovulation and Menstruation

The menstrual cycle is defined as the cycle of change that a female body undergoes in preparation for the possibility of pregnancy. Each cycle (which usually occurs every month, although this may vary in different women), involves the release of a mature egg from the ovaries, by a process called ovulation. If the released egg is met with a sperm, fertilisation occurs and the fused egg and sperm is then implanted into the thickened and blood-enriched uterine wall which has been ‘prepared’ by the same hormones that releases the mature egg. However, if fertilisation or implantation does not occur, the egg, along with the thickened lining is shed, resulting in vaginal bleeding due to menstruation. It is important to remember that ovulation usually occurs 2 weeks before menstruation (bleeding) and is usually the period when a women is considered most fertile. This is a relevant consideration when it comes to contraception, which will be discussed later in this article.

 

The role of breastfeeding

The type of nutrition that an infant receives (breastmilk, formula or both), can determine how soon that infant’s mother may get her period. Women who, for various reasons, do not breastfeed their babies, can expect to have their first period approximately six to eight weeks after they have given birth. This is considered a relatively quick return to fertility.

However, women who do breastfeed their babies, have a less clear idea of when their period will return. Some who exclusively breastfeed (feed their baby only breastmilk and no other supplementation), may not have a period for their entire breastfeeding journey (which may span over months and even years), whilst others will. Research has shown that in populations of breastfeeding mothers, other factors which can influence the rate of menstruation return are: the frequency of breastfeeding and the total amount of time at the breast per 24 hours.

Breastfeeding delays a mother’s return to fertility and this phenomenon may be explained by the physiological mechanism of your baby suckling. When a baby suckles his mother’s breast, signals are sent to the mother’s brain to: increase the hormone that produces and releases breastmilk (prolactin and oxytocin), and to simultaneously stop or suppress the hormones that trigger ovulation (oestrogen).

So, if there is a delay or a longer gap between feeding sessions (for whatever reason), there is less nipple stimulation, which means less signals for prolactin release are sent to the brain, which means that oestrogen levels increase- thus increasing the chance of ovulation and quicker return of the menstrual period. However, if a mother feeds her baby frequently, then signals for prolactin release continue and oestrogen levels are suppressed and are low-this means that ovulation and menstruation is delayed.

What will the period after pregnancy be like?

All women who have had a baby (by natural or caesarean section), will experience vaginal discharge in the weeks after giving birth. This discharge is made up of mucous, blood and uterine tissue. You may notice that the flow of the lochia is heavier at first and reduces with time, and there may even be clots that are present. Lochia can be present for about six weeks postpartum. If your lochia turns into a clear or creamy white colour and stops for a while, the red blood that you notice after this gap, is then likely to be your period.
It is not possible to predict how your returning period will be- whether it will be heavier (as there is an increased amount of uterine lining that has accumulated and which therefore will be shed), lighter (in the case of some women with endometriosis), longer, shorter, regular or irregular, as compared to how your period was before you became pregnant. Some women may experience increased pain, small blood clots and even irregular cycle lengths as the body adjusts after pregnancy.

Is it lochia or is it your period?

There are a few ways to help you determine whether the discharge that you are experiencing is from your pregnancy (lochia) or whether it is the return of your period,

 Lochia Menstrual blood
When it's likely to be present Usually immediately after birth until 6 weeks Usually after 6 or more weeks from birth
Appearance lighter, watery, white, may be tinged with blood Bright red bleeding
Quantity Increases with exertion
Reduces with rest
Occurs regardless of exertion or activity
Odour ‘sweet’ smell – due to mixing with leftover tissue from pregnancy Smells of blood – metallic smell

 

What is ‘abnormal’ bleeding? When should you contact your doctor?

It is important to be aware of what scenarios are ‘not normal’ and those which require urgent medical attention. Contact your doctor or hospital immediately if you are:
  • Soaking more than one pad every hour (with blood)
  • Experiencing sudden or severe pain or trouble breathing 
  • Experiencing a sudden fever
  • Having blood clots that are bigger than a softball
  • Foul smelling discharge during urinating 
  • Experiencing severe head-aches or visual changes 

What to expect?

It is common for breastfeeding mothers to experience PMS type symptoms and even cyclical cramping which may suggest an oncoming period, without actually having a period. These symptoms may occur for weeks and even months before an actual period occurs. This ‘preparation’ for menstruation, has been thought to b delayed by active breastfeeding. Although it may be frustrating, it is beneficial for mothers to take measures such as exercise, rest, warm packs and pain relief, to be comfortable, especially when simultaneously having to care for a new-born infant.

Some women may not have no change in their breastmilk supply once their period starts, however others may experience a temporary dip in their supply when their period starts. In cases where there is a decrease, it may be an estimated 30-60ml decrease in the average daily milk production. However, the good news is that the initially decreased supply does rebound (although not always fully) once your period is over. If you are pumping, it may be useful for you to record:

  • The decrease, if any, in volume of breastmilk production at the start of your period
  • The recovery volume of your breastmilk at the end of your period 
  • The nett loss of breastmilk production (difference between the two volumes)
  • How your volume may change each month with each menstrual cycle (a gradual decline over time?) 

What to do if there is a dip in your breastmilk supply when you are on your period?

  • Calcium/Magnesium supplement

During ovulation, which is the middle of a menstrual cycle, there is a drop in blood calcium levels, and this ,may be associated to the drop in your supply. In order to deal with this, supplementing your diet with a calcium/magnesium supplement may help. It is important to take the calcium WITH magnesium combined supplement (1500mg calcium + 750mg magnesium) as it is not safe to take that amount of
calcium on its own.

