Information For My Pregnant Patients

In non-breastfeeding women, the average time to first ovulation is 45 days (range, 25-72 days) after delivery (1). Many women resume intercourse well before they return for their postpartum checkup, thus some women are at risk of becoming pregnant. 

For breastfeeding women, however, the situation is different. Exclusive breastfeeding helps prevent pregnancy for the first 6 months after delivery, but should be relied on only temporarily and when it meets carefully observed criteria of the lactational amenorrhea method (LAM) (see "Lactational Amenorrhea Method"). 

Nonhormonal Methods

If a breastfeeding woman needs or wants more protection from pregnancy, options are available that do not affect breastfeeding or pose even a theoretical risk to the infant. She should first consider the nonhormonal methods such as copper intrauterine contraceptive devices, condoms, or other barrier methods (see the box, "ACOG Recommendations for Nonhormonal Contraception for Breastfeeding Women"). Condoms have additional, noncontraceptive advantages. Female sterilization or vasectomy may be considered by couples desiring permanent methods of birth control (1). 

Hormonal Methods

ACOG Recommendations for Nonhormonal Contraception for Breastfeeding Women Exclusive breastfeeding up to 6 months meeting lactational amenorrhea method criteria (see "Lactational Amenorrhea Method"). Additional protection if desired:  Prelubricated latex condoms  Other barrier methods  Copper intrauterine contraceptive devices  Male or female sterilization if permanent contraception is desired

Hormonal contraception offers effective protection from becoming pregnant. Several factors should be considered before prescribing hormonal contraception for the lactating woman. Contradictory lines of thought have resulted in conflicting recommendations that have been put forward by generally authoritative sources. The ACOG recommendations represent a more practical approach to the woman's needs, based on relevant research. 

Progestin-Only Contraceptives
Progestin-only contraceptives, including progestin-only tablets (minipills), depot medroxyprogesterone acetate (DMPA), and levonorgestrel implants, do not affect the quality of breast milk and may slightly increase the volume of milk and duration of breastfeeding compared with nonhormonal methods (2-6). Accordingly, progestin-only methods are the hormonal contraceptives of choice for breastfeeding women. Nonetheless, some authorities have recommended delays of various lengths before introduction of progestin-only contraceptives on the basis of two sets of theoretical concerns: 

The normal 2-3-day postdelivery decrease of progesterone is part of the process that initiates lactation. There is theoretical concern that giving progestins in the first few days before lactation is established could interfere with optimal lactation. Note that DMPA enters the milk at approximately the same level found in the woman's blood; by contrast norgestrel and norethindrone enter the milk at only one tenth the level in the woman's blood. The injectable route of administration also may result in a comparatively high initial dose (1). 

Progestin methods carry a theoretical risk to the newborn because of exposure to exogenous steroids at a time when the newborn's system is very immature in its ability to metabolize drugs. Because of this concern, research studies presented to the FDA for drug approval investigated only the effects of these methods administered several weeks after birth. Because documentation of experience with earlier initiation was not presented to the FDA, package inserts recommend initiation of progestin-only oral contraceptives at 6 weeks for women who are exclusively breastfeeding and at 3 weeks for those who are breastfeeding with supplementation. Most authorities recommend introduction of long-acting progestin-only injectables or implants 6 weeks after delivery for breastfeeding women (1, 7, 8).

To balance these conservative recommendations, it is important to understand that the few studies that included early administration of progestin-only methods-oral contraceptives at 1 week postpartum (9, 10) and injectable medroxyprogesterone acetate at 2 days (11) and 7 days (12)-found no adverse effects on the newborn or on breastfeeding. In the absence of evidence that earlier introduction of progestin-only contraceptives has adverse effects on the newborn and on breastfeeding, the labeling for progestin-only oral contraceptives focuses instead on what is known about fertility after childbirth. Taking only biologic factors into account, contraception is not needed in the first 3 weeks postpartum because of a delay in return of ovulation in all women. And this delay is extended for women who breastfeed exclusively. An implied prohibition on earlier administration is more in the nature of a pragmatic rather than a scientific resolution of the question. From the perspective of routine clinical practice, it would appear reasonable to apply the same rationale, even though conservative, to the initiation of DMPA and implants in postpartum breastfeeding women. However, the package labeling for these methods has the effect of being even more conservative as noted, outlining a 6-week start for all breastfeeding women, with no flexibility. Sometimes, however, there are practical reasons a breastfeeding woman may consider initiating hormonal contraception while in the hospital or shortly after. For example, there may be uncertainty about opportunities for follow-up visits. The breastfeeding woman and her physician can then weigh the reasons for early use of these contraceptives against potential disadvantages, make an appropriate decision, and continue to evaluate the woman's individual breastfeeding experience if hormonal contraceptives are chosen. 

