Are oral contraceptives (OCs) recommended for breastfeeding mothers?

Oral Contraceptives for Breastfeeding Mothers

Progestin-only pills (POPs) are recommended and can be started immediately postpartum in breastfeeding mothers, while combined oral contraceptives containing estrogen should be avoided, particularly during the first 6 months postpartum. 1, 2

Progestin-Only Pills: The Preferred Option

Progestin-only pills are the safest oral contraceptive choice for breastfeeding women and carry no restrictions on timing of initiation. 1

Timing and Backup Contraception

• POPs can be started immediately postpartum without concern for milk production or infant safety 1, 3
• No backup contraception is needed if 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

Safety Profile

• Progestin-only methods do not adversely affect milk volume, milk composition, or cause harmful effects in infants 4, 5
• Steroids transfer into milk in very small quantities that are usually undetectable in infants and pose no risk to neonatal development 5
• Evidence consistently demonstrates no adverse effects on neonatal well-being, growth, or early development 5, 6

Combined Oral Contraceptives: Avoid During Breastfeeding

Combined hormonal contraceptives containing estrogen are contraindicated or strongly discouraged during breastfeeding, especially in the first 6 months postpartum. 1, 2

Timing Restrictions Based on Risk

• Absolutely contraindicated (U.S. MEC Category 4) in the first 3 weeks postpartum due to markedly increased venous thromboembolism risk 1, 3
• Generally should not be used (U.S. MEC Category 3) from 4 weeks to 6 months postpartum due to potential negative effects on breastfeeding performance and milk production 1, 3
• Additional VTE risk factors make combined hormonal contraceptives inadvisable at 4-6 weeks postpartum 1

Effects on Lactation

• Estrogen-containing contraceptives diminish milk production, which is the primary concern during breastfeeding 4
• Combined oral contraceptives can reduce milk volume and may lead to earlier discontinuation of breastfeeding or need for supplementation 6
• While minor reductions in initial infant growth rate may sometimes occur, no major detrimental effects on infant development have been definitively shown 5

Clinical Algorithm for Decision-Making

For Women Who Insist on Combined Hormonal Contraceptives

If a breastfeeding woman strongly prefers combined oral contraceptives despite counseling:

• Wait a minimum of 6 weeks postpartum 1
• Ensure no additional VTE risk factors are present 1
• Confirm access to supplemental milk in case of reduced milk production 1
• Counsel extensively about risks to milk supply 2

Common Pitfalls to Avoid

• Do not prescribe combined oral contraceptives before 3 weeks postpartum under any circumstances due to unacceptable VTE risk 1, 3
• Do not assume that "low-dose" combined pills are safe during early breastfeeding—all estrogen-containing formulations can reduce milk production 4
• Do not delay offering progestin-only methods due to unfounded concerns about infant hormone exposure—the evidence shows safety 5, 6

Summary of Recommendations by Timing

Immediate to 3 weeks postpartum:

• Progestin-only pills: Safe and recommended 1, 3
• Combined oral contraceptives: Absolutely contraindicated 1, 3

3 weeks to 6 months postpartum:

• Progestin-only pills: Safe and recommended 1, 3
• Combined oral contraceptives: Generally should not be used; risks usually outweigh benefits 1, 3

After 6 months postpartum:

• Progestin-only pills: Continue to be safe 1
• Combined oral contraceptives: May be considered if breastfeeding is well-established and supplementation is available, though progestin-only methods remain preferred 1