Injected progestogen and lactation

Breastfeeding and Hormonal Contraception: A Scoping Review of Clinical Guidelines, Professional Association Recommendations, and the Literature

Background: Postpartum contraceptive use can help prevent short-interval pregnancies, which have been associated with adverse neonatal and maternal health outcomes. Many contraceptive methods are safe for postpartum use, but patients and providers may be confused as to what impact hormonal contraception has on lactation. We performed a scoping review of the most recent U.S.-based guidelines regarding hormonal contraception on lactation to provide synthesis and recommendations to aid providers in counseling their patients. Methods: We conducted a scoping review by identifying the most recent clinical recommendations and guidelines from the Centers for Disease Control and Prevention (CDC) and three maternal and child health professional associations (American College of Obstetricians and Gynecologists [ACOG], Society for Maternal-Fetal Medicine [SMFM], and Academy of Breastfeeding Medicine [ABM]). We also reviewed the citations in these guidelines used in their development. We then conducted an updated literature review to capture studies published since the most recent systematic reviews were conducted. Results: We reviewed 1 clinical guideline from the CDC and 2 systematic reviews cited in its references, 6 professional association recommendations, and 28 publications identified through the updated literature review. Progestin-only contraceptive methods continue to demonstrate safety in breastfeeding patients, while low-quality evidence supports concerns of decreased milk supply with combined hormonal contraception. Discussion: Organizations should consider updating counseling recommendations regarding progestin-only contraceptives and lactation. Further research is needed to examine new contraceptive methods as well as the effect of hormonal contraception on lactation in the setting of preterm birth.

Progestogen-only contraceptive use among breastfeeding women: a systematic review

BACKGROUND

Postpartum women need effective contraception. Concerns have been raised that use of progestogen-only contraceptives (POCs) may affect breastfeeding performance and infant health outcomes.

OBJECTIVES

We investigated the clinical outcomes of breastfeeding duration, initiation of supplemental feeding and weaning, as well as infant outcomes including infant growth, health and development among breastfeeding women using POCs compared with breastfeeding women not using POCs.

SEARCH STRATEGY

We searched the PubMed database for all articles published from database inception through December 2014.

SELECTION CRITERIA

We included primary research studies of breastfeeding women of any age or parity who received POCs, including progestogen-only pills, injectables, implants or hormonal intrauterine devices (IUDs). The main outcomes were breastfeeding performance (as measured by initiation, continuation, frequency and exclusivity of breastfeeding) and infant health (as measured by growth, development or adverse health effects).

RESULTS

Forty-nine articles reporting on 47 different studies were identified that investigated the use of POCs in breastfeeding women and reported clinically relevant outcomes of infant growth, health or breastfeeding performance. Studies ranged from poor to fair methodological quality and generally failed to show negative effects of the use of POCs on breastfeeding outcomes or on infant growth or development. One randomized controlled trial (RCT) raises concerns that immediate insertion of the levonorgestrel IUD postpartum may be associated with poorer breastfeeding performance when compared with delayed insertion, although two other RCTs evaluating early etonogestrel implants compared with delayed initiation of implants or depot medroxyprogesterone acetate failed to find such an association.

CONCLUSION

The preponderance of evidence fails to demonstrate adverse breastfeeding outcomes or negative health outcomes in infants such as restricted growth, health problems or impaired development. Evidence newly added to this review was largely consistent with previous evidence.

Combined hormonal versus nonhormonal versus progestin-only contraception in lactation

BACKGROUND

Postpartum contraception improves the health of mothers and children by lengthening birth intervals. For lactating women, contraception choices are limited by concerns about hormonal effects on milk quality and quantity and passage of hormones to the infant. Ideally, the contraceptive chosen should not interfere with lactation or infant growth. Timing of contraception initiation is also important. Immediately postpartum, most women have contact with a health professional, but many do not return for follow-up contraceptive counseling. However, immediate initiation of hormonal methods may disrupt the onset of milk production.

OBJECTIVES

To determine the effects of hormonal contraceptives on lactation and infant growth

SEARCH METHODS

We searched for eligible trials until 2 March 2015. Sources included the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, POPLINE, Web of Science, LILACS, ClinicalTrials.gov, and ICTRP. We also examined review articles and contacted investigators.

SELECTION CRITERIA

We sought randomized controlled trials in any language that compared hormonal contraception versus another form of hormonal contraception, nonhormonal contraception, or placebo during lactation. Hormonal contraception includes combined or progestin-only oral contraceptives, injectable contraceptives, implants, and intrauterine devices.Trials had to have one of our primary outcomes: breast milk quantity or biochemical composition; lactation initiation, maintenance, or duration; infant growth; or timing of contraception initiation and effect on lactation. Secondary outcomes included contraceptive efficacy while breastfeeding and birth interval.

DATA COLLECTION AND ANALYSIS

For continuous variables, we calculated the mean difference (MD) with 95% confidence interval (CI). For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio (OR) with 95% CI. Due to differing interventions and outcome measures, we did not aggregate the data in a meta-analysis.

