What are the recommended oral contraceptive pills (OCPs) for women who are breastfeeding?

Recommended Oral Contraceptive Pills for Breastfeeding Women

Progestin-only pills (POPs) are the recommended oral contraceptive for breastfeeding women, as they can be safely used throughout the entire lactation period without affecting milk supply or infant development. 1, 2

Timing of Initiation

• For women < 6 months postpartum who are fully breastfeeding:

  • POPs can be started immediately postpartum (U.S. MEC category 2 if <1 month postpartum)
  • No backup contraception needed if the woman is:
    • Fully or nearly fully breastfeeding (≥85% of feeds are breastfeeds)
    • Amenorrheic
    • Less than 6 months postpartum 1, 2

• For women not fully breastfeeding or >6 months postpartum:

  • POPs can still be used (U.S. MEC category 1 if ≥1 month postpartum)
  • Backup contraception needed for 2 days after starting 1, 2

Why POPs Are Preferred for Breastfeeding Women

1. No impact on milk production: Unlike combined hormonal contraceptives (CHCs), POPs do not decrease milk volume or composition 3, 4

2. Safety profile: No detrimental effects have been shown on infant growth or development 4

3. Immediate availability: Can be started immediately postpartum without waiting 2

4. Avoids thromboembolism risk: Breastfeeding women should avoid estrogen-containing contraceptives, especially in the early postpartum period due to already elevated thromboembolism risk 2, 3

Important Considerations for POP Use

• Timing is crucial: POPs must be taken at approximately the same time each day (within 3 hours) for maximum effectiveness 1

• Missed pill management:

  • If >3 hours late: Take one pill as soon as possible
  • Continue taking pills daily at the same time
  • Use backup contraception for 2 consecutive days
  • Consider emergency contraception if unprotected intercourse occurred 1

• Vomiting/diarrhea management:

  • If vomiting or severe diarrhea occurs within 3 hours of taking a pill, take another pill
  • Use backup contraception until 2 days after symptoms resolve 1

Combined Hormonal Contraceptives (CHCs)

• NOT recommended during the first 3 weeks postpartum for any woman due to thromboembolism risk 2

• Generally NOT recommended during the fourth week postpartum for breastfeeding women (U.S. MEC category 3) 1, 2

• If a breastfeeding woman wishes to switch to CHCs, experts agree this should only be considered after 6 months postpartum 5

• CHCs may decrease milk volume and should be used with caution in women who cannot obtain supplemental milk 4

Common Pitfalls to Avoid

1. Inconsistent timing: Unlike CHCs, POPs have a narrower window for taking pills (within 3 hours) - emphasize the importance of consistent timing 1

2. Inadequate counseling about bleeding patterns: Irregular bleeding is the most common complaint with POPs. Proper counseling improves compliance and acceptance 3

3. Unnecessary medical tests: For healthy women, no physical examination or laboratory tests are needed to safely provide POPs 1

4. Premature switching to CHCs: There is no need to switch from POPs to CHCs during lactation; POPs can be used safely throughout the entire breastfeeding period 5

5. Underutilization: Despite their safety profile, POPs are rarely used in the US (only 0.4% of reproductive-aged women), even among those who would benefit most 6

By following these recommendations, healthcare providers can help breastfeeding women choose appropriate contraception that protects against pregnancy while supporting successful breastfeeding.