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GCO 270613


OPINION Lactation and contraception
Neha R. Bhardwaj and Eve Espey

Purpose of review
This review examines evidence relevant to the effect of hormonal contraception on breastfeeding; and
compares global and US recommendations for contraceptive initiation and use. Breastfeeding and use of
postpartum contraception have high public health priority, making research in this area critical for
optimizing guidance.
Recent findings
High-quality evidence remains limited with only a small number of well conducted randomized controlled
trials of hormonal methods and breastfeeding/neonatal growth outcomes. More evidence supports early
initiation of progestin-only methods. Evidence on early initiation of combination hormonal methods is
The WHO Medical Eligibility Criteria (MEC) differs from that of the US MEC. Generally, the WHO MEC is
more restrictive, reflecting the potential greater impact on maternal child health if there is a negative impact
from hormonal contraception on breastfeeding. Only well conducted clinical trials will further elucidate
such an impact.
Video abstract:
breastfeeding, hormonal contraception, lactation, long-acting reversible contraceptives, postpartum

INTRODUCTION about the effect of hormonal contraception on lac-
Few postpartum health issues are as controversial, or tation as well as guidelines for use of these methods
raise as much emotion, as that of lactation and by postpartum women.
initiation of hormonal contraception. Caregivers
may become polarized by their beliefs that hormo-
nal contraception has a negative impact on breast-
feeding. A major reason for the controversy is the The physiology of lactation has fascinated since
lack of high-quality data on the impact of hormonal ancient times; Hippocrates hypothesized a diverting
contraception on a number of breastfeeding out- vessel from the mother’s uterus to her breast, allow-
come measures. ing for menstrual blood to nourish her child via
The importance of both contraception and breast milk [5,6]. Lactogenesis begins in midpreg-
breastfeeding is undisputed. The WHO and Centers nancy and results in milk secretion.
for Disease Control and Prevention (CDC) recom-
mend exclusive breastfeeding until 6 months, and (1) Stage I lactogenesis spans midpregnancy to the
continuation of breastfeeding through two years initial postpartum period and is characterized
based on good quality evidence that breastfeeding by secretory differentiation of mammary glands
reduces infant mortality and prevents acute and [6,7] through production of colostrum [8].
chronic disease in both the infant and mother
[1–3]. Similarly, health benefits of contraception
to avoid the negative effects of unintended preg- Department of Obstetrics and Gynecology, University of New Mexico,
nancy and short birth interval are broadly appreci- Albuquerque, New Mexico, USA
ated [4]. Given the widespread practice of both Correspondence to Neha R. Bhardwaj, MD, University of New Mexico,
hormonal contraceptive use and breastfeeding, 2211 Lomas Blvd NE, Albuquerque, NM 87131, USA.
understanding the relationship between the two is E-mail:
of paramount importance. This article reviews the Curr Opin Obstet Gynecol 2015, 27:000–000
physiology of lactogenesis and current knowledge DOI:10.1097/GCO.0000000000000216

1040-872X Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

There is a theoretical risk of adverse outcomes MEC and the US MEC (Table 1 [3. GCO/270613. GUIDELINES FOR USE OF HORMONAL quency and intensity of suckling. thus the con. Unauthorized reproduction of this article is prohibited. .8% for LNG [16–18].26]). Although large studies with follow-up are lacking. 48  Progestin-only methods of contraception likely have a breast-fed children whose mothers began hormonal minimal impact on breastfeeding. estradiol. 