MAIN RESULTS

In 2014, we added seven trials for a new total of 11. Five reports were published before 1985 and six from 2005 to 2014. They included 1482 women. Four trials examined combined oral contraceptives (COCs), and three studied a levonorgestrel-releasing intrauterine system (LNG-IUS). We found two trials of progestin-only pills (POPs) and two of the etonogestrel-releasing implant. Older studies often lacked quantified results. Most trials did not report significant differences between the study arms in breastfeeding duration, breast milk composition, or infant growth. Exceptions were seen mainly in older studies with limited information.For breastfeeding duration, two of eight trials indicated a negative effect on lactation. A COC study reported a negative effect on lactation duration compared to placebo but did not quantify results. Another trial showed a lower percentage of the LNG-IUS group breastfeeding at 75 days versus the nonhormonal IUD group (reported P < 0.05) but no significant difference at one year.For breast milk volume, two older studies indicated lower volume for the COC group versus the placebo group. One trial did not quantify results. The other showed lower means (mL) for the COC group, e.g. at 16 weeks (MD -24.00, 95% CI -34.53 to -13.47) and at 24 weeks (MD -24.90, 95% CI -36.01 to -13.79). Another four trials did not report any significant difference between the study groups in milk volume or composition with two POPs, a COC, or the etonogestrel implant.Seven trials studied infant growth; one showed greater weight gain (grams) for the etonogestrel implant versus no method for six weeks (MD 426.00, 95% CI 58.94 to 793.06) but less compared with depot medroxyprogesterone acetate (DMPA) from 6 to 12 weeks (MD -271.00, 95% CI -355.10 to -186.90). The others studied POPs, COCs versus POPs, or an LNG-IUS.

AUTHORS' CONCLUSIONS

Results were not consistent across the 11 trials. The evidence was limited for any particular hormonal method. The quality of evidence was moderate overall and low for three of four placebo-controlled trials of COCs or POPs. The sensitivity analysis included six trials with moderate quality evidence and sufficient outcome data. Five trials indicated no significant difference between groups in breastfeeding duration (etonogestrel implant insertion times, COC versus POP, and LNG-IUS). For breast milk volume or composition, a COC study showed a negative effect, while an implant trial showed no significant difference. Of four trials that assessed infant growth, three indicated no significant difference between groups. One showed greater weight gain in the etonogestrel implant group versus no method but less versus DMPA.

Pharmacological overview of galactogogues

Galactogogues are substances used to induce, maintain, and increase milk production, both in human clinical conditions (like noninfectious agalactias and hypogalactias) and in massification of production in the animal dairy industry. This paper aims to report the state of the art on the possible mechanisms of action, effectiveness, and side effects of galactogogues, including potential uses in veterinary and human medicine. The knowledge gaps in veterinary clinical practice use of galactogogues, especially in the standardization of the lactogenic dose in some pure drugs and herbal preparations, are reviewed.

Impact of injectable progestogen contraception in early puerperium on lactation and infant health

INTRODUCTION

Unmet need for family planning approaches 40% or higher and many women are at risk of unintended pregnancy. Progesterone contraception after birth is frequently recommended, but concern remain of inhibition of lactation or effects on infant health. In present study we aimed to evaluate impact of short term use of injectable depot medroxy progesterone acetate (DMPA) if given in early post partum period on infant health and breast feeding performance.

MATERIAL AND METHODS

A prospective case control study was conducted and 250 women immediately after delivery were recruited in the study. 150 women who were recruited as study group received Inj. DMPA 150 mg intra muscularly after initiation of lactation before discharge from hospital (Day 2-Day 10 of their delivery). 100 post partum women, not using hormonal contraception were taken as controls. All the subjects were followed to complete a full 6 months follow up. Duration and frequency of lactation, gain in weight, gain in height and any illness spells in the infant were noted at 6 weeks, 3 months and 6 months follow up. In the study group 100 subjects completed 6 months follow-up. The statistical analysis was carried out by using SPSS software version 7. The statistical technique used was z score(significance shown by z score> 1.96) and repeated measure analysis (two way Anova technique).

RESULTS

Hundred percent of primigravidas in the study group and 95% in the control group were satisfied with their lactation amount. The average gain in height was comparable in both study and control group {4.36±0.56 vs 4.33±0.54 (z score 0.38) at 6 weeks, 12.44±0.73 vs 12.40±0.71 (z score 0.39) at 3 months 17.30±0.91 vs 17.28±0.83 (z score 0.16) at 6 months}. Similarly average gain in weight was also not significantly different in two groups {0.89±0.11 vs 0.93±0.10 (z score 0.71) at 6 weeks, 1.77±0.17 vs 1.78±0.16 (z score 1.07) at 3 months and 3.53±0.30 vs 3.46±0.33 (z score 1.19) at 6 months}. The results were comparable with other studies.

CONCLUSION

Injectable DMPA use as a contraceptive in the immediate post partum period was found to be a safe and effective alternate method with no deleterious effect on mother's milk and infant's growth.

The use of galactogogues in the breastfeeding mother

OBJECTIVE

To review data regarding the efficacy of galactogogues available in the US to increase breast milk production in postpartum mothers.

DATA SOURCES

Literature was sought using PubMed (1966-June 2012) and EMBASE (1973-June 2012). Search terms included breastfeeding, breast milk, lactation, galactogogue, metoclopramide, oxytocin, fenugreek, milk thistle, silymarin, growth hormone, thyroid releasing hormone, medroxyprogesterone, domperidone, goat's rue, beer, Asparagus racemosus, shatavari, Medicago sativa, alfalfa, Onicus benedictus, blessed thistle, Galega officinalis, brewer's yeast, and herbals.

STUDY SELECTION AND DATA EXTRACTION

All studies including humans and published in English with data assessing the efficacy of galactogogues for increasing breast milk production were evaluated.

DATA SYNTHESIS

Breast milk is considered the optimal food source for newborns through 1 year of age. Many factors influence overall maternal production, including maternal pain, illness, balance of time when returning to work, anxiety, or emotional stress. Although a variety of herbal and pharmaceutical options have anecdotal evidence of their ability to improve breast milk production, peer-reviewed studies proving their efficacy are lacking. Metoclopramide, oxytocin, fenugreek, and milk thistle have shown mixed results in improving milk production; however, the trials were small and had a variety of limitations.

