From the Guidelines
Combination oral contraceptive pills (COCPs) should not be used as the first choice for contraception while breastfeeding, especially during the first 3 weeks postpartum, due to concerns about increased risk for venous thromboembolism and potential effects on breastfeeding performance 1. When considering contraception while breastfeeding, it's essential to prioritize methods that do not interfere with milk supply. Progestin-only methods like the mini-pill, implant, or hormonal IUD are preferred because estrogen-containing contraceptives may reduce milk supply, especially in the first 6 months postpartum when milk production is being established. Some key points to consider when using COCPs while breastfeeding include:
- Waiting until at least 6 weeks postpartum when milk supply is more established, and ideally until 6 months if possible, to minimize the risk of decreased milk production 1.
- Monitoring for signs of decreased milk production, such as baby seeming hungry after feeds or reduced wet diapers.
- Being aware that the estrogen in combined pills can interfere with prolactin, the hormone responsible for milk production, which is why progestin-only methods are preferred.
- Contacting a healthcare provider to discuss alternative contraceptive options that won't affect breastfeeding if a drop in milk supply is noticed after starting COCPs. It's also important to note that while some studies may suggest the use of oral contraceptives in specific patient populations, such as those with hidradenitis suppurativa 1, the primary concern when it comes to breastfeeding is minimizing the risk of decreased milk production and ensuring the best possible outcome for both mother and baby.
From the Research
Effects of Combined Oral Contraceptives (COCs) on Breastfeeding
- The use of COCs among breastfeeding women has been found to have inconsistent effects on breastfeeding performance and infant health outcomes 2, 3.
- Some studies have demonstrated greater supplementation and decreased breastfeeding continuation among COC users compared with nonusers, while others have found no effect 2, 3.
- For infant outcomes, some studies have found decreases in infant weight gain for COC users compared with nonusers when COCs were initiated at <6 weeks postpartum, while other studies have found no effect 2, 3.
Timing of Initiation of COCs
- Combined hormonal pills are not recommended prior to 6 weeks postpartum in breastfeeding women due to effects on milk production 4.
- The evidence demonstrates conflicting results on whether early initiation of COCs affects infant outcomes, but generally finds no negative impact on infant outcomes with later initiation of COCs 2.
Progestogen-Only Pills
- Progestogen-only pills do not adversely affect milk production, but the lack of data regarding possible effects on infants exposed to progestogens in breastmilk renders the timing of initiation of this method controversial 4.
- One study found that breastfeeding continuation rates at 8 weeks did not differ between users of progestin-only and combined hormonal contraceptive pills 5.
Alternative Contraceptive Methods
- Postpartum women should be counseled about the full range of safe alternative contraceptive methods, particularly during the first 6 weeks postpartum when the risk of venous thromboembolism is highest and use of estrogen may exacerbate this risk 2.
- The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective, long-term, safe, reversible contraceptive method that can be used by breastfeeding women 6.