Hormonal contraception and lactation

Prevalence, patterns, and determinants of breastfeeding cessation among mothers of children under 24 months in Uganda

BACKGROUND

Breastfeeding duration is a critical component of infant and child nutrition, providing immediate and long-term benefits to both children and their mothers. This study uses data from the lot quality assurance sampling (LQAS) survey to examine the prevalence, patterns, and determinants of breastfeeding cessation in Uganda.

METHODS

This study was a secondary analysis of data collected by the cross-sectional LQAS surveys in 2021 and 2022 covering 77 districts in Uganda. The LQAS survey methodology employs a systematic sampling approach to assess whether predefined quality standards are met within specific subgroups of a population. The study employed spatial analysis, bivariate analysis and logistic regression, both with and without clustering, to explore associations between independent variables and breastfeeding cessation. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated. Statistical significance was set at 5%.

RESULTS

Overall, the study analysed 26,377 records of mothers with children under 24 months old. The mothers' mean age was 27.9 years while that of their children was 11.0 months. While the general breastfeeding cessation rate was 17.7%, cessation was highest (49.7%) among mothers of children 18-23 months. Factors associated with increased odds of breastfeeding cessation included older child's age, older mother's age, using modern family planning, being pregnant and having an unknown pregnancy status. Lower odds of breastfeeding cessation were observed among mothers who; were married, lived in larger households, lived in rural residences, whose children received vitamin A supplementation and among all other regions compared to Kampala.

CONCLUSION

One in five mothers cessed breastfeeding before their child reached 2 years, with a significant increase in cessation odds among mothers of older children. These findings underscore the importance of interventions to promote breastfeeding continuation and adequate nutrition for non-breastfed infants, particularly in regions with high cessation rates.

Evaluating Shared Decision-Making in Postpartum Contraceptive Counseling Using Objective Structured Clinical Examinations

Background

Shared decision-making (SDM) may support widespread uptake of progestin-containing long-acting reversible contraceptives in the immediate postpartum period. We piloted an Objective Structured Clinical Examination (OSCE) to evaluate first-year obstetrics and gynecology resident physicians' use of SDM in postpartum contraception counseling.

Methods

As part of their 2015 and 2016 OSCEs, first-year OB/GYN residents were instructed to provide contraceptive counseling to a Standardized Patient (SP) portraying a 29-year-old postpartum patient seen during rounds on the morning following her delivery. Three investigators independently scored each resident encounter using a 10-item rubric adapted from a 9-item SDM measure and assigned scores of 0 (absent), 1 (partial), or 2 (complete). Each encounter was video and audio recorded, then transcribed for qualitative analysis. Descriptive statistics was produced using SPSS version 24.

Results

Eighteen residents participated. The majority (78%) discussed contraceptive options and timing of initiation. Nearly 33% elicited factors most important to the SP in influencing her preference. Only 6% discussed the benefits of exclusive breastfeeding, and few addressed the uncertainty of progesterone on milk supply and production.

Conclusion

Although residents conveyed ample clinical information, the vast majority did not discuss elements of SDM, such as her preferences, values, and goals for future fertility and breastfeeding. Our work revealed that critical elements of SDM are often not explored and deliberated by resident physicians. Trainings (e.g., OSCEs) are needed to equip residents with effective communication skills to facilitate more SDM in postpartum contraceptive care.

Key to Life: Physiological Role and Clinical Implications of Progesterone

The most recent studies of progesterone research provide remarkable insights into the physiological role and clinical importance of this hormone. Although the name progesterone itself means "promoting gestation", this steroid hormone is far more than a gestational agent. Progesterone is recognized as a key physiological component of not only the menstrual cycle and pregnancy but also as an essential steroidogenic precursor of other gonadal and non-gonadal hormones such as aldosterone, cortisol, estradiol, and testosterone. Based on current findings, progesterone and novel progesterone-based drugs have many important functions, including contraception, treatment of dysfunctional uterine bleeding, immune response, and prevention of cancer. Considering the above, reproduction and life are not possible without progesterone; thus, a better understanding of this essential molecule could enable safe and effective use of this hormone in many clinical conditions.

