Contraception during breastfeeding
Choice of contraception for a breastfeeding woman. Per WHO MEC 2015 and SEGO 2023, during the first 6 weeks postpartum combined hormonal methods (COCs, ring, patch) with estrogen are category 4 (contraindicated) due to VTE risk. After 6 weeks with established lactation – category 2 (acceptable). Progestin-only methods (mini-pill, implant, LNG-IUS, depot MPA) – category 1 from day 1 postpartum. Lactational amenorrhea method (LAM) works only with exclusive breastfeeding every 4 h day and 6 h night, up to 6 months or resumed menses.
ICD-10 Z30.015 drugs
Also known as: Postpartum contraception, Breastfeeding-friendly contraception
Drugs used for this condition
- ACopper intrauterine deviceFirst line · Non-hormonal intrauterine contraceptive deviceContraception during breastfeeding. WHO MEC 2015 category 1 from day 1 postpartum (category 2 in first 4 weeks – perforation risk). No effect on lactation – no systemic copper, no hormones. Ideal choice when avoiding hormones.
- ADesogestrelFirst line · Progestogen-only pill (POP)Contraception during breastfeeding. WHO MEC 2015 and SEGO 2023 – category 1 from day 1 postpartum (fully compatible). Does not reduce milk supply, unlike COCs. Etonogestrel (active metabolite) transfers to milk in small amounts, RID about 0.2%, no adverse infant effects. First-choice contraceptive for breastfeeding women.
- AEtonogestrel (implant)First line · Subcutaneous long-acting hormonal implant (LARC)Contraception during breastfeeding. WHO MEC 2015 category 1 from day 1 postpartum (category 2 if inserted in first 3 weeks – minimal theoretical risk, acceptable in practice). Etonogestrel does not reduce milk supply, RID about 0.2%. Ideal for women who don't want daily pill-taking.
- ALevonorgestrelFirst line · Progestogen-only contraceptive (POP + emergency contraception)Levonorgestrel POP 30 µg during breastfeeding – WHO MEC 2015 category 1. Does not reduce milk supply. Emergency 1.5 mg in breastfeeding women is also compatible (Hale L2), no feeding interruption needed. RID about 1.3%.
- ALevonorgestrel (intrauterine system)First line · Long-acting intrauterine hormonal system (LARC)Contraception during breastfeeding. WHO MEC 2015 category 2 in first 4 weeks postpartum (theoretical perforation risk, acceptable in practice), category 1 from week 4. Local levonorgestrel exposure minimally affects lactation. RID about 1.3% (via maternal systemic circulation). Does not reduce milk supply.
- AMedroxyprogesterone acetate depotFirst line · Progestogen-only long-acting injectable contraceptiveContraception during breastfeeding. WHO MEC 2015 category 1 from day 1 postpartum. Does not reduce milk supply. RID about 1%, Hale L1. Good option if daily pill-taking is unacceptable.
- ANorethisteroneFirst line · Older-generation progestogen-only pillContraception during breastfeeding. WHO MEC 2015 category 1 from day 1 postpartum. Compatible with lactation, does not reduce milk supply. RID about 1–2%. Alternative to desogestrel where available.
- BUlipristal acetateSecond line · Selective progesterone receptor modulator (SPRM)Ulipristal while breastfeeding. Per EllaOne SmPC and SEGO 2023, pump and discard milk for 7 days after a dose – infant safety data are limited. Hale L3. For breastfeeding women, levonorgestrel 1.5 mg is preferred (Hale L2, RID about 1.3%, no feeding interruption) or a copper IUD.
Marketing claims without evidence base
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
- DEstradiol + Nomegestrol acetateNot recommended · Monophasic COC with natural estrogenZoely while breastfeeding. WHO MEC 2015 category 4 first 6 weeks, then 2. Natural estradiol still affects milk supply. Nomegestrol transfers to milk in small amounts. Progestin-only is preferred.
- DEstradiol valerate + DienogestNot recommended · COC with natural estrogen (quadriphasic)Qlaira during breastfeeding. WHO MEC 2015 category 4 first 6 weeks, then 2. Although estradiol is natural (milder than ethinylestradiol), it still reduces milk supply. Dienogest transfers to milk in small amounts (RID about 1%). Progestin-only is preferred.
- DEthinylestradiol + DesogestrelNot recommended · Combined oral contraceptives (COC), third generationEthinylestradiol + Desogestrel during breastfeeding. WHO MEC 2015 category 4 in the first 6 weeks postpartum (higher VTE risk than 2nd-gen COCs), category 2 after 6 weeks with established lactation. Estrogen reduces milk supply more than 2nd-gen COCs. Desogestrel via etonogestrel metabolite transfers to milk, RID about 0.7%. Progestin-only is preferred. If prescribed in the first 6 weeks, consider a second opinion.
- DEthinylestradiol + GestodeneNot recommended · COC third generation with gestodeneGestodene COCs during breastfeeding. WHO MEC 2015 category 4 first 6 weeks, then 2. Gestodene transfers to milk in small amounts, RID about 0.6%. Main issue – estrogen reduces milk supply. Progestin-only preferred while breastfeeding.
- DEthinylestradiol + LevonorgestrelNot recommended · Combined oral contraceptives (COC), second generationEthinylestradiol + Levonorgestrel during breastfeeding. WHO MEC 2015 and SEGO 2023 classify combined COCs with estrogen as category 4 (contraindicated) in the first 6 weeks postpartum due to elevated VTE risk. From week 6 to 24 with established lactation – category 2 (acceptable). Estrogen lowers milk supply, especially before lactation stabilizes. Alternatives are progestin-only methods (Cerazette, desogestrel or levonorgestrel mini-pills, implant, LNG-IUS) from day 1 postpartum. If breastfeeding matters and you have a choice, consider a second opinion.
- DEtonogestrel + Ethinylestradiol (vaginal ring)Not recommended · Combined hormonal contraceptive, vaginal routeNuvaRing during breastfeeding. WHO MEC 2015 category 4 first 6 weeks postpartum due to VTE risk. Category 2 after 6 weeks with established lactation. Ethinylestradiol reduces milk supply even at low systemic dose. Progestin-only is preferred.
- DNorelgestromin + Ethinylestradiol (transdermal patch)Not recommended · Combined hormonal contraceptive, transdermal routeEvra patch during breastfeeding. WHO MEC 2015 category 4 first 6 weeks, then 2. Higher systemic estrogen exposure than COCs raises milk-supply reduction risk. Not used while breastfeeding.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit