Can I take Medroxyprogesterone Acetate while breastfeeding?
Although nonhormonal methods are preferred during breastfeeding, progestin-only contraceptives such as depot medroxyprogesterone acetate (DMPA) are considered the hormonal contraceptives of choice during all stages of lactation. Fair quality evidence indicates that DMPA does not adversely affect the composition of milk, the growth and development of the infant, or the milk supply.[1][2][3] Some evidence indicates that progestin-only contraceptives may offer protection against bone mineral density loss during lactation, or at least do not exacerbate it.[4][5][6]
The timing of initiation of DMPA is controversial.[7] The product labeling states that it should be started no sooner than 6 weeks postpartum, based on data submitted for product approval. Studies of fair quality seem to indicate that concerns about immediate adverse effects on the infants is unfounded; however, starting too soon theoretically could affect the newborn infant adversely because of slower metabolism of the drug than older infants. Of concern is that no data exist on the effects of progesterone on brain and liver development at this age. Administration sooner than 6 weeks postpartum could interfere with the exclusivity or duration of lactation. A systematic review of studies using early postpartum initiation of DMPA concluded that all of the studies were of low quality and inadequate to disprove the concern about DMPA’s effects on milk production if given sooner than 6 weeks after delivery.[8] A subsequent study raised the possibility of a slight reduction in breastfeeding duration in women given DMPA before hospital discharge.[9]
Expert opinion in the United States holds that the risks of progestin-only contraceptive products usually are acceptable for nursing mothers at any time postpartum.[10] The World Health Association recommends introduction of progestin-only contraceptives at 6 weeks postpartum.[11]
Drug levels
Maternal Levels. Seven women were given a single intramuscular dose of depot medroxyprogesterone acetate 150 mg 1 week after delivery. Peak milk levels occurred at varying times between days 8 to 28 after the injection, with most between 1 and 2 weeks. Peak levels ranged from 1.3 to 2.3 mcg/L. In 3 women, levels were measured 50 to 87 days after the dose and were still detectable in milk in the range of 0.54 to 0.98 mcg/L.[12]
Ten women received a single dose of depot medroxyprogesterone acetate 150 mg at 6 to 7 weeks postpartum. Breastmilk levels were measured weekly for 12 weeks. Average milk levels were highest at 1 week after injection at about 7.5 mcg/L and gradually fell to about 0.5 mcg/L at 12 weeks after the injection. The authors estimated that a breastfed infant would receive 1 to 13 mcg/day at 1 week after injection, 0.2 to 1.5 mcg/day 8 weeks after injection and up to 1 mcg/day at 12 weeks after injection.[13]
Infant Levels. Thirteen male infants whose mothers received 150 mg of medroxyprogesterone acetate intramuscularly at weeks 6 and 18 postpartum were breastfed. Complete 4-hour urine specimens were collected on 20 occasions during maternal treatment, including on the days after the injection known to have high maternal serum levels. No medroxyprogesterone or metabolites were detected by GC-MS assay (lower limit not specified) in the urine of the infants.[14]
Effects in breastfed infants
Maternal Levels. Seven women were given a single intramuscular dose of depot medroxyprogesterone acetate 150 mg 1 week after delivery. Peak milk levels occurred at varying times between days 8 to 28 after the injection, with most between 1 and 2 weeks. Peak levels ranged from 1.3 to 2.3 mcg/L. In 3 women, levels were measured 50 to 87 days after the dose and were still detectable in milk in the range of 0.54 to 0.98 mcg/L.[12]
Ten women received a single dose of depot medroxyprogesterone acetate 150 mg at 6 to 7 weeks postpartum. Breastmilk levels were measured weekly for 12 weeks. Average milk levels were highest at 1 week after injection at about 7.5 mcg/L and gradually fell to about 0.5 mcg/L at 12 weeks after the injection. The authors estimated that a breastfed infant would receive 1 to 13 mcg/day at 1 week after injection, 0.2 to 1.5 mcg/day 8 weeks after injection and up to 1 mcg/day at 12 weeks after injection.[13]
Infant Levels. Thirteen male infants whose mothers received 150 mg of medroxyprogesterone acetate intramuscularly at weeks 6 and 18 postpartum were breastfed. Complete 4-hour urine specimens were collected on 20 occasions during maternal treatment, including on the days after the injection known to have high maternal serum levels. No medroxyprogesterone or metabolites were detected by GC-MS assay (lower limit not specified) in the urine of the infants.[14]
