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REVIEW

CURRENT
OPINION Lactation and contraception
Neha R. Bhardwaj and Eve Espey

Purpose of review
This review examines evidence relevant to the effect of hormonal contraception on breastfeeding; and
compares global and US recommendations for contraceptive initiation and use. Breastfeeding and use of
postpartum contraception have high public health priority, making research in this area critical for
optimizing guidance.
Recent findings
High-quality evidence remains limited with only a small number of well conducted randomized controlled
trials of hormonal methods and breastfeeding/neonatal growth outcomes. More evidence supports early
initiation of progestin-only methods. Evidence on early initiation of combination hormonal methods is
sparse.
Summary
The WHO Medical Eligibility Criteria (MEC) differs from that of the US MEC. Generally, the WHO MEC is
more restrictive, reflecting the potential greater impact on maternal child health if there is a negative impact
from hormonal contraception on breastfeeding. Only well conducted clinical trials will further elucidate
such an impact.
Video abstract: http://links.lww.com/COG/A15.
Keywords
breastfeeding, hormonal contraception, lactation, long-acting reversible contraceptives, postpartum

INTRODUCTION about the effect of hormonal contraception on lac-

Few postpartum health issues are as controversial, or
raise as much emotion, as that of lactation and
initiation of hormonal contraception. Caregivers
may become polarized by their beliefs that hormo-
nal contraception has a negative impact on breast-
feeding. A major reason for the controversy is the
lack of high-quality data on the impact of hormonal
contraception on a number of breastfeeding out-
come measures.
The importance of both contraception and
breastfeeding is undisputed. The WHO and Centers
for Disease Control and Prevention (CDC) recom-
mend exclusive breastfeeding until 6 months, and
continuation of breastfeeding through two years
based on good quality evidence that breastfeeding
reduces infant mortality and prevents acute and
chronic disease in both the infant and mother
[1–3]. Similarly, health benefits of contraception
to avoid the negative effects of unintended preg-
nancy and short birth interval are broadly appreci-
ated [4]. Given the widespread practice of both
hormonal contraceptive use and breastfeeding,
understanding the relationship between the two is
of paramount importance. This article reviews the
physiology of lactogenesis and current knowledge
tation as well as guidelines for use of these methods
by postpartum women.
LACTOGENESIS
The physiology of lactation has fascinated since
ancient times; Hippocrates hypothesized a diverting
vessel from the mother’s uterus to her breast, allow-
ing for menstrual blood to nourish her child via
breast milk [5,6]. Lactogenesis begins in midpreg-
nancy and results in milk secretion.
(1) Stage I lactogenesis spans midpregnancy to the
initial postpartum period and is characterized
by secretory differentiation of mammary glands
[6,7] through production of colostrum [8].
Department of Obstetrics and Gynecology, University of New Mexico,
Albuquerque, New Mexico, USA
Correspondence to Neha R. Bhardwaj, MD, University of New Mexico,
2211 Lomas Blvd NE, Albuquerque, NM 87131, USA.
E-mail: nbhardwaj@salud.unm.edu
Curr Opin Obstet Gynecol 2015, 27:000–000
DOI:10.1097/GCO.0000000000000216

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KEY POINTS

A large unmet need for postpartum contraception
exists, and filling this need may help decrease rapid
repeat pregnancy and unintended pregnancy.

Progestin-only methods of contraception likely have a
minimal impact on breastfeeding.

There is insufficient evidence examining the possible
effects of hormonal contraception on breastfeeding;
additional research is needed.