0. day 41–43 showed no changes in hormone profiles one and serves as the trigger for secretory activation. The USA adapted the guidance Steroids within hormonal contraception are trans. and sex organs from KEY POINTS exposure to exogenous steroids.7]. and filling this need may help decrease rapid few studies that have examined effects of transferred repeat pregnancy and unintended pregnancy.6–3.25.7% for etonogestrel. ception were followed until age eight [14]. Nonbiological factors may be as important or the small amount of steroid transfer is not con- more important for lactogenesis. culminating in production of copious ma. and no differences in psychomotor cern that initiation of hormonal contraceptives development were noted between the implant and a could have a negative impact on lactogenesis and nonhormonal IUD after 3 years of use [23. and sidered a contraindication for use of hormonal con- born reflexes. The health status of the mother. method used by postpartum breastfeeding women are informed by systematic reviews of the evidence and published by the WHO as the Medical Eligibility STEROID TRANSFER Criteria (WHO MEC). as maternal blood. early separation CONTRACEPTIVES IN POSTPARTUM of the mother and infant and cultural and socio. the primary producer receiving DMPA for contraception on postpartum of progesterone. The amount of  A large unmet need for postpartum contraception hormone transferred appears to be small and the exists. GCO 270613 Family planning for the neonatal liver. lactation. (LNG) oral pills or Norplant 4–15 weeks postpartum tin increase.10]. as the CDC MEC.24]. Numerous new. male infants of lactating mothers tin. administered to the mother is <1% for ethinyl ture milk [8]. Total nos of Pages: 7. Secretory activation and onset of For oral contraceptives. In one of the largest and longest studies. need for  Women should be provided with additional lactation special tutoring in school. The WHO 2 www.11–13]. traceptives in lactating women. contraception 2 months postpartum and matched  There is insufficient evidence examining the possible controls whose mothers used nonhormonal contra- effects of hormonal contraception on breastfeeding. Suckling also stimulates prolactin secretion.CE: Alpana. sucking. (2) Stage II lactogenesis occurs from postpartum The amount of hormone transferred depends on days 2–5 after a sharp decline in serum pro. Another study showed no differences between male infant follicle stimulat- ing hormone. ences were found in serious illnesses. Plasma progesterone levels fall to follicular phase The amount of hormone transferred is similar levels by postpartum day 2–3 [9]. birth interval. and testoster- one levels in mothers who began levonorgestrel During stage I. During pregnancy. the percentage of hormone milk secretion characterize stage II lactogenesis transferred to the newborn compared with the dose [6. brain. fre. Four categories of recommen- ferred from the mother to her newborn via breast dations guide decision-making for both the WHO milk. mature milk [7. intrauterine device (IUD). 2.9. ceptive implant. or approximately one pill per 4 years While numerous hormonal changes occur of full lactation [19. such as rooting. and height or weight [14]. BREASTFEEDING WOMEN economic factors and pressures also impact lacto. Inc. as compared to controls [16. hormones show no adverse newborn outcomes. support in the postpartum period. as compared to controls [15]. high-levels Although depot medroxyprogesterone acetate of estrogen and progesterone inhibit lactation from (DMPA) is found in breast milk at the same levels occurring. ing are key to the establishment of lactation.1% of a daily dose was one withdrawal is the likely trigger for production of transferred to the infant via breast milk [21]. serum progesterone and prolac. and 2. hyperbilirubinemia.22]. luteinizing hormone.20]. In examining a 30 mg LNG during the immediate postpartum period. progester. No differ- additional research is needed. Delivery of the placenta. gesterone. results in a sharp drop in progester. Lactation depends between progestin-only pills (POPs) and the contra- on withdrawal of steroid hormones. Recommendations for hormonal contraceptive genesis [8. the hormone type and dose and the delivery system. despite high-circulating levels of Volume 27  Number 00  Month 2015 Copyright © 2015 Wolters Kluwer Health.

