What medication and dosing is recommended to stop lactation in a postpartum woman, including alternatives and contraindications?

Medication to Stop Breastfeeding

Cabergoline 1 mg as a single oral dose is the recommended first-line medication for lactation suppression, achieving complete inhibition in 90% of women with superior tolerability compared to alternatives. 1, 2

Recommended Medication and Dosing

Cabergoline (First-Line)

• Standard dose: 1 mg orally as a single dose within 24 hours after delivery 2
• Alternative regimen: 0.25 mg twice daily for 2 days (total 1 mg) to minimize adverse effects while maintaining efficacy 3
• Lower doses (0.5-0.75 mg) show reduced efficacy: 45% and 62.5% complete inhibition respectively, compared to 90% with 1 mg 2
• Mechanism: Long-acting dopamine D2 receptor agonist that directly inhibits prolactin secretion from pituitary lactotrophs 4
• Time to effect: Lactation cessation typically occurs within 0-1 day 1

Bromocriptine (Alternative)

• Dose: 2.5 mg orally twice daily for 14 days 5, 6
• Efficacy: Significantly reduces lactation compared to no treatment (RR 0.36,95% CI 0.24-0.54) 6
• Limitations: Higher incidence of rebound symptoms, nausea, vomiting, and requires twice-daily dosing for 2 weeks compared to single-dose cabergoline 5, 3

Comparative Effectiveness

Cabergoline demonstrates superior efficacy and tolerability over bromocriptine with significantly fewer rebound symptoms and adverse effects while requiring only once or twice weekly dosing versus twice-daily bromocriptine 5, 3

Contraindications and Safety Concerns

Absolute Contraindications

• Uncontrolled hypertension - both bromocriptine and cabergoline are contraindicated 7
• Hypersensitivity to ergot alkaloids 7
• History of coronary artery disease or severe cardiovascular conditions in the postpartum period unless medically necessary 7

Critical Safety Warnings for Bromocriptine

• Serious cardiovascular events: Hypertension, myocardial infarction, seizures, and stroke have been reported in postpartum women, often developing in the second week of therapy 7
• Warning signs requiring immediate discontinuation: Severe progressive headache (with or without visual disturbance), hypertension, or CNS toxicity 7
• Mandatory thromboprophylaxis: If bromocriptine is used, it must be accompanied by prophylactic or therapeutic anticoagulation 8
• Blood pressure monitoring: Required during the first weeks of therapy 7

Common Adverse Effects (Generally Self-Limited)

• Dizziness, headache, and nausea are the most commonly reported side effects with cabergoline 1
• These effects are typically mild and transient 2

Special Clinical Situations

Peripartum Cardiomyopathy

Bromocriptine can be considered postpartum to stop lactation as it may enhance cardiac function recovery in peripartum cardiomyopathy, but must be accompanied by prophylactic or therapeutic anticoagulation. 8

When Lactation Suppression is Not Recommended

• The FDA does not recommend bromocriptine for routine prevention of physiological lactation due to cardiovascular risks 7
• Current evidence suggests cabergoline should be reserved for women with clear medical or personal indications for lactation suppression rather than routine use 1, 6

Clinical Algorithm for Medication Selection

1. Assess for contraindications: Screen for uncontrolled hypertension, cardiovascular disease, and ergot sensitivity 7

2. First-line choice: Cabergoline 1 mg single dose (or 0.25 mg twice daily for 2 days) within 24 hours of delivery 2, 3

3. If cabergoline unavailable or contraindicated: Bromocriptine 2.5 mg twice daily for 14 days with mandatory blood pressure monitoring and consideration of thromboprophylaxis 7, 5

4. Monitor for treatment failure: If symptoms persist at day 14, an additional 1 mg dose of cabergoline may be administered 2

Key Clinical Pitfalls

• Avoid bromocriptine in women with hypertensive disorders of pregnancy (preeclampsia, eclampsia, pregnancy-induced hypertension) unless medically essential 7
• Do not use concomitantly with other ergot alkaloids due to potential interactions 7
• Warn patients about sudden sleep onset and somnolence - advise against driving or operating machinery during treatment 7
• Insufficient evidence exists for non-pharmacologic methods - no trials demonstrate their effectiveness compared to no treatment 6