Women should be provided with additional lactation
support in the postpartum period.
During stage I, serum progesterone and prolac-
tin increase.
(2) Stage II lactogenesis occurs from postpartum
days 2–5 after a sharp decline in serum pro-
gesterone. Secretory activation and onset of
milk secretion characterize stage II lactogenesis
[6,7], culminating in production of copious ma-
ture milk [8].
While numerous hormonal changes occur
during the immediate postpartum period, progester-
one withdrawal is the likely trigger for production of
mature milk [7,9,10]. During pregnancy, high-levels
of estrogen and progesterone inhibit lactation from
occurring, despite high-circulating levels of prolac-
tin. Delivery of the placenta, the primary producer
of progesterone, results in a sharp drop in progester-
one and serves as the trigger for secretory activation.
Plasma progesterone levels fall to follicular phase
levels by postpartum day 2–3 [9]. Lactation depends
on withdrawal of steroid hormones, thus the con-
cern that initiation of hormonal contraceptives
could have a negative impact on lactogenesis and
lactation.
Nonbiological factors may be as important or
more important for lactogenesis. Numerous new-
born reflexes, such as rooting, sucking, and swallow-
ing are key to the establishment of lactation.
Suckling also stimulates prolactin secretion. The
health status of the mother, birth interval, fre-
quency and intensity of suckling, early separation
of the mother and infant and cultural and socio-
economic factors and pressures also impact lacto-
genesis [8,11–13].
STEROID TRANSFER
Steroids within hormonal contraception are trans-
ferred from the mother to her newborn via breast
milk. There is a theoretical risk of adverse outcomes
2 www.co-obgyn.com
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for the neonatal liver, brain, and sex organs from
exposure to exogenous steroids. The amount of
hormone transferred appears to be small and the
few studies that have examined effects of transferred
hormones show no adverse newborn outcomes.
In one of the largest and longest studies, 48
breast-fed children whose mothers began hormonal
contraception 2 months postpartum and matched
controls whose mothers used nonhormonal contra-
ception were followed until age eight [14]. No differ-
ences were found in serious illnesses, need for
special tutoring in school, hyperbilirubinemia,
and height or weight [14]. Another study showed
no differences between male infant follicle stimulat-
ing hormone, luteinizing hormone, and testoster-
one levels in mothers who began levonorgestrel
(LNG) oral pills or Norplant 4–15 weeks postpartum
as compared to controls [15].
The amount of hormone transferred depends on
the hormone type and dose and the delivery system.
For oral contraceptives, the percentage of hormone
transferred to the newborn compared with the dose
administered to the mother is <1% for ethinyl
estradiol, 2.6–3.7% for etonogestrel, and 2.8% for
LNG [16–18], or approximately one pill per 4 years
of full lactation [19,20]. In examining a 30 mg LNG
intrauterine device (IUD), 0.1% of a daily dose was
transferred to the infant via breast milk [21].
Although depot medroxyprogesterone acetate
(DMPA) is found in breast milk at the same levels
as maternal blood, male infants of lactating mothers
receiving DMPA for contraception on postpartum
day 41–43 showed no changes in hormone profiles
as compared to controls [16,22].
The amount of hormone transferred is similar
between progestin-only pills (POPs) and the contra-
ceptive implant, and no differences in psychomotor
development were noted between the implant and a
nonhormonal IUD after 3 years of use [23,24].
Although large studies with follow-up are lacking,
the small amount of steroid transfer is not con-
sidered a contraindication for use of hormonal con-
traceptives in lactating women.
GUIDELINES FOR USE OF HORMONAL
CONTRACEPTIVES IN POSTPARTUM
BREASTFEEDING WOMEN
Recommendations for hormonal contraceptive
method used by postpartum breastfeeding women
are informed by systematic reviews of the evidence
and published by the WHO as the Medical Eligibility
Criteria (WHO MEC). The USA adapted the guidance
as the CDC MEC. Four categories of recommen-
dations guide decision-making for both the WHO
MEC and the US MEC (Table 1 [3,25,26]). The WHO
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Lactation and contraception Bhardwaj and Espey

Table 1. Categories of recommendations for women’s use of contraceptives [3,25,26]