pdf?ua ¼ 1&ua ¼ 1. long with no difference in supplementation as ided into six sections: POPs. Progestin-only pills partum breastfeeding women with respect to hor. Medical Eligibility Criteria for Contraceptive Use. 2011. medical eligibility criteria for contraceptive use. 4th edition and 5th edition Executive Summary. intrauterine device.26] Category 1 Category 2 Category 3 Category 4 WHO-MEC A condition for which there is A condition where the A condition where the A condition which represents no restriction for the use of advantages of using the theoretical or proven risks an unacceptable health risk the contraceptive method method generally outweigh usually outweigh the if the contraceptive method the theoretical or proven advantages of using the is used risks method US-MEC No restriction (method can Advantages generally Theoretical or proven risks Unacceptable health risks be used) outweigh theoretical or usually outweigh the (method not to be used) proven risks advantages Source: World Health Organization. CDC. CDC.25. http://whqlibdoc.26] Combined hormonal Progestogen. http://whqlibdoc.60 (No. U. MMWR bitstream/10665/172915/1/WHO_RHR_15.59 (No.59 (No. hormonal contraceptives [27.26]). WHO and US Medical Eligibility Criteria for use of hormonal contraceptives in postpartum breastfeeding women [3. CDC. medical eligibility criteria for contraceptive use.25. progesterone vag. Inc. A number of cohort and nonrandomized studies HORMONAL CONTRACEPTIVE METHODS suggest that women using POPs breastfeed for as Review of hormonal contraceptive methods is MMWR 2011. Categories of recommendations for women’s use of contraceptives [3. and USA both make recommendations for post. 2010. MMWR 2010.07_eng. Medical Eligibility Criteria for Contraceptive Use. CDC. 26). . GCO 270613 Lactation and contraception Bhardwaj and Espey Table 1. GCO/270613. Geneva.pdf?ua ¼ 1 and http://apps. 2011. RR-4). 26). In two contraceptive implant. 1040-872X Copyright ß 2015 Wolters Kluwer Health.S.CE: Alpana.28]. IUD. and combined hormonal contraceptives POPs (LNG and norgestrel) with women using non- (CHC). LNG IUD.S. The effect of POPs on lactation is relatively better monal contraception (Table 2 [3.who. nonrandomized studies comparing women using inal ring. 1–86. Total nos of Pages: 7. 878–883. although randomized controlled trials are few. Switzerland: World Health Organization. medical eligibility criteria for contraceptive use. MMWR 2010. Inc. etonogestrel women using nonhormonal contraception. those in the Table 2.25. MEC.pdf?ua¼1 and http://apps. RR-4).07_eng.S. 2010 and 2014. 2010 and 2014. DMPA.S. All rights reserved. medical eligibility criteria for contraceptive 3 Copyright © 2015 Wolters Kluwer Health. Geneva. U. U.60 (No. studied than that of other hormonal contraceptives. Unauthorized reproduction of this article is prohibited. Progestin-only Levonorgestrel Copper Time contraceptives only pills injectables Implants IUD IUD WHO-MEC <48 h 4 2 3 2 2 1 48 h to <4 weeks 4 2 3 2 3 2 4 weeks to <6 weeks 4 2 3 2 1 1 6 weeks to <6 months 3 1 1 1 1 1 6 months 2 1 1 1 1 1 US-MEC <10 min of placental NA NA NA NA 2 1 delivery 10 min to <4 weeks of NA NA NA NA 2 2 placental delivery 4 weeks NA NA NA NA 1 1 <21 days 4 1 1 1 NA NA 21–42 days with other 3 1 1 1 NA NA VTE risk factors 21–42 days without other 2 1 1 1 NA NA VTE risk factors >42 days 1 1 1 1 NA NA Source: World Health Organization. 1– bitstream/10665/172915/1/WHO_RHR_15. www.who. Switzerland: World Health Organization.pdf?ua¼1&ua¼1.who. medical eligibility criteria. 4th edition and 5th edition Executive Summary. 878–883. venous thromboembolism. 2010.

