All forms of contraception during lactation are considered safe for the infant but not necessarily for milk production. The medical eligibility criteria for contraception during lactation by The Centers for Disease Control (https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html )and the World Health Organization (https://www.who.int/reproductivehealth/publications/family_planning/mec-wheel-5th/en/)
both acknowledge that the current research pertaining to the effect of contraception during lactation is low quality. The Centers for Disease Control states that there is a theoretical risk of a decreased milk production from hormonal methods, despite studies not necessary demonstrating such effect. This is because studies done on the effect of hormonal contraception during lactation don’t include individuals who are struggling with low milk production, have premature infants, have multiple infants, and/or other risk factors associated with low milk production. In addition, studies typically measure the effect on lactation by evaluating infant weight and whether the mothers were still breastfeeding, rather than assessing actual changes in milk production1.
Non-hormonal contraception methods are the safest during lactation, as they do not interfere with milk production. These include the female and male condoms, spermicide, vaginal sponge, cervical cap, diaphragm and the copper IUD. For more information on the risk of pregnancy using these methods, please visit https://www.bedsider.org/birth-control
Hormonal contraception during lactation has the risk of decreasing milk production depending on the form and when it is administered.
The progestin-only birth control tablet is considered the safest hormonal form of birth control during lactation in regard to protecting milk production.
For other hormonal contraception methods, the timing of initiation might play a role in how significantly it impacts lactation.
The progesterone IUD is safest when placed at 4-6 weeks postpartum. At least 1 study demonstrated reduced breastfeeding among women receiving the progesterone IUD within 10 minutes after birth.2
The etonogestrel implant (Nexplanon) and depot medroxyprogesterone (Depo-Provera) have been documented to prevent the milk from ‘coming in’ (secretory activation) when administered in the first 2 days postpartum. There are also cases of significant decreased production when these are administered at 4-6 weeks. This negative effect on lactation is quite variable, and thus far we don’t have adequate research to understand who is at highest risk.3
Forms of combined contraception that contain both estrogen and progesterone include the birth control tablet, patch and vaginal ring. Estrogen is much more likely to decrease milk production than progestin-only forms. Lactating individuals should be warned that they have a significant risk of decreased production whenever given a contraceptive method with estrogen.4,5
Options for emergency contraception include the copper IUD, progestin-only tablets, combination estrogen/progesterone tablets, and the progesterone receptor modulator ulipristal (Ella). The best options to protect milk production include the copper IUD or the progestin-only tablets. The combined estrogen/progesterone tablets can decrease milk production, and there is not enough information on the safety of ulipristal during lactation, in terms of exposure to the infant.6
- Berens P, Labbok M and The Academy of Breastfeeding Medicine ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015 Breastfeeding Med 10(1) 2015
- Chen BA, Reeves MF, Creinin MD, Schwarz EB. Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration Contraception 84 (2011) 499-504
- Stuebe AM, Bryand AG, Lewis R, Muddana A. Association of Etonogestrel- Releasing Contraceptive Implant with Reduced Weight Gain in an Exclusively Breastfed Infant: Report and Literature Review Breastfeeding Med 11(4) 2016 p. 203- 206
- Kapp N, Curtis KM Combined oral contraceptive use among breastfeeding women: a systematic review Contraception 82 (2010) 10-16
- Lopez LM, Grey TW, Stuebe AM et al Combined hormonal versus nonhormonal versus progestin-only contraception in lactation Cochrane Database of Systematic Reviews 2015, Issue 3
- LactMed Drugs and Lactation Database https://www.ncbi.nlm.nih.gov/books/NBK500655/, accessed Dec 19, 2021