Category 1 Category 2 Category 3 Category 4

WHO-MEC A condition for which there is
no restriction for the use of
the contraceptive method
US-MEC No restriction (method can
be used)
A condition where the
advantages of using the
method generally outweigh
the theoretical or proven
risks
Advantages generally
outweigh theoretical or
proven risks
A condition where the
theoretical or proven risks
usually outweigh the
advantages of using the
method
Theoretical or proven risks
usually outweigh the
advantages
A condition which represents
an unacceptable health risk
if the contraceptive method
is used
Unacceptable health risks
(method not to be used)

Source: World Health Organization, Medical Eligibility Criteria for Contraceptive Use, 4th edition and 5th edition Executive Summary. Geneva, Switzerland:
World Health Organization; 2010 and 2014. http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf?ua¼1 and http://apps.who.int/iris/
bitstream/10665/172915/1/WHO_RHR_15.07_eng.pdf?ua¼1&ua¼1. CDC. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR 2010;59
(No. RR-4); 1–86. CDC. U.S. medical eligibility criteria for contraceptive use, 2011. MMWR 2011;60 (No. 26); 878–883.

and USA both make recommendations for post- Progestin-only pills

partum breastfeeding women with respect to hor-
monal contraception (Table 2 [3,25,26]).
HORMONAL CONTRACEPTIVE METHODS
Review of hormonal contraceptive methods is div-
ided into six sections: POPs, DMPA, etonogestrel
contraceptive implant, LNG IUD, progesterone vag-
inal ring, and combined hormonal contraceptives
(CHC).
The effect of POPs on lactation is relatively better
studied than that of other hormonal contraceptives,
although randomized controlled trials are few. A
number of cohort and nonrandomized studies
suggest that women using POPs breastfeed for as
long with no difference in supplementation as
women using nonhormonal contraception. In two
nonrandomized studies comparing women using
POPs (LNG and norgestrel) with women using non-
hormonal contraceptives [27,28], those in the

Table 2. WHO and US Medical Eligibility Criteria for use of hormonal contraceptives in postpartum breastfeeding women
[3,25,26]
Combined hormonal Progestogen- Progestin-only Levonorgestrel Copper
Time contraceptives only pills injectables Implants IUD IUD

WHO-MEC <48 h 4 2 3 2 2 1
48 h to <4 weeks 4 2 3 2 3 2
4 weeks to <6 weeks 4 2 3 2 1 1
6 weeks to <6 months 3 1 1 1 1 1
6 months 2 1 1 1 1 1
US-MEC <10 min of placental NA NA NA NA 2 1
delivery
10 min to <4 weeks of NA NA NA NA 2 2
placental delivery
4 weeks NA NA NA NA 1 1
<21 days 4 1 1 1 NA NA
21–42 days with other 3 1 1 1 NA NA
VTE risk factors
21–42 days without other 2 1 1 1 NA NA
VTE risk factors
>42 days 1 1 1 1 NA NA

Source: World Health Organization, Medical Eligibility Criteria for Contraceptive Use, 4th edition and 5th edition Executive Summary. Geneva, Switzerland:
World Health Organization; 2010 and 2014. http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf?ua ¼ 1 and http://apps.who.int/iris/
bitstream/10665/172915/1/WHO_RHR_15.07_eng.pdf?ua ¼ 1&ua ¼ 1. CDC. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR 2010;59
(No. RR-4); 1–86. CDC. U.S. medical eligibility criteria for contraceptive use, 2011. MMWR 2011;60 (No. 26); 878–883. IUD, intrauterine device; MEC,
medical eligibility criteria; VTE, venous thromboembolism.

