What birth control methods are acceptable for breastfeeding mothers?

Birth Control Methods for Breastfeeding Mothers

Breastfeeding mothers can safely use multiple contraceptive methods, with progestin-only options being preferred during the first 6 months postpartum, while combined hormonal contraceptives (containing estrogen) should be avoided until at least 3 weeks after delivery and ideally delayed until after 6 weeks due to concerns about milk production and thromboembolism risk. 1

Timing-Based Approach to Contraception During Breastfeeding

Lactational Amenorrhea Method (LAM)

• Can be used immediately postpartum if all three criteria are met: (1) amenorrhea, (2) fully or nearly fully breastfeeding, and (3) less than 6 months postpartum 1
• Provides approximately 98% contraceptive efficacy when criteria are strictly followed 1
• Critical limitation: Does not protect against STIs/HIV; condoms should be added if any STI/HIV risk exists 1

Progestin-Only Methods (Preferred During Breastfeeding)

These methods do not adversely affect milk production or infant health and can be initiated early postpartum:

• Progestin-only pills (POPs): Can be started at any time postpartum in non-breastfeeding women; for breastfeeding women, ideally started at 6 weeks to minimize infant hormone exposure, though can be used earlier if needed 2, 3
• DMPA (Depo-Provera injection): Category 2 (advantages generally outweigh risks) for breastfeeding women less than 1 month postpartum 1
• Implants: Category 2 for breastfeeding women less than 1 month postpartum 1
• Levonorgestrel IUD (LNG-IUD): Category 2 for breastfeeding women less than 1 month postpartum 1
• Progestin-only vaginal rings: Deliver hormones insufficiently active by oral route, minimizing infant exposure through breast milk; can be used continuously for 3-12 months with high efficacy (>98.5%) 4

Key advantage: Progestin-only methods may actually prolong lactational amenorrhea to 10-12 months, providing additional health benefits 4

Combined Hormonal Contraceptives (Estrogen + Progestin)

Strict timing restrictions apply due to dual concerns:

For Breastfeeding Women:

• Category 4 (unacceptable health risk) before 3 weeks postpartum due to increased venous thromboembolism risk 1
• Category 3 (risks usually outweigh benefits) from 3 weeks to 6 months postpartum due to potential negative effects on milk production 1
• Combined oral contraceptives (COCs), transdermal patches, and vaginal rings (like NuvaRing) all fall under these restrictions 1, 5
• Estrogen can reduce milk production, which may lead to earlier weaning or need for supplementation 2, 3

For Non-Breastfeeding Women:

• Category 4 before 21 days postpartum due to thromboembolism risk 1, 6
• Category 3 from 21-42 days if additional VTE risk factors present 1, 6
• No restrictions after 42 days postpartum for otherwise healthy women 6

Barrier and Non-Hormonal Methods

These methods are always acceptable during breastfeeding:

• Condoms: Do not affect breastfeeding; provide STI/HIV protection 1
• Copper IUD (Cu-IUD): Can be inserted as early as 10 minutes after placental delivery, though expertise required due to soft uterine wall 1, 3
• Withdrawal (coitus interruptus): Does not affect breastfeeding if used correctly, though has higher typical-use failure rates 1
• Diaphragm/cervical cap: Should NOT be used as backup with vaginal ring methods due to interference with proper placement 5

Sterilization

• Tubal sterilization and vasectomy are safe options with no restrictions related to breastfeeding status 1
• No medical conditions absolutely restrict eligibility except known allergies to materials used 1

Clinical Decision Algorithm

Week 0-3 postpartum (breastfeeding):

• LAM alone (if criteria met)
• Progestin-only methods (POPs, DMPA, implants, LNG-IUD)
• Barrier methods
• Copper IUD
• Avoid all combined hormonal contraceptives

Week 3-6 postpartum (breastfeeding):

• Continue above options
• Combined hormonal contraceptives may be considered but generally not recommended (Category 3)

After 6 weeks postpartum (breastfeeding):

• All methods become more acceptable
• Combined hormonal contraceptives still carry concerns about milk supply reduction but may be appropriate for women planning gradual weaning 2

Important Caveats

• Drug interactions: Multiple medications can reduce contraceptive effectiveness, including anticonvulsants, rifampin, St. John's wort, and certain HIV/HCV medications; use additional barrier methods for 28 days after stopping these medications 5
• Small amounts of contraceptive steroids pass into breast milk with all hormonal methods, though no harmful effects have been observed in breastfed infants 5, 4
• Women with conditions making pregnancy high-risk should not rely on LAM alone due to higher typical-use failure rates 1
• Immediate postpartum initiation of progestin-only methods is safe and may be preferable for women with limited healthcare access 2