Thank you, Sarah, for your reaction!

Heidi

Op 4 jun. 2012 wk 23, om 15:23 heeft Sarah Vaughan het volgende geschreven:

> Heidi Akkers wrote:
>> Dear all,
>> 
>> ptp
>> 
>> I have a mother breastfeeding a 7,5 month old baby. She and her baby enjoy breastfeeding very much and it is all going very well. :-D
>> 
>> The mother has not yet had her period. She and her partner would like to become pregnant again. The mother feeds between 7-9 and expresses her milk at work at 11 am and 15 pm. She then feeds when returning to home about 2 times. The baby sleeps from 21 pm until next morning.
> 
> I recall reading that, on average, menstruation in a breastfeeding woman will return between 7 and 15 months postpartum. That means there's a very good chance her period will return in the next few months even if she does nothing differently.
> 
> If she's very eager to get pregnant as soon as possible, an intermediate step rather than weaning would be for her to cut the daytime feeds (including pumps) down to a maximum of 4-hourly. This of course would mean an increased chance that she would need to supplement before a year, and she would need to weigh up the pros and cons of how she feels about this. (It wouldn't necessarily happen - many mothers find that, once breastfeeding is well established, they can consolidate their feeding pattern into a lower number of larger feeds - but there would certainly be a risk it could happen.)
> 
> For some women, even cutting down the feeds isn't enough and they don't become fertile until they've stopped breastfeeding altogether. However, this does seem to be only a minority of women. Unless she is very impatient to get pregnant, I would think it would be well worth her waiting.
> 
> One other important point to remember is that ovulation can return before menstruation, so she could get pregnant even before seeing a period. Tell her to be aware of this possibility and aware of pregnancy symptoms even if she hasn't had a period (and to have a low threshold for testing for pregnancy if she thinks she might be pregnant, even if she hasn't seen her period return).
> 
>> The mother has a slightly slow working thyroid and both she and her partner are carrier of Progeria. They have lost one child previously.
>> 
>> The mother takes Citalopram, which states Amenorrhea as a side effect. Now I would think that this might have more impact on her absence of menstruation cycle than when she would cut down in her number of breastfeeds. A part from that my gut feeling would be to wait a month or two and see what happens, but maybe it might be a good idea for her to talk to her doctor about her Citalopram use and perhaps change to Escilatopram as the suggested alternative?
> 
> I have never personally known a patient to complain of amenorrhoea as a side-effect of citalopram, which suggests to me that it's probably rather an uncommon side-effect. I just did some googling and found the ehealth.me site - no idea how accurate this is, but it gave a rate of approximately 1:1000 of developing amenorrhoea as an SE on either Citalopram or Escitalopram. That may of course be an underestimate because I think this was as a frequency amongst all patients taking it (i.e. out of a thousand patients on Citalopram, approximately one would experience amenorrhoea) whereas, of course, this would only be a side-effect that would affect women of reproductive age who didn't have any other reasons for amenorrhoea, so in fact the rate amongst the subgroup of patients on Citalopram who are menstruating women would be correspondingly higher. However, that would still give us figures that would indicate a much lower likelihood of amenorrhoea with Citalopram than there would be with breastfeeding a baby this age, so the odds are still that it's the breastfeeding rather than the Citalopram that's having this effect. (Also, the odds are that changing to Escitalopram wouldn't make a difference even if it is the Citalopram that's responsible, since rates of amenorrhoea were similar with both according to this source.)
> 
> With all of that said - if she's trying to get pregnant, she should be discussing her antidepressants with her doctor anyway, due to possible implications of taking those tablets during pregnancy.
> 
> 
>> Apart from her medication: what role could the slower working thyroid play in all this?
> 
> That can cause amenorrhoea and delayed fertility too. Presumably this is being monitored to see whether she needs replacement or not?
> 
>> I found following percentages: 9-30% of women that begin menstruating again at month 0-3 while breastfeeding, and 19-53% at 6 months, with some not having their cycle back until they fully weaned. These numbers seem quite dated: (1972, 1987 and 1999) Would any of you have more recent references?
> 
> I would think they'd still be valid. After all, womens' bodies shouldn't have changed substantially in that time. ;-)
> 
> 
> Best wishes,
> 
> Dr Sarah Vaughan
> MBChB MRCGP
> 
> (with apologies for having not yet got to the many posts waiting for my response in the other thread - have had considerably less time available in recent days!)
> 
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