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nonhormone group were more likely to supplement
nutrition or perceive decreases in milk production.
One study found that women using desogestrel
POPs breastfed longer than women using a copper
IUD [18]. In a large prospective study conducted
across five countries, no difference was found in
breastfeeding performance among women initiat-
ing POPs or nonhormonal methods [29,30]. In
Halderman and Nelson’s study [31] of early initiation
of POPs before hospital discharge, no difference was
found between POP users and nonhormone users in
breastfeeding initiation or outcomes after 6 weeks. In
another study where POPs were initiated at 57 days
postpartum, no difference was noted in mean and
total breastfeeding time as compared to nonhormo-
nal contraceptive method users [32].
In the previously mentioned large prospective
five-country study, women were prospectively fol-
lowed after choosing a contraceptive method of
their choice [29,30]. Method choice included LNG
0.0375 mg POPs, DMPA, norethisterone enanthate
(NET-EN), LNG subdermal implant, nonhormonal
methods (IUDs), barrier methods, or sterilization. Of
the 2466 women participating, 475 chose POPs that
were initiated 6 weeks postpartum. No difference
was noted between contraceptive groups in breast-
feeding duration or number of feeds per hour.
Additionally, numerous prospective nonrando-
mized studies show no difference in infant weight
when comparing POP users to nonhormonal contra-
ceptive method users [18,27,29,30,32,33]. The larg-
est study across five countries shows no difference
between POP users and nonhormonal contracep-
tion users in infant growth and development
[29,30]. In a similar study, no difference was found
in infant growth parameters at 9 months, even when
POPs were initiated at 1 week postpartum [27]. A
recent systematic review of progestogen-only con-
traceptive used among breastfeeding women con-
cluded that while studies investigating this topic are
fair or poor in quality, progestogen-only methods
do not reduce the ability to successfully breastfeed
or have a negative impact on infant growth or
development during the first year of life [34].
Depot medroxyprogesterone acetate
DMPA is a safe, highly effective long-acting proges-
tin-only contraceptive injection. In recent years, its
use has increased: 4.5% of US women reported ever
use in 1995 compared with 23% in 2006–2010 [35].
Although few randomized-controlled trials
evaluate the effect of DMPA on breastfeeding out-
comes, most suggest that DMPA does not appear to
decrease duration of breastfeeding. One double-
blind trial evaluated the effects of a NET-EN
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injection on postnatal depression, but also measured
breastfeeding duration. No difference was found
between the placebo and NET-EN groups for number
of women breastfeeding at day 1, 6, and 12 weeks, or
number of women reporting ‘not enough milk’ [36].
In a cohort study, women who received DMPA had
lower pregnancy rates and were more likely to breast-
feed for over 20 months than women on nonhormo-
nal methods [37]. In a retrospective cohort study,
women using DMPA or nonhormonal contraception
were more likely to breastfeed longer than those not
using contraception or CHC [38].
In several nonrandomized trials, early initiation
of DMPA – prior to hospital discharge, within 48 h
of delivery, or immediately postpartum – does not
appear to affect breastfeeding continuation or
duration, supplementation, or perception of insuf-
ficient milk production [31,36,39,40].
Among a cohort study with almost five years of
follow-up, children of mothers using DMPA as com-
pared to those using nonhormonal methods showed
no differences in growth and development or health
status [41]. Of note, a common cause of breastfeed-
ing cessation was a new pregnancy, highlighting the
importance of contraceptive efficacy when consid-
ering the potentially small changes in breast milk
volume that DMPA may or may not be associated
with [38].
Etonogestrel contraceptive implant
The etonogestrel contraceptive implant offers
highly efficacious long-acting reversible contracep-
tion. Although it is a newer form of contraception, a
few fair and good quality studies examine the
implant and its possible effects on breastfeeding.
A prospective cohort study compared 38 women
choosing a nonhormonal IUD and 48 choosing the
etonogestrel implant initiated at 28–56 days post-
partum [42]. No difference was noted between
groups in breast milk volume, infant weight or milk
composition. Furthermore, infants whose mothers
used the implant tended to have a higher rate of
growth in body length. A subsequent prospective
cohort study showed no difference in growth
parameters or psychomotor development among
infants whose mothers initiated the nonhormonal
