In response to the question on the use of progestin only methods
by nursing women during the first 6 weeks postpartum, I can quote
the following paragraph taken from "Contraception in lactating
women" by Diaz S and Croxatto HB, Current Opinion in Obstetrics and
Gynecology 1993, 5:815-822 where you can find the references that
support this recommendation.

"Transference of steroids to the breastfed child: Contraceptive
steroids are excreted in milk. There is concern of their impact on
infant development, based on the effect of intrauterine and
postnatal administration of sex steroids to animals and
observations after intrauterine exposure to certain steroids in
humans. This has prompted debate on when to initiate use.
     Progestin concentration in milk depends on the concentration
of the unbound fraction in plasma. The plasma:milk ratio ranges
from 1:1 for progesterone and DMPA to 10;1 and 20:1 for
the 19-nortestosterone derivatives, such as levonorgestrel and
norethisterone. The estimated daily dose received by
a fully nursed child is small (Table 2). Very low progestin levels
have been detected in the plasma of breastfed infants. The
short or long term studies available on development of children
have found no differences with the control groups.
     Some consider that the small amount of steroids in milk
represent no risk to the child and that progestin only methods can
be provided since the first post partum days. Others recommend
to delay its use beyond 6 to 8 weeks postpartum, interval
in fully nursing amenorrheic women have no risk of pregnancy and
the central nervous system of the newborn experiences a period of
very rapid growth. Fears that the transfer of steroids may affect
development is not substantiated by the few long term follow up
studies available, but the information is so scarce that it is not
reassuring either. Therefore, we think that the early use of orally
active steroids should be discouraged."


     In addition, Dr Soledad Diaz would like to state that:

* The studies performed in the last years clearly show that fully
nursing amenorrheic women have no risk of pregnancy and need no
contraception in the first 6 postpartum months.
* The last weeks of pregnancy and the first weeks of extrauterine
life correspond to the period of more rapid growth of the central
nervous system in the human and the period in which it may be more
vulnerable to deleterious stimuli.
* These first postpartum weeks are also the period in which the
liver and other systems are less mature and there is no information
on how the child handles exogenous steroids, even if administered
in the minimal amounts found in maternal milk.
* In this period, the endogenous production of ovarian steroids is
reduced to a minimun amount, suggesting that nature has taken care
of an steroid free milk in the first weeks postpartum.
* There are ethical considerations involved. The mother has the
right and the need of delaying another pregnancy and the right to
choose the best method for herself. The child will greatly benefit
from breastfeeding and a prolonged birth interval. On the other
hand, if the mother starts an hormonal method, the child would
receive a drug not required for his or her one sake. In some sense,
the newborn becomes the recipient of a treatment without informed
consent. Since the mother takes the responsibility for the child,
she should know that, unfortunately, the longterm effects on
development have not been thoroughly assessed. She should also be
informed that non hormonal methods are the first option during
lactation and, if hormonal methods are her choice, that they are
not necessary in the first weeks postpartum.



                            TABLE 2

        Estimated steroid intake by fully nursed infants
            whose mothers use progestin only methods

      ____________________________________________________

      Method                                 Daily Intake*
      (dose)
      ____________________________________________________

      Injectable

        DMPA (150 mg/3 months)               0.3 -  10 ug
        NET-EN (200 mg/8 weeks)              0.5 - 2.4 ug

      Oral

        Levonorgestrel (30 ug/day)            40 - 140 ng
        Ethynodiol Diacetate (500 ug/day)    100 - 600 ng
        Norethisterone (350 ug/day)          100 - 300 ng

      Implant

        NORPLANTR (100-30 ug/day)             25 - 300 ng
        NestoroneTM (ST-1435, 50 ug/day)**    50 - 60 ng

      Contraceptive Ring

        Progesterone (10 mg/day)**                   6 ug
      ___________________________________________________

      *  Estimated from milk concentrations (38, 46, 49,
         50, 61, 62) assuming a daily intake of milk of
         800-1000 mL.
      ** Orally inactive steroids.






     Regards.

     Heli Bathija