Sara Twogood, MD
As an OBGYN, I was well aware of the intense post partum changes
that I should expect from my own body. The
biggest challenge of all, and one that my medical experience didn’t prepare me
for, was the sometimes painful, emotionally turbulent, and occasionally wonderful
experience of breastfeeding. Happily, I was going to the breastfeeding support
groups at The Pump Station & Nurtury™. They provided me with a wonderful
blend of camaraderie and information. Much of that information was new to me,
but I soon came to realize that there was at least one area about which my
group-mates often had questions in which I was well versed. At almost every
class, someone would ask about contraception choices – what was the best to use
while breastfeeding? What was safe? Knowing I was an OBGYN, our group leader
would defer these questions to me. There are certainly many possible choices,
but the most controversial seems to be the questions surrounding progesterone. The
lactation consultant would inextricably tell women that it would decrease milk
supply, citing expert opinion and legitimate sources. The medical literature I
was familiar with told me that progesterone would have no effect at all on breast
feeding.
So which
one was it? Are progesterone methods of contraception friend or foe to the
breastfeeding woman?
I did a thorough medical search and found a ton of information
(some helpful, some useless). I am clearly not the only person trying to answer
this question.
Before I go through this information, let me get you up to speed
with progesterone contraception.
Progesterone
forms of contraception:
· The
progesterone only pill: AKA “mini pill”. It is a miniature version of the
combined oral contraceptive pill (our beloved “the pill”). It’s miniature
because it only contains one hormone – progesterone. The combined oral
contraceptive contains a combination of estrogen and progesterone. Everyone
agrees that the estrogen component decreases breast milk supply, so we aren’t
talking about this pill now. The other
difference is that the progesterone only pill does not have a placebo week –
you take a hormone pill every day, and your period comes when it wants to (ie
irregular bleeding is common … as it is with all of these forms with
progesterone only).
· Depo
provera injection: an injection you get every 3 months. It gets a bad rep
because it’s been linked to weight gain (not sure if it’s causal or an
association only) and depression (in a small percentage of patients only). Some
patients love it. Some hate it.
· Nexplanon:
the implant. Former incarnations are Norplant and Implanon. It’s a small rod
placed under the skin of your arm and secretes a small amount of hormone daily
over the course of 3 years. It’s one of the most effective forms of birth
control on the market today.
· The Mirena
IUD also contains progesterone. You probably recognize the name of this IUD
from commercials, although I can’t guarantee your life will be like the ads -
all flowers and sunshine - with its use.
Progesterone
types:
There are many different types of progesterone used for
contraception – names like norethindrone, levonorgestrel, norgestimate. They
vary slightly depending on the delivery method (swallowed, injected, etc), but
are sometimes lumped together for ease of analysis.
What do the
studies show?
I don’t want to bore you with the extraneous details (I bored
myself reviewing some of this information) … but here’s the gist:
Lactation is made possible, in part, because of a sudden drop in
maternal progesterone levels the first few days post partum. Addition of a
progesterone at this time may, theoretically, halt this natural process.
Current
evidence to support either argument is weak. The studies are not uniform. The
outcomes are not consistent.
· A large
international study conducted by the WHO tells us that the use of progesterone
contraception, in various forms (including the pill, the injectable, and the
implant), will not affect breast feeding performance or rate of infant growth.
· A small
cohort of women reported a significant decrease in milk production after taking
the progesterone only pill. When most of these women stopped taking the pill,
their milk supply returned.
· In a
different study with the progesterone only pill, there was no change in milk
volume in the first months after initiation. At 18 weeks of use, there was a
12% drop (compared to a 6% drop for women not using hormonal contraception).
However, supplemental feeding was the same in both groups.
· In a study
of urban women, when Depo Provera (the 3 month injectable) was given
immediately after delivery, there were no detrimental effects on duration of
lactation, frequency of lactation, or timing of introduction of formula within
the first 16 weeks post-partum.
Still
confused?
I don’t blame you. I haven’t given you an answer because there
is no straightforward answer.
My
Counseling:
I believe that large studies show us, overall, that progesterone
only contraceptives CAN be a good option. They are unlikely to have a
detrimental effect on breast feeding or infant outcomes. This is the
information your OBGYN will site. I know I have. BUT, and I urge to remember
this, some women may be sensitive to progesterone. Lactation consultants see
this sensitivity consistently and with more frequency than the literature
suggests. Although the data is unpublished and at this point anecdotal, I
believe it is enough to question progesterone only methods. Breast feeding is
hard enough as it is ... your choice of contraception should not make it
harder.
I suggest
you proceed with caution:
· Non
hormonal methods of contraception will avoid any risk to your milk supply.
· If you do
decide a progesterone form of contraception is right for you, follow these
guidelines:
o
Wait about 6 weeks after delivery before starting, so your milk
supply is established.
o
Use a rapidly reversible form, like the pill. You can stop and
reverse the effects (hopefully) if you do notice a drop in supply. With the
option of Depo Provera, if you notice a drop in your supply, you can’t reverse
the effects any faster than the 3 months it will persist. The implant and IUD
are quickly reversible, but it would be a shame (both physically and cost
effectiveness) to remove these shortly after insertion.
Get educated on all forms of contraception. Come to my class, Sex and Contraception for the Post Partum Woman July 18th at 1pm at The Pump Station-Hollywood to learn more!
I write about additional reproductive and fertility issues on
Dr. Sara Twogood’s LadyParts Blog. Visit me at LadyPartsBlog.com
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