Oral Contraception for Breastfeeding Women
Progestin-only pills (POPs) are the recommended oral contraceptive for breastfeeding mothers and can be started immediately postpartum, while combined hormonal contraceptives containing estrogen should be avoided during the first 6 weeks and generally not used until after 6 months of breastfeeding. 1, 2
Progestin-Only Pills: The Preferred Choice
POPs are safe for immediate postpartum initiation and do not adversely affect milk production or infant growth. 1, 2
Timing and Backup Contraception Requirements
No backup contraception is needed if POPs are started within 6 months postpartum while the mother is amenorrheic and fully or nearly fully breastfeeding (≥85% of feeds are breastfeeds). 1, 2
If started >21 days postpartum without return of menses, use backup contraception for 7 days. 1, 2
POPs can be initiated within days of delivery with adequate data showing no detrimental effects on lactation or infant health. 3
Evidence Supporting Safety
Multiple trials demonstrate no significant differences in breastfeeding duration, breast milk composition, or infant growth with POP use. 4
Progestin-only methods do not appear to affect milk volume or composition and cause no deleterious effects in infants. 3, 5
Steroids transfer from plasma into milk in very small quantities, typically too low to detect in infants, and theoretical concerns about effects on neonatal reproductive development are unwarranted. 5
Combined Hormonal Contraceptives: Avoid During Breastfeeding
Combined oral contraceptives containing estrogen should not be used during breastfeeding, particularly in the first 6 months postpartum. 1, 2, 6
Timing Restrictions Based on Risk Categories
<3 weeks postpartum: Absolutely contraindicated (U.S. MEC Category 4) due to increased venous thromboembolism (VTE) risk. 1, 2, 7
4 weeks to 6 months postpartum: Generally not recommended (U.S. MEC Category 3) due to potential negative effects on breastfeeding performance and milk production. 1, 2
After 6 months postpartum: CHCs may be considered if milk supply is well-established and supplementation is available, though POPs remain preferred. 2
Risks of Combined Hormonal Contraceptives
Estrogen-containing contraceptives can reduce milk production, with older studies showing lower milk volume compared to placebo (e.g., at 16 weeks: mean difference -24.00 mL, 95% CI -34.53 to -13.47). 4
Additional VTE risk factors make CHCs inadvisable at 4-6 weeks postpartum. 1, 2
Reduced milk supply can lead to earlier discontinuation of contraception and potential unintended pregnancy if supplementation is inadequate. 3
If a Woman Insists on CHCs
Wait a minimum of 6 weeks postpartum, ensure no additional VTE risk factors exist, and confirm access to supplemental milk. 1, 2
Special Population: Prior Gestational Diabetes
In women with prior gestational diabetes, particularly in Latino populations, use progestin-only oral contraceptives with caution due to a two- to threefold increase in diabetes risk. 2
Consider discussing non-hormonal alternatives in this population. 2
Clinical Algorithm for Selection
First 3 weeks postpartum: POPs only (CHCs are Category 4—unacceptable health risk). 1, 2
3 weeks to 6 months postpartum: POPs strongly preferred (CHCs are Category 3—risks usually outweigh benefits). 1, 2
After 6 months postpartum: POPs remain preferred, but CHCs may be considered if milk supply is well-established and supplementation is available. 2
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. 2
Common Pitfalls to Avoid
Do not delay contraception counseling until the 6-week postpartum visit, as many women do not return for follow-up and immediate postpartum contact provides an optimal opportunity for contraceptive initiation. 3, 8
Do not prescribe CHCs to breastfeeding women without adequate access to supplemental milk, as decreased milk volume can lead to contraceptive discontinuation and unintended pregnancy. 3
Do not assume all hormonal contraceptives affect lactation equally—the evidence clearly distinguishes between progestin-only methods (safe) and combined methods (problematic during early breastfeeding). 8, 4