Molecular Effects of Topical Estrogen on Vaginal Granulation Tissue in Postpartum Women

OBJECTIVE

The aims of this study were to evaluate the biomolecular properties of vaginal and perineal granulation tissue in postpartum women and assess the potential impact of vaginal estrogen application.

METHODS

We prospectively identified women referred to a subspecialty peripartum clinic between September 2016 and April 2018 who developed symptomatic perineal or vaginal granulation tissue. As part of routine clinical care, granulation tissue was excised from each participant by a urogynecologist and subjected to RNA extraction, real-time quantitative polymerase chain reaction, histologic evaluation, and immunohistochemistry. Serum steroid hormone levels were measured. Comparisons were made between participants who used topical vaginal estradiol (E2) and those who did not (non-E2 controls).

RESULTS

Sixteen postpartum women were recruited for this pilot study. More than 30% of patients (n = 5, 31%) had used topical vaginal estradiol (E2) during their postpartum recovery. Histological appearance of granulation tissue evaluated by hematoxylin and eosin staining was similar in women treated with vaginal E2 and non-E2 controls. Both estrogen receptor α (ERα) and ERβ mRNA and ERα protein were readily detectable in the granulation tissue of E2-treated women. Although not statistically significant, participants who used topical E2 developed granulation tissue that exhibited local estrogen-responsive gene upregulation. Serum levels of estrone, E2, dehydroepiandrosterone, progesterone, and testosterone did not differ between vaginal E2-treated patients and controls.

CONCLUSIONS

Estrogen receptor α seems to be the predominant receptor mediating estrogen action in postpartum perineal and vaginal granulation tissue. Vaginal E2 use does not seem to affect serum levels of estrone, E2, dehydroepiandrosterone, progesterone, and testosterone in postpartum women.

Case of rupture ectopic pregnancy with emergency contraception levonorgestrel 0.075 mg in a lactating woman

Levonorgestrel emergency contraception (LNG-EC) tends to make uterus unfavorable for implantation but does not prevent embryo implantation. Emergency contraceptives pills should be used with caution among lactating women who at the same time should be monitored closely for ectopic pregnancy.

The effects of early life stress on motivated behaviors: A role for gonadal hormones

Motivated behaviors are controlled by the mesocorticolimbic dopamine (DA) system, consisting of projections from the ventral tegmental area (VTA) to the nucleus accumbens (NAc) and prefrontal cortex (PFC), with input from structures including the medial preoptic area (mPOA). Sex differences are present in this circuit, and gonadal hormones (e.g., estradiol and testosterone) are important for regulating DA transmission. Early life stress (ELS) also regulates the mesocorticolimbic DA system. ELS modifies motivated behaviors and the underlying DA circuitry, increasing risk for disorders such as substance use disorder, major depression, and schizophrenia. ELS has been shown to change gonadal hormone signaling in both sexes. Thus, one way that ELS could impact mesocorticolimbic DA is by altering the efficacy of gonadal hormones. This review provides evidence for this idea by integrating the gonadal hormone, motivation, and ELS literature to argue that ELS alters gonadal hormone signaling to impact motivated behavior. We also discuss the importance of these effects in the context of understanding risk and treatments for psychiatric disorders in men and women.

The injection or the injection? Restricted contraceptive choices among women living with HIV

Historically, women living with HIV (WLWH) have been vulnerable to biased advice from healthcare workers regarding contraception and childbearing. However, antiretroviral therapy (ART) has made motherhood safer, prompting a re-examination of whether contraceptive services enable the realisation of WLWH’s reproductive intentions. We use longitudinal quantitative data on contraceptive choice and use, and childbearing intentions collected in (up to) six interviews between entry into antenatal care (ANC) and 18 months post-partum from a cohort of 471 ART-initiated WLWH in Cape Town, South Africa. Thirty-nine of these women were randomly selected for in-depth interview where they described experiences of contraception services and use. We find high prevalence of injectable contraceptive (IC) use after birth (74%). With increasing post-partum duration, greater proportions of women discontinue this method (at 18 months 21% were not using contraception), while desires for another child remain stable. We find little consistency between method choice and use: many women who elected to use the intrauterine device, sterilisation or oral contraceptives at first ANC visit are using IC after birth. Women commonly report receiving an IC shortly after birth, including those who had previously chosen to use another method or no method. Among WLWH, injectables dominated the contraceptive method mix. Despite a human rights-grounded policy and attempts to introduce new methods, contraceptive services in South Africa remain largely unchanged over time. Women are frequently unable to make autonomous contraceptive choices. Despite low desires for future pregnancy, we observed high rates of contraceptive discontinuation, resulting in heightened risk of unintended pregnancy.

