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 (CDC US Medical Eligibility Criteria for Contraceptive Use) and the World Health Organization (WHO Medical Eligibility Criteria for Contraceptive Use) 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 decreased milk production from hormonal methods, despite studies not necessarily 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, 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 production.1
For more detailed information and references on specific medications, please refer to LactMed, e-lactancia, Infant Risk, or Mother to Baby.
Non-hormonal contraception methods are least likely to interfere with milk production. These include the various fertility awareness-based methods (FABMs), lactational amenorrhea method (LAM), female and male condoms, spermicide, vaginal sponge, cervical cap, diaphragm, the copper IUD, and female and male sterilization. For more information on the risk of pregnancy using these methods, please visit https://www.bedsider.org/birth-control.
Fertility Awareness Based Methods (FABM)
FABMs have limited evidence for efficacy during lactation. They are challenging to use appropriately during lactation because of altered cycling among those who have restarted ovulation. Alternative methods are preferred due to the limitations of using these methods in the postpartum period and during lactational amenorrhea.2 If an FABM is preferred by the patient, patients should speak to a professional regarding the use of the specific method during lactation.
Lactational Amenorrhea Method (LAM)
LAM is up to 98% effective with appropriate use. Safe and effective use of LAM includes3:
- Amenorrhea (no menses)
- “Full” or “near full” breastfeeding (no more than 1-2 supplemental feedings each week)
- Less than 6 months postpartum
This method is not appropriate for women who are back to work or pumping and bottle feeding. See ABM Protocol #13 more information on LAM.1
These methods are considered safe during lactation and have no impact on milk production.1 Barrier methods include:
- Diaphragms/Cervical Cap
- Vaginal Sponge
Copper Intrauterine Device (IUD)
Copper IUDs have no known impact on lactation and are generally considered safe during lactation.1
Sterilization is a safe and effective permanent form of contraception during lactation. If a lactating individual has chosen to have sterilization early postpartum, we recommend minimizing the time of separation from their infant to allow for frequent nursing, which is crucial for the establishment of milk production.1 For more information on anesthesia during lactation, please see the section on Anesthesia.
Hormonal contraception during lactation poses a theoretical risk to milk production as estrogen and progesterone can inhibit the effectiveness of prolactin at the lactocyte. Current evidence regarding the impact of hormonal contraception on milk production is considered low quality. The studies are small, they generally do not provide data on volume changes in milk production, and most often include healthy lactating women with no risk factors for low milk production, nor women in higher risk situations such as preterm or multiple births.5 Estrogen, progesterone, and testosterone hormones given before 6 weeks increase the risk of insufficient milk production as noted in the Academy of Breastfeeding Medicine (ABM) Protocol.1
Families should be counseled appropriately regarding the theoretical risks to lactation and the types, routes, and timing of placement/use of hormonal contraception should be considered as outlined by the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO).
The WHO uses the following categories6:
- Use the method in any circumstance.
- Generally use the method.
- Use of the method not usually recommended unless other, more appropriate methods are not available or acceptable.
- Method NOT to be used.
The CDC uses the following categories4:
- A condition for which there is no restriction for the use of the contraceptive method.
- A condition for which the advantages of using the method generally outweigh the theoretical or proven risks.
- A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
- A condition that represents an unacceptable health risk if the contraceptive method is used.
In both of these systems, categories 1 and 4 are considered clearly defined recommendations to safely use or to definitely not use a method. Categories 2 and 3 require clinical judgement and providers should engage patients in shared decision making around using methods in these categories. For full definitions of these scoring systems and the data behind their recommendations, please see the WHO and CDC guidelines referenced below.4,6 The following table summarizes the current WHO recommendations for commonly used contraceptive options and has been used in developing the recommendations noted below. If the CDC guidelines differ from the WHO, this has been noted in parentheses in the table.
