Birth Control and Breastfeeding; Do they work together?

birth control and breastfeedingCurrent research validates what many mothers have discovered on their own: some forms of birth control may have a negative affect on milk production. A discussion about the side effects of specific types of birth control on lactation should begin with a brief explanation of the birth control methods. Below is an overview of birth control options in the United States.

Native Mothering recommends that you consult with your health care provider before taking medications while breastfeeding. This article’s intent is to share information and references and is not meant to be used for diagnosing or treating any medical condition. The information contained in this article and website is not meant to replace medical advice.  

Breastfeeding mothers should be encouraged to make sure that any medications they use, including hormonal contraceptives, are compatible with breastfeeding. Forms of birth control that have no noted effect on lactation are: Condoms, diaphragms, cervical caps, fertility awareness-based methods, the Paragard IUD, birth control sponges, spermicide, vasectomy, abstinence, sterilization, and outercourse. A descriptive list of the forms of birth control listed in this section is available from Planned Parenthood.

Natural Family Planning 

Periodic abstinence is a method of birth control in which the man and woman avoid sex during fertile periods of time in the woman’s menstrual cycle. These methods are sometimes referred to as Fertility Awareness-Based Methods (FABMs) or Natural Family Planning (NFP). The four methods that are most commonly used are called The Calendar method, The Ovulation method, The Sympto-Thermal method, and The Post-Ovulation method. All of them require awareness and evaluation of fertility signals but do not involve consuming prescription medication or taking herbal supplements. They do necessitate barrier protection or abstinence during “unsafe” periods (times in a woman’s cycle when she could get pregnant). FABMs are appropriate for a couple who wants to avoid pregnancy and objects to the use of other methods. They do not have a negative effect a mother’s ability to make milk for her baby. Between 12% to 25% of these couples will get pregnant each year if they fail to use the methods correctly.

The Academy of Breastfeeding Medicine states that yearly pregnancy rates with perfect use of the following methods are:

  • Calendar method: 9%
  • Ovulation method 3%
  • Sympto-Thermal method 2%
  • Post-Ovulation method 1%

(Academy of Breastfeeding Medicine, Clinical Protocol #13, p. 2, Table 2 Effectiveness of Contraceptive Methods during Breastfeeding, 2005)

For more information, please see: A Natural Approach to Birth Control

LAM is short for Lactational Amenorrhea Method, which is an NFP method that relies on the period of time in which a lactating woman’s menstrual cycle is suppressed by the hormones governing her milk production. Amenorrhea (uh-men-o-REE-uh) means absence of menstruation. Nursing frequently during the early postpartum period will offer a mother substantial protection from conceiving. If she meets the following criteria, she is unlikely to ovulate and become pregnant while breastfeeding:

  • No bleeding for more than two days in a row since postpartum discharge, lochia (loh-kee-uh), has stopped
  • Breastfeeding exclusively: baby receives no formula, “solid” food, or water, is breastfeeding frequently (meaning long periods of time do not occur between feedings during the night or day), and regular use of a pacifier is avoided
  • Baby is younger than 6 months old

If a mother meets all of these criteria*, there is only a1-2% chance of her getting pregnant. Another way to look at the outcome of LAM is to say that it is 98% effective.

* If she no longer meets any one of the three criteria, she has an increased chance of ovulating and becoming pregnant. Some mothers have observed that intervals of five hours or so between feedings in 24 hours over a period of time seem to increase the likelihood of the menstrual cycle returning. Lactational ammenorrhea is linked significantly to the frequency with which a mother nurses during the day and night. In Breastfeeding and Human Lactation, author Jan Riordan states that there is no magic number of breastfeeds that has been identified to keep all women ovulation-free. Once a mother no longer meets all of the three criteria, she is encouraged to talk to her health care provider about other methods of birth control if she does not plan on getting pregnant right away.

Barrier Methods

Condoms are a thin sheath of latex or plastic that are worn over the penis during intercourse. Condoms collect semen after ejaculation and prevent sperm from entering the vagina. With perfect use, condoms are 98% effective against pregnancy. Typical use carries a rate of 85% effective. Note that condoms are also protective against sexually transmitted diseases (STDs).

The Birth Control Sponge (brand name Today Sponge) is a small sponge that is covered in spermicide (usually nonoxynol-9) and is inserted into the vagina prior to intercourse. It blocks sperm from entering the cervix and has a variable pregnancy risk rate depending on whether or not the mother has had a baby before. If she has never given birth, the rate of pregnancy is 9-16%, but if she has given birth, the rate is 20-32%.