Combination Estrogen-Progestin Contraceptives
The postpartum patient has a hypercoagulable state that predisposes her to venous thrombosis (13). The use of estrogen-containing contraceptives during this phase of approximately 3 weeks after childbirth could contribute to this state. Furthermore, estrogen-progestin contraceptives have been shown to reduce the quantity and quality of breast milk. The World Health Organization recommends that the breastfeeding woman wait at least 6 months after childbirth to start using them (7). Labeling required by the FDA for combined oral contraceptives states, "If possible, the nursing mother should be advised not to use oral contraceptives but to use other forms of contraception until she has completely weaned her child" (8). These conservative approaches emanate for the most part from earlier combination oral contraceptive studies using higher doses of estrogens. Low-dose tablets (35 µg or lower) probably have a lesser effect on quality and quantity of breast milk. Effects are variable and if there are strong reasons the woman wishes to start combined estrogen-progestin contraceptive use earlier, she should understand and weigh the potential disadvantages. If estrogen-progestin contraceptives are prescribed, they should not be started before 6 weeks postpartum, and the physician should continue to evaluate the woman's individual breastfeeding experience. 

The summary recommendations given in the box, "ACOG Recommendations for Hormonal Contraception If Used by Breastfeeding Women," with regard to progestin-only methods are based on the conservative timing outlined in labeling. Exceptions may be considered for earlier use on an individual basis. With combined estrogen-progestin contraceptives, a minimum 6-week delay is prudent because practical obstacles in developing successful breastfeeding techniques are likely to be resolved by 6 weeks. Most women experience reduced milk volume as a result of estrogen ingestion; this may be dealt with more easily after breastfeeding skills and patterns are established, should combined contraceptives be chosen despite this disadvantage. FDA labeling, however, is more conservative than the summary recommendation offered for combined estrogen-progestin contraceptives here. As noted earlier, prelubricated condoms are a good interim contraceptive choice and will address vaginal dryness associated with breastfeeding as well as help prevent infection. 

ACOG Recommendations for Hormonal Contraception If Used by Breastfeeding Women Progestin-only oral contraceptives prescribed or dispensed at discharge from the hospital to be started 2-3 weeks postpartum (eg, the first Sunday after the newborn is 2 weeks old)  Depot medroxyprogesterone acetate initiated at 6 weeks postpartum*  Hormonal implants inserted at 6 weeks postpartum*  Combined estrogen-progestin contraceptives, if prescribed, should not be started before 6 weeks postpartum, and only when lactation is well established and the infant's nutritional status well-monitored *There are certain clinical situations in which earlier initiation might be considered.

Lactational Amenorrhea Method

Women who breastfeed can make use of the natural contraceptive effect of lactation. The LAM is most appropriate for women who plan to fully breastfeed 6 months or longer. If the baby is fed only mother's milk or is given supplemental nonbreast-milk feedings only to a minor extent and the woman has not experienced her first postpartum menses, then breastfeeding provides more than 98% protection from pregnancy in the first 6 months following delivery (1, 14, 15). Four prospective clinical trials of the contraceptive effect of LAM demonstrated cumulative 6-month life-table, perfect-use pregnancy rates of 0.5%, 0.6%, 1.0%, and 1.5% among women who relied solely on it. Women should be advised that for significant fertility impact, intervals between feedings should not exceed 4 hours during the day or 6 hours at night. Supplemental feedings should not exceed 5-10% of the total (16-20). For example, more than one supplemental feeding out of every 10 might increase the likelihood of returning fertility. Feeding practices other than direct breastfeeding, insofar as they may reduce the vigor and frequency of suckling and the maternal neuroendocrine response, increase the probability of returning ovulation (21). If there is uncertainty regarding the extent to which a given woman is breastfeeding, it would be prudent to recommend additional contraception. 