WHO Guidelines (CDC)
|Contraception Method||<48 hours||48 hours to <4 weeks||4 weeks to <6 weeks||6 weeks to <6 months|
|Progestin-Only Pills||2||2||2 (1)||1|
|Progestin Injectables||3 (2)||3 (2)||3 (2)||1|
|Progestin Implants||2||2||2 (1)||1|
|Progestin IUD||2||3 (2)||1||1|
|Combined Hormonal Contraception||4||4||4 (3)||3 (2)|
In general, progestin-only contraceptives have a lower risk of impacting milk production compared to estrogen containing hormonal contraceptives. Recommendations from the CDC and WHO surrounding the use of progestin-only contraceptives during lactation depend on the route of administration and timing after delivery.4,6 Based on the experience of lactation medicine specialists, the effect on milk production seems less pronounced with progestin IUDs and the progestin-only pills than with the use of longer acting progestins such as injectable progestins or norgestrel implants.7
Progestin-only pills (POP) or minipills , such as the norethindrone/Ortho Micronor, are considered the safest form of hormonal birth control during lactation with regards to milk production. There is a theoretical risk to milk production as with any hormonal birth control.1 Based on the CDC and WHO recommendations, this is of the most concern during the first 4-6 weeks postpartum when POPs have a category 2 rating.1,4,6 Providers should engage lactating parents in shared decision making about the theoretical risk to milk production. There is no absolute indication to pump and dump.
Progestin Vaginal Rings
While progestin-only vaginal rings, such as Progering (available in Latin America), may theoretically impact milk production,1 there is no absolute indication to pump and dump.
Depot medroxyprogesterone (Depo-Provera) has 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 do not have adequate research to understand who is at highest risk.8 Progestin injections are category 3 per the WHO guidelines and category 2 per the CDC during the first 6 weeks postpartum.4,6 Patients should be appropriately counseled about the risk to milk production and the inability to reverse this form of contraception during shared decision making with their providers. Providers should engage lactating individuals in shared decision making about using injectable progestin contraception and alternatives are preferred for lactating individuals due to the risks to milk production. There is no absolute indication to pump and dump.
Progestin implants (etonogestrel/Implanon/Nexplanon, levonorgestrel/Jadelle) poses a risk to milk production and can inhibit secretory activation (or milk “coming in”) when placed within the first 2 days postpartum. Additionally, experts in breastfeeding medicine have noted significant decreases in milk production when placed 4-6 weeks postpartum. This negative effect on lactation is variable and we do not have adequate research to risk stratify patients.8 The WHO and CDC assign a category 2 rating to progestin implants during the early postpartum period.4,6 While providers should engage lactating parents in shared decision making about the theoretical risk to milk production, there is no absolute indication to pump and dump.
Progestin IUDs (levonorgestrel/Mirena/Skyla/Liletta) pose a theoretical risk to milk production and are safest when placed at least 4-6 weeks postpartum. At least 1 study demonstrated reduced breastfeeding among women receiving the progesterone IUD within 10 minutes after birth.9 Per the WHO and CDC guidelines, progestin IUDs are category 3 and 2 respectively during the first 4 weeks postpartum due to risks to milk production.4,6 While providers should engage lactating parents in shared decision making about the theoretical risk to milk production, there is no absolute indication to pump and dump.
Combined Hormonal Contraception (CHC)
Combined hormonal contraception (CHC) contain both estrogen and progesterone and 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.10,11 The WHO rates CHC category 4 (recommends against use) during the first 6 weeks postpartum and a category 3 after 6 weeks until at least 6 months postpartum (use of this method is not recommended unless alternatives are not available).6 The CDC is slightly more liberal about the use of combined hormonal contraception after 4 weeks, giving CHCs a category 3 rating from 4-6 weeks and category 2 rating after 6 weeks.4 Given the risks to milk production and the availability of other forms of contraception, lactating patients should be counseled on the risks of CHC to milk production and alternatives are preferred during lactation. There is no absolute indication to pump and dump.
There are many preparations of CHC tablets with varying doses of estrogen and progesterone. Estrogen containing contraceptives carry a significant risk of decreasing milk production.1,10,11 Due to the risk to milk production, alternatives are preferred during lactation. There is no absolute indication to pump and dump.
The transdermal patch/Ortho-Evra contains estrogen (ethinyl estradiol) and progestin (norelgestromin) components. Because of the estrogen component, the patch carries a risk of decreased milk production,1,10,11 so alternatives are preferred during lactation. There is no absolute indication to pump and dump.
CHC Vaginal Ring
The vaginal ring/Nuvaring contains estrogen (ethinyl estradiol) and progesterone (etonogestrel) components. Due to the estrogen component, there is a risk of decreased milk production,10,11 so alternatives are preferred during lactation. There is no absolute indication to pump and dump.
Options for emergency contraception include the copper IUD, progesterone 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 .1
See above. There is no absolute indication to pump and dump.
A recent non-inferiority trial showed the levonorgestrel IUD was non-inferior to the copper IUD for emergency contraception.12 See above. There is no absolute indication to pump and dump.