CONCLUSIONS

Nonpharmacologic recommendations should be exhausted before adding therapy. Although anecdotal evidence encourages the use of metoclopramide, fenugreek, asparagus, and milk thistle for their galactogogue properties, efficacy and safety data in the literature are lacking. Oxytocin and domperidone are potentially available for compounding purposes, but safety data are limited. More studies are needed to evaluate the effects of available galactogogues on breast milk production.

A systematic review of early postpartum medroxyprogesterone receipt and early breastfeeding cessation: evaluating the methodological rigor of the evidence

BACKGROUND

Breastfeeding has numerous maternal and infant benefits. Progesterone contraception after birth is frequently recommended, but because a decrease in progesterone is required to initiate lactation, early postpartum progesterone contraception use could inhibit lactation. The purpose of this article is to critically evaluate the scientific basis for conflicting clinical recommendations related to postpartum medroxyprogesterone use among breastfeeding women.

METHODS

Relevant peer-reviewed literature was identified through a comprehensive search of PubMed through December 2010. The search was restricted to clinical trials, randomized clinical trials, or comparative studies written in English and conducted among humans. The studies included in this review addressed the effect of medroxyprogesterone administration at <6 weeks postpartum on breastfeeding exclusivity and/or duration and measured breastfeeding outcomes at ≥ 6 weeks postpartum.

RESULTS

Of the 20 articles identified, only three studies satisfied the inclusion criteria. However, all three studies were of low-quality methodological rigor, and none accounted for potential confounders.

CONCLUSION

Current evidence is methodologically weak and provides an inadequate basis for inference about a possible causal relationship between early postpartum medroxyprogesterone use and poor breastfeeding outcomes. However, given the presence of a strong biological model describing the potential deleterious effect of postpartum medroxyprogesterone use on lactation, further research that improves on current literature is warranted. Meanwhile, we recommend that potential breastfeeding risks associated with early (<6 weeks) postpartum medroxyprogesterone use be disclosed to allow for a fully informed consent and decision-making process.

Side effects of steroid contraception

Side effects of steroid contraception during lactation are discussed and followed by a review of the relevant literature. It appears that oestrogen has an inhibiting effect on lactation performance, but progestogen alone does not. Most of the undesirable systemic side effects of oral contraceptives on the mother are connected with the relative excess or deficiency of the oestrogen and/or the progestogen component. It is likely that a low oestrogen content preparation causes no dangerous side effects. There are few data about the appearance of contraceptive steroids in breast milk. Probably only a small proportion of the steroids are excreted into the milk. Any adverse effects, on the infant, such as slow weight gain, neonatal breast hypertrophy and breast milk jaundice, are dependent on the two preceding factors. It is doubtful whether the small amount of contraceptive steroids contained in modern pills exert any influence on the fetus. Although further examinations are necessary, the low dosage of progestogen and oestrogen combined contraceptives given at fully established lactation under close control seems to be advantageous to both mothers and their infants.

Appearance of contraceptive steroids in human milk: effects on the child

The realization that steroidal contraceptives administered immediately after delivery to lactating women may be excreted into milk, and adversely affect the neonate, is a cause for concern. Most investigations on hormonal contraceptives have dealt with the efficacy of ovulation suppression, and systemic side effects, but little is known about the appearance of steroids or their metabolites in milk. Apart from the immediate side effects on the neonate, unforeseen long-term consequences require special consideration. Until research provides us with more information, women should use breast-feeding and IUDs instead of steroidal contraceptives during the first trimester post-partum.

Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study

BACKGROUND

The effects of etonogestrel (ETG)-releasing contraceptive implant during the immediate postpartum period on maternal safety are unknown.

STUDY DESIGN

Forty healthy women exclusively breastfeeding were randomized to receive either ETG-releasing implant 24-48 h after delivery (n=20) or depot medroxyprogesterone acetate (DMPA group; n=20) at the sixth week postpartum. We measured blood pressure, maternal and neonatal weight, body mass index (BMI; kg/m(2)), waist circumference (WC), complete blood count, C-reactive protein, interleukin-6, tumor necrosis factor (TNF-alpha), lipid profile, fasting serum glucose and maintenance of exclusive lactation up to the 12th week postpartum.

RESULTS

Decreases in mean maternal weight, BMI (kg/m(2)) and WC were significantly greater in the ETG-releasing implant group than in the DMPA group during the first 6 weeks postpartum (-4.64+/-2.71 kg vs. -2.6+/-2.45 kg mean+/-SD, p=.017; -1.77+/-1.06 kg/m(2) vs. -0.97+/-0.95 kg/m(2), p=.026; -15.3+/-6.72 cm vs. -9.05+/-5.84 cm, p=.003, respectively). In addition, total cholesterol and HDL, were lower in DMPA users, and TNF-alpha and leukocytes were higher in DMPA users compared to in the implant group, between 6 and 12 weeks after delivery. The newborns of implant users showed a trend towards gaining more weight, as compared with the infants of the DMPA mothers during the first 6 weeks of life (implant group: +1460.50+/-621.34 g vs. DMPA group: +1035.0+/-562.43 g, p=.05). The remaining variables, including the duration of exclusive breastfeeding, were similar between the groups.

CONCLUSION

The insertion of ETG-releasing contraceptive implant during the immediate postpartum period was not associated with deleterious maternal clinical effects or with significant maternal metabolic alterations or decreased infant weight gain.

