Birth Control and Breastfeeding

July 28, 2011. Posted in: Medications & Vaccines

By Kelly Bonyata, IBCLC

Combination contraceptives

It’s recommended that any estrogen-containing contraceptive be avoided until baby is at least six months old AND after baby is well-established on solid foods.

Combination contraceptives contain both progesterone and estrogen and come in several different forms:

  • The combination birth control pill (Alesse, Yasmin, Seasonale, Mircette, Loestrin, Lo/ovral, Demulen, Desogen, Nordette, Ortho Tri-Cyclen, Triphasil, Norinyl, Ortho-Novum, Ovral, etc.)
  • the monthly injection (Lunelle)
  • the birth control patch (Ortho Evra)
  • the vaginal ring (NuvaRing).

Milk supply: Estrogen-containing contraceptives have been linked to low milk supply and a shorter duration of breastfeeding even when started when baby is older, after milk supply is well established. Not all mothers who take contraceptives containing estrogen will experience a low milk supply, but these unaffected mothers appear to be a very small minority.

Safety: Both progestin (progesterone) and estrogen are approved by the American Academy of Pediatrics (AAP) for use in breastfeeding mothers. See below for additional information on side effects related to lactation.

Progestin-only contraceptives

Progestin-only contraceptives are the preferred choice for breastfeeding mothers when something hormonal is desired or necessary.

Progestin-only contraceptives come in several different forms:

  • the progestin-only pill (POP) also called the “mini-pill” (Micronor, Errin, Nor-QD, Ovrette, Microval, etc)
  • the birth control injection (Depo Provera)
  • the progesterone-releasing IUD (Mirena, Progestasert)
  • the birth control implant (Norplant, Implanon).

Milk supply: For most mothers, progestin-only forms of contraception do not cause problems with milk supply if started after the 6th-8th week postpartum and if given at normal doses. However, there are many reports (most anecdotal but nevertheless worth paying attention to) that some women do experience supply problems with these pills, so if you choose this method you still need to proceed with some caution.

If you’re interested in one of the longer lasting progestin-only forms of birth control (the Depo-Provera shot lasts at least 12 weeks, but effects may be seen up to a year; the Mirena/Progestasert IUD and the Norplant implant can last up to 5 years), it may be a good idea to do a trial of progestin-only pills (mini-pill) for a month or more before deciding on the longer-term form of birth control. If you find that you are among the women whose supply drops significantly due to progestin-only birth control, you can simply discontinue the pills – rather than struggling with low milk supply for several months until the shot wears off or you get the implant or IUD removed.

Do note that the Mirena/Progestasert IUD delivers its hormone directly to the lining of the uterus, which only leads to a slight increase in progesterone levels in the blood stream (much lower than that found with the progesterone-only pill). As a result, there is much less chance of side effects from the progesterone than from the Depo-Provera shot or mini-pill.

Milk composition: At higher doses than normal this type of pill can affect the content of breastmilk. At these higher doses it has been shown to decrease the protein/nitrogen and lactose content of the milk. At regular doses, this does not seem to be as likely.

Safety: Progestin (progesterone) is approved by the AAP for use in breastfeeding mothers. See below for additional information on side effects related to lactation.

Morning-After pills

Morning-after pills should be used only as a last resort (whether you are breastfeeding or not).

There are currently two types of products on the market packaged specifically as “morning-after pills:”

  • a combination pill containing estrogen and progestin (Preven, Ovral)
  • a progestin-only pill (Plan B).

Milk supply: Estrogen, in particular, has been linked to low milk supply in nursing moms. There may be a slight drop in milk supply a few days after taking the morning-after pill, but milk levels should rebound thereafter. See Increasing Low Milk Supply for additional info on increasing milk supply. Talk to your health care provider and/or lactation consultant about using an herb that increases milk supply (fenugreek, for example) to reduce any adverse effects on supply.

Safety: The morning after pill is considered compatible with breastfeeding, but should only be used rarely. Not the first choice for routine birth control, it should be used only as a last resort (whether breastfeeding or not). Both progestin and estrogen are considered compatible with breastfeeding by the AAP. See below for additional information on side effects related to lactation.

Side effects related to lactation

Milk supply: As noted above, hormonal birth control pills (particularly those containing estrogen) have the potential to decrease milk supply, sometimes dramatically.

Effects on baby: There have been no adverse reports of side effects to the baby. Both progestin and estrogen are approved by the AAP for use by nursing moms. Children whose mothers used hormonal birth control while nursing have been followed as late as 17 years of age. The exception to this is the very young baby – less than 6 weeks old. There may be some concern about the baby’s immature liver being able to metabolize the hormones passed through the milk well enough.

