BREASTFEEDING AND THE PROGESTIN-ONLY PILL Adapted from post to LACTNET 23 April 2007

BREASTFEEDING AND THE PROGESTIN-ONLY PILL
Adapted from post to LACTNET
23 April 2007
Pamela Morrison IBCLC



Responding to a query on oral contraceptives during breastfeeding, I have a thick segment of my card index file devoted to oral contraceptives, compiled over the time I practised as a private practice Lactation Consultant in Harare.


I found that there was an apparent lack of research on this topic, which was frustrating because oral contraceptives caused an inordinate amount of problems for the mothers and babies I worked with.


Summarizing this experience I found:

1. Mothers were often prescribed the progestin-only pill ~six weeks after birth (at postpartum check-up), but sometimes much earlier, almost from hospital discharge.

2. Mothers sought an LC consult because of perceptions of "not enough milk" (as we know, the most common reason worldwide for quitting breastfeeding) and often because they had already, or were about to, start supplementing with formula.

3. Mothers had experienced difficulties with breastfeeding, or noticed marked changes in baby's behaviour 2 - 21 days after commencing the mini-pill. The babies were anywhere from 2 weeks to 14 months of age.

4. Symptoms described by mothers included:

• fussiness in their babies,
• frequent breastfeeding (ie much more frequent than "normal"),
• low weight gain,
• prolonged jaundice,
• baby dissatisfied,
• breasts seem "empty",
• baby very wakeful (noticed especially at night),
• sometimes frank breast refusal,
• mother queries whether milk is "rich enough",
• "not enough milk",
• baby "feeding all the time",
• "baby crying, very frequent and prolonged breastfeeding".
• recorded low weight gain in spite of very frequent breastfeeding.


5. The most likely mini-pills to be prescribed when mothers reported these Sx were

• Microval (levonorgestrel),
• Ovrette (norgestrel) or
• Exluton (lynestrenol) provided by the local Family Planning Clinics at a reduced price, consequently used very often, and I learned that it was subsidized by USAID.

6. I became aware that different OB/GYNs had "favourite" mini-pills that they would prescribe. Often hearing the baby's symptoms and finding out the name of the OB/GYN rang anticipatory alarm bells of what the cause of the problem might be.

7. Mothers often did not classify mini-pills in their own minds as medications. If asked if they were taking any medications they would say No, but when asked specifically about oral contraceptives they would say Yes.

8. My recommendations after checking P & A, BF frequency and duration, swallowing etc. were

• continued frequent exclusive breastfeeding,
• ask OB/GYN for medical advice about changing the mini-pill for a different brand,
• or stopping altogether (substitute condoms) and
• close follow-up, including weight checks.

9. Most mothers, who were quite desperate by the time they sought help, elected to stop the pills altogether. Symptoms in the baby would often miraculously disappear within 2 days to 2 weeks. The results on withdrawal of the mini-pill were often quite dramatic:

• Babies would become calm, "normal", "happy".
• Babies who had had low gain would somehow start gaining at twice or triple the previous rate.
• Mothers who had been supplementing with formula were able to re-build their milk supplies to reduce and then eliminate supplements.
• The mothers, needless to say, were delighted. And then - putting two and two together - became quite indignant and angry about the apparent consequences of the mini-pill on their breastfeeding experience.

10. Extensive searching for info about progestin-only pills revealed little firm research, but lots of anecdotal reports in the literature, and on LACTNET. It seems there are many types and families of progestins and tracking them all down is difficult. Furthermore, early research establishing that there was no apparent effect of progesterone and synthetic progestins on breastfeeding/lactation was conducted on babies who had been non-exclusively breastfed, so that the effects would not have been easy to accurately assess. I found this excerpt in Neville & Neifert's Lactation, Physiology, Nutrition and Breastfeeding, "19-norprogestogens (norethynodrel, norethinolone, quingestenol) have the potential of behaving more like combination estrogen-progestogen contraceptives because they are partly metabolized to estrogen in vivo". Certainly my experience seemed to fit this statement. I finally had a long conversation with a very baby-friendly OB/GYN who confirmed that there are many types of progestin-only pills, and some of them do have estrogenic effects for some women; in short, different drugs have different effects on different women, so there is no one-size-fits-all cause for their many problems and side-effects on any women, including breastfeeding mothers. Consequently this was the information I gave to ante-natal mothers in breastfeeding-preparation classes, suggesting that they seek an LC consult if they had worries about "not enough milk" after their babies were born.


Conclusion

My hypothesis is that there is a more-likely/less-likely possibility: that women have an individual response to hormonal contraception; some progestins may behave like estrogens for some mothers, to possibly cause negative consequences on breastmilk quantity (affecting prolactin levels, reduced milk production and symptoms of depression for the mother?) and/or maybe on breastmilk quality (reduced fat/protein content in the milk?)

We need to bear in mind the strong links between the pharmaceutical and formula industry - often the companies that manufacture oral contraceptives for mothers are the same ones who manufacture formula to feed their babies when breastfeeding fails.

I think all mothers should receive anticipatory advice about the possible consequences of hormonal contraceptives so that if they happen to be in the group that experiences negative effects they can take remedial action in time to avoid compromising their babies' health.





© Pamela Morrison IBCLC
Rustington, England
(formerly in private practice in Harare, Zimbabwe 1990-2003)