References

1. Hatcher RA, Trussell J, Stewart F, Cates W Jr, Stewart GK, Guest F, et al. Contraceptive technology. 17th rev. ed. New York: Ardent Media, Inc, 1998 
2. Tankeyoon M, Dusitsin N, Chalapati S, Koetsawang S, Saibiang S, Sas M, et al. Effects of hormonal contraceptives on milk volume and infant growth. WHO Special Programme of Research, Development, and Research Training in Human Reproduction, Task Force on Oral Contraceptives. Contraception 1984;30:505-522 
3. World Health Organization (WHO) Task Force on Oral Contraceptives. Effects of hormonal contraceptives on milk composition and infant growth. Stud Fam Plann 1988;19:361-369 
4. Speroff L, Darney P. A clinical guide for contraception. 2nd ed. Baltimore, Maryland: Williams & Wilkins, 1996 
5. Abdulla KA, Elwan SI, Salem HS, Shaaban MM. Effect of early postpartum use of the contraceptive implants, NORPLANT, on the serum levels of immunoglobulins of the mothers and their breastfed infants. Contraception 1985; 32:261-266 
6. Shaaban MM, Salem HT, Abdullah KA. Influence of levonorgestrel contraceptive implants, NORPLANT, initiated early postpartum upon lactation and infant growth. Contraception 1985;32:623-635 
7. World Health Organization. Division of Family and Reproductive Health. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. Geneva: WHO, 1996 
8. Physicians' Desk Reference. 53rd ed. Montvale, New Jersey: Medical Economics, Inc, 1999 
9. McCann MF, Moggia AV, Higgins JE, Potts M, Becker C. The effects of a progestin-only oral contraceptive (levonorgestrel 0.03 mg) on breast-feeding. Contraception 1989;40:635-648 
10. Moggia AV, Harris GS, Dunson TR, Diaz R, Moggia MS, Ferrer MA, et al. A comparative study of a progestin-only oral contraceptive versus non-hormonal methods in lactating women in Buenos Aires, Argentina. Contraception 1991;44:31-43 
11. Guiloff E, Ibarra-Polo A, Zañartu J, Toscanini C, Mischler TW, Gómez-Rogers C. Effect of contraception on lactation. Am J Obstet Gynecol 1974;118:42-45 
12. Karim M, Ammar R, el Mahgoub S, el Ganzoury B, Fikri F, Abdou I. Injected progestogen and lactation. BMJ 1971;1:200-203 
13. WHO Task Force on Oral Contraceptives. Contraception during the postpartum period and during lactation: the effects on women's health. Int J Gynaecol Obstet 1987;25 (suppl):13-26 
14. Kennedy KI, Rivera R, McNeilly AS. Consensus statement on the use of breastfeeding as a family planning method. Contraception 1989;39:477-496 
15. World Health Organization. Task Force on Methods for the Natural Regulation of Fertility. The WHO multinational study of breast-feeding and lactational amenorrhea. III. Pregnancy during breast-feeding. Fertil Steril 1999;72;431-440 
16. Perez A, Labbok MH, Queenan JT. Clinical study of the lactational amenorrhoea method for family planning. Lancet 1992;339:968-970 
17. Ramos R, Kennedy KI, Visness CM. Effectiveness of lactational amenorrhea in prevention of pregnancy in Manila, the Philippines: non-comparative prospective trial. BMJ 1996;313:909-912 
18. Labbok MH, Hight-Laukaran V, Peterson AE, Fletcher V, von Hertzen H, Van Look PF. Multicenter study of the Lactational Amenorrhea Method (LAM): I. Efficacy, duration and implications for clinical application. Contraception 1997;55:327-336 
19. Kazi A, Kennedy KI, Visness CM, Khan T. Effectiveness of the lactational amenorrhea method in Pakistan. Fertil Steril 1995;64:717-723 
20. Labbok M, Cooney K, Coly S. Guidelines: breastfeeding, family planning, and the lactational amenorrhea method--LAM. Washington, DC: Institute for Reproductive Health, Georgetown University, 1994 
21. Campbell OM, Gray RH. Characteristics and determinants of postpartum ovarian function in women in the United States. Am J Obstet Gynecol 1993;169:55-60