What oral contraceptives are safe for a breastfeeding mother?

Oral Contraceptives in Breastfeeding Mothers

Progestin-only pills (POPs) are the safest oral contraceptive option for breastfeeding mothers and can be started immediately postpartum, while combined hormonal contraceptives containing estrogen should be avoided entirely during the first 6 weeks and generally not used until after 6 months of breastfeeding. 1, 2

Progestin-Only Pills (POPs): First-Line Choice

POPs are the preferred oral contraceptive for breastfeeding women and carry no restrictions on timing of initiation. 1, 2

Timing and Backup Contraception

• No backup contraception is needed if POPs are started within 6 months postpartum while amenorrheic and fully/nearly fully breastfeeding (≥85% of feeds are breastfeeds). 1
• If started >21 days postpartum without return of menses, use backup contraception for 7 days. 1
• POPs can be initiated immediately postpartum without adverse effects on lactation or infant development. 3, 4

Safety Profile

• POPs do not adversely affect milk production, volume, or composition. 3, 4
• No detrimental effects have been demonstrated on infant growth or development. 3, 4
• Steroids transfer into breast milk in very small quantities that are usually undetectable in infants. 4
• The typical failure rate for POPs is approximately 5% with typical use, compared to 0.5% with perfect use. 5

Common Side Effects

• The most commonly reported complaint is irregular bleeding patterns. 6
• Counseling about variable bleeding patterns may improve compliance and acceptance. 6

Combined Hormonal Contraceptives (CHCs): Avoid During Breastfeeding

Combined oral contraceptives containing estrogen should not be used during breastfeeding, particularly in the first 6 months postpartum. 1, 2

Absolute Contraindications by Timing

• <3 weeks postpartum: U.S. MEC Category 4 (unacceptable health risk) due to increased venous thromboembolism (VTE) risk. 1, 2
• 4 weeks to 6 months postpartum: U.S. MEC Category 3 (risks usually outweigh benefits) due to potential negative effects on breastfeeding performance. 1, 2
• Additional VTE risk factors make CHCs inadvisable at 4-6 weeks postpartum. 1

Effects on Lactation

• Estrogen-containing contraceptives can reduce milk production and volume. 3, 7
• Two older placebo-controlled trials demonstrated significantly lower breast milk volume in COC users, with mean differences of -24.00 mL at 16 weeks and -24.90 mL at 24 weeks. 7
• Some studies showed negative effects on lactation duration with COCs compared to placebo. 7

Special Circumstances

• If a woman insists on using CHCs, wait a minimum of 6 weeks postpartum, ensure no additional VTE risk factors exist, and confirm access to supplemental milk. 1
• For women planning to gradually wean their infant, COCs may provide an easier transition to bottle-feeding, but should be used with caution in women unable to obtain supplemental milk. 3

Important Clinical Caveat for Women with Prior Gestational Diabetes

In Latino populations of breastfeeding women, progestin-only oral contraceptives (0.35 mg/day norethindrone) and depot medroxyprogesterone acetate were associated with a two- to threefold increase in diabetes risk, so progestin-only agents should be used with caution during breastfeeding in women with prior gestational diabetes. 8

• This represents an important population-specific consideration when counseling women with GDM history about contraceptive options. 8
• Combination oral contraceptives containing the lowest doses can be started 6-8 weeks after delivery if the woman is breastfeeding, though this conflicts with the general CDC guidance to avoid CHCs. 8

Algorithm for Selection

1. First 3 weeks postpartum: POPs only (CHCs are Category 4). 1, 2
2. 3 weeks to 6 months postpartum: POPs preferred (CHCs are Category 3). 1, 2
3. After 6 months postpartum: POPs remain preferred, but CHCs may be considered if milk supply is well-established and supplementation is available. 1
4. Special consideration: In women with prior gestational diabetes, particularly in Latino populations, discuss increased diabetes risk with progestin-only methods and consider non-hormonal alternatives. 8