Is Contraceptives, Oral, Combined Safe in Breastfeeding

I am a breastfeeding mother and i want to know if it is safe to use Contraceptives, Oral, Combined? Is Contraceptives, Oral, Combined safe for nursing mother and child? Does Contraceptives, Oral, Combined extracts into breast milk? Does Contraceptives, Oral, Combined has any long term or short term side effects on infants? Can Contraceptives, Oral, Combined influence milk supply or can Contraceptives, Oral, Combined decrease milk supply in lactating mothers?

Evidence on the safety and desirability of using combined oral contraceptives during lactation ranges in quality from poor to fair.[1][2][3] The weight of current evidence seems to indicate that combination oral contraceptives probably do not affect the composition of milk substantially in healthy, well-nourished mothers and do not adversely affect long-term infant growth and development. Combined oral contraceptives might transiently affect growth negatively during the first month after introduction. The magnitude of the effect on lactation likely depends on the dose and the time of introduction postpartum. Ethinyl estradiol in doses greater than 30 mcg daily can suppress lactation and lead to more supplementation and possibly earlier discontinuation of breastfeeding than nonhormonal or progestin-only contraception. Additionally, introduction of an estrogen before 3 weeks postpartum may increase the risk of thromboembolism in postpartum women. Rare cases of reversible breast enlargement in breastfed infants have been reported, mostly with estrogen doses higher than are currently used. Based on the available evidence, expert opinion in the United States is that postpartum women who are breastfeeding should not use combined hormonal contraceptives during the first 3 weeks after delivery because of concerns about increased risk for venous thromboembolism. Postpartum breastfeeding women with other risk factors for venous thromboembolism generally should not use combined hormonal contraceptives 4 to 6 weeks after delivery. Nursing mothers generally should not use combined hormonal contraceptives during the fourth week postpartum because of the potential to adversely affect the milk supply.[4] World Health Organization guidelines are more restrictive, stating that combined oral contraceptives should not be used in nursing mothers before 42 days postpartum and the disadvantages of using the method generally outweigh the advantages between 6 weeks and 6 months postpartum.[5]

Bilateral breast enlargement was reported in a 3-week-old male breastfed infant whose mother began taking an oral contraceptive containing norethynodrel 2.5 mg and mestranol 100 mcg on day 3 postpartum. On the second cycle, she began taking norethynodrel 5 mg and mestranol 75 mcg in error and the breast enlargement became more pronounced. After discontinuation of breastfeeding, the breasts returned to normal within 2 to 3 weeks.[8] The contraceptive probably caused the breast enlargement. Bilateral breast enlargement occurred in an otherwise normal 3-month-old male infant whose mother began a combination contraceptive containing 100 mcg of ethinyl estradiol for 21 days with the last 6 days also containing 5 mg of norethindrone. The woman stopped the contraception and the gynecomastia disappeared completely in about 4 weeks.[9] The contraceptive possibly caused the breast enlargement. In a study of women given a combination of 50 mcg of ethinyl estradiol and 250 mcg of levonorgestrel, an infant (sex not stated) developed transient gynecomastia after 3 months of maternal therapy.[6] The contraceptive possibly caused the breast enlargement. An 18-month old partially breastfed girl developed bilateral breast enlargement 3 months after her mother began taking an oral contraceptive containing ethinyl estradiol 30 mcg and levonorgestrel 150 mcg. Breastfeeding was discontinued and the breast enlargement decreased over the next 6 months. The girl was growing and developing normally at 7 years of age.[10]The contraceptive possibly caused the breast enlargement. A 10-month-old male infant presented after 3 weeks of vomiting, diarrhea and deterioration in nutritional status. Laboratory evaluation found folic acid deficiency and macrocytic anemia which responded well to folic acid. The mother had been taking a combination oral contraceptive (ingredients not specified) for 3 months. The authors attributed the folic acid deficiency to maternal contraceptive use.[11] The contraceptive possibly caused the folate deficiency. Forty-eight children (20 boys and 28 girls) whose mothers used a combination oral contraceptive containing 50 mcg of ethinyl estradiol during lactation beginning 2 months postpartum were compared to age- and sex-matched control children whose mothers breastfed, but took no contraceptive. Using several different sources of health records, no differences in the height or weight, illnesses, or intellectual development of the groups at several time points were found up to 8 years of age.[12]