40].5% of US women reported ever As the immediate postpartum period is an use in 1995 compared with 23% in 2006–2010 [35]. Furthermore. DMPA. . no difference was noted in mean and of DMPA – prior to hospital discharge. Unauthorized reproduction of this article is prohibited. In a retrospective cohort study. no difference was found in In a cohort study. POPs were initiated at 1 week postpartum [27]. choosing a nonhormonal IUD and 48 choosing the traceptive used among breastfeeding women con.32. Method choice included LNG follow-up.CE: Alpana. In a large prospective study conducted number of women reporting ‘not enough milk’ [36]. breastfeeding duration.29. numerous prospective nonrando. Etonogestrel contraceptive implant est study across five countries shows no difference The etonogestrel contraceptive implant offers between POP users and nonhormonal contracep. even when implant and its possible effects on breastfeeding. growth in body length. a [29. women who received DMPA had breastfeeding performance among women initiat. barrier methods. mized studies show no difference in infant weight when comparing POP users to nonhormonal contra- ceptive method users [18. lowed after choosing a contraceptive method of Among a cohort study with almost five years of their choice [29.0375 mg POPs. highly efficacious long-acting reversible contracep- tion users in infant growth and development tion. Although it is a newer form of contraception. of delivery. The larg. no difference was found few fair and good quality studies examine the in infant growth parameters at 9 months. In using contraception or CHC [38]. or perception of insuf- five-country study. Of status [41]. In recent years. A A prospective cohort study compared 38 women recent systematic review of progestogen-only con. or IUD [18]. ficient milk production [31. no difference was women using DMPA or nonhormonal contraception found between POP users and nonhormone users in were more likely to breastfeed longer than those not breastfeeding initiation or outcomes after 6 weeks. but also measured nutrition or perceive decreases in milk production. supplementation. early initiation Volume 27  Number 00  Month 2015 Copyright © 2015 Wolters Kluwer Health. of POPs before hospital discharge. children of mothers using DMPA as com- 0. a common cause of breastfeed- the 2466 women participating. opportune time to initiate contraception. In a similar study. 6. a pilot Although few randomized-controlled trials study examined the safety of immediate postpartum evaluate the effect of DMPA on breastfeeding out. Over the 12-week follow-up. within 24–48 h postpartum or DMPA initiated blind trial evaluated the effects of a NET-EN 6 weeks postpartum. LNG subdermal implant. insertion of the etonogestrel implant [43].27.30. In feed for over 20 months than women on nonhormo- Halderman and Nelson’s study [31] of early initiation nal methods [37]. One double.36. across five countries. No difference was noted between fair or poor in quality. highly effective long-acting proges. Total nos of Pages: 7. with [38]. GCO/270613. lower pregnancy rates and were more likely to breast- ing POPs or nonhormonal methods [29. its tum [24]. or sterilization.30]. GCO 270613 Family planning nonhormone group were more likely to supplement injection on postnatal depression. nonhormonal no differences in growth and development or health methods (IUDs).30]. Forty 475 chose POPs that ing cessation was a new pregnancy. Inc. 4 www. No difference importance of contraceptive efficacy when consid- was noted between contraceptive groups in breast. highlighting the were initiated 6 weeks postpartum. women were prospectively fol. No difference was found One study found that women using desogestrel between the placebo and NET-EN groups for number POPs breastfed longer than women using a copper of women breastfeeding at day 1. progestogen-only methods groups in breast milk volume. norethisterone enanthate pared to those using nonhormonal methods showed (NET-EN). most suggest that DMPA does not appear to women were randomized to implant insertion decrease duration of breastfeeding. and 12 weeks. etonogestrel implant initiated at 28–56 days post- cluded that while studies investigating this topic are partum [42]. volume that DMPA may or may not be associated Additionally. or immediately postpartum – does not nal contraceptive method users [32]. within 48 h total breastfeeding time as compared to nonhormo. IUD or etonogestrel implant at 28–56 days postpar- tin-only contraceptive injection.30]. infant weight or milk do not reduce the ability to successfully breastfeed composition. A subsequent prospective cohort study showed no difference in growth parameters or psychomotor development among Depot medroxyprogesterone acetate infants whose mothers initiated the nonhormonal DMPA is a safe. use has increased: 4. Of note. infants whose mothers or have a negative impact on infant growth or used the implant tended to have a higher rate of development during the first year of life [34]. ering the potentially small changes in breast milk feeding duration or number of feeds per hour. another study where POPs were initiated at 57 days In several nonrandomized trials.33]. appear to affect breastfeeding continuation or In the previously mentioned large prospective duration.

