Current research validates what many mothers have discovered on their own; some forms of birth control impact a mother’s 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 is intended 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 assure medications are compatible with breastfeeding, including hormonal contraceptives. 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 are available from Planned Parenthood.
Natural Family Planning
Periodic abstinence is a method of birth control where a man and woman avoid sex during specific periods of time in a woman’s menstrual cycle. These 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 these require awareness and evaluation of fertily 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 effective when a couple wants to avoid pregnancy and objects to the use of other methods. They do not negatively impact a mother’s ability to make milk for her baby. Between 12% to 25% of couples will get pregnant each year if they fail to use the methods correctly.
The Academy of Breastfeeding Medicine, Clinical Protocol #13, page two, Table 2 Effectiveness of Contraceptive Methods during Breastfeeding, 2005, states that yearly pregnancy rates with perfect use are:
- Calendar method: 9%
- Ovulation method 3%
- Sympto-Thermal method 2%
- Post-Ovulation method 1%
For more information, please see: A Natural Approach to Birth Control
LAM is short for Lactational Amenorrhea Method, which is a 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 menstration. Frequently nursing during the early postpartum period will offer a mother substantial protection from conceiving. If you meet the following criteria, you are at a low risk to ovulate and become pregnant while breastfeeding:
- You had no bleeding for more than two days in a row since your postpartum discharge, lochia (loh-kee-uh), has stopped
- You are breastfeeding exclusively meaning your baby receives no formula, “solid” food, or water, you are breastfeeding frequently meaning long periods of time do not occur between feedings during the night or day, and you avoid the regular use of a pacifier
- Your baby is less than 6 months old
If you meet all of these criteria, there is only a 1-2% chance of getting pregnant (another way to look at the outcome of LAM is to say that it is 98% effective).
* If you no longer meet any of the 3 criteria, you have an increased chance of ovulating and becoming pregnant. Anecdotally, some mothers have observed that intervals of five hours or so between feedings in 24 hours over a period of time seemed to increase the likelihood of the menstrual cycle returning. Lactational ammenorrhea is linked significantly to the frequency a mother nurses during the day and night. In Breastfeeding and Human Lactation, 4th edition (pg 709), author Jan Riordan talks about how there is no magic number of breastfeeds that has been identified to keep all women ovulation free. Once you no longer meet any of the 3 criteria, you are encouraged to talk to your health care provider about other methods of birth control if you do not plan on getting pregant 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 is 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 you have delivered a baby before. If you have never given birth the rates are 9-16%, if you have 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 of sperm with the active ingredient nonoxynol-9 or oxynol. Currently there is little research available about the possible impact on a mother’s milk supply, but there has been no link between a low milk supply and nonoxynol-9 to date. Spermicides used alone vary in failure rates. Used perfectly a woman has about a 15% chance of pregnancy, used improperly the rate goes up to about 29%.
The Diaphrgam and Cervical Cap both 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 delivered a baby 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 this can mean no penetration at all, vaginally, anally or orally. Outercourse is 100% effective against pregnancy when used correctly, and it does not impact 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, 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 impact 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. Medications and Mother’s Milk, by Dr. Hale, 2010 (pg 599) 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. Since some mothers have reported adverse affects 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. It is much easier to discontinue a pill if it does interfere with milk production, than it would be to have an IUD removed.
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 Clinical Protocol #13 Contraception During Breastfeeding (pg. 10) 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”
Depro Provera is administered as a shot once every three months. The hormone progestin is injected into the woman’s body, which prevents egg maturation, resulting 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. (Medications and Mothers’ Milk, pg. 638) The current recommendation is that oral progestins be administered after 6 weeks postpartum, when most mothers’ milk production is well established. Depro 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, which will take up to 12 weeks. For that reason, it is important that mothers talk to their health care provider 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. It is much easier to discontinue a pill if it does interfere with milk production, than it would be to wait for the progestin from the Depo Provera shot to leave the mother’s sytem. 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 compatible with breastfeeding. “Progestin-only contraceptives are generally preferred as they produce fewer changes in milk production compared to estrogen-containing products.” (Medications and Mothers’ Milk, pg. 391). 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. These 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 high probability of affecting milk production. An expert on the topic of medications during lactation, Dr. Hale, says “Estrogen containing contraceptives may interfere with milk production by decreasing the quality and quantity of milk production.” (Medications and Mothers’ Milk, pg 390). Mothers should be aware of the impact combination hormonal contraceptives can 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 less impact on 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 mothers due to their low cost and ease of use. There are many types and brands to choose from, with some possibly being detrimental to a woman’s ability to make milk. There are basically two types of birth control pills, a combination estrogen and progestin pill, and a progestin-only pill. The combination pill can negatively impact a woman’s milk production. There is citing of numerous 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 an elevation of up to 8% when 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. If this happens, a mother can discontinue the pill (contact health care provider), and seek help from a lactation specialist for assistance with increasing milk production.
If you are interested in learning more about how the birth control pill prevents pregnancy, you 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 pgs 1159, 1160. The impact 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. *If you need to take emergency contraception, talk to your health care provider, IBCLC, and/or call the InfantRisk Center for information about compatibility with breastfeeding in your unique situation.
The Negative Physiological Impact 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 baby’s sucking. Prolactin is secreted by the anterior pituitary gland in the brain, and it stimulates the mammary glands to produce both lacalbumin and casein. Water is attracted by the heavy concentration of proteins and follows these two solutes, it combines into a solution, making what we commonly refer to as milk. Human Physiology 11th edition by Stuart Ira Fox 2009 pg. 739 says that, “Prolactin is controlled by prolactin-inhibiting hormone (PIH), identified as dopamine.”
The secretion of PIH from the hypothalamus is governed by estrogen, this means higher levels of estrogen in the lactating mother suppresses her prolactin levels. Combination hormonal birth control methods elevate dopamine levels (PIH), which 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 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 you add estrogen into the milk making equation, you may encounter a downward spiral of prolactin levels and dwindling milk production. If a mother experiences milk production issues 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 a mother 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 assure her baby gets enough milk while doing so.
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
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