Etonogestrel use while Breastfeeding
Drugs containing Etonogestrel: NuvaRing, Nexplanon, Implanon
Etonogestrel Levels and Effects while Breastfeeding
Summary of Use during Lactation
Etonogestrel is available in the United States in a combination contraceptive vaginal ring (NuvaRing) that releases 120 mcg of etonogestrel and 15 mcg of ethinyl estradiol daily, and a subcutaneous implant (Nexplanon) that releases etonogestrel at a decreasing rate over a 3-year period.
Based on the available evidence, expert opinion in the United States holds that the risks of combination contraceptive products usually outweigh the benefits before 4 weeks postpartum. Between 4 weeks and 6 months postpartum, the advantages of using the method generally outweigh the theoretical or proven risks, although the evidence of lack of effect on lactation is poor and does not include preterm or ill infants. After 6 months postpartum, combination contraceptives, including oral tablets, the transdermal patch and vaginal ring, can be used, but progestin-only methods are preferred if breastfeeding will be continued. Although nonhormonal methods are preferred during breastfeeding, progestin-only contraceptives such as the etonogestrel implant are considered the hormonal contraceptives of choice during lactation. The etonogestrel implant can be inserted at 4 weeks postpartum in nursing mothers, although some data indicate that insertion as early as 1 to 3 days postpartum does not adversely affect lactation. However, it may be prudent to avoid insertion of the implants until lactation is well established.
Maternal Levels. Forty-two women had an etonogestrel subcutaneous implant inserted implant inserted between 28 and 56 days postpartum. Breastmilk samples were obtained at 1, 2 and 4 months after insertion. The average breastmilk concentration of etonogestrel was 178 ng/L at 1 month, 153 ng/L at 2 months, and 131 ng/L at 4 months after insertion. The authors calculated that the infants would receive an average of 19.9 ng/kg daily at 1 month, 15.1 ng/kg daily at 2 months and 10.5 ng/kg daily at 4 months after insertion. The decreasing doses were caused by both a reduced quantity in milk and a lower breastmilk intake as time passed.
Infant Levels. Relevant published information was not found as of the revision date.
Effects in Breastfed Infants
Forty-two women had an etonogestrel subcutaneous implant (Implanon) inserted between 28 and 56 days postpartum. Compared with the infants of 38 similar mothers who had a nonhormonal intrauterine device, no statistically significant difference was found in infant illnesses or growth rates between the groups, except for a statistically nonsignificant higher weight gain in the male infants, and respiratory conditions and skin disorders in the infants of women who received the implants. Infants were followed up at 3 years of age; no differences in growth or psychomotor development were found.
A non-blinded, randomized study of exclusively breastfeeding women compared those who received an etonogestrel implant 24-48 hours after delivery (n = 20) to those who received a 150 mg depot medroxyprogesterone acetate injection at 6 weeks postpartum (n = 20). No difference in infant weight gain was noted between the two groups.
Effects on Lactation and Breastmilk
Forty-two women had an etonogestrel subcutaneous implant (Implanon) inserted between 28 and 56 days postpartum. Compared with 38 similar mothers who had a nonhormonal intrauterine device, no difference was found in milk volume, or in milk lactose, protein or fat content. No difference was seen between the two groups in duration of lactation, averaging 421 days in the Implanon group and 423 days in the IUD group.
A non-blinded, randomized study of exclusively breastfeeding women compared those who received an etonogestrel implant 24-48 hours after delivery (n = 20) to those who received a 150 mg depot medroxyprogesterone acetate injection at 6 weeks postpartum (n = 20). The rates of exclusive breastfeeding were similar between the groups at 6 and 12 weeks postpartum.
A randomized, controlled study compared etonogestrel implant insertion at 1 to 3 days postpartum (n = 35) to insertion at 4 to 8 weeks postpartum (n = 34). Several outcome parameters were measured: time to lactogenesis II, prevalence of lactation failure, use of formula supplementation and milk composition at 6 weeks postpartum. No differences were found in any of the outcomes between the two groups.
A prospective, nonrandomized trial compared 4 contraceptives in 10 women each to assess their effect on milk production. One of the following were begun on day 42 postpartum as chosen by the mother: combined ethinyl estradiol 30 mcg plus levonorgestrel 150 mcg (Microvlar), etonogestrel implant (Implanon), levonorgestrel intrauterine system (Myrena), or a copper IUD (Optima). Milk intake was measured using deuterium oxide given to the mother and measured in the infants' saliva as well as numbers of wet diapers per day. Infants were also weighed and measured to assess growth. No differences in milk intake or infant growth were observed between the methods from days 42 through 63.
Alternate Drugs to Consider
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3. Reinprayoon D, Taneepanichskul S, Bunyavejchevin S et al. Effects of the etonogestrel-releasing contraceptive implant (Implanon) on parameters of breastfeeding compared to those of an intrauterine device. Contraception. 2000;62:239-46. PMID: 11172794
4. Taneepanichskul S, Reinprayoon D, Thaithumyanon P et al. Effects of the etonogestrel-releasing implant Implanon(R) and a nonmedicated intrauterine device on the growth of breast-fed infants. Contraception. 2006;73:368-71. PMID: 16531169
5. 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
6. Gurtcheff SE, Turok DK, Stoddard G et al. Lactogenesis after early postpartum use of the contraceptive implant: a randomized controlled trial. Obstet Gynecol. 2011;117:1114-21. PMID: 21508750
7. Bahamondes L, Bahamondes MV, Modesto W et al. Effect of hormonal contraceptives during breastfeeding on infant's milk ingestion and growth. Fertil Steril. 2013;100:445-50. PMID: 23623474
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Contraceptive Agents, Female
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