Hormone replacement therapy in young women with primary ovarian insufficiency and early menopause

Primary ovarian insufficiency (POI) is a rare but important cause of ovarian hormone deficiency and infertility in women. In addition to causing infertility, POI is associated with multiple health risks, including bothersome menopausal symptoms, decreased bone density and increased risk of fractures, early progression of cardiovascular disease, psychologic impact that may include depression, anxiety, and decreased perceived psychosocial support, potential early decline in cognition, and dry eye syndrome. Appropriate hormone replacement therapy (HRT) to replace premenopausal levels of ovarian sex steroids is paramount to increasing quality of life for women with POI and ameliorating associated health risks. In this review, we discuss POI and complications associated with this disorder, as well as safe and effective HRT options. To decrease morbidity associated with POI, we recommend using HRT formulations that most closely mimic normal ovarian hormone production and continuing HRT until the normal age of natural menopause, ∼50 years. We address special populations of women with POI, including women with Turner syndrome, women with increased risk of breast or ovarian cancer, women approaching the age of natural menopause, and breastfeeding women.

The Use of Cellulose Membrane to Eliminate Burst Release from Intravaginal Rings

Burst release was observed when ethylene vinyl acetate copolymer (EVA) intravaginal rings were tested for progesterone release in our previous work (Helbling et al. Pharm Res. 31(3):795-808, 2014). Burst release is undesirable in controlled delivery devices because release is uncontrollable and higher levels of active pharmaceutical ingredient could lead to the occurrence of adverse effect. The present contribution is about the use of membranes to coat EVA rings to eliminate burst release. Physicochemical state of progesterone in uncoated rings and the solubility and diffusion coefficient in membrane were studied. Hormone delivery from several rings of different sizes was compared. A mathematical model was used to analyze the effects of membrane properties on delivery rate. No chemical interactions were detected between hormone and polymer. Hormone was mainly forming amorphous aggregates inside rings, and migration to membrane was not observed during storage. Diffusion coefficient was smaller in membrane (∼10(-8) cm(2) s(-1)) than in matrix (∼10(-7) cm(2) s(-1)). Zero-order release kinetics were obtained for coated rings, and release rate decreases as the thickness of the coat increases. Cellulose membrane successfully eliminates burst release and controls the delivery from EVA rings. The equations developed can be used to determine the appropriate coat thickness to produce specific release rate.

"Natural" relief of pregnancy-related symptoms and neonatal outcomes: above all do no harm

ETHNOPHARMACOLOGICAL RELEVANCE

In the South of Italy the use of herbal remedies to alleviate pregnancy-related symptoms is very common.

OBJECTIVES

To investigate the proportion, prevalence of use, attitude and knowledge base in a sample of Italian pregnant women in the South of Italy. To explore the possible influence and risks of herbal consumption on pregnancy and neonatal outcomes.

METHODS

A retrospective observational study was conducted during the study period November 2010-September 2013. Six hundred and thirty expectant mothers were interviewed within three days after childbirth in a public Hospital in the South of Italy.

RESULTS

Due to a lack of data, a total of six hundred interviews were considered. Four hundred and eighty six women (81%) reported to have constantly used at least one herbal product throughout the pregnancy period. The study enrolled mostly women between 31 and 40 years of age, with a middle-high level of education, married and employed. The most commonly used herbal products, taken by oral route and for the entire period of pregnancy, were chamomile, fennel, propolis, cranberry, lemon balm, ginger, valerian and mallow. The most relevant source of information for the majority of participants was the doctor (95%), and most of the women (72%) informed their doctors about their use of herbal remedies.

CONCLUSIONS

The regular chamomile consumption resulted in a higher risk of pre-term delivery, lower birth weight and lower length of the newborn. Also a regular use of fennel resulted in a shorter gestational age. Finally, ginger intake resulted in a shorter gestational age and in a smaller circumference of the newborn's skull.

