Responding to Michelle's post 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 LC in Harare.  Like Michelle, 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".  Sometimes there was 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 (containing levonorgestrel), Ovrette 
(norgestrel) or Exluton (containing lynestrenol).  The latter was 
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.  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 
results on withdrawal of the mini-pill were often quite 
dramatic.  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 digging 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 finally 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 
told me that indeed 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.
11.  My hypothesis is that there is a more-likely/less-likely thing 
going on:  that women have an individual response to hormonal 
contraception; some progestins may indeed behave like estrogens for 
some mothers, to possibly cause negative consequences breastmilk 
quantity (affecting prolactin levels, reduced milk production and 
symptoms of depression for the mother?) and/or maybe on the quality 
(reduced fat/protein content in the milk?)   I think 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.

I hope this helps.

Pamela Morrison IBCLC
Rustington, England
-------------------------------------------
Date:    Sun, 22 Apr 2007 22:39:41 -0400
From:    "Michelle A. Crosby" <[log in to unmask]>
Subject: Breastfeeding and Birth Control

My name is Michelle, and I am currently a junior in a baccalaureate nursing
program I took interest in a recent post and did some research to find out
more on this topic.  What I found was an apparent lack in research on this
subject. .....What has been your clinical experience with birth 
control and breastfeeding?

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