Sunday, July 13, 2014

Breastfeeding and Contraception – The Progesterone Controversy

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

Thursday, July 10, 2014

News from The Pump Station & Nurtury

Hello Pump Station & Nurtury™ Friends & Families,

We have some exciting news to share with our great Moms and Dads in the Conejo Valley and across Los Angeles. Over the years, we have expanded from our flagship Santa Monica location into Hollywood and then the Conejo Valley so we could support more new moms with our world-class educational programs and lactation support, and maybe even sell a cute onesie along the way. We're more motivated than ever to continue our mission, and we've been working hard to figure out the best way to do it.

As part of our planning, we've been listening to what you've been saying - which is that new moms want more of what we have to offer, closer to you. So we're excited to announce that over the next year we'll be opening up several new classroom locations across the Conejo and San Fernando Valleys, as well as in the South Bay and Pasadena areas, along with local lactation support services.

As you know, we're a small, family-owned business, and while we've enjoyed some success thanks to your support over the years, we can't open up and operate stores all over Los Angeles - it's just too expensive. So we're rethinking how we do things, and one of the important issues we've been looking at is our Westlake Village store. As some of you may have heard, our lease at that location is up at the end of the summer. We have decided to close that location in August, but we're not going anywhere! We are finalizing partnerships with other great family-oriented businesses in the area to continue to offer our parenting support classes, and we will still be there to help new moms with our breastfeeding support services. We should be able to announce these within the next couple of weeks - we're just letting you know what's going on since the word was starting to leak out and we didn't want you to be concerned.

So...we're still offering the same great classes, and consultations plus our breastfeeding support groups, with the same great teachers and nurses in the Conejo Valley. We'll just be doing it at more places. For anyone who is currently enrolled in any of our classes, we're continuing them as before. If for some reason our new locations don't work for you, we'll happily refund your remaining session balance once the move takes place, but we hope you continue to help us help you with your little ones.

We have a lot more to talk about in the next few months, including new customer-service-friendly systems and a completely revamped website on top of our new classes and locations. If you have any questions please don't hesitate to ask our wonderful staff and they will do their best to address your concerns.

Thanks for all your support; we hope you have a wonderful summer!

Cheryl Petran
CEO of The Pump Station & Nurtury™