Contraception and Breastfeeding

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The information provided is taken from various reference sources.  It is provided as a guideline.  No responsibility can be taken by the author or the Breastfeeding Network for the way in which the information is used.  Clinical decisions remain the responsibility of medical and breastfeeding practitioners.  The data presented here is intended to provide some immediate information but cannot replace input from professionals.

According to the Family Planning Association (www.fpa.org.uk/home) lactational amenorrhoea (LAM) can be up to 98 per cent effective (RCOG suggest over 98%) in preventing pregnancy if all of the following conditions apply:

  • you are fully breastfeeding – this means you are not giving your baby any other liquid or solid food and
  • your baby is less than six months old and
  • you have no periods.

The risk of pregnancy increases if:

  • you start breastfeeding less often especially if there are long intervals between feeds – both day and night, or
  • you stop night feeds or
  • you use a dummy/pacifier or
  • you give any artificial supplements

Even if a woman expresses breast milk, or if she is separated from her baby by more than a few hours, she cannot expect a high level of contraceptive protection (Valdes 2000, http://irh.org/projects/fam_project/lactational-amenorrhea-method-lam/).  Dummy/pacifier use which may decrease feeding frequency increasing the risk of return of fertility (Ingram 2004).  Once your baby is over six months old the risk of getting pregnant increases, so even if you don’t have periods and are fully breastfeeding, you should use another contraceptive method (FPA). 

The Progesterone only pill (mini-pill POP)

The progesterone only contraceptive pill (mini-pill) is generally recommended during breastfeeding.  It needs to be taken at the same time every day continuously –  a delay of more than 3 hours may mean contraceptive protection is lost.  The POP is generally started a minimum of 3 weeks after delivery but ideally no less than 6 weeks to avoid interfering with milk production.  Vomiting and severe diarrhoea can interfere with absorption.  New UKMEC guidelines (2016) suggest that use from birth will not diminish supply.  This is at variance with the experience of many breastfeeding workers and is currently a cause for concern.  Decisions should be made with mothers fully informed about the risk of initiating contraception early.  

Oral progestogen-only contraceptives can be started up to and including day 21 postpartum without the need for additional contraceptive precautions.  If started more than 21 days postpartum, additional contraceptive precautions are required for 2 days.  In most cases contraception is initiated at the 6 week post natal check.  Initiation too early after delivery may interfere with priming of prolactin receptors. 

Normally, the POP does not affect lactation but I have had anecdotal reports from quite a few women who have noted a rapid drop in milk supply after beginning it.  Anyone noticing such an effect should report it to the MHRA via http://yellowcard.mhra.gov.uk/ 

Brand names; Desogestrel (Cerazette®), Ethynodiol diacetate (Femulen®), Norethisterone (Micronor ®, Noriday®), Levonorgestrel (Norgeston ®)

Progesterone depo injection

The progesterone depo injection is often given to new mothers, particularly younger ones who value not having to remember to take a tablet daily.  Medroxyprogesterone acetate (Depo Provera®) can be used 6 weeks after delivery and repeated every 12 weeks.  It is used 5 days after delivery for mothers who do not intend to breastfeed.  Too early use may interfere with prolactin priming. 

Progesterone depo (subdermal implant) products

Norethisterone enantate (Noristerat®) is not advised if baby has symptoms of severe or persistant jaundice – it is repeated every 8 weeks.

Etonogestrel releasing implant (Nexplanon®) consists of a single, radiopaque, rod-shaped implant.  It must be removed no later than by the end of the third year. It can be inserted after the 4th week post-partum.

In light of the response of some mothers to oral preparations of progesterone it may be advisable to try one month of tablets before using any depo product to rule out any lowering a milk supply. 

Intra Uterine Progestogen Only Contraceptives

Intra- uterine Progestogen-only contraceptives release levonorgestrel directly into the uterine cavity.  The Mirena® system is used as a contraceptive method for women with excessively heavy periods.  It can be inserted 6 weeks after delivery and is effective for 5 years.  As with the depo injection in light of the response of some mothers to oral preparations of progesterone, it may be advisable to try one month of tablets before using the coil. 

Simple coil (intra uterine device)

An IUD is a small plastic and copper device that is inserted into the uterus.  There are different types and sizes of IUD to suit different women.  An IUD can stay in for 5–10 years, depending on type.  An IUD is sometimes called a ‘coil’.  Simple coils can be used in breastfeeding mothers without complication as no medication is involved. 

Emergency Hormonal Contraception

See separate fact sheet

The combined oral contraceptive pill

According to the most recent UKMEC guidelines (2016) “Based on breastfeeding status alone, CHC can be used by breastfeeding women safely after 6 weeks following childbirth”

This is at variance with the previous guidelines that the combined pill is not suitable for a breastfeeding mother in the first 6 months after delivery and with the experience of many breastfeeding workers and is currently a cause for concern.  Decisions should be made with mothers fully informed about the risk of initiating contraception early.

In theory after this time the supply is established and will not be lowered by the oestrogen content of the combined pill.  However, some mothers do notice an effect so the decision to use it should not be undertaken lightly if you want to carry on breastfeeding.  If you take it and do notice your supply diminishes you can stop taking it (remember to take additional precautions!) and re-stimulate your supply with frequent breastfeeds. 