Possible effects on lactation
Galactorrhea has been reported in nonpregnant, nonlactating women using depot medroxyprogesterone acetate (DMPA). In one case series, 3.6% of 360 adolescents who used depot medroxyprogesterone acetate as a contraceptive for at least 6 months developed galactorrhea with normal prolactin levels.[23]
Numerous studies found that the use of intramuscular depot medroxyprogesterone acetate as a contraceptive beginning at 7 days postpartum or later either has no negative effect or causes increases in the milk supply, duration of lactation or quality of breastmilk.[15][17][19][20][24][25][26][27][28][29][30] However, most of these were so seriously flawed that no valid conclusion can be drawn on the effect of early initiation on breastfeeding duration.[8]
Twenty-five women who were 6 weeks postpartum were given a single injection of 150 mg of depot medroxyprogesterone acetate. Serum prolactin levels were compared to those of 25 women who used an IUD. All women breastfed their infants to about the same extent. Basal serum prolactin levels were similar between the groups at the beginning of the study. These levels slowly decreased in the IUD group, but increased in the medroxyprogesterone group. The differences were statistically significant at 6 weeks after the start of the study. Basal prolactin increases in the medroxyprogesterone were 14% over baseline and 59% over the IUD group at 6 weeks.[31]
Women (n = 80) were assigned randomly to receive intramuscular depot medroxyprogesterone acetate (DMPA) 250 mg 1 to 2 days postpartum. Other women in the study (n = 616) were started on DMPA at 30 days postpartum. The median duration of lactation in both groups was longer in these women than the lactation duration following previous births.[32]
A nonrandomized, nonblinded study compared women who received either nonhormonal contraception (n = 56) or depot medroxyprogesterone acetate (n = 47) 150 mg intramuscularly upon discharge from the hospital. No statistical differences were found in the breastfeeding rates or percentage of women exclusively breastfeeding between the 2 groups of women at 1, 4, 8, 12 or 16 weeks postpartum.[33]
In a nonrandomized, nonblinded study comparing women who were breastfeeding at discharge, 102 postpartum women received depot medroxyprogesterone acetate (dosage not stated) in the early postpartum period (average 51.9 hours postpartum; range 6.25 to 132 hours), 181 received another progestin-only contraceptive and 138 used nonhormonal contraception. No differences in breastfeeding rates were seen at 2 and 6 weeks, but women receiving any hormonal contraceptive were breastfeeding at a lower rate (72.1% vs 77.6%) at 4 weeks postpartum. The authors concluded that progestin-only contraception initiated in the early postpartum period had no adverse effects on breastfeeding rates.[34]
A survey of 183 women who delivered in one hospital compared those who received DMPA after delivery and prior to discharge (n = 68) to those who did not receive the treatment (n = 115). There was a slight, but not statistically significant reduction in the duration of lactation among the mothers who received the early DMPA.[9]
One-hundred-fifty mothers were given 150 mg of depot medroxyprogesterone acetate intramuscularly after breastfeeding was established postpartum, but before discharge at 2 to 10 days; a second dose was given at 3 months postpartum. In a case-control study these mothers were compared to a control group of women receiving no postpartum contraception. No difference was found between the groups in the number of nursings per day over the 6-month follow-up period, nor was there a difference in patient satisfaction in multiparous mothers compared to previous breastfeeding experience(s).[22]
Alternate drugs to consider
Intrauterine Copper Contraceptive, Levonorgestrel, Norethindrone
References
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20. Jimenez J, Ochoa M, Soler MP et al. Long-term follow-up of children breast-fed by mothers receiving depot-medroxyprogesterone acetate. Contraception. 1984;30:523-33. PMID: 6241560
21. Brito MB, Ferriani RA, Quintana SM et al. Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study. Contraception. 2009;80:519-26. PMID: 19913145
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Last Revision Date
20151001
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Source: LactMed – National Library of Medicine (NLM)