Long-acting contraceptives in adolescents

PURPOSE OF REVIEW

To help clinicians guide adolescent patients to sound choices regarding long-acting contraceptives. The safety, side effects and non-contraceptive benefits of injectable, implantable and intrauterine contraception are detailed.

RECENT FINDINGS

The use of depot medroxyprogesterone acetate contraceptive injections has been associated with declines in teenage pregnancies in the United States. Although the US Food and Drug Administration has placed a black box warning concerning skeletal health and depot medroxyprogesterone acetate, data in adolescents confirm that declines in bone mineral density with depot medroxyprogesterone acetate are fully reversible. Concerns regarding skeletal health should not restrict the initiation or continuation of depot medroxyprogesterone acetate in adolescents. A highly effective, convenient, and easy to insert/remove single rod progestin-only contraceptive implant (Implanon) is now available in the United States. Although not widely used in adolescents, intrauterine devices offer selected adolescents convenient, highly effective, safe birth control. Use of the progestin-releasing intrauterine device (Mirena) is also associated with important non-contraceptive benefits.

SUMMARY

The efficacy and convenience associated with long-acting contraceptives make them indispensable for adolescent patients. This review will help clinicians guide teenage patients towards sound contraceptive choices and the successful long-term use of injectable, implantable and intrauterine methods of birth control.

A comparative study of the levonorgestrel-releasing intrauterine system Mirena versus the Copper T380A intrauterine device during lactation: breast-feeding performance, infant growth and infant development

BACKGROUND

Mirena is a levonorgestrel-releasing intrauterine system (LNG-IUS) that provides highly effective and long-acting progestogen-only contraception.

OBJECTIVE

The objective of this study was to analyze the possible effects of using LNG-20 microg IUS on breast-feeding performance, infant growth and infant development during the first postpartum year as compared with the Copper T380A intrauterine device (Cu T380A IUD).

DESIGN

This study is a prospective, controlled and randomized trial.

SETTING

The study was conducted at the Department of Obstetrics and Gynecology, Assiut University Hospital, Egypt.

METHODS

Three hundred twenty lactating women asking for initiation of contraception during the early postpartum stage were assigned randomly into two groups, the LNG-20 microg IUS group (n=163) and the Cu T380A group (n=157). The insertions were done 6-8 weeks postpartum. Each participant was followed up at three monthly intervals after insertion and until the first birthday of her baby. During these visits, the breast-feeding pattern was assessed, certain infant physical growth parameters were measured and a set of infant development tests was performed.

RESULTS

No pregnancy occurred in both groups. There were no significant differences in the net continuation rates between the two groups (89.3 for LNG-IUS vs. 90.9 for Cu T380A). The LNG-20 microg IUS group had comparable rates of breast-feeding continuation, complete weaning, full breast-feeding and partial breast-feeding, with the Cu-IUD group. No statistically significant differences were found between groups with regard to all infant physical growth parameters and various infant development tests.

CONCLUSION

The findings of the current study confirm that the use of LNG-20 microg IUS during the first postpartum year in lactating women provides highly effective and acceptable contraception and does not negatively influence breast-feeding or the growth and development of breast-fed infants.

Combined hormonal versus nonhormonal versus progestin-only contraception in lactation

BACKGROUND

Contraception for women who are breastfeeding is a public health issue of global importance. Each year over 100 million women make decisions about beginning or resuming contraception after childbirth. These decisions include both the choice of contraceptive method and the time at which its use begins, both of which continue to be debated by experts. Choices of contraception may be limited for lactating women due to concerns about hormonal effects on quality and quantity of milk, passage of hormones to the infant, and infant growth. Ideally, the contraceptive method chosen should not interfere with lactation. Additionally, because the return of menstruation and ovulation can be unpredictable in breastfeeding women, the timing of contraception initiation is important.

OBJECTIVES

To determine the effect of combined oral contraceptives and progestin-only contraceptives on lactation. The a priori hypothesis is that combined oral contraception impairs lactation, making it less appropriate than progestin-only or nonhormonal contraception for breastfeeding women.

SEARCH STRATEGY

We used PUBMED, POPLINE, EMBASE, LILACS, and Cochrane Controlled Trials Register computer searches, supplemented by review articles and contact with investigators.

SELECTION CRITERIA

We sought all randomized controlled trials, reported in any language, that included any form of hormonal contraception compared with another form of hormonal contraception, nonhormonal contraception, or placebo during lactation. Hormonal contraception could include combined oral or injectable contraceptives, progestin-only oral or injectable contraceptives, hormonal implants, or hormonal intrauterine devices. Study participants included breastfeeding women of any age or parity who desired contraception.

DATA COLLECTION AND ANALYSIS

We evaluated the methodological quality of each report and sought to identify duplicate reporting of data from multicenter trials. We abstracted data onto data collection forms. Principal outcome measures included quantity of milk; biochemical analysis of milk composition; initiation, maintenance and duration of lactation; infant growth; efficacy of contraceptive method while breastfeeding; and timing of contraception initiation and its effects on lactation. Because the trials did not have uniform interventions, often lacked quantifiable outcomes, and had poor methodological quality, we could not aggregate the data in a meta-analyses.

MAIN RESULTS

Seven reports from five randomized controlled trials met our inclusion criteria. Most of the five trials did not specify their method used to generate a random sequence, method of allocation concealment, blinding of treatments, or use of an intention-to-treat analysis. Additionally, high loss to follow-up rates invalidated at least two studies. The findings from two reports comparing oral contraceptives to placebo during lactation were conflicting. Another trial found no inhibitory effects on lactation from progestin-only contraceptives. Finally, the WHO trial found no effect of progestin-only contraceptives on lactation but a decline in breast milk volume from combination contraceptives during lactation. High loss to follow-up rates, however, undermine the credibility of the WHO trial. No significant differences in infant growth or weight appeared in any of the included trials as a result of the use of hormonal contraception during lactation.

