Is it safe for nursing moms to use a hormonal method of birth control?
Contraceptives that contain only progestin are compatible with breastfeeding and are a safe option, assuming there's no medical reason you can't use this hormone.
On the other hand, combined contraceptives – ones that contain both estrogen and progestin – aren't a good choice for nursing mothers, particularly in the first six months, because they may cause you to produce less milk. This applies to all methods that contain estrogen and progestin, such as the combined birth control pill, the patch (Ortho Evra), and the vaginal ring (NuvaRing).
What are my choices in progestin-only contraceptives (POCs)?
If you live in the United States, your progestin-only contraceptive options include pills (also known as the minipill), injectable progestin, birth control implants, and an intrauterine device (IUD).
Progestin-only vaginal rings can also provide contraception, but this method isn't available in the United States.
Birth control pills (the "minipill")
The progestin-only birth control pill – sometimes called the minipill because it contains only a very low dose of one hormone – is a good contraceptive choice for some nursing mothers. The formulations currently on the market in the United States work primarily by thickening cervical mucus so sperm can't get through. They also thin the lining of the uterus and sometimes suppress ovulation.
Because you're less fertile when you're breastfeeding, particularly in the first six months, if taken exactly as instructed the minipill is nearly 100 percent effective in combination with exclusive nursing. (In women who aren't breastfeeding, the minipill's failure rate is estimated to be only 0.5 percent with "perfect use" – taking the pill consistently and correctly. Among "typical users" it's about 5 percent higher.)
For the minipill to be effective, you have to take the pill at nearly the same time every day. In fact, if you're just three hours late, you must use backup contraception or abstain from sex for the next two days.
For some mothers with a new baby, remembering to take a pill at the same time each day seems like an impossible task. If you're in this category, you might consider injectable progestin, implants, or an IUD.
You may have heard about a newer progestin-only pill that's more effective because it suppresses ovulation in up to 99 percent of cycles and has a more flexible dosing timetable. Unfortunately, it's not available in the United States and won't be anytime soon: The manufacturer has not even applied for FDA approval.
Birth control shots
The progestin-only birth control shot, commonly known by the trade names Depo-Provera and depo-subQ provera 104, is one good alternative. This method suppresses ovulation, and with perfect use (meaning you return to your caregiver at the right time for shots) it's more than 99 percent effective in women who aren't breastfeeding. Theoretically it's even more effective in nursing mothers.
Depo-Provera is injected into muscle in your upper arm or buttock. Depo-subQ provera 104 is given in the tissue just under the skin and contains a lower dose of the same type of progestin.
You can get a birth control shot at your six-week postpartum visit, but you have to go back every 12 weeks for another dose. Unlike other POCs, this method doesn't wear off right away when you stop using it; you may not be fertile for a year or longer after discontinuing the shots. Take this into account when you make your choice.
Something else to consider: Injectable progestins have been associated with a reduction in bone mineral density, and the loss may be greater the longer you use this type of birth control. Both shots carry warnings that the loss may not be completely reversible and that women should not use injectable progestin for longer than two years.
However, recent studies show reassuring evidence that bone mineral density can rebound after injectable progestin use. Research into this area is ongoing.
In one type of implant, a flexible rod is placed under the skin of your upper arm and continually delivers a small amount of progestin. Implants are more than 99 percent effective and last for several years (depending on which implant is used). Your fertility returns soon after the implant is removed.
The options currently available in the United States, Implanon and Nexplanon, each use a single flexible rod. Once implanted, the rod can remain in place for up to three years and is nearly 100 percent effective. The drawback is that you may have irregular menstrual cycles or spotting or bleeding several days a month.
An intrauterine device is another type of implant: It's a T-shaped rod your doctor inserts in your uterus. (You'll need a follow-up visit four to 12 weeks after so she can make sure it's still in place.)
Unlike the copper IUD, the Mirena IUD releases a small amount of progestin. Not only is it more than 99 percent effective as a form of birth control, but most women who use Mirena eventually have much lighter menstrual flow – and some users stop having periods completely. The progestin IUD can stay in place for up to five years.
How much progestin gets into breast milk, and will it affect my baby?
If you use progestin-only hormonal birth control, just a small amount of progestin passes into breast milk. With the minipill, for example, the level in breast milk is estimated to be 1 to 6 percent of the amount in the mother's body.
Research to date shows no adverse effects on lactation, or on infant weight gain, health, or development. Most family planning experts and many organizations – including the World Health Organization, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, Planned Parenthood Federation of America, and Family Health International – consider progestin-only contraceptives compatible with breastfeeding.
Can I start taking POCs right away?
Experts disagree about when it's best to begin taking POCs. Some say that breastfeeding mothers should wait six weeks after childbirth, when your milk supply is well established and your baby is a bit more mature.
Others prescribe these methods earlier for women who aren't exclusively breastfeeding or aren't sure how long they'll continue to nurse. Generally healthcare providers recommend that women who aren't exclusively breastfeeding begin contraception three weeks after delivery.
If you are exclusively breastfeeding, there's no reason to start taking hormones before your six-week postpartum visit. But if you're not nursing regularly, talk to your caregiver about the possibility of starting hormonal contraception earlier. If you decide to wait, be sure to use condoms in the meantime.
Are there any side effects or disadvantages to POCs?
Although POCs are considered safe to use while nursing, some women (whether breastfeeding or bottle-feeding) are not good candidates for any kind of hormonal birth control. That said, some women who can't use any of the combined hormonal methods (because of the estrogen component) can still safely use progestin-only methods.
The most common complaint about POCs is breakthrough vaginal bleeding, but some women experience other side effects, including weight gain, headaches, and nausea.
Unlike condoms, hormonal birth control methods (with or without estrogen) offer no protection against sexually transmitted infections – an important consideration if you're not in a mutually monogamous relationship.
Talk over the pros and cons with your midwife or doctor. She knows your health history and can help you choose a safe, effective contraceptive method that's right for you.