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.

Does Contraceptive Use Always Reduce Breast-feeding?

Previous studies suggest that access to modern contraceptives can reduce breast-feeding rates because women who had been using breast-feeding to avoid pregnancy substitute away from it. This article shows that contraceptive use can also have a positive effect on breast-feeding. A mother often weans a child if she becomes pregnant again, which can occur sooner than desired if she lacks access to contraceptives. Thus, by enabling longer birth spacing and preventing unwanted pregnancies, contraceptive use allows for a longer duration of breast-feeding. This positive effect should primarily affect infants who are past the first few months of life because their mothers are more fecund then, and the negative effect should affect infants who are very young because the contraceptive property of breast-feeding is strongest then. I test for these dual effects using Demographic and Health Survey data for Indonesia. I find evidence of the positive birth-spacing effect: contraceptive use increases the likelihood that children continue to be breast-fed past age 1. There is also suggestive evidence of a negative substitution effect among infants age 3 months and younger.

Weight and body fat changes in postpartum depot-medroxyprogesterone acetate users

BACKGROUND

Although postpartum depot-medroxyprogesterone acetate (DMPA) recipients often cite weight gain as the reason for discontinuing DMPA, little is known about body composition changes in postpartum DMPA recipients.

STUDY DESIGN

Women who used DMPA during the postpartum year were measured on several anthropometric dimensions of body composition and compared with women who elected surgical sterilization with bilateral partial salpingectomy (BPS).

RESULTS

After 1 year, DMPA recipients did not differ from the BPS group in weight or percent body fat changes. Almost half the women using DMPA returned to pregravid weight; nearly half gained weight. Higher pre-pregnancy body mass index was associated with weight gain among DMPA recipients.

CONCLUSIONS

DMPA recipients who were overweight or obese before pregnancy may have greater risk for weight gain in the first year postpartum. However, when counseling women, the risk for DMPA-related weight gain should be balanced against the potential for increased weight from subsequent pregnancies.

Levonorgestrel used for emergency contraception during lactation-a prospective observational cohort study on maternal and infant safety

OBJECTIVE

To identify possible effects of levonorgestrel used as an emergency contraceptive during breastfeeding on mothers and their infants.

STUDY DESIGN

A prospective observational cohort study of all women who contacted the Teratology Information Service between January, 2005 and January, 2010. Breastfeeding women who used levonorgestrel as an emergency contraceptive (study group) were compared to breastfeeding women who used either ethynodiol diacetate or desogestrel (control group). Women were followed for 6-24 months. Main outcome measures were adverse maternal and infant effects and continuation of breastfeeding.

RESULTS

We followed 71 of 128 study group women and 72 of 100 control group women. Maternal adverse effects were mainly vaginal bleeding, which was less frequent in the study vs. control group (16 of 71 vs. 27 of 72, p = 0.068). Decreased lactation was uncommon and similar in both groups. Breastfeeding was reinitiated within less than 8 h in 75% of the levonorgestrel group women. Adverse infant effects were rare (0 of 72 infants vs. 2 of 72 infants, p = 0.5 in the study vs. control group).

CONCLUSIONS

Our findings support the safety of using levonorgestrel as an emergency contraceptive during lactation without the need for withholding breastfeeding.

Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference?

OBJECTIVE

The purpose of this study was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant (IPI) insertion.

STUDY DESIGN

Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, 171) vs other methods (control group, 225). Contraceptive continuation and repeat pregnancies were determined.

RESULTS

Implant continuation at 6 months was 96.9% (156/161 participants); at 12 months, the continuation rate was 86.3% (132/153 participants). At 6 months, 9.9% of the control participants were pregnant (21/213); there were no IPI pregnancies. By 12 months, 18.6% of control participants (38/204) experienced pregnancy vs 2.6% of IPI recipients (4/153; relative risk, 5.0; 95% confidence interval [CI], 1.9-12.7). Repeat pregnancy at 12 months was predicted by not receiving IPI insertion (odds ratio, 8.0; 95% CI, 2.8-23.0) and having >1 child (odds ratio, 2.1; 95% CI, 1.1-4.3; P = .03).