High-dose estrogens, alone or in combination with an androgen, were formerly used to suppress lactation in women who did not wish to breastfeed.[13] Combination oral contraceptives containing mestranol 100 mcg daily has also been used as a method for decreasing postpartum breast engorgement in women who did not breastfeed.[14][15] In a randomized, double-blind study, 2 tablets twice daily for 5 days of a combination oral contraceptive containing 50 mcg of ethinyl estradiol had similar efficacy to bromocriptine (dosage not stated) in suppressing postpartum breast engorgement and lactation.[16] Changes in milk composition of breastmilk (total and nonprotein nitrogen, alpha-lactalbumin, lactoferrin, and albumin) have been observed in women taking various combination contraceptives containing 30 to 50 mcg of ethinyl estradiol and levonorgestrel 150 to 250 mcg or megesterol acetate 4 mg. However, the changes were generally within the normal range of values for healthy women.[17] Similar results were reported by another group with similar combined contraceptives.[18] Another study found no clinically important changes in the composition in the milk of mothers taking a combination contraceptive containing 150 mcg of levonorgestrel and 30 mcg of ethinyl estradiol starting at 6 weeks postpartum. However, milk volume was decreased compared to women who used no hormonal contraception.[19][20] In a partially randomized study, 25 postpartum women who want to breastfeed their infants were given an oral contraceptive containing mestranol 80 mcg and norethindrone 1 mg daily starting 6 weeks postpartum. The duration of lactation and the weight gain of the breastfed infants was reduced among the mothers who received the contraceptive compared to 25 mothers randomized to received a placebo or who took no tablets.[21] In a double-blind trial (randomization not stated), mothers were given either placebo (n = 218) or a combination oral contraceptive containing mestranol 50 mcg and norethindrone 1 mg (n = 233) daily from the day after birth to day 8 postpartum. Although there was no difference in the percentage of mothers breastfeeding, women taking the active drug needed to provide supplementary feedings more frequently than placebo-treated patients (12% vs 3.5%). The authors concluded that mothers wishing to breastfeed should not receive this contraceptive.[22] A nonrandomized study compared 100 women who were 4 to 24 weeks postpartum and were given a combination contraceptive containing mestranol 100 mcg and ethynodiol diacetate 1 mg to women who chose not to use oral contraception. Women who received the contraceptive produced less milk per week than control mothers in the 8 weeks after beginning the contraceptive.[23] An observational report on 83 women who were given 1 of 9 combination oral contraceptives containing 50 mcg of ethinyl estradiol and 80 to 100 mcg of mestranol starting at 5 days postpartum found that 54% were still breastfeeding at 6 weeks postpartum. This was in comparison to 59% of women who were not taking an oral contraceptive. The authors noted that some mothers who wished to breastfeed had difficulty.[24] Because of the overall low breastfeeding rates, lack of randomization and high loss to follow-up, the results of this study are questionable. In a randomized trial, 367 women receiving one of several methods of hormonal contraception and 249 women receiving nonhormonal contraception. Women receiving combination contraceptive containing ethinyl estradiol 50 mcg and norethindrone 1 mg beginning 1 month postpartum had a median duration of lactation shorter than control mothers who used no contraception (5.3 vs 4.6 months), but the difference was not statistically significant. Women who used oral contraceptives containing mestranol had a statistically shorter duration of lactation than those using nonhormal contraception.[25] One nonrandomized study of 6 women found that daily use of a combination contraceptive containing 10 mcg of ethinyl estradiol and 350 mcg of norethindrone experienced decreases in protein, lipids, calcium and phosphorus compared to 11 women who received nonhormonal contraception. However these changes were not statistically significant. Milk volume was similar in the two groups.[26] One group of investigators studied lactational performance in a randomized controlled trial of fully nursing mothers given an oral contraceptive containing levonorgestrel 150 mcg and ethinyl estradiol 30 mcg daily beginning at 30 to 35 days postpartum. Comparison groups were mothers who received no hormonal contraception. Of the mothers evaluated at 91 days postpartum (contraceptive n = 103; placebo n = 188), the contraceptive group had a lower percentage of exclusively breastfeeding mothers (81% vs 92%) and lower average daily infant weight gain during the first month of use and lower absolute weights at 61 and 91 days compared to the control groups.[27] The negative effect of the hormonal contrace