What are the recommended contraception methods for lactating women?

Recommended Contraception Methods for Lactating Women

For lactating women, progestin-only contraceptive methods are the most appropriate choice due to their safety profile and lack of impact on breastfeeding. 1, 2

First-Line Options for Lactating Women

Progestin-Only Methods

1. Progestin-only pills (POPs)

   • Safe to use during breastfeeding
   • Do not decrease milk volume or composition
   • No detrimental effects on infant growth or development 2
   • Can be started immediately postpartum

2. Etonogestrel Implant

   • Can be inserted at any time postpartum (U.S. MEC 2 if <1 month postpartum and U.S. MEC 1 if ≥1 month postpartum) 1
   • Highly effective with <1% failure rate 3
   • Randomized controlled trials show no reduction in breastfeeding outcomes 1
   • No back-up contraception needed if inserted within 6 months postpartum in fully breastfeeding women 1

3. Progestin-only Injectable (DMPA)

   • Safe for use during breastfeeding
   • Can be started immediately postpartum

4. Levonorgestrel IUD

   • Safe for breastfeeding women
   • Highly effective with <1% failure rate 3
   • Associated with reduced menstrual blood loss; amenorrhea occurs in 35% of women after 2 years 4

Non-Hormonal Methods

1. Copper IUD

   • First-line option for breastfeeding women 4
   • Extremely effective with failure rate of about 6 pregnancies per 1000 woman-years 4
   • No hormonal effects on lactation
   • Can be safely used immediately after delivery 4
   • May cause heavier menstrual bleeding and cramping 4

2. Barrier Methods

   • Condoms (male or female)
   • Diaphragm with spermicide
   • No effect on breastfeeding but higher failure rates than hormonal or IUD methods 3

3. Lactational Amenorrhea Method (LAM)

   • Effective for up to 6 months postpartum if:
     • Woman is exclusively or nearly exclusively breastfeeding (≥85% of feeds)
     • Has not had return of menses
     • Baby is less than 6 months old 1

Methods to Avoid During Breastfeeding

Combined hormonal contraceptives (CHCs) containing estrogen:

• Should be avoided, especially in early postpartum period
• May decrease milk volume
• Should only be considered after 6 months postpartum if needed 2
• Increased risk of thromboembolism in postpartum period 2

Timing of Contraception Initiation

• Progestin-only methods: Can be started immediately postpartum
• IUDs: Can be inserted immediately postpartum or after 4-6 weeks
  • Note: Risk of uterine perforation is higher when inserted less than 4-6 weeks after delivery 4
• For women <6 months postpartum who are amenorrheic and fully/nearly fully breastfeeding:
  • No need for back-up contraception when starting progestin-only methods 1

Important Considerations

• Effectiveness: Long-acting reversible contraceptives (LARCs) like IUDs and implants have the highest effectiveness (>99%) 3
• Expulsion risk: IUDs have a 5-10% expulsion rate within 5 years 4
• STI protection: Counsel that hormonal methods and IUDs do not protect against STIs; condoms should be used if STI protection is needed 4
• Patient satisfaction: Immediate postpartum LARC placement has high satisfaction and continuation rates 1

Follow-up Recommendations

• Schedule follow-up to assess contraceptive tolerance and address concerns
• For IUD users, check for proper placement and teach patient to check for strings
• Monitor for any signs of complications specific to the chosen method

By following these recommendations, healthcare providers can help lactating women choose safe and effective contraception that supports their breastfeeding goals while preventing unintended pregnancy.