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#320 Oh Baby: Combined oral contraceptives during breastfeeding


CLINICAL QUESTION
QUESTION CLINIQUE
Do combined oral contraceptives (COCs) affect breastfeeding or infant outcomes?


BOTTOM LINE
RÉSULTAT FINAL
Trials are older (>35 years), small (<300 mom/infants) and highly unreliable. If results are real, COCs may lower infant growth (by~240g) and rates of exclusive breastfeeding (81% versus 92%) compared to placebo at 90 days. Progestin-only pill (POP) evidence is inconsistent/unreliable. If results are real, infant growth is not different compared to placebo. If early postpartum contraception is desired, guidelines recommend progestin-only methods due to increased venous thromboembolism risk.



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EVIDENCE
DONNÉES PROBANTES
  • Randomized controlled trials (RCTs) from two systematic reviews.1,2 Oral contraceptives started 2-6 weeks postpartum. Results statistically different unless indicated.
  • COC versus placebo:
    • Infant weight:
      • 182 women, ethinyl estradiol 30mcg/levonorgestrel 0.15mg:3
        • At 91 days postpartum: 6011g versus 6250g (placebo).
      • 50 women, mestranol 80mcg with progestin:4
        • Between weeks 2-5 postpartum: Weight gain ~7oz less versus placebo, statistics not reported.
    • Exclusive breastfeeding:
      • At 91 days:3 81% versus 92% (placebo).
    • Supplemental formula:
      • At 91 days:3 Proportion supplementing: 18% versus 8% (placebo), not statistically different.
      • At 5 weeks:4 ~710 versus 190 supplemental calories/week (placebo), statistics not reported.
  • POP versus placebo:
    • Started ≤6 weeks postpartum: Two low-quality RCTs (20 and 400 women).5,6
      • Infant growth: No difference.2
  • COC versus POP:
    • Largest RCT (171 women) comparing ethinyl estradiol 30mcg/levonorgestrel 150mcg versus levonorgestrel 150mcg over 6-24 weeks postpartum:7
      • No difference: Infant weight or supplementation.
      • Milk volume: Decreased 42% COC vs 12%.
    • Results consistent with other RCT (127 women);8
      • No difference: Breastfeeding or adverse effects at 6 months.
  • Limitations: Old trials (>35 years);3-5,7 incomplete reporting;3,4,7 underpowered;8 high drop-outs;7,8 unclear randomization;3 some formulations/doses no longer used.4,9
  • COC adverse effects on mother/child pairs from non-RCTs:
    • 48 pair: No difference in growth/intellectual development versus control, ≤8 years.9
    • 103 versus 227 pairs (placebo/intrauterine device): No difference in infant breast/genital changes at 1 year.10
Context
  • Guidelines recommend:
    • Progestin-only contraception during early postpartum period.11,12
    • Against COC within first 4-6 weeks postpartum while breastfeeding due to venous thromboembolism risk.12,13
      • Early postpartum risk is 15-35 times non-pregnant,12,14 returning to baseline at 6-12 weeks.14


Hifsa Khan August 1, 2022

I learn some thing new and will start practicing acc to new recommendations. Baseline risk at 12 wks is reassuring.

Shiraz Shariff August 7, 2022

It makes no sense to prescribe bcp to a breast feeding mother. The bcp will appear in the breast milk.

Gilbert Bretecher November 5, 2022

Progestin is relatively safe to use early postpartum


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Author(s)
Auteur(s)
  • Jennifer Potter MD CCFP
  • Samantha Moe PharmD
  • Allison Paige MD CCFP

1. Tepper NK, Phillips SJ, Kapp N, et al Contraception. 2016; 3(94): 262-74.

2. Lopez LM, Grey TW, Stuebe AM, et al. Cochrane Database Syst Rev. 2015; 3:CD003988.

3. Diaz S, Peralta O, Juez G, et al. Contraception. 1983; 27:1:1-11.

4. Miller GH, Hughes LR. Obstet Gynecol. 1970; 35(1):44-50.

5. Giner Velazquez, Cortes Gallegos V, Sotelo Lopez A, et al. Ginecol Obstet Mex 1976; 40(237):31-9.

6. Dutta DK, Dutta I. J Indian Med Assoc 2013; 111(8):553-5.

7. Tankeyoon M, Dusitsin N, Chalapati, S, et al. Contraception. 1984; 30(6):505-22.

8. Espey E, Ogburn T, Leeman L et al. Obstet Gynecol. 2012; 119(1):5-13.

9. Nilsson S, Mellbin T, Hofvander Y, et al. Contraception. 1986; 34(5):443-57.

10. Croxatto HB, Diaz S, Peralta O, et al. Contraception. 1983: 27(1):13-25.

11. Black A, Guilbert E, Costescu D, et al. JOGC. 2016; 38(3):279-300.

12. The Faculty of Sexual and Reproductive Healthcare. https://www.fsrh.org/standards-and-guidance/documents/contraception-after-pregnancy-guideline-january-2017/. Accessed June 29, 2022.

13. Black A, Guilbert E, Costescu D, et al. JOGC 2017; 39(4): 229-268.

14. Thrombosis Canada. https://thrombosiscanada.ca/wp-uploads/uploads/2021/11/42.-Pregnancy-Diagnosis-of-DVT-and-PE_14Sept2021.pdf. Accessed June 29, 2022.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.