Contraception While Breastfeeding

Breastfeeding delays but does not reliably prevent ovulation, so a method is still needed once the lactational amenorrhoea method no longer applies. Progestin-only methods, intrauterine devices and barrier methods do not reduce milk volume or harm infant growth. Oestrogen-containing methods reduce milk production and are avoided early.

Lactational amenorrhoea method. Protects reliably only while all three criteria hold: the infant is under 6 months old, the mother is amenorrhoeic, and she is fully or nearly fully breastfeeding. First-year pregnancy rate is about 2 per 100 women for 6 months of use with typical use and about 0.5 with perfect use. When any criterion fails, another method must begin the same day.

Assessment. Record infant age, feeding pattern (night feeds, supplements, expressed milk), maternal bleeding, return to work or school, maternal medicines, HIV status and thrombosis risk factors.

Transfer into breast milk. Progestins reach milk in small amounts and have no known adverse effect on infant growth or development. Copper has no systemic effect. Ethinylestradiol lowers milk volume.

Pregnancy exclusion. Fully or nearly fully breastfeeding, amenorrhoeic and under 6 months postpartum counts as reasonably certain non-pregnancy; later, a urine test is needed unless another criterion is met.

Eligibility.

• Intrauterine devices: copper category 1 within 48 hours and from 4 weeks; levonorgestrel device within 48 hours category 2 in breastfeeding women; between 48 hours and 4 weeks not done.

• Implants: category 2 under 6 weeks, category 1 from 6 weeks; may be inserted immediately postpartum.

• Progestin-only pills: category 2 immediately, category 1 from 4 weeks.

• Injectables: category 3 under 6 weeks, from 6 weeks category 1 for DMPA; start from 6 weeks.

• Combined pills: category 4 under 6 weeks, category 3 from 6 weeks to 6 months, category 2 from 6 months once the infant is weaned.

• Condoms: category 1; diaphragm and cervical cap from 6 weeks.

• Emergency contraception: levonorgestrel 1.5 mg is category 1; ulipristal 30 mg is category 2 because it passes into milk, so breastfeeding is paused for 1 week after a dose with milk expressed and discarded.

• Fertility awareness methods: unreliable until cycles are re-established.

Method comparison. Implants, intrauterine devices and DMPA need no daily action and are the usual choices. Progestin-only pills need strict timing and have a short late window.

Special groups. Women living with HIV who breastfeed on antiretroviral therapy can use all of these methods, with efavirenz and ritonavir-boosted protease inhibitors reducing pill and implant effect. Adolescent mothers benefit from immediate long-acting methods. Women with sickle cell disease can use progestin-only methods.

Regimen lines.

• Etonogestrel 68 mg rod: subdermal, any time postpartum if reasonably not pregnant; replace at 3 years; no effect on milk.

• Levonorgestrel two 75 mg rods: subdermal; replace at 5 years or 3 years by system.

• DMPA 150 mg intramuscularly every 13 weeks or 104 mg subcutaneously every 13 weeks; repeat allowed up to 4 weeks late; start from 6 weeks; backup 7 days if started after day 7 of bleeding or when amenorrhoeic outside the lactational criteria.

• Norethisterone enanthate 200 mg intramuscularly every 8 weeks; up to 2 weeks late.

• Progestin-only pill, one tablet daily without a break: traditional pill late window 3 hours, desogestrel 12 hours, drospirenone 24 hours; about 48 hours of use is needed for the cervical mucus effect; backup 2 days after a late or missed pill.

• Copper T 380A up to 12 years; levonorgestrel 52 mg device 5 years.

Switching. Move from the lactational amenorrhoea method to another method before 6 months or when a criterion fails. Move from pills to a long-acting method at any visit, with overlap of the pill until the method protects.

Follow up. Review at 6 weeks, at each immunisation visit, and at 6 months when the lactational criteria end. Reassess when the infant starts solid feeding or the mother returns to work.

Bleeding. Irregular bleeding is common with progestin methods and is not harmful. For bothersome bleeding give ibuprofen 800 mg three times daily for 5 days after excluding infection, retained products and pregnancy.

Reduced milk supply. If supply falls on a combined pill (started contrary to advice), stop it and switch to a progestin-only or non-hormonal method.

Mastitis and breast lumps. Assess any new lump; breast cancer is category 4 for hormonal methods and needs diagnosis before a hormonal method is continued.

Red flags. Leg swelling, chest pain, severe headache, jaundice, pelvic pain with amenorrhoea after the lactational criteria have ended.

Referral and escalation. Refer suspected breast cancer, thrombosis, and suspected ectopic pregnancy urgently.