CONCLUSION

IPI placement in adolescents has excellent continuation 1 year after delivery; rapid repeat pregnancy is significantly decreased compared with control participants.

Levonorgestrel pharmacokinetics in plasma and milk of lactating women who take 1.5 mg for emergency contraception

BACKGROUND

Progestin-only methods are among the contraceptive options available for breastfeeding women, however the doses of progestin used in emergency contraception (EC) have not been evaluated in nursing mothers. We therefore investigated the pharmacokinetics of 1.5 mg levonorgestrel (LNG) in lactating women.

METHODS

Twelve healthy exclusively breastfeeding volunteers received 1.5 mg LNG. Women refrained from nursing for 72 h after dosing and fed their infants with milk frozen beforehand. Serial blood and milk samples were collected for 120 h and assayed for LNG and sex hormone binding globulin.

RESULTS

LNG concentrations peaked in plasma and in milk 1-4 h and 2-4 h after dosing, respectively. Concentrations in milk (M) paralleled those in plasma (P) but were consistently lower (mean M:P ratio 0.28). Estimated infant exposure to LNG is 1.6 microg on the day of dosing (1 microg in the first 8 h), 0.3 microg on the second day and 0.2 microg on the third day.

CONCLUSIONS

Nursing mothers may need EC. These results suggest that to limit infant exposure to the period of maximum LNG excretion in milk, mothers should discontinue nursing for at least 8 h, but not more than 24 h, after EC.

Effects of the etonogestrel-releasing implant Implanon® and a nonmedicated intrauterine device on the growth of breast-fed infants

The study objectives were to compare the effects of an etonogestrel-releasing implant (Implanon) and a nonmedicated intrauterine device (IUD) on parameters of lactation in breast-feeding women and on the growth of their breast-fed infants over a 3-year period. Healthy lactating women (28-56 days postpartum) chose either the implant (n=42) or the IUD (n=38). Infant growth during a 3-year follow-up period is reported here. Total duration of breast-feeding coinciding with the mothers' treatment was 421.0 and 423.4 days in the Implanon and IUD groups, respectively. There were no differences between the infant groups in terms of body length, biparietal head circumference and body weight. No abnormalities were reported in psychomotor development or during physical examination. No treatment-related side effects were observed in either group. In conclusion, there were no differences in the growth of breast-fed infants of women treated with Implanon or a nonmedicated IUD. Implanon, therefore, appears to be a safe contraceptive option for breast-feeding women and their infants.

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.

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.

Comparative study of the effects of a progestogen-only pill containing desogestrel and an intrauterine contraceptive device in lactating women

OBJECTIVE

To evaluate the effects of desogestrel 75 microg/day, as a progestogen-only pill compared with a copper-bearing intrauterine contraceptive device (IUCD) on lactation and to study the safety of both treatments in mothers and children. Transfer of etonogestrel to breast milk was studied in a subgroup of desogestrel users. The children were to be followed up until 2.5 years of age.

DESIGN

An open, non-randomised, group-comparative study in lactating women.

SETTING

University Hospital, Reykjavik, Iceland.

PARTICIPANTS

A total of 83 lactating women; 42 received desogestrel and 41 had an IUCD inserted for seven consecutive treatment cycles of 28 days.

METHODS

Evaluation visits were planned at baseline and at the end of treatment cycles 1, 4 and 7. The amount of breast milk was determined by weighing the infants before and after feeding, at baseline and after treatment cycles I and 4. Milk samples were obtained at the same time for constituent measurements. Safety was studied by structured medical examinations and by recording adverse experiences in mothers and children.

RESULTS

There were no significant differences between the desogestrel and IUCD groups in composition and quantity of breast milk nor in growth and development of the children followed up to the age of 2.5 years. In the desogestrel group a slightly higher incidence of mild adverse experiences of a hormonal nature was reported among both mothers and infants. Of the children 82% were followed until 1.5 years of age and 50% until 2.5 years.

CONCLUSION

The use of desogestrel 75 microg/day did not change the amount and composition of breast milk nor did it affect growth and development of the breastfed children. It appears to be a safe and effective contraceptive method for lactating women