Is Ethinylestradiol + Norethindrone compatible with breastfeeding? Do we have alternatives for Ethinylestradiol + Norethindrone?

Ethinylestradiol + Norethindrone

February 7, 2016 (Low Risk)

Birth control pill that contains the combination of an estrogen (Ethinyl estradiol) and a progestin (Noretindronel) for oral use. It is also used for treatment of acne.

Ethinylestradiol is a synthetic estrogen with similar action as estradiol. Used in combination with progestogens for contraception.
Ethinylestradiol is excreted into the breast milk in no or small amount.
There is evidence (albeit inconsistent) that estrogen-containing pills may decrease milk production, especially during the first few weeks postpartum with a daily dose above 30 micrograms of ethinyl estradiol.
It may reduce the protein content of the milk.
No problems have been observed in infants whose mothers were treated, except some cases of transient gynecomastia in infants whose mothers were receiving a higher dose than usual.

Norethindrone or norethisterone is a progestin derivative of 19-nortestosterone. It is excreted into breast milk in clinically non-significant amount and no problems have been observed in infants whose mothers were treated with it. Its plasma levels in these infants were undetectable or very low.

With other similar combined contraceptives no differences have been observed in the frequency of breastfeeding or the amount of milk produced or weight gain of breastfed infants compared to other contraceptive methods (intrauterine devices, isolated progestogens). However, it would be advisable to avoid them until breastfeeding is well established (4-6 weeks).

During lactation, progestin-only contraceptive pills are preferred to Estrogen containing ones, otherwise, the lowest estrogen dose should be used.
During the first 6 postpartum weeks, non-hormonal methods are in the first line of choice.

Hormone containing contraceptives do not affect the composition of milk, minerals (Mg, Fe, Cu, Ca, P) fat, lactose and calories but only a few the proteins.

Alternatives

Very Low Risk

Compatible. Not risky for breastfeeding or infant.

Low Risk

Moderately safe. Mild risk possible. Follow up recommended. Read the Comment.

High Risk

Poorly safe. Evaluate carefully. Use a safer alternative. Read the Comment.

Very High Risk

Not recommended. Cessation of breastfeeding or alternative.

Writings

  • Αιθυνυλοιστραδιόλη + νοραιθιστερόνη (Greek)
  • نورإيثيستيرون + إيثينيلإيستراديول (Arabic)
  • 炔雌醇 + 炔诺酮 (Chinese)
  • エチニルエストラジオール + ノルエチステロン (Japanese)
  • C20H24O2 + C20H26O2 (Molecular formula)

References

  1. Lopez LM, Grey TW, Stuebe AM, Chen M, Truitt ST, Gallo MF. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev. 2015Abstract
  2. Tepper NK, Phillips SJ, Kapp N, Gaffield ME, Curtis KM. Combined hormonal contraceptive use among breastfeeding women: an updated systematic review. Contraception. 2015Abstract
  3. Bhardwaj NR, Espey E. Lactation and contraception. Curr Opin Obstet Gynecol. 2015Abstract
  4. Berens P, Labbok M; Academy of Breastfeeding Medicine. Protocolo clínico de la ABM n.º 13: Anticoncepción durante la lactancia, revisado en 2015. Breastfeed Med. 2015 Full text (link to original source)
  5. Berens P, Labbok M; Academy of Breastfeeding Medicine. ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015. Breastfeed Med. 2015Abstract Full text (link to original source) Full text (in our servers)
  6. Department of Reproductive Health and Research World Health Organization. Medical Eligibility Criteria for Contraceptive Use. WHO/RHR/15.07. 2015Abstract Full text (link to original source) Full text (in our servers)
  7. Mwalwanda CS, Black KI. Immediate post-partum initiation of intrauterine contraception and implants: a review of the safety and guidelines for use. Aust N Z J Obstet Gynaecol. 2013Abstract
  8. Bahamondes L, Bahamondes MV, Modesto W, Tilley IB, Magalhães A, Pinto e Silva JL, Amaral E, Mishell DR Jr. Effect of hormonal contraceptives during breastfeeding on infant's milk ingestion and growth. Fertil Steril. 2013Abstract Full text (link to original source) Full text (in our servers)
  9. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC). U.S. Selected Practice Recommendations for Contraceptive Use, 2013: adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edition. MMWR Recomm Rep. 2013Abstract Full text (link to original source) Full text (in our servers)
  10. Centers for Disease Control and Prevention (CDC). U S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep. 2010Abstract Full text (link to original source) Full text (in our servers)
  11. [No authors listed] Intrauterine devices: an effective alternative to oral hormonal contraception. Prescrire Int. 2009Abstract
  12. Taneepanichskul S, Reinprayoon D, Thaithumyanon P, Praisuwanna P, Tosukhowong P, Dieben T. Effects of the etonogestrel-releasing implant Implanon and a nonmedicated intrauterine device on the growth of breast-fed infants. Contraception. 2006Abstract
  13. Díaz S. Contraceptive implants and lactation. Contraception. 2002Abstract
  14. Reinprayoon D, Taneepanichskul S, Bunyavejchevin S, Thaithumyanon P, Punnahitananda S, Tosukhowong P, Machielsen C, van Beek A. Effects of the etonogestrel-releasing contraceptive implant (Implanon on parameters of breastfeeding compared to those of an intrauterine device. Contraception. 2000Abstract