IUD or etonogestrel implant at 28–56 days postpar-
tum [24].
As the immediate postpartum period is an
opportune time to initiate contraception, a pilot
study examined the safety of immediate postpartum
insertion of the etonogestrel implant [43]. Forty
women were randomized to implant insertion
within 24–48 h postpartum or DMPA initiated
6 weeks postpartum. Over the 12-week follow-up,
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no difference was noted in infant weight gain.
Almost half of women initiated sexual intercourse
prior to 42 days postpartum, emphasizing the
importance of early postpartum contraception. A
subsequent randomized controlled noninferiority
trial evaluated lactogenesis among women who
initiated the etonogestrel implant 1–3 days post-
partum compared with 4–8 weeks postpartum [44].
Early initiation was noninferior to delayed insertion
for lactation failure and time to lactogenesis stage II.
No difference was noted in mean milk creamatocrit
values between the two groups.
Current evidence suggests that the etonogestrel
implant has no effect on breast milk amount or
composition or infant growth and development.
Although data remain limited, early initiation
appears acceptable.
Levonorgestrel intrauterine device
In a single randomized controlled trial examining
the effect of IUDs initiated at 6–8 weeks postpartum
on breastfeeding outcomes, women in the LNG
intrauterine system group (n ¼ 163) were similar to
women in the copper IUD group (n ¼ 157) in breast-
feeding duration and infant growth [45].
A secondary analysis of a small randomized trial
of immediate (n ¼ 27) vs. delayed (n ¼ 21) IUD place-
ment showed no difference at 6–8 weeks and
3 months of patient reported breastfeeding; how-
ever, more women in the delayed placement group
reported they continued to breastfeed at 6 months
[10].
As with all hormonal methods, women should
be counseled regarding the theoretical risk of
reduced breast milk production. Overall current
studies have not shown a negative effect on breast-
feeding with immediate postpartum placement of a
hormonal IUD. In women who receive immediate
postpartum hormonal contraception and have
difficulty with lactogenesis, removal of the implant
or LNG intrauterine system may be considered
although other forms of breastfeeding support
should also be considered first line.
Progesterone vaginal ring
The progesterone vaginal ring (PVR) is a new form
of contraception currently only available in Latin
America and whose target market is breastfeeding
women. Currently in its infancy, the potential impact
of the PVR is large given its effectiveness and that
it is woman controlled. PVR releases an average of
10 mg/day of progesterone and is used continuously
over a 90-day period [46]. In preliminary studies, PVR
is initiated on postpartum day 29–60.
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Lactation and contraception Bhardwaj and Espey
In six cohort studies, the PVR and copper IUD
appear to have similar pregnancy rates of 1.5% at
12 months [32,47–52]. Compared with non-
hormone IUD users, PVR users had equal numbers
of breastfeeding episodes per 24 h period and equal
lactation performance at 1 year postpartum
[48,50,51]. In the majority of cohort studies, no
differences in infant weight were noted between
PVR and nonhormonal IUD users at 12 months
[48–52]. However, studies suggest that women
may be less satisfied with the PVR than with the
copper IUD since more discontinued the PVR than
the IUD, citing ring use-related problems and
vaginal problems [48–50].
The PVR is a new contraceptive method and is
not included on the CDC or WHO medical eligi-
bility contraceptive guidelines. A recent systematic
review concludes that although current evidence is
poor to fair, the PVR does not appear to affect
breastfeeding performance or infant weight gain
&
in the first year [53 ].
Combined hormonal contraceptives
The effect of combined – estrogen and progestin
containing – hormonal contraceptives, on lactation
is particularly important because they are used so
commonly. Worldwide, the ‘pill’ is the third most
common method, used by 9% of reproductive-aged,
married, or cohabiting women and is the second
most common method in the USA, used by 16% of
women [35,54]. The pill also has the widest geo-
graphic distribution of any contraceptive method
and is available over the counter in many countries
[55].
Few high-quality studies have examined the
relationship between CHC use and breastfeeding
outcomes. A recently updated rigorous systematic
&
review by Tepper et al. [56 ] includes 13 studies, all
reporting on combined oral contraceptives (COCs)
examining two questions: does initiation of COCs
by breastfeeding women have worse breastfeeding/
infant outcomes as compared to nonhormonal/no
method use; and does initiation of COCs before
