perspectives

in nutrition

Effect
Joginder

of
G.

steroid
Chopra, M.D.,

contraceptives
M.P.H., M.S., F.A.C.N.

on

lactation

Contraceptive lactation

per capita income is low and subfoodstuffs are not easily available, the infant is practically dependent on human It took one million years to attain the presmilk for its survival and normal growth, and ent world population of 3,600 million; if the failure of breast feeding may lead rapidly to existing trends continue, it will take only 30 an increase in the prevalence of protein-calyears to double this figure. The facts are simorie malnutrition. This situation deserves pie but daunting. In 1969, world births averspecial study in respect to the already high aged 3.9 and deaths, 1 .7/sec. This gain of incidence of protein malnutrition in children 2.2/sec meant that each day there were in these communities. 190,000 more mouths to feed. The distribuA very important point to be considered in tion, too, is grossly uneven; in Europe the indeciding whether lactating women should crease is 1 % or less; in Asia and Central and take oral gestagens is the possible effect of South America it is 3 % or more. Despite the preparations in suppressing lactation. some encouraging trends in food production Several studies have been published on this, after the successful introduction of highand the results are somewhat conflicting. yielding strains of cereals, the prospect of There are a large number of oral contracepproviding an adequate diet for the undertive preparations that differ considerably in nourished and malnourished (79% of the their formulation and hence in their possible population in the poorer countries) remains effect on lactation. If lactation is adversely illusory as long as the present rate of populaaffected by oral contraceptives, a major probtion growth continues. lem can arise in countries where breast milk In view of the above situation, many counis commonly used as a sole source for infant tries have initiated family planning programs. feeding. During the past decade there has been a surmethods performance and tries where

stitute

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prisingly rapid acceptance of IUDs and Lactation of and contraception steroid oral contraceptives. These substances During lactation there exists a phase of are of two major types, combined and seamenorrhea and nonovulation, the duration quential. They both consist of estrogenic and of which varies greatly. The exact mechanism progestational compounds that either inhibit of this ovarian inhibition is unknown. The ovulation or alter the characteristics of entwo chief physiologic mechanisms involved dometrial and cervical mucus. The net result in the maintenance of lactation are the secreis a high level of protection against conception of prolactin from the anterior pituitary tion. The original reports on hormonal congland (the result of sucking stimulation) and traceptive agents were primarily concerned the ejection reflex leading to the release of with efficacy of ovulation suppression, pregoxytocin from the posterior pituitary gland nancy protection, and systematic side effects. Advisor, Nutrition Research, Pan American Relatively little attention has been paid to Health Organization, Regional Office for the World the effect on lactation performance and the Health Organization, 525-23rd Street, N. W., Washbreast-fed infant. In several developing coun- ington, D. C. 20037.
1

1202

The

America,z

Journal

of

ainical

Nutrition 25:

NOVEMBER

1972,

pp.

1202-1214.

Printed

in U.S.A.