In preliminary differences in infant weight were noted between Early initiation was noninferior to delayed insertion PVR and nonhormonal IUD users at 12 months for lactation failure and time to lactogenesis stage II. However. the PVR and copper IUD Almost half of women initiated sexual intercourse appear to have similar pregnancy rates of 1. A hormone IUD users. all postpartum hormonal contraception and have reporting on combined oral contraceptives (COCs) difficulty with lactogenesis. early initiation not included on the CDC or WHO medical eligi- appears acceptable. The PVR is a new contraceptive method and is Although data remain limited. All rights reserved. published in 2012. and does initiation of COCs before 6 weeks vs. In the majority of cohort studies. emphasizing the 12 months [32. www. bility contraceptive guidelines. In women who receive immediate review by Tepper et al. The pill also has the widest geo- [10]. citing ring use-related problems and implant has no effect on breast milk amount or vaginal problems [48–50]. 3 months of patient reported breastfeeding. In six cohort studies. married. removal of the implant examining two questions: does initiation of COCs or LNG intrauterine system may be considered by breastfeeding women have worse breastfeeding/ although other forms of breastfeeding support infant outcomes as compared to nonhormonal/no should also be considered first line. America and whose target market is breastfeeding supplementation/time to supplementation. [56 ] includes 13 studies. [48–52]. women in the LNG intrauterine system group (n ¼ 163) were similar to Combined hormonal contraceptives women in the copper IUD group (n ¼ 157) in breast. containing – hormonal contraceptives. how. provided indirect is initiated on postpartum day 29–60. PVR users had equal numbers subsequent randomized controlled noninferiority of breastfeeding episodes per 24 h period and equal trial evaluated lactogenesis among women who lactation performance at 1 year postpartum initiated the etonogestrel implant 1–3 days post. Total nos of Pages: 7. GCO/270613. used by 16% of reported they continued to breastfeed at 6 months women [35.50. after 6 weeks postpartum have negative effects on breastfeeding/infant outcomes. no partum compared with 4–8 weeks postpartum [44]. the effect of IUDs initiated at 6–8 weeks postpartum on breastfeeding outcomes. Progesterone vaginal ring Six studies examined the impact of COCs The progesterone vaginal ring (PVR) is a new form initiated prior to 6 weeks on breastfeeding and infant of contraception currently only available in Latin outcomes including duration of breastfeeding. Unauthorized reproduction of this article is prohibited. and infant weight and length. method use. A recent systematic review concludes that although current evidence is poor to fair. delayed (n ¼ 21) IUD place. Compared with non- importance of early postpartum contraception.CE: Alpana.51]. women should and is available over the counter in many countries be counseled regarding the theoretical risk of [55]. The effect of combined – estrogen and progestin feeding duration and infant growth [45]. of the PVR is large given its effectiveness and that Five of six studies were published prior to 1985. GCO 270613 Lactation and contraception Bhardwaj and Espey no difference was noted in infant weight gain. [48. composition or infant growth and development. PVR releases an average of of six were considered to be methodologically of poor 10 mg/day of progesterone and is used continuously quality and the other two of fair quality. Worldwide. Inc. or cohabiting women and is the second ever.54]. Inc. reduced breast milk production. Currently in its infancy.47–52]. graphic distribution of any contraceptive method As with all hormonal 5 Copyright © 2015 Wolters Kluwer Health. more women in the delayed placement group most common method in the USA. . relationship between CHC use and breastfeeding feeding with immediate postpartum placement of a outcomes. the PVR does not appear to affect Levonorgestrel intrauterine device breastfeeding performance or infant weight gain & In a single randomized controlled trial examining in the first year [53 ]. used by 9% of reproductive-aged. exclu- women. The only over a 90-day period [46]. Overall current Few high-quality studies have examined the studies have not shown a negative effect on breast. the potential impact sive breastfeeding. studies suggest that women No difference was noted in mean milk creamatocrit may be less satisfied with the PVR than with the values between the two groups. PVR recent study.5% at prior to 42 days postpartum. the ‘pill’ is the third most ment showed no difference at 6–8 weeks and common method. A recently updated rigorous systematic & hormonal IUD. evidence as it compared breastfeeding/infant 1040-872X Copyright ß 2015 Wolters Kluwer Health. on lactation A secondary analysis of a small randomized trial is particularly important because they are used so of immediate (n ¼ 27) vs. commonly. four it is woman controlled. copper IUD since more discontinued the PVR than Current evidence suggests that the etonogestrel the IUD.