REVIEWER'S CONCLUSIONS

Evidence from randomized controlled trials on the effect of hormonal contraceptives during lactation is limited and of poor quality; results should be interpreted with caution. The existing randomized controlled trials are insufficient to establish an effect of hormonal contraception, if any, on milk quality and quantity. Evidence is inadequate to make recommendations regarding hormonal contraceptive use for lactating women. At least one properly conducted randomized controlled trial of adequate size is urgently needed to address this question.

Impact of early postpartum administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns

OBJECTIVE

The purpose of this study was to identify the impact on breast-feeding patterns of early postpartum initiation of progestin-only birth control methods compared with nonhormonal methods.

STUDY DESIGN

A prospective, nonrandomized trial was performed comparing progestin-only contraceptive methods administered before hospital discharge with nonhormonal methods on breast-feeding continuation rates, exclusive breast-feeding, and supplementation at 2, 4, and 6 weeks after delivery.

RESULTS

Three hundred nineteen women provided complete data until hospital discharge. The hormonal group had higher risk factors for not breast-feeding, but there was no difference among any of the subgroups in breast-feeding continuation rates except at week 4. Supplementation or perception of insufficient milk production did not differ between groups. By week 6, 23.5% of women discontinued breast-feeding, and 64.5% of those breast-feeding were supplementing.

CONCLUSION

This study demonstrates that there is no detectable adverse impact on breast-feeding attributable to progestin-only contraceptive methods initiated within the first 3 days post partum.

Injectable contraception. New and existing options

DMPA and MPA/E2C contraception offer women safe, effective, convenient, and reversible birth control choices. The use of DMPA, a 3-month injectable, is characteristically associated with amenorrhea. Lactating women and women in whom contraceptive doses of estrogen are contraindicated can use this progestin-only birth control method. Return of fertility can be delayed in women discontinuing DMPA to become pregnant. In some cases, the use of DMPA also confers important noncontraceptive and therapeutic benefits. A monthly estrogen/progestin injectable contraceptive, MPA/E2C should appeal to women who are concerned about daily pill taking, who prefer regular cycles to amenorrhea, and who find monthly injections acceptable and accessible. As is true for oral contraceptives, MPA/E2C represents an appropriate choice for women who prefer a rapidly reversible contraceptive. Currently, the proposed contraindications for MPA/E2C parallel those for combined oral contraceptives. As MPA/E2C contraception becomes available for American women, clinicians will learn how to best include this new method among the array of contraceptive choices. By individualizing contraceptive selection, counseling, and management approaches based on the relevant behavioral and medical considerations reviewed herein, clinicians can maximize their patients' success with injectable contraceptives. The more innovative that clinicians, family planning agencies, and insurers are in facilitating access to care (including reinjections), the more women will be able to avail themselves of safe, effective, and reversible methods of contraception. In addition to the physician's office or health clinic, other sites at which women might receive contraceptive injections include employee health clinics, college health clinics, or perhaps the pharmacy where the prescription is filled. Self-administration may become an appropriate option for some users of injectable contraception.

Hormonal contraception and lactation

Hormonal contraceptive measures can be used immediately postpartum if the patient so desires. Progestin-only contraceptives are preferable to estrogen-containing methods if initiated during the first six months after delivery. Progestin only contraceptives do not appear to affect milk volume, composition, or to cause deleterious effects in the infant. Ideally for women who desire a form of contraception in addition to lactation-induced amenorrhea, progestin-only methods should be started at six weeks postpartum if the woman is fully breastfeeding. Since contraception protection is provided by lactation amenorrhea, the six week delay will decrease infant exposure to exogenous hormones and decrease the incidence of irregular postpartum bleeding. Milk volume may decrease with the use of estrogen; however, no detrimental effects have been shown on infant growth or development. For women who are planning to gradually wean their infant, use of COCs may provide an easier transition to bottle-feeding. COCs should be used with caution by women who are not able to obtain supplemental milk. A decrease in milk volume can lead to earlier discontinuation of the hormonal contraceptive in an attempt to increase milk quantity. Supplementation is often needed, and then the woman ovulates again, possibly resulting in an unintended pregnancy. Many women are motivated immediately postpartum to accept contraception. For other women, lack of access to health care may provide barriers in obtaining adequate contraception later. In either case, there are adequate data to show no detriments of starting progestin-only contraceptives within days of delivery. Therefore, the best method for the patient should be employed to ensure adequate contraception while preserving optimal lactation.

Contraception. A clinical review for the internist

Effective use of contraception allows couples to control their fertility and, in certain instances, is associated with important noncontraceptive benefits. Surgical sterilization offers safe, effective, and permanent contraception for women and men. Low-dose OCPs offer safe, effective contraception for most women able and willing to take pills consistently. In addition, their use confers a variety of important noncontraceptive benefits. The availability of long-acting progestin injectable and implantable methods has made highly effective and convenient birth control available for women who are not good pill takers as well as for those for whom contraceptive doses of estrogen are contraindicated. Barrier methods are readily available and provide protection against STDs; unfortunately, erratic use is all too often associated with inadequate contraceptive efficacy. IUDs offer convenient, highly effective contraception for appropriate candidates.