  • Use food galactagogues

It is important to maintain good hydration and to eat healthy, balanced foods whilst breastfeeding. Foods such as oats have been anecdotally recommended for generations to increase milk production in many cultures. Fenugreek is another commonly used spice which is often used to increase milk production, however caution must be taken with regards to the use of this especially in mothers with metabolic disorders such as diabetes and thyroid disease, where avoidance is recommended.

  • Increase the length of your pumping session / powerpump

This is likely to initiate an additional let-down and therefore additional milk- or at least the stimulation to the brain to make more milk. Use a warm compress, vibration and relaxation techniques to also trigger additional let-downs.

  • Seek help

A consultation with a certified lactation consultant may be beneficial, in order to help you gain a holistic view about milk supply and what other interventions (specific to your needs and goals) may be available.

 

Changes in baby

Some mothers do report changes in their baby’s behaviours when the mothers start their period. This may be due to several reasons such as: an altered taste of the breastmilk (due to hormonal changes related to menstruation), and a possible change (usually a decrease) in breastmilk supply, which may lead to frustration and irritation in the baby.

Skin to skin contact and kangaroo care may be very useful in order to comfort and nourish your baby through these changes. It will also help to calm you and baby as an increase of the stress hormone (cortisol), results in a decrease of the milk producing hormone (prolactin). Despite possible changes in breastmilk taste and volume, your breastmilk is still safe and recommended to be fed to your baby.

 Factors that make your period return faster Factors that delay your period

Factors that delay your period
Abrupt changes to breastfeeding patterns (eg. Cutting down the number of nursing sessions in the day)
Gradually decreasing the nursing times per session
When your child sleeps for more than 4 hours at a time, during the day 
High levels of progesterone
When your child sleeps for more than 6 hours at a time, through the night 
Co-sleeping with your baby
When your child starts solid foods (this must not be done earlier than 4 months old) 
Frequent demand breastfeeding
sessions
Having low levels of the hormone progesterone in your body
High levels of progesterone in mum
Supplementing your baby's feeds with formula milk
Baby has not started solid foods
The use of a dummy/pacifier
Skin to skin and kangaroo mother care
Bottle feeding 
Separation from your baby for more than 4 hours in the day

 

The role of pumping?

Although the mechanism of how a breastpump works, may not be the same as when a baby suckles directly at a breast, the resulting effect is the removal of breastmilk from the mother’s breast. This therefore mimics the physiological and hormonal changes that occur as described in the introduction section of the article. That is- suckling (mimicked by the breastpump), stimulates the release of lactation hormones prolactin and oxytocin, which inhibits the release of oestrogen, which in turn reduces the chances of ovulation. Therefore, dropping a pumping session, due to reasons such as returning to work, may therefore initiate oestrogen release an stimulate ovulation- thus bring on your period faster, whilst reducing your milk supply (due to decreased prolactin).

Contraception

At the 6 week post-partum appointment, most doctors will ask new mums about: their baby’s feeding methods, and what type of contraception the new mother maybe considering. Although it may seem like it is too early to think about contraception at this stage, it is important as some mothers may indeed become fertile quicker than others (depending on the many factors as discussed in this article). So, consideration of contraception is still important, especially if the new mother is not ready to become pregnant again.

Lactational Amenorrhea Method (LAM) is a method of contraception that has been used since ancient times, yet is often misunderstood, as many people are not aware of the strict criteria that applies in order for this method to be effective. Even in instances of exclusive breastfeeding, there is still a chance that a new mother may ovulate and conceive again, without even realising that she is fertile again. This method is therefore recommended for women who are comfortable with the possibility of another pregnancy in the first year after giving birth.

Although breastfeeding can reduce the chance of fertility, there is not absolute guarantee that you will not become pregnant again. If you are breastfeeding and your period does return, it means that you are fertile and can become pregnant again. Remember also, that ovulation occurs 2 weeks before menstruation, so you can still fall pregnant, during the fertile period of ovulation (even before your period has returned).

From a breastfeeding and breastmilk supply perspective- non-hormonal methods such as condoms, the copper intra-uterine device, and diaphragms are less likely to reduce your milk supply. Some hormonal contraceptives (such as: progestin only pills, or low-dose combination pills) may be suitable and safe for breastfeeding mothers. However, if you do choose these methods, you are encouraged to keep a close eye on your milk supply and the growth of your baby, as there is a greater risk of reduced milk supply when hormones are involved.

On the same note, if you do want to fall pregnant sooner, let your doctor and lactation consultant know so that they may advise you accordingly. Every woman and family is unique and it is important to discuss this decision with your partner and your healthcare providers, in order to help you make an informed decision.

 

Conclusion

After having her baby, every woman has a unique time within which she will return to fertility. Factors such as: the baby’s nursing pattern, physical contact with baby, nipple stimulation and the mother’s sensitivity to hormones, can influence the rate of how soon or late a mother will become fertile again. Some women may get

their period back within weeks of having their baby, whilst others may only get their period after they wean their baby off breastfeeding, which may span over months or years. It is not possible to predict exactly when a woman’s period will return, as all women are different. The return of menstruation, is the body’s way of adjusting and ‘recovering’ from pregnancy. All parents must be aware of circumstances where bleeding is not normal and may be as a result of infection or other health problems. If this is suspected, mothers are strongly advised to seek urgent medical help. Although the return of your period may result in a decreased breastmilk supply, with information and support, you can be empowered to increase your supply and successfully continue with your breastfeeding journey.