Which progestin‑only contraceptives can be prescribed for a breastfeeding postpartum patient?

Progestin-Only Contraceptives for Breastfeeding Postpartum Patients

All progestin-only contraceptive methods are safe and appropriate to prescribe for breastfeeding postpartum patients, including progestin-only pills (norethindrone, norgestrel, and drospirenone), depot medroxyprogesterone acetate (DMPA), the etonogestrel implant (Nexplanon), and levonorgestrel intrauterine devices (Mirena, Liletta, Kyleena, Skyla). 1

Available Progestin-Only Contraceptive Options

Long-Acting Reversible Contraceptives (LARC)

Subdermal Implant:

• Nexplanon (etonogestrel 68 mg) - effective for 3 years 2
• Can be initiated anytime postpartum
• Requires 7 days of backup contraception if started >5 days after menses 1
• No examination needed before initiation 1

Levonorgestrel Intrauterine Devices:

• Mirena (52 mg levonorgestrel) - 5 years 2
• Liletta (52 mg levonorgestrel) - 5 years 2
• Kyleena (19.5 mg levonorgestrel) - 5 years 2
• Skyla (13.5 mg levonorgestrel) - 3 years 2
• Can be placed immediately postpartum (though expulsion rates are higher, long-term continuation rates are superior) 2
• Requires 7 days of backup contraception if started >7 days after menses 1

Injectable Contraception

DMPA (Depot Medroxyprogesterone Acetate):

• Can be initiated anytime postpartum 1
• Requires 7 days of backup contraception if started >7 days after menses 1
• No examination needed before initiation 1

Oral Progestin-Only Pills (POPs)

Norethindrone or Norgestrel POPs:

• Can be initiated anytime postpartum 1
• Requires only 2 days of backup contraception if started >5 days after menses 1
• No examination needed before initiation 1

Drospirenone POP:

• Can be initiated anytime postpartum 1
• Requires 7 days of backup contraception if started >1 day after menses 1
• No examination needed before initiation 1

Evidence Supporting Use During Breastfeeding

Progestin-only methods do not negatively influence lactation. Current evidence from multiple sources confirms that LARC methods, including implants and LNG-IUDs, do not adversely affect breastfeeding 2. Progestin-only contraceptives demonstrate safety in breastfeeding patients and do not appear to affect milk volume, composition, or cause deleterious effects in infants 3, 4, 5, 6.

Clinical Considerations

Timing of Initiation

Progestin-only methods can be started immediately postpartum if desired 5. For women who are fully breastfeeding and desire contraception in addition to lactation-induced amenorrhea, starting at 6 weeks postpartum may decrease infant exposure to exogenous hormones and reduce irregular postpartum bleeding 5.

Common Pitfall: Continuation Rates

Be aware that approximately half of women who choose POPs at the postpartum visit will not be using them at 3 months postpartum 7. This highlights the importance of counseling about adherence challenges with daily pills and considering LARC methods for higher continuation rates.

Contraindication Note

Avoid combined hormonal contraceptives (containing estrogen) in breastfeeding women, as low-quality evidence supports concerns about decreased milk supply 3. Progestin-only methods are the preferred hormonal option for lactating patients 4.