Here is the letter I sent to Dr. Hatcher, the USBC and OB-GYN NEWS: Contraception Does Begin at Birth I have no issue with using contraception early postpartum in non-lactating women but the use of progesterone-only contraceptives during lactation especially early post-partum has been poorly researched. Low quality research with methodology issues, high loss to follow up rates, failure to define exclusive breastfeeding, incorrect definitions, use of outdated growth charts to assess infant weight gains and pharmaceutical funding are among a few of the problems. There is no acceptable double-blinded randomized control trial published that looks at early post-partum contraception with progesterone-only methods. The current Cochrane Review on hormonal contraception backs this assertion up. Too few studies have been conducted, much less properly conducted, which investigate the effects on milk supply when given early postpartum. Few studies have controlled for exclusive breastfeeding, rates of supplementation and infant weight gain. None have been done using Peter Harmann’s new technology for evaluating milk supply. They have not been researched for use in premature or ill infants yet progesterone-only contraceptives are being used in these populations. Of the studies that are properly conducted, a lowering of milk supply in exclusively breastfeeding mothers has been found. Moreover, case reports of lowered milk supply have and are documented even in p roduct packaging. Despite these facts, most health care providers continue to recommend progesterone-only contraception carte blanche to exclusively breastfeeding women with or without normal health infants (and some even recommend combination methods). I have never cared for a woman taking progesterone-only contraceptives who was told it could lower her supply. I have cared for numerous mothers who were pumping and bottle-feeding for compromised infants despite the fact there is not one study done in this population. I have cared for mothers who had a sudden drop in supply that could only be explained by the onset of progesterone-only contraception. The current recommendation to encourage and support exclusive breastfeeding has been clearly communicated to all medical specialties and throughout our communities. Exclusive breastfeeding (properly defined as providing only human milk for 6 months) is the gold standard but, our usual care does not reflect putting the philosophy into practice. Maybe we do not understand how to put this philosophy into action because, the idea of “Exclusive Breastfeeding” is such a newer concept and not taught to most of us in our respective fields, By this I mean that, there is a lack of treatment of low milk supply and a lack of education when a mother is inappropriately supplementing. Moreover, there is a lack of support for the use of LAM. When a woman presents, suffering from real or perceived low milk supply, she deserv es assessment and treatment. Progesterone-only contraceptives are not treatment for low milk supply. Galactogogues are an effective treatment and so is the use of LAM. LAM is not only a treatment for low milk supply; it is 98% effective contraception. Instead of handing the supplementing mother hormonal contraception, we should be taking a history and doing an exam. There are a myriad of reasons why moms supplement and they all need to be considered (see table 1). Rarely, 5% or less, is low supply due to a true uncorrectable disease. Once a reason or reasons are identified, then recommendations for treatment need to be made. If she has perceived low milk, then education is the best initial step. If there is true low milk supply, then first and foremost more breast stimulation is needed. Next, herbs like fenugreek can be suggested and she should be evaluated for the use of metoclopramide (Reglan). If a disease state is suspected, then labs can be drawn. If the infant is not latching or sucking incorrectly a referral to a lactation specialist is warranted. The Speroff article’s emphasis on the use of hormonal contraception will not serve but will harm breastfeeding women and their babies. The emphasis should be on clearly communicating to our mothers the importance of exclusive breastfeeding and then managing low milk supply. In terms of contraception, the emphasis should be on the proper use of LAM fo r up to 6 months. Until better studies are done, the recommendation to use these contraceptives early postpartum or even at 3 months is premature and not evidenced based. This is not to say women should be denied their use early postpartum but, they need to know that it can and has lowered supply. They have a right to be informed of the risk of lower milk production, even if most mothers do not experience this effect. Failure to do so can lead to serious medical consequences particularly in the premature and compromised infant and it is reminiscent of the hormone replacement therapy debacle. Christine M. Betzold NP CLC MSN PS One interesting finding that I noticed is it appears that infants exposed to depo and other progesterones had higher morbidity/mortality rates. Hmmm, wonder why? tion write in the body of an email: set lactnet nomail 2. To start it again: set lactnet mail 3. To unsubscribe: unsubscribe lactnet 4. To get a comprehensive list of rules and directions: get lactnet welcome *********************************************** Archives: http://community.lsoft.com/archives/LACTNET.html To reach list owners: [log in to unmask] Mail all list management commands to: [log in to unmask] COMMANDS: 1. To temporarily stop your subscription write in the body of an email: set lactnet nomail 2. To start it again: set lactnet mail 3. To unsubscribe: unsubscribe lactnet 4. To get a comprehensive list of rules and directions: get lactnet welcome