Excretion of MPA in the milk of lactating ewes treated for synchronization of estrus

Ten mature lactating ewes of the Chios island breed 3.5 +/- 0.5 (Mean +/- SEM) yr of age and weighing 51.9 +/- 1.6 kg (Mean +/- SEM) were synchronized for estrus with intravaginal sponges impregnated with 60 mg 6a-methyl-17-acetoxyprogesterone (MPA). The sponges remained in place for 14 d and 500 IU im PMSG were injected at their withdrawal. Daily milk samples (3 d pretreatment, 14 d on treatment, and 5 d posttreatment) were collected and analyzed by a double antibody RIA procedure for MPA. The concentration of MPA (Mean +/- SEM) in the milk increased to 5.05 +/- 0.11 ng/ml within the first day of sponge insertion, then declined and remained at a constant level (3.08 +/- 0.26 ng/ml) while the sponge was in place, eventually dropping to the background level (0.65 +/- 0.05 ng/ml) 24 h following sponge withdrawal. The curve for the quantity of MPA excreted in the milk was identical to that of MPA concentrations, showing significant differences among experimental days and among ewes. Finally, there was a significant relationship between milk production and MPA excretion into the milk (r = +0.581( * *)). It is concluded that only a very small percentage (0.08 +/- 0.01) of MPA contained in each sponge is excreted into the milk from the moment of sponge insertion until 5 d after its removal.

Adverse effects of drugs and chemicals in breast milk on the nursing infant

Breastfeeding is an essential physiologic process that provides nutrition to the infant and protects the child against infection and immunologic disorders. The incidence of various diseases and metabolic disorders is known to be less in a breastfed infant compared with a child given a milk substitute. Psychologically, a breastfed infant forms a maternal bond that enables adaptation more readily to a social environment. It is well-established that all drugs are excreted into breast milk and are bioavailable to the infant. In general the majority of drugs do not pose a significant problem to the nursing infant and breastfeeding should be encouraged. The physician should be aware of which drugs are contraindicated during lactation and which drugs should be used with caution. There are also environmental chemicals that readily enter breast milk and may induce adverse effects. At present, the advantages of breastfeeding for infant development outweigh the potential adverse consequences and this physiologic process should be encouraged. With the use of available data on pharmacokinetics, milk-to-plasma ratio, excretion, etc. a supportive approach can be delineated by the pediatrician to reassure the nursing mother that they can safely breastfeed and continue therapy with minimal effects on the infant. It is thus imperative to document the extent to which a drug or chemical appears in breast milk and any apparent effects in the infant.

Concentration of fat, protein, lactose and energy in milk of mothers using hormonal contraceptives

Energy, protein, lactose and fat were studied in the milk of mothers who were using different types of contraceptives. One hundred and eleven mothers made up the following groups. C: control (barrier and natural methods, or sterilization), n = 22; combined pill: LDP (low dose pill (levonorgestrel 0.15 mg + ethinylestradiol 0.03 mg)), n = 12 and MDP (medium dose pill (levonorgestrel 0.25 mg + ethinylestradiol 0.05 mg)), n = 13; MP (minipill (norethindrone 0.35 mg)), n = 37; DMPA (injectable progesterone (depot medroxiprogesterone acetate 150 mg)), n = 17; and IUD (plastic or copper intrauterine device), n = 10. The mean stages of lactation were, respectively, 15, 17, 5, 9, 5 and 9 weeks. The mean duration of observation for the study groups ranged from 2 to 4 weeks. Milk samples were collected before and after initiation of treatment (mean = 20 days; range = 14-103 days). The stage of lactation and the interval of nursing before sampling were recorded so that statistical account could be taken of these uncontrollable sources of variability. When incorporated as covariates, they showed that no significant differences existed between the groups tested, either before or after treatment.

Long-term follow-up of children breast-fed by mothers using oral contraceptives

In a long-term follow-up study 48 breast-fed children, whose mothers had used oral contraceptives containing 50 micrograms of ethinylestradiol while lactating, were compared to a matched control group whose mothers had not used any hormonal contraceptives during lactation. In spite of a very large number of data collected from several different sources of information, no effect could be demonstrated of the ingested steroid, neither upon the panorama of diseases nor upon intellectual or psychological behaviour of the infants and children up to 8 years of age. The mothers who used oral contraceptives lactated a significantly shorter period of time than the controls, but no differences were found in weight gain and height increase in the children between cases and controls.

Influence of levonorgestrel contraceptive implants, NORPLANT, initiated early postpartum upon lactation and infant growth

This study was undertaken to investigate the effect of use of levonorgestrel contraceptive implants, NORPLANT, by breastfeeding mothers on lactational performance and infant growth. NORPLANT implants were inserted between days 30 and 42 postpartum in 50 lactating women. Two control groups of breastfeeding mothers, 50 each, were studied in parallel: the first used an intrauterine device (Cu T380-Ag) and the second used either barrier or no contraception. There was no difference in lactational performance among the three groups. The increments in infant weight and height in the three groups were within the normal range for Egyptian infants. However, the rates of weight and height gain in the early postpartum months were slightly, but significantly, lower in the NORPLANT group than in the two control groups. However, by the sixth postpartum month, there were no significant group differences in these growth parameters. The possible confusing effect of supplementary feeding is discussed.

Long-term follow-up of children breast-fed by mothers receiving depot-medroxyprogesterone acetate

A long-term follow-up study compared development and health of 128 breast-fed children whose mothers had received depot-medroxyprogesterone acetate (depot-MPA) while lactating and 142 control children whose mothers had used mechanical contraceptives or no contraceptives or had undergone sterilization. The children, who were approximately 4-1/2 years old at follow-up, showed no ill effects on their growth and development and health status from exposure to depot-MPA. Depot-MPA-treated mothers lactated significantly longer than controls and also had greater parity than controls. These factors apparently contributed to a difference in weight at follow-up. Compared with the Sempe-Pedron standard, more of the depot-MPA group were underweight and more controls were overweight.