Spermicidal Foam, Cream, Suppositories, Jelly, and Vaginal Contraceptive Film (VCF) block access to the cervix and kill sperm by dissolving the exterior cell membrane with the active ingredient nonoxynol-9 or oxynol. Currently, there is little research available about the possible effect on a mother’s milk supply, but there has been no link observed between a low milk supply and nonoxynol-9 to date. Spermicides used alone vary in failure rates. If they are used perfectly, a woman has about a 15% chance of pregnancy; if they are used improperly, the rate goes up to about 29%. Some men and women may experience skin irritation or allergic reaction to spermicide and should avoid using it.

The Diaphrgam and Cervical Cap work by blocking the entrace to the cervix. These devices are prescribed by a physician. They must be covered with spermicidal foam or jelly and inserted into the vagina before intercourse. The diaphram is about 94% effective with perfect use and 88% effective with typical use. The cervical cap is about 86% effective for a mother who has not given birth vaginally and 71% effective for a mother who has delivered vaginally.

Other Forms of Intimacy

“Outercourse” can be defined as modified sexual contact without vaginal penetration. For some people, it can mean no penetration at all, vaginally, anally or orally. Outercourse is 100% effective against pregnancy when used correctly, and it does not affect a mother’s milk supply.

Intra-Uterine Devices

IUDs  that are available in the US are the ParaGard and the Mirena. They are inserted into the uterus and work by interfering with sperm travel and preventing the sperm from joining with the egg. The pregnancy rate with the use of an IUD is less than 1% per year. The ParaGard is a non-hormonal, copper IUD. It is good for up to 12 years, and it does not affect lactation. The Mirena IUD contains the hormone progestin which is released in small amounts to prevent pregnancy by suppressing ovulation. It is good for 5 years.  Thomas Hale, PhD (2010) says of Mirena IUDs, “The data from Levonorgestrel-only intrauterine devices suggests minimal to no effect on breastfeeding, but some caution is recommended as I’ve received three accounts of milk suppression following insertion of Mirena IUDs.” (Note: Levonorgestrel is the form of progestin used in the Mirena IUD.) There are studies that conclude that most mothers have no ill effects on their milk supply when using this product. Because some mothers have reported adverse effects on their milk production, some experts recommend that it may be beneficial to try a progestin-only birth control pill (also known as the “mini-pill”) for a couple of months before deciding on the longer-term form of birth control. The reasoning is that it is much easier to discontinue a pill if it interferes with milk production than it would be to have an IUD removed. However, it is not known whether the decrease in milk production that some women observe while using these hormones is easily-remedied or relatively permanent.

Hormone Injections, Patches, Rings, Implants, and Pills

The Academy of Breastfeeding Medicine has reported that any hormonal birth control could be viewed as possessing the potential to reduce a mother’s milk supply. In particular the ABM says that women experiencing any of the following conditions should be discouraged from using hormonal birth control while nursing:

1) existing low milk supply or history of lactation failure
2) history of breast surgery
3) multiple birth (twins, triplets)
4) preterm birth
5) compromised health of mother and/or baby

(Academy of Breastfeeding Medicine, Clinical Protocol #13 Contraception During Breastfeeding)

Depro Provera is administered as a shot once every three months. The hormone progestin is injected into the woman’s body, prevents egg maturation, and results in suppression of ovulation. The pregnancy rate is very low with this medication, only 1%. Some studies have shown that Depo Provera can inhibit a mother’s milk production if given 12-24 hours postpartum (Hale 2010). The current recommendation is that oral progestins be administered after 6 weeks postpartum, when most mothers’ milk production is well-established. Depo Provera is long-acting (3 months), and if a mother and her health care provider conclude that the medication is interfering with her milk production, the only recourse is to wait for the remainder of the medication to leave her system, up to 12 weeks. For this reason, it is important that mothers talk to their health care providers about using a method of birth control that is compatible with breastfeeding, especially during the first six weeks postpartum. As with the Mirena IUD,  some experts recommend that it may be beneficial to try a progestin-only birth control pill (also known as the “mini-pill”) for a couple of months before deciding on the longer-term form of birth control. If a mother finds she has a decrease in milk production after the injection, implementing breast compressions, frequent milk removal and standard breast milk increasing protocols can assist in improving milk production. Talk to your health care provider or lactation professional for more information. Note that because of the hormone used, the Depo Provera shot is thought to be less likely to interfere with established milk supply (after first 6 weeks and milk production is keeping up with baby’s demands) than some of the other hormonal birth control options. Interestingly, one study found that prolactin is actually increased in some mothers with the use of Depo Provera.