EFFECT

OF

STEROID

CONTRACEPTIVES

ON

LACTATION

1203

that lactation tends to be associated upon the stimulus of the nipple. The former is true with prolonged amenorrhea and ovulation is essential for the continuation of an adeit must be remembered that quate milk supply, but the latter causes uter-suppression, is a 5 % risk of conception during postme contraction, leading ultimately to involu- there partum amenorrhea, which risk increases tion. The effect on blood loss has been after menstruation has returned. shown to be slight in well-nourished women, rapidly Kamal et al. (4) analyzed 290 lactation pebut the significance in repeatedly pregnant, They showed the average age of weananemic, iron-deficient mothers whose babies nods. with full lactation for suckle the breast from shortly after birth ing to be 51 months, 9 months and supplementation for 6 months. needs further investigation (1). of lactation was closely related to Evidence supports traditional medical The period age, parity, and interpregnancy inskepticism that lactating and nursing mothers maternal are protected against a new pregnancy. Tay-tervals. Pregnancy accounted for 33 % of weaning. Milk insufficiency was the cause of brs review (1) of the literature suggests that supplementation in 75 % of the cases. Onepostpartum amenorrhea lasts 6 to 8 weeks in third of the lactating mothers started to menthe absence of lactation, and for a population in which the women practice breast feeding struate during the first 3 months after delivery. By the 9th month, two-thirds of the one should increase the period of postpartum were menstruating. At the end of 15 infecundity by three-fourths of the average patients months, which was the average age for period of lactation. He further notes that ap87 of the women were menstruatproximately one-half the women conceive weaning, More than one-half of the patients bewithin 3 months of the menstrual period post- ing. pregnant during lactation, even during partum and about 80% within 1 year. Hence, came amenorrhea. These authors conthe pregnancy potential is largely exhausted, lactation as only relatively infecund women remain. eluded that lactation was far from being a Das and Mitra (2) studied 1 1 0 lactating satisfactory method of birth control. occurrence of amenorrhea during lacwomen for at least 1 year after childbirth and The reported that 12 women resumed menstrua- tation is regarded by many observers as Janney (5) considers lactation tion after the puerperium and had no appre- physiologic. mechanism similar to amenorciable period of amenorrhea. The remaining to be a safety in debility or in cases in which the orga98 women were followed 6 to 52 weeks afterrhea delivery with varying periods of amenorrhea. nism is subjected to unusual stress. Pundel that, in general, menstruation Of 93 who nursed their babies 6 to (6) 12 reported months, menstruation was re-established does not occur prior to the 6th week followwithin 12 weeks in 53 (47.2%), within 18 ing delivery. However, this time varies from weeks in 72 (65.4%), within 24 weeks in 89 one woman to another. Engel (7) observed the duration of amenorrhea was longer (80.9%), and within 30 weeks in 93 (82.7%) that of the cases. Amenorrhea lasted over 1 yearif the breast-fed infant was not given supplein 12 cases (10.9%). Indication of ovulation, mentary feedings. He also noted amenorrhea as evidenced by a secretory endometrium, increased with age and parity. In study a of glycogen activity, and reduced alkaline phos- 25 cases of lactation amenorrhea, Topkins phatase activity, was demonstrated in 11.8% (8) found that 6% showed secretory changes. of the cases during lactational amenorrhea. Davis (9), using basal body temperature graphs, found that the second menstruation Ovulation is common when menstruation is resumed before 13 weeks. Lactational amen- is ovulatory in one-half the cases. In studying orrhea, especially within this period, should the first menstrual period 60 postpartum of not be considered as an indication of a safe women, EIsner (10) reported to it be anovuperiod. In a few cases, ovulation may occurlatory in only 42%. Sharman (11) found as early as 1 month after childbirth. that menstruation during the first 6 weeks Tietze (3) states that in thebsence a of lacwas always anovulatory, whereas the mentation the median duration of postpartum struation that occurred after 6 weeks was amenorrhea is from to 8 weeks. 6 Although it ovulatory in 58% of the subjects. Twenty-