the US MEC gives a Category infant. For DMPA. but the majority Five studies examined the impact of COCs supports minimal impact of progestin-only methods initiated after 6 weeks on breastfeeding outcomes. a feeding is highly limited. GCO/270613. with advo- published in 2013. Routledge. U. it had small numbers. All but two of the studies comprehensive program and certification that are old. Switzerland: World Health Organization. and regional exposures and health consequences. hormonal methods suggest no or minimal effect on breastfeeding performance and neonatal growth parameters. Best practices include face-to- design limited this study.CE: Alpana. CHC. short partum contraception exists globally. 2002. Stud Fam Plann 2008. breastfeeding women. substantial differences in neo. of hormonal contraception on breastfeeding COC initiation on infant growth. 2003. If there were even a small negative READING Papers of particular interest. contraception on breastfeeding. 2010. a large unmet need for post- between the groups. without contraindications after 42 days postpartum 3. and the WHO MEC gives a Category 3 until 6 months 4. Conflicts of interest Although the majority of data presented for most There are no conflicts of interest. Although the authors considered studies are urgently needed to elucidate the effect. The authors concluded that of support for breastfeeding Total nos of Pages: 7. Unauthorized reproduction of this article is prohibited. Inc. delayed. and less conclusive effect for combined estrogen– Four of the five were published prior to 1990 and progestin methods. Evidence has follow-up of infant outcomes. The Baby Friendly Hospital Initiative. Bhutta ZA. MMWR Recomm Rep 2010. Although this study found no differ. RECOMMENDATIONS WHO and US MEC recommendations differ widely Financial support and sponsorship with respect to use of hormonal contraceptives in None. Maternal and child undernutrition: global result. . Global strategy for infant and young child feeding. child. is a prospective cohort study of cates lining up for early vs. and over 20% loss to yielded mixed results on the impact of hormonal follow-up in both groups. provides a high standard those for today’s trials. et al. face support. ongoing scheduled visits and support Overall. the quality and quantity of the data REFERENCES AND RECOMMENDED remain limited. For 260. medical eligibility criteria for contraceptive use. but small numbers and the nonrandomized breastfeeding [57]. of hormonal methods is controversial. Allen LH. World Health Organization. have impact on breastfeeding performance for women in been highlighted as: & of special interest developing countries. These differences may reflect the potential differential impact on maternal–child health between developing countries and the USA. CONCLUSION women who initiated progestin-only pills at 2 weeks Postpartum contraception is increasingly recognized postpartum. GCO 270613 Family planning outcomes among women who initiated COCs vs. due to poor methodology. 2. Gipson JD. Centers for Disease Control and Prevention (CDC). 371:243– ence in recommendations are CHC and DMPA. the US MEC gives a Category 1 for all women Geneva. mize their own and their families’ health as they make important contraceptive choices. whereas the 5. fair to poor quality data were conflicting on whether Given the major public health impact of breast- early or late COC initiation has a negative impact on feeding and use of hormonal contraception. research that is sensitive to the needs of the individual examining the possible effects of CHC on breast. The two contraceptives with the largest differ. Hindin MJ. 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