Brand names: Gedarel® 20/150, Mercilon®, Femodette®, Millinette® 20/75, Sunya 20/75®, Loestrin 20®, Gedarel® 30/150, Marvelon®, Yasmin®, Femodene®, Katya 30/75®, Millinette® 30/75, Levest®, Microgynon 30®, Ovranette®, Rigevidon®, Loestrin 30®, Cilest®, Brevinor®, Ovysmen®, Norimin®,Norinyl-1®, Femodene® ED, Microgynon 30 ED®, Triadene®. Logynon®. TriRegol®, BiNovum®, Synphase®, TriNovum®, Logynon ED®, Qlaira®

Contraceptive Patch

The contraceptive patch contains Ethinylestradiol with Norelgestromin (Evra®) so is a combined oral contraceptive which may reduce supply depending on the time when it is first used.  The instructions are: apply first patch on day 1 of cycle, change patch on days 8 and 15; remove third patch on day 22 and apply new patch after 7-day patch-free interval to start subsequent contraceptive cycle.

Other forms of contraception

Barrier methods of contraception such as condoms, diaphragms and caps have no implications for breastfeeding.  Lubricants and spermicides are also compatible with breastfeeding. 

Yellow card reporting of adverse events 

If mothers notice lowered milk supply with early use of progesterone only contraception or combined oral contraception, a yellow card report should be filed https://yellowcard.mhra.gov.uk/.  Until evidence is collected to support the concerns of breastfeeding advocates breastmilk supply may be put at risk in mothers who have not had the opportunity to make fully informed decisions.

Other sources of information on oral contraceptives

  1. Hale Medications and Mother’s Milk (online access Jan 2017) “Clinicians should suggest that the mother establish a good milk production prior to beginning oral contraceptives. Avoid combination (estrogen-progestin) contraceptives it at all possible.  Use oral progestin-only preparations initially preferably after 4 weeks postpartum.  Warn mothers that even progestin-only preparations may suppress milk production and to discontinue them at the first sign of low milk supply.  Use medroxyprogesterne (Depo-Provera) only in those patients who have used it previously and have not experienced breastfeeding problems, or in those who have used progestin-only mini pills without problems.  Attempt to wait for 4 weeks postpartum prior to using medroxyprogesterone.  The transfer of progestins and estrogens into breastmilk is exceedingly low, and numerous studies confirm that they have minimal or no effect on sexual development in infants.

Suggestions for OC therapy

  1. Always start with an oral progestin-only pill first, if only for a month. If milk production is sustained, then continue on the oral preparation, or a sustained release preparation like Depo medroxyprogesterone may be suitable.
  2. Avoid using any form of progesterone the first week postpartum, as these may suppress early milk production.
  3. Avoid estrogen-containing preparations, particularly early postpartum. While controversial, extensive clinical experience with these preparations suggest caution as signficant loss of milk supply has been frequently reported.
  4. We have numerous reports of loss of milk supply following placement of Mirena IUDs. While one suggests no such loss, caution is recommended until this is clear”
  5. World Health Organization (WHO) Task Force on Oral Contraceptives. Effects of hormonal contraceptives on breast milk composition and infant growth. Stud Fam Plann. 1988 NovDec;19(6 Pt 1):361-9.  “Breast milk volume and composition and infant growth were measured at three- and four-week intervals, up to six months, in a multicenter randomized double-blind trial comparing a low-dose combined oral contraceptive (OC) with a progestogen-only OC.  A nonrandom group using nonhormonal methods was also studied in the three centers: Szeged, Hungary; Bangkok, Thailand; and Khon Kaen, Thailand.  A fourth group, users of depot-medroxyprogesterone acetate (DMPA) was included in the two Thai centers.  Altogether, 341 women were recruited into the study.  Combined OCs caused a significant decrease in milk output and total energy content as well as widespread changes in milk constituents.  In the DMPA group, no significant changes were observed in milk volume, and only minor shifts occurred in milk composition, which varied between centers.  No differences were found between the progestogen-only pill and DMPA.  No hormonal contraceptive was associated with any significant difference in infant weight or fat fold, nor in the rate of discontinuation for failure to gain weight.  This study reiterates the need to avoid combined OCs during the first few weeks or months of lactation.  Both norgestrel and DMPA appear to be safe for use in both developing and developed countries, at least when the nutritional status of the mother and infant are adequate, but further research is needed on the safety of these contraceptives in populations with malnutrition.”
  6. Lopez LM, Grey TW, Stuebe AM, Chen M, Truitt ST, Gallo MF. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev. 2015 Mar 20;(3):CD003988. doi: 10.1002/14651858.CD003988.pub2. Older studies often lacked quantified results.  Most trials did not report significant differences between the study arms in breastfeeding duration, breast milk composition, or infant growth.  Exceptions were seen mainly in older studies with limited information.  For breastfeeding duration, two of eight trials indicated a negative effect on lactation

Mothers should be enabled to make an informed decision based on their own family circumstances, the risk of pregnancy and be aware of the need to be alert for lowered milk supply.  Breastfeeding advocates world wide seem to be aware of anecdotal reports of lowered, lost milk supply but these reports do not appear to have been published leading to variance with academic researchers.

Bibliography

With thanks to Sarah Panzetta for her valuable input on fertility awareness and LAM.

References

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©Dr Wendy Jones MBE, MRPharmS and the Breastfeeding Network Sept 2019