Effects of hormonal contraceptives on milk volume and infant growth. WHO Special Programme of Research, Development and Research Training in Human Reproduction Task force on oral contraceptives

WHO conducted a three-centre study in Hungary and Thailand to evaluate the effects of hormonal contraception on lactation and infant growth. Women choosing oral contraceptives were randomly assigned to a combined oral contraceptive containing 30 micrograms ethinyl estradiol and 150 micrograms levonorgestrel (N = 86) or a progestin-only preparation containing 75 micrograms dl-norgestrel (N = 85). Identical packaging and treatment schedules allowed double-blind observation. One-hundred-and-eleven women using no contraception or non-hormonal methods acted as controls. In the two Thai centres 59 women using depot-medroxyprogesterone acetate formed an additional comparison group. All subjects were healthy women with normal deliveries, whose infants had normal birth weights and satisfactory growth in the neonatal period. Breast milk volume was determined by pump expression using standardized procedures. Information was obtained on nursing frequency and supplementation, infant growth and morbidity. Pretreatment observations at 6 weeks post-partum were used as a baseline, and subjects were followed-up at 9, 12, 16, 20 and 24 weeks post-partum. Women using combined oral contraceptives had a decline in milk volume within 6 weeks of initiating treatment, whereas no significant decrease was observed in the other treatment groups. After 18 weeks of treatment, combined oral contraceptive users experienced a 41.9% decline in milk volume, compared to 12.0% with progestin-only minipills and 6.1% in the non-hormonal controls. The prevalence of complementary feeding and withdrawals due to inadequate milk supply were comparable in the four treatment groups. However, data were not available on the daily amounts of complementary feeds. There were no significant differences in growth of infants between treatment groups. Thus, women may have compensated for declines in milk volume by more supplementary feeding or by more prolonged and intense suckling episodes. We conclude that 30 micrograms estrogen-containing combined oral contraceptives impair milk secretion, but in the selected healthy group of mothers and children studied with the prevailing level of supplementary feeding, this did not adversely affect infant growth.

Norethisterone levels in maternal serum and milk after intramuscular injection of norethisterone oenanthate as a contraceptive

There is concern that the breast-fed infant whose mother is receiving intra-muscular progestogens for contraception will be exposed to significant quantities of the steroid. Norethisterone levels in maternal serum and milk were studied throughout an injection interval after intramuscular administration of 200mg norethisterone oenanthate. Milk samples were taken at the beginning and at the end of the feed. Norethisterone concentrations in milk were very much lower, but declined more slowly, than serum concentrations. Post-suckling concentrations were higher than pre-suckling concentrations. Experiments in adults receiving an oral dose of norethisterone in cow's milk comparable to that ingested by an infant in a day resulted in low serum levels. It is concluded that only very low concentrations of norethisterone would be present in the infant's circulation.

Long acting contraceptives. Present status

Long acting injectable hormonal contraceptives are among the most effective fertility regulating agents developed; yet they are also among the most controversial because of animal data indicating a possible carcinogenic potential in several species. A critical analysis of these animal findings has revealed, in all instances, the existence of specific mechanisms not occurring in the human. For this reason, most national and international scientific bodies who have reviewed this issue have concluded that there are no toxicological reasons for not using long acting hormonal contraceptives. Long acting agents can be divided into 2 separate groups: those having a duration of action of one month, which are composed of a long acting oestrogen and a progestagen, and those lasting for several months which consist of only a progestagen. Among the injectable progestagen-only contraceptives tested, only 2 have so far reached the international market: depot medroxyprogesterone acetate (DMPA), which has been administered at 3- or 6-month intervals and norethisterone enanthate, which has been injected at intervals ranging between 2 and 3 months. The most important side effect observed with these 2 agents is a complete disruption of the menstrual bleeding pattern, leading - in some cases - to total amenorrhoea, which is more frequent with depot medroxyprogesterone acetate than with norethisterone enanthate. The latter, however, has a shorter duration of action with a higher pregnancy rate than the former. Other adverse reactions are rare and of no real importance. Metabolic effects with progestagen-only injectable preparations are, in general, mild and less marked than with combined oestrogen-progestagen formulations. Recent investigations have shown that the return of fertility following their use is delayed but in no way impaired. Monthly injectable oestrogen-progestagen combinations have been tested to a more limited extent and these agents are available only in a very few countries. Their main advantage over progestagen-only preparations is that they allow a reasonable menstrual bleeding pattern in the majority of cases. Their obvious disadvantage is that they contain a long acting oestrogen.

Puerperal insertion of a copper-releasing and a levonorgestrel-releasing intrauterine contraceptive device

A copper-releasing IUD and levonorgestrel-releasing IUDs releasing 30 micrograms and 10 micrograms levonorgestrel per day were inserted six weeks after delivery in 110 volunteers. During the treatment, events and patterns of bleeding were recorded and plasma levonorgestrel concentrations were measured. The number of events in one year of follow-up was very low, four removals out of 40 in the copper-releasing IUD group and five removals out of 70 in the levonorgestrel-releasing IUD group. Bleeding and spotting was significantly more common after insertion of a levonorgestrel-releasing IUD than a copper-releasing IUD, but it was scanty and well-tolerated. After three months, levonorgestrel-releasing IUD patients had less bleeding and spotting than the copper-releasing IUD patients. No pregnancies occurred during the study period. There were two uterine perforations with a uterine sound at the insertion. In the 30-micrograms per day levonorgestrel-releasing IUD group, initially high plasma levonorgestrel concentrations reached a plateau four weeks after the insertion. In the 10-micrograms per day levonorgestrel-releasing IUD group, the plasma concentrations of levonorgestrel stabilized after the initial two weeks.