Implanon is a progestin-only implant that prevents pregnancy for up to 3 years. The Implant suppresses fertility by preventing ovulation and also by thickening the mucous layer in the cervix. Implanon is considered to be compatible with breastfeeding, but as with any hormonal birth control, caution should be the rule. “Progestin-only contraceptives are generally preferred as they produce fewer changes in milk production compared to estrogen-containing products.” (Hale 2010). The effectiveness of Implanon is high, with only 1% of users becoming pregnant per year.

NuvaRing is a contraceptive ring that is inserted into the vagina and worn for 3 weeks, then removed for 1 week a month (to allow for menustration). It contains a mixture of two hormones, estrogen and progestin. They work together to suppress fertility by preventing ovulation and also by thickening the mucous layer in the cervix.  Birth control that contains both progestin and estrogen has a higher probability of affecting milk production. An expert on the topic of medications during lactation, Thomas Hale, PhD, states, “Estrogen containing contraceptives may interfere with milk production by decreasing the quality and quantity of milk production.” (Hale 2010). Mothers should be aware of the effect combination hormonal contraceptives may have on milk production. NuvaRing is better than 99% effective if used perfectly. With typical use, the rate of pregnancy goes up to about 8%. These rates are similar to other forms of birth control that have a lower chance of affecting a mother’s milk supply.

Ortho Evra is the brand name for the birth control patch, combination hormonal birth control made from estrogen and progestin. A woman typically changes her patch once a week for three consecutive weeks and then abstains from reapplying the patch for one week. Like other combination birth control, it suppresses a woman’s ovulation and also thickens the cervical mucous. Because Ortho Evra contains estrogen, there is an elevated risk of reduction of milk supply for breastfeeding mothers. Resulting pregnancy rates with the use of the birth control patch are less than 1%. With imperfect use, the rate of pregnancy goes up to about 8%.

Birth Control Pills are frequently used by women due to their low cost and ease of use. There are many varieties and brands to choose from, and they may be detrimental to a woman’s ability to make milk. There are two basic types of birth control pills, a combination estrogen and progestin pill and a progestin-only pill. The combination pill is more likely to have a negative affect on a woman’s milk production. There have been many reports of women who have experienced their milk “drying up” with the use of a combination birth control pill, and there are ample studies on this topic. The Progestin-only pill is more often prescribed to breastfeeding mothers because of the lowered risk of milk production complications. With both types of pills, the risk of pregnancy is 1% with perfect use , and the rate goes up to 8% when they are used incorrectly. Most lactation experts recommend that mothers avoid any hormonal birth control containing estrogen. A “mini pill” (progestin only) is the most commonly recommended birth control pill for breastfeeding mothers. Anecdotally, some mothers have reported that they had a reduction in milk supply while taking the “mini pill” despite it being categorized as compatible with breastfeeding. A mother who has this experience can discontinue the pill under the supervision of her health care provider and seek help from a lactation specialist for assistance with increasing milk production. When birth control pills are discontinued, other forms of birth control (such as condoms) must be used in order to prevent pregnancy.

Women interested in learning more about how the birth control pill prevents pregnancy can watch this documentary made by PBS: How the Pill Works .

The Morning After Pill (brand names Plan B and Next Choice) is an emergency contraceptive pill that can be taken up to 5 days after unprotected sex in order to prevent pregnancy. It is 89% effective when started within 72 hours. These pills contain Levonorgestrel, a synthetic form of progestin. Emergency contraceptives containing only progestin are compatible with breastfeeding according to Medications and Mothers’ Milk (2010). The effect of emergency contraceptives on a mother’s milk production is supposed to be minimal in part because they are administered as a one-time dose. *A woman who needs to take emergency contraception should talk to her health care provider, IBCLC, and/or the InfantRisk Center for information about compatibility with breastfeeding in her unique situation.

The Negative Physiological Effect of Estrogen on Human Lactation

In order to cover this topic thoroughly, we are offering greater detail in this particular section. For milk production to be sustained, levels of prolactin must be able to rise and fall with the stimulation of the baby’s sucking. Prolactin is secreted by the anterior pituitary gland in the brain, and it stimulates the mammary glands to produce both lactalbumin and casein. Water is attracted by the heavy concentration of proteins and sugars, and it combines into a solution, what we commonly refer to as milk. Fox (2009) says that, “Prolactin is controlled by prolactin-inhibiting hormone (PIH), identified as dopamine.”

