Progesterone-Only Pills for Premenstrual Syndrome in Breastfeeding Women
Progesterone-only pills (POPs) are safe for breastfeeding women and can be started immediately postpartum, but they are not effective for treating premenstrual syndrome (PMS). 1, 2, 3
Safety of POPs During Breastfeeding
POPs are the safest oral contraceptive option for breastfeeding mothers and pose no restrictions on use:
- POPs can be initiated immediately postpartum without concerns about milk production or infant safety. 1, 4, 5
- 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, 5
- If started >21 days postpartum without return of menses, use backup contraception for 7 days. 1, 5
- POPs are classified as Category 1 (no restriction) or Category 2 (advantages generally outweigh risks) for breastfeeding women at all postpartum time points. 6
Ineffectiveness of Progesterone for PMS Treatment
The evidence consistently demonstrates that progesterone does not effectively treat PMS:
- A large randomized, placebo-controlled, double-blind crossover study of 168 women found that progesterone suppositories (400 mg and 800 mg doses) did not significantly improve premenstrual symptoms compared to placebo on any measure, including daily symptom reports, clinician evaluation, or patient global reports. 2
- A Cochrane systematic review concluded that trials did not show progesterone is an effective treatment for PMS, nor that it is not—the evidence is simply insufficient and of poor quality. 3
- No symptom cluster or individual PMS symptom differed significantly between progesterone and placebo treatment. 2
Clinical Implications
For a breastfeeding woman seeking both contraception and PMS relief:
- Use POPs for contraception without hesitation, as they are safe and effective for breastfeeding mothers. 1, 4, 5
- Do not prescribe POPs with the expectation of PMS symptom improvement, as progesterone has not demonstrated efficacy for this indication. 2, 3
- Consider evidence-based PMS treatments separately: serotonergic antidepressants (SSRIs) have the strongest evidence for PMS symptom reduction, followed by calcium supplements, Vitex agnus castus (chasteberry), and cognitive-behavioral therapies. 7
- Some oral contraceptives containing both estrogen and progestin have demonstrated efficacy for PMS, but combined hormonal contraceptives should be avoided during breastfeeding, particularly in the first 6 months postpartum (Category 3-4 depending on timing and VTE risk factors). 1, 4, 5
Important Caveats
- While progesterone theory proposes that PMS results from enhanced progesterone sensitivity following ovulation, treatment with exogenous progesterone has failed to demonstrate clinical benefit. 8, 3
- The lack of efficacy applies to both oral and vaginally absorbed progesterone formulations. 3
- For women with prior gestational diabetes, particularly in Latino populations, use POPs with caution during breastfeeding due to a two- to threefold increase in diabetes risk. 1