Any hormonal birth control may cause fussiness in the baby (not reported in the literature but often anecdotally by mothers). This may be due to the hormones causing a minimal decrease in the protein/nitrogen/lactose content of the milk. Some mothers have reported marked improvement in their baby’s degree of fussiness once they come off hormonal birth control.

Effects on mother: If you had gestational diabetes during pregnancy, talk to your doctor about the safety of using the mini-pill while breastfeeding. A 1998 study conducted at the University of Southern California School of Medicine in Los Angeles (Kjos SL, et al. Contraception and the risk of type 2 diabetes mellitus in Latina women with prior gestational diabetes mellitus. JAMA. 1998 Aug 12;280(6):533-8.) indicated that for certain women, taking the mini-pill while breastfeeding may increase the risk of chronic, non-insulin-dependent diabetes. This study of more than 900 Latinas found that those who had been diagnosed with gestational diabetes and then took mini-pills while breastfeeding had an almost threefold risk of developing type II diabetes within a year, compared with those who used different contraception. This study concentrated on Hispanic women, and thus it is not clear whether the results can be applied to all ethnic groups. Other, smaller studies on the mini-pill did not show any increased rates of diabetes, so more research in needed on this subject.

Here’s the bottom line…

  • Use any hormonal type of birth control with caution (particularly the forms that contain estrogen).
  • Use as low a dose as possible.
  • If you experience supply problems (or if baby’s weight gain slows more than expected or stops) and are using any type of hormonal birth control, it’s a good idea to discontinue using it for a time and see if your supply rebounds as a result.

Info on selected contraceptive meds

Info on selected contraceptive meds
Name of medication
AAP approved?*
Pregnancy Risk Category**
Progestin-only contraceptives

Etonogestrel Implant
(Implanon)
NR X L2
Levonorgestrel
(Mirena, Norplant, Plan B)
Approved
X
L2
Medroxyprogesterone
(Provera, Depo-Provera, Cycrin)
Approved
D
L1
L4 (if used first 3 days postpartum)
Norethindrone
(Aygestin, Camila, Errin, Jolivette, Micronor, Nora-BE, Norlutin, Nor-QD, Ortho-Micronor)
NR
X
L1
Norethynodrel
(Enovid)
Approved
X
L2
Progesterone
(Crinone, Prometrium)
Approved
-
L3
Estrogen-containing contraceptives
Desogestrel + Ethinyl Estradiol
(Cyclessa, Desogen, Mircette)
NR X L3
Drospirenone + Ethinyl Estradiol
(Yasmin)
NR X L3
Estrogen-Estradiol
Approved
X
L3
Ethynodiol Diacetate + Ethinyl Estradiol
(Demulen)
NR Estradiol is X Estradiol is L3
Etonogestrel + Ethinyl Estradiol
(Nuvaring)
NR X L3
Levonorgestrel + Ethinyl Estradiol
(Alesse, Nordette, Preven, Seasonale, Triphasil)
NR X L3
Medroxyprogesterone + Estradiol Cypionate
(Lunelle)
NR X L3
Norelgestromin + Ethinyl Estradiol
(Ortho Evra patch)
NR - L3
Norethindrone + Ethinyl Estradiol
(Loestrin, Norinyl, Ortho-Novum)
NR Estradiol is X Estradiol is L3; Norethindrone is L1
Norgestimate + Ethinyl Estradiol
(Ortho Tri-Cyclen)
NR Estradiol is X Estradiol is L3
Norgestrel + Ethinyl Estradiol
(Lo/Ovral, Ovral)
NR Estradiol is X Estradiol is L3
Oral Contraceptive pill with estrogen/progesterone
(Norinyl, Norlestin, Ortho-Novum, Ovral, etc.)
Approved
X
L3

*  Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001.

** Per Medications’ and Mothers’ Milk by Thomas Hale, PhD (2004 edition). Note: Hale urges caution if estrogen-containing contraceptives are used by nursing moms, due to the risk for a dramatic reduction in milk supply.

 Lactation Risk Categories   Pregnancy Risk Categories 
  • L1 (safest)
  • L2 (safer)
  • L3 (moderately safe)
  • L4 (possibly hazardous)
  • L5 (contraindicated)
  • A (controlled studies show no risk)
  • B (no evidence of risk in humans)
  • C (risk cannot be ruled out)
  • D (positive evidence of risk)
  • X (contraindicated in pregnancy)
NR: Not Reviewed. This drug has not yet been reviewed by Hale.

References

Additional information

General information on birth control choices

Related Posts Plugin for WordPress, Blogger...