Breastfeeding and contraception – the progesterone controversy

Many moons ago The Pump Station and Nurtury asked me to teach a class and write a blog entry about contraception while breastfeeding

pump station

Here’s my blog entry for them, for you:

As an OBGYN, I was well aware of the intense post partum changes that I should expect from my own body. The biggest challenge of all, and one that my medical experience didn’t prepare me for, was the sometimes painful, emotionally turbulent, and occasionally wonderful experience of breastfeeding. Happily, I was going to the breastfeeding support groups at the Pump Station. They provided me with a wonderful blend of camaraderie and information. Much of that information was new to me, but I soon came to realize that there was at least one area about which my group-mates often had questions in which I was well versed. At almost every class, someone would ask about contraception choices – what was the best to use while breastfeeding? What was safe? Knowing I was an OBGYN, our group leader would defer these questions to me.

There are certainly many possible choices, but the most controversial seems to be the questions surrounding progesterone. The lactation consultant would inextricably tell women that it would decrease milk supply, citing expert opinion and legitimate sources. The medical literature I was familiar with told me that progesterone would have no effect at all on breast feeding.

So which one was it? Are progesterone methods of contraception friend or foe to the breastfeeding woman?

I did a thorough medical search and found a ton of information (some helpful, some useless). I am clearly not the only person trying to answer this question.

Before I go through this information, let me get you up to speed with progesterone contraception.

Progesterone forms of contraception:

  • The progesterone only pill: AKA “mini pill”. It is a miniature version of the combined oral contraceptive pill (our beloved “the pill”). It’s miniature because it only contains one hormone – progesterone. The combined oral contraceptive contains a combination of estrogen and progesterone. Everyone agrees that the estrogen component decreases breast milk supply, so we aren’t talking about this pill now. The other difference is that the progesterone only pill does not have a placebo week – you take a hormone pill every day, and your period comes when it wants to (ie irregular bleeding is common … as it is with all of these forms with progesterone only).
  • Depo provera injection: an injection you get every 3 months. It gets a bad rep because it’s been linked to weight gain (not sure if it’s causal or an association only) and depression (in a small percentage of patients only). Some patients love it. Some hate it.
  • Nexplanon: the implant. Former incarnations are Norplant and Implanon. It’s a small rod placed under the skin of your arm and secretes a small amount of hormone daily over the course of 3 years. It’s one of the most effective forms of birth control on the market today.
  • The Mirena IUD also contains progesterone. You probably recognize the name of this IUD from commercials, although I can’t guarantee your life will be like the ads – all flowers and sunshine – with its use.

Progesterone types:

There are many different types of progesterone used for contraception – names like norethindrone, levonorgestrel, norgestimate. They vary slightly depending on the delivery method (swallowed, injected, etc), but are sometimes lumped together for ease of analysis.

What do the studies show?

I don’t want to bore you with the extraneous details (I bored myself reviewing some of this information) … but here’s the gist:

Lactation is made possible, in part, because of a sudden drop in maternal progesterone levels the first few days post partum. Addition of a progesterone at this time may, theoretically, halt this natural process.

Current evidence to support either argument is weak. The studies are not uniform. The outcomes are not consistent.

  • A large international study conducted by the WHO tells us that the use of progesterone contraception, in various forms (including the pill, the injectable, and the implant), will not affect breast feeding performance or rate of infant growth.
  • A small cohort of women reported a significant decrease in milk production after taking the progesterone only pill. When most of these women stopped taking the pill, their milk supply returned.
  • In a different study with the progesterone only pill, there was no change in milk volume in the first months after initiation. At 18 weeks of use, there was a 12% drop (compared to a 6% drop for women not using hormonal contraception). However, supplemental feeding was the same in both groups.
  • In a study of urban women, when Depo Provera (the 3 month injectable) was given immediately after delivery, there were no detrimental effects on duration of lactation, frequency of lactation, or timing of introduction of formula within the first 16 weeks post partum.

Still confused?

I don’t blame you. I haven’t given you an answer because there is no straightforward answer.

My Counseling:

I believe that large studies show us, overall, that progesterone only contraceptives CAN be a good option. They are unlikely to have a detrimental effect on breast feeding or infant outcomes. This is the information your OBGYN will site. I know I have.

BUT, and I urge to remember this, some women may be sensitive to progesterone. Lactation consultants see this sensitivity consistently and with more frequency than the literature suggests. Although the data is unpublished and at this point anecdotal, I believe it is enough to question progesterone only methods. Breast feeding is hard enough as it is … your choice of contraception should not make it harder.

I suggest you proceed with caution:

  • Non hormonal methods of contraception will avoid any risk to your milk supply.
  • If you do decide a progesterone form of contraception is right for you, follow these guidelines:
    • Wait about 6 weeks after delivery before starting, so your milk supply is established.
    • Use a rapidly reversible form, like the pill. You can stop and reverse the effects (hopefully) if you do notice a drop in supply. With the option of Depo Provera, if you notice a drop in your supply, you can’t reverse the effects any faster than the 3 months it will persist. The implant and IUD are quickly reversible, but it would be a shame (both physically and cost effectiveness) to remove these shortly after insertion.

 

Get educated on all forms of contraception. Come to my class, Sex and Contraception for the Post Partum Woman to learn more!

Also seen here: http://pumpstationblog.blogspot.com/2014/07/breastfeeding-and-contraception.html

 

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