Duration of breast-feeding and development of children after insertion of a levonorgestrel-releasing intrauterine contraceptive device

IUDs releasing levonorgestrel, 10 micrograms per day (30 patients) and 30 micrograms per day (40 patients), and copper-releasing IUDs (Nova-T) (40 patients) were inserted six weeks after delivery in 110 breast-feeding amenorrheic women. The infants were carefully followed-up by recording monthly weight gain and growth, age of eruption of the first tooth, age of being able to walk without support and morbidity to infective diseases. No differences were noticed between the study groups. Plasma samples were collected from 13 children at the age of eight months, while the mothers were breast-feeding. Six mothers had a levonorgestrel-releasing IUD and seven others the Nova-T or no hormonal or intrauterine contraceptive. No differences were noticed between the groups in Na, K, Cl, Ca, P, protein, albumin, creatinine, urate, Fe, cholesterol, triglyceride, bilirubin, alkaline phosphatase, aspargine aminotransferase, alanine aminotransferase, lactate-dehydrogenase or high density lipoprotein cholesterol serum concentrations in the children. The duration of breast-feeding and initiation of supplementary feeding was recorded. The continuation of breast-feeding 75 days after the insertion of a 30-micrograms per day levonorgestrel-releasing IUD was 56 percent while in the Nova-T group only 21 percent had discontinued which is a statistically significant difference (p less than 0.05); later the difference disappeared. Compared with the lactation time of their previous breast-feeding reported by women in both groups, the present lactation time increased by ten weeks. The infants received substitute foods including substitute milk, juices, etc., in the Nova-T group at 3.9 months and in the levonorgestrel-releasing IUD group at 3.4 months after delivery.

The Depo-Provera debate. Commentary on the article "Depo-Provera, a critical analysis"

A widely publicized article has in recent months caused a great deal of concern among individuals interested in responsible promotion of family planning. The article contains a long series of factual errors, distortions and biased quotations. This commentary presents evidence, based on current knowledge, that Depo-Provera is a satisfactory contraceptive with several advantages and some disadvantages, and poses no more unresolved problems than oral contraceptives. There is no evidence that, at contraceptive doses, it increases the risk of cancer, impairs bone mineralization, "shocks" the hypothalamus, damages the liver or the immune system, or causes premature aging. Studies to date have not shown damaging effects on infants exposed to the drug in utero or via breast milk. To most women, disruption of the menstrual cycle, the major side effect, is not a health hazard. Finally, women in various parts of the world have shown to be quite capable of choosing for themselves whether or not the advantages of the drug can overcome the disadvantage of almost certain menstrual disturbance.

Plasma levels of norethidrone in Indian women receiving norethidrone enanthate (20 mg) injectable

Plasma norethindrone (NET) and progesterone were estimated by radioimmunoassay in seven Indian women after intramuscular administration of 20 mg NET enanthate. One subject had intermenstrual bleeding throughout the cycle. Out of the six subjects considered for analysis, three subjects showed ovulation suppression, two had delayed ovulation and the remaining one exhibited normal ovulatory pattern. Post-peak average plasma NET values ranged from 1.0 to 2.1 ng/ml. These values showed a significant positive correlation with the anthropometric indices such as body weight and mid-arm-circumference. The subjects with lower anthropometry showed exponential decline of plasma NET. A possible role for nutritional status of an individual in drug disposition is indicated from this study.

The effect of depot-medroxyprogesterone acetate on the fetus and nursing infant: a review

Data from published studies of the quantity of medroxyprogesterone acetate and/or its metabolites in the milk of lactating women receiving Depo-Provera for contraception is extrapolated into the amount of drug ingested daily by a theoretically average infant. Comparisons are made with the results of similar studies in animals. Fetal metabolism of medroxyprogesterone acetate is reviewed. Embryonic and fetal development of the human reproductive system is discussed. Results of studies of the effects of steroidal hormones, particularly medroxyprogesterone acetate, on mental development and sexual dimorphic behavior after exposure in utero are presented. It is concluded that the very small amount of drug and/or its metabolites ingested by the nursing infant via breast milk is highly unlikely to have any significant effect on the nursing infant.

A randomized, single blind comparative trial of norethindrone enanthate and depo-medroxyprogesterone acetate in Bangladesh

A randomized, single blind comparative trial of norethindrone enanthate (NET-ENT) and depo-medroxyprogesterone acetate (DMPA) was conducted in the Model Clinic, Decca, Bangladesh, to determine if there were differences in reported side effects, reasons for discontinuation and discontinuation rates of these two injectables. On all follow-up visits the proportion of women reporting no bleeding (amenorrhea) was higher for the DMPA clients compared to the NET-ENT clients. Concurrent with these findings, the proportion of women reporting irregular bleeding was consistently higher for the NET-ENT clients. Concurrent with these findings, the proportion of women reporting irregular bleeding was consistently higher for the NET-ENT clients compared to those receiving DMPA. By the fourth injection, less than 15% of the clients in both drug groups still reported having regular cyclic bleeding (4 of the 26 DMPA clients and 4 of the 28 NET-ENT clients). Five of the 133 women on DMPA and 6 of the 106 women on NET-ENT became pregnant while using the injectables. At the end of one year of follow-up, 14 of the 133 DMPA and 14 of the 106 NET-ENT clients were still continuing (came back for a fifth injection).