Progestin-only Tablets/Plan B
The progestin-only levonorgestrel/Plan B emergency contraceptive tablet poses a theoretical risk to milk production like other forms of hormonal contraception. There is no absolute indication to pump and dump.
Combination Estrogen/Progesterone Tablets
Combination estrogen/progesterone emergency contraceptive tablets such as Preven or Yuzpe method carry a higher risk of decreasing milk production (see above regarding estrogen and milk production), so alternatives are preferred. There is no absolute indication to pump and dump.
Ulipristal/Ella is a progesterone receptor modulator. Milk levels are low per the package insert based on the assessment of milk from 12 lactating women.13 The FDA approved labeling does not suggest withholding breastfeeding after taking ulipristal. Data is limited so alternatives are preferred. There is no absolute indication to pump and dump and providers should engage patients in shared decision making if ulipristal is used.
(1) Berens, P.; Labbok, M.; Academy of Breastfeeding Medicine. ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015. Breastfeed Med 2015, 10 (1), 3–12. https://doi.org/10.1089/bfm.2015.9999.
(2) Peragallo Urrutia, R.; Polis, C. B.; Jensen, E. T.; Greene, M. E.; Kennedy, E.; Stanford, J. B. Effectiveness of Fertility Awareness–Based Methods for Pregnancy Prevention: A Systematic Review. Obstetrics & Gynecology 2018, 132 (3), 591. https://doi.org/10.1097/AOG.0000000000002784.
(3) Calik-Ksepka, A.; Stradczuk, M.; Czarnecka, K.; Grymowicz, M.; Smolarczyk, R. Lactational Amenorrhea: Neuroendocrine Pathways Controlling Fertility and Bone Turnover. Int J Mol Sci 2022, 23 (3), 1633. https://doi.org/10.3390/ijms23031633.
(4) Curtis, K. M. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016, 65. https://doi.org/10.15585/mmwr.rr6503a1.
(5) Bryant, A. G.; Lyerly, A. D.; DeVane-Johnson, S.; Kistler, C. E.; Stuebe, A. M. Hormonal Contraception, Breastfeeding and Bedside Advocacy: The Case for Patient-Centered Care. Contraception 2019, 99 (2), 73–76. https://doi.org/10.1016/j.contraception.2018.10.011.
(6) World Health Organization. Medical Eligibility Criteria for Contraceptive Use; World Health Organization, 2015.
(7) Eglash, A.; Leeper, K. Little Green Book of Breastfeeding Management.
(8) Stuebe, A. M.; Bryant, A. G.; Lewis, R.; Muddana, A. Association of Etonogestrel-Releasing Contraceptive Implant with Reduced Weight Gain in an Exclusively Breastfed Infant: Report and Literature Review. Breastfeed Med 2016, 11, 203–206. https://doi.org/10.1089/bfm.2016.0017.
(9) Chen, B. A.; Reeves, M. F.; Creinin, M. D.; Schwarz, E. B. Postplacental or Delayed Levonorgestrel Intrauterine Device Insertion and Breast-Feeding Duration. Contraception 2011, 84 (5), 499–504. https://doi.org/10.1016/j.contraception.2011.01.022.
(10) Tepper, N. K.; Phillips, S. J.; Kapp, N.; Gaffield, M. E.; Curtis, K. M. Combined Hormonal Contraceptive Use among Breastfeeding Women: An Updated Systematic Review. Contraception 2016, 94 (3), 262–274. https://doi.org/10.1016/j.contraception.2015.05.006.
(11) Lopez, L. M.; Grey, T. W.; Stuebe, A. M.; Chen, M.; Truitt, S. T.; Gallo, M. F. Combined Hormonal versus Nonhormonal versus Progestin‐only Contraception in Lactation. Cochrane Database of Systematic Reviews 2015, No. 3. https://doi.org/10.1002/14651858.CD003988.pub2.
(12) Turok, D. K.; Gero, A.; Simmons, R. G.; Kaiser, J. E.; Stoddard, G. J.; Sexsmith, C. D.; Gawron, L. M.; Sanders, J. N. Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception. N Engl J Med 2021, 384 (4), 335–344. https://doi.org/10.1056/NEJMoa2022141.
(13) Afaxys Inc. ELLA (ulipristal acetate) tablet,for oral use Initial U.S. Approval: 2010. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=052bfe45-c485-49e5-8fc4-51990b2efba4 (accessed 2023-02-20).