6 weeks vs. after 6 weeks postpartum have negative
effects on breastfeeding/infant outcomes.
Six studies examined the impact of COCs
initiated prior to 6 weeks on breastfeeding and infant
outcomes including duration of breastfeeding,
supplementation/time to supplementation, exclu-
sive breastfeeding, and infant weight and length.
Five of six studies were published prior to 1985; four
of six were considered to be methodologically of poor
quality and the other two of fair quality. The only
recent study, published in 2012, provided indirect
evidence as it compared breastfeeding/infant
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outcomes among women who initiated COCs vs.
women who initiated progestin-only pills at 2 weeks
postpartum. Although this study found no differ-
ences in breastfeeding continuation or infant growth
between the groups, it had small numbers, short
follow-up of infant outcomes, and over 20% loss to
follow-up in both groups.
Five studies examined the impact of COCs
initiated after 6 weeks on breastfeeding outcomes.
Four of the five were published prior to 1990 and
were of fair quality at best. The only recent study,
published in 2013, is a prospective cohort study of
40 women who chose one of four contraceptive
methods. No major differences in breastfeeding or
infant growth outcomes were seen between the
groups, but small numbers and the nonrandomized
design limited this study.
Overall, due to poor methodology, research
examining the possible effects of CHC on breast-
feeding is highly limited. All but two of the studies
are old, conducted at a time when standards for
study design were considerably less rigorous than
those for today’s trials. The authors concluded that
fair to poor quality data were conflicting on whether
early or late COC initiation has a negative impact on
breastfeeding. Although the authors considered
these data to be conflicting on impact of early
COC initiation on infant growth, they concluded
that late (>6 weeks) initiation of COCs did not
appear to have a negative impact on infant growth.
DIFFERENCES BETWEEN THE WHO AND
US MEDICAL ELIGIBILITY CRITERIA
RECOMMENDATIONS
WHO and US MEC recommendations differ widely
with respect to use of hormonal contraceptives in
breastfeeding women. These differences may reflect
the potential differential impact on maternal–child
health between developing countries and the USA.
Although the majority of data presented for most
hormonal methods suggest no or minimal effect on
breastfeeding performance and neonatal growth
parameters, the quality and quantity of the data
remain limited. If there were even a small negative
impact on breastfeeding performance for women in
developing countries, substantial differences in neo-
natal and maternal morbidity and mortality could
result. The two contraceptives with the largest differ-
ence in recommendations are CHC and DMPA. For
CHC, the US MEC gives a Category 1 for all women
without contraindications after 42 days postpartum
and the WHO MEC gives a Category 3 until 6 months
postpartum. For DMPA, the US MEC gives a Category
1 for both early and later initiation, whereas the
WHO MEC gives a Category 3 until 6 weeks.
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CONCLUSION
Postpartum contraception is increasingly recognized
for its role in reducing rapid repeat pregnancy and
unintended pregnancy; a large unmet need for post-
partum contraception exists globally. Evidence has
yielded mixed results on the impact of hormonal
contraception on breastfeeding, but the majority
supports minimal impact of progestin-only methods
and less conclusive effect for combined estrogen–
progestin methods. Although timing of initiation
of hormonal methods is controversial, with advo-
cates lining up for early vs. delayed, other factors
may have a profound impact on breastfeeding.
There is good evidence that additional lactation
support is effective in increasing the duration of
breastfeeding [57]. Best practices include face-to-
face support, ongoing scheduled visits and support
that is sensitive to the needs of the individual
woman. The Baby Friendly Hospital Initiative, a
comprehensive program and certification that
includes training of providers and staff in active
support of breastfeeding, provides a high standard
of support for breastfeeding women.
Given the major public health impact of breast-
feeding and use of hormonal contraception, more
studies are urgently needed to elucidate the effect, if
any, of hormonal contraception on breastfeeding
performance. Only high-quality evidence can pro-
vide best guidance to postpartum women to opti-
mize their own and their families’ health as they
make important contraceptive choices.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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