The secretion of PIH from the hypothalamus is governed by estrogen, so higher levels of estrogen in the lactating mother suppresses her prolactin levels. Combination hormonal birth control methods elevate dopamine levels (PIH) and reduce a mother’s ability to produce adequate levels of prolactin. The neuroendocrine reflex involved in lactation is achieved when a baby suckles. There are sensory endings on the nipple which send pulsating messages to the hypothalamus and inhibit PIH. A mother would theoretically have to follow strict milk increasing protocol to work against the effects of artificial estrogen. The protocol would require very frequent milk removal in order to elevate prolactin levels.

The basic message is that once estrogen is added into the milk-making equation, mothers may encounter a downward spiral of low prolactin and dwindling milk production. If a mother experiences milk production troubles after beginning hormonal birth control, she should be encouraged to contact an IBCLC or other lactation specialist who can offer information that will assist the mother in discussing birth control methods with her health care provider. The lactation specialist can also help her find evidence-based material to support the choice to change medications and create a care plan to help the mother increase her milk production and ensure her baby gets enough milk.

When considering safe and effective birth control methods, mothers should be encouraged to analyze how important breastfeeding is to her baby and for herself and be empowered with information that helps her make truly informed choices. There are many affordable options that do not affect a mother’s ability to make milk.

 

References:

Hale, Thomas. PhD (2010) Medications and Mothers’ Milk Amarillo, TX. Hale Publishing

Riordan, Jan and Wambach, Karen (2010) Breastfeeding and Human Lactation Sudbury, MA. Jones and Bartlett Publishers

Fox, Stuart Ira. PhD.  (2009) Human Physiology  New York, NY.  McGraw-Hill Publishers

The Academy of Breastfeeding Medicine Protocol Committee (2005) ABM Clinical Protocol #13: Contraception During Breastfeeding

Planned Parenthood

© Serena Meyer, IBCLC, ADN–All Rights Reserved

Updated 7/09/14

Share on Facebook129Share on Google+5Tweet about this on TwitterShare on LinkedIn0Pin on Pinterest6Print this pageEmail this to someone
This entry was posted in Breastfeeding, Women's Issues and tagged , . Bookmark the permalink.

5 Responses to Birth Control and Breastfeeding; Do they work together?

  1. Pingback: I’m Worried My Milk Supply is Drying Up, What Can I Do!? | Native Mothering

  2. carol bunuan red says:

    Hope you feature an article about breastfeeding twins. 🙂

  3. Pingback: Rapid Weaning for Emergency Situations | Native Mothering™

  4. Pingback: What causes low milk production? | Native Mothering™

  5. Lobsang says:

    No, regular birth cotronls pills are NOT okay if you are still breastfeeding. You don’t want to take anything that contains estrogen, as it can have a negative effect on your milk supply. The only pill considered safe for breastfeeding moms is known as the mini-pill, which is a progesterone-only pill.It is just as effective as regular birth control if taken correctly, but taken correctly with the mini-pill is a bit more specific than regular ones by that I mean that you have to take it at the same time each day. While you might be able to have a difference of a few hours with a regular pill, the mini-pill should be taken within one hour of the time you took it the day before, otherwise it will not be as effective. Some people have trouble with such a tight schedule, especially while trying to care for a 6-month-old!The mini-pill isn’t supposed to affect your milk supply and many women have success with it; however, my mother-in-law is a lactation consultant and she has had clients have an issue with the mini-pill and milk supply in some cases. You may want to talk to your doctor about all of your options, including other hormonal methods such as implants.Just personal opinion, I was completely uncomfortable taking any hormonal method of birth control while breastfeeding. There are so many things that were once considered safe during pregnancy and breastfeeding that we now know are not, so what’s to say that the mini-pill won’t be next on that list? I figure that if it’s in MY body, it could be passed to my baby, and I’d just as soon avoid that. It was a real drag, but my husband and I used condoms for the 14.5 months that our daughter nursed. I figured it was temporary and in her best interest, so it wouldn’t kill us to suck it up and use them for a bit. But again, that’s just my opinion, you have to figure out what’s right for you. Was this answer helpful?

Leave a Reply

Your email address will not be published. Required fields are marked *