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nine percent of the nonlactating women had (beyond 28 days), delays ovulation. The duovulatory first cycles according to Malkarn ration of the delay depends upon the length breast feeding (17). Evidence of and Mirchandani (12). Minawi (13) stated of complete that, with the addition of supplementary feeds failure of ovulation comes from basal body temperature records and from vaginal cytolduring lactation, 50% of endometrial biopogy. Among women who are breast feeding sies showed secretory changes, in contrast to completely, ovulation may rarely occur and only 1 0% in subjects whose infants were pregnancy is possible, but the risk is relacompletely breast fed (13). tively small (20). Once weaning is begun, There have been other recent physiologic however, ovulation, menstruation, and the studies (14) that have confirmed the folk belikelihood of pregnancy follow rapidly. lief in many communities that unimpaired, The proportion of women who breast feed unsupplemented breast feeding increases the infant varies in different countries and length of postpartum amenorrhea and has their a cultures. In the affluent countries, the numcontraceptive effect, at least in the early ber of women who practice breast feeding months after delivery (15, 16). Thus, Cronin not exceed 20% and lactation is often (17) has shown that ovulation is postponed does duration, whereas in many of the until the 10th postpartum week when lacta- of short developing areas of the world, approximately tion is undertaken successfully, whereas in of the infants are breast fed for periods Rwanda a prospective study (16) showed 90% between 2 and 36 months (21). lactation to have an overall pregnancy spac-varying As pregnancy accounts frequently for ing effect of 5 1 months. Although breast weaning, it may prove advantageous to reinfeeding has a declining effect with time and force the physiological postpartum anovulaneeds reinforcement with other contraceptive tory period by suitable contraception and methods, it has been calculated that prothereby prevent lactation failure due to prelonged lactation in a highly fertile community conception. could prevent up to 20% of the births (14). mature conception during lactation, efIt is commonly believed that lactation fails To control fective measures should be instituted, ideally with early resumption of menstruation. It postpartum or at the time of seems more probable, however, that men-immediately examination and certainly after struation returns earlier when lactation fails.postpartum menstrual period. McEwan and Gibson (18) have suggested the first that this failure of lactation results in the regestagens and lactation duction of the stimulus of sucking, whichOral leads indirectly to the return of menstrual With family planning programs burgeoncycles. ing in all countries and cultures, oral, injectMoreover, one has to be aware of the able, and intrauterine contraception is infact that the process resulting in menstrua- creasing globally. The increase is far more tion and that responsible for lactation depend rapid in the developed countries (22). Yet upon proper hormonal balance of pituitary very little information is available as to the secretions and sex steroids. Because of this effects of the contemporary oral gestagens on link, it is difficult to assign priority to one lactation. of WHO scientific groups (23) have the changes and regard the changes of the recently recommended investigation of the other as consequences of the former. reciprocal relation between ovarian function The hormonal changes accompanying lac-and lactation, and on the effect of prolonged tation inhibit ovulation. Women who do not treatment with ovarian inhibitors on laclactate ovulate, as shown by basal body tem-tational performance. Additionally recomperatures, on the average 73.5 days after mended was further study of the effects of delivery (17), although in some cases ovula- oral contraceptives and their products on laction may occur as early as 25 days after detation and of effects, if any, on breast-fed livery (19). Lactation, when not accompanied babies (24). Since the introduction of oral by appreciable complementary feeding, and contraceptives, physicians have suspected an provided that it becomes well established inhibitory effect on lactation. Several studies

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EFFECT

OF STEROID

CONTRACEPTIVES

ON

LACTATION

1205

found the daily production of milk to be idenpublished on this subject but the tical in the treated and control groups. He been somewhat conflicting. then administered the study drug and placeDrill (25) and Goldzieher and Rice-Wray (26) have concisely summarized the earlier bos to a second group of 70 lactating mothers 10 to 3 1 days postpartum and found studies that did make mention of the in-from milk production in the treated group. fluence of oral contraceptive regimens on higher The parity and previous nursing experience lactation. In general, they point out that the of the two groups were not described. The high doses of norethynodrel originally used estrogen used in both of these investigations may reduce or inhibit lactation in many mestranol, the higher doses being used women, but as dosages were reduced, lacta- was in the study that showed a beneficial effect tion suppression was also reduced. milk production. Semm concludes that Chinnatamby (27) studied the effects of on 2.5 mg Lyndiol taken daily has no inhibitory 2.5 mg norethynodrel, 2.5 and 5.0 mg lynesinfluence on lactation regardless of whether trenol, 4.0 mg norethisterone, and 0. 1 0.5, administration was started immediately 1.0, 2.0, and 3.0 mg ethynodiol on 150 post-the or 10 days later. partum women. The patients were 1 6 to postpartum 40 Kamal et al. (30) used placeyears of age; parity ranged from 1 to 1 1 ; all By contrast, bos, 0. 1 mg ethinyl estradiol, 0.5 mg 3were of low socioeconomic status; 8 1% 1 9-norethisterone (lynestrenol), or 1 weighed under 100 lb; and all had lactated desoxymg lynestrenol with 0. 1 mg mestranol on 40 more than 3 months in previous pregnancies. Caesarean-section subjects on the 2nd day The oral drug was started at 4 weeks postpostpartum, parity ranging between one and partum in 22 mothers, at 6 in 50 mothers, at five. The results showed greater milk secre8 in 40 mothers, and at 12 weeks postpartum tion and weight gained by babies whose in 38 mothers. Lactation ceased in 5.3% in were receiving either estrogen or the first cycle. Marked suppression occurred mothers or the combined pill. The fact in 29.7% in three cycles. Lactation continued progestogen that progestogen when administered alone for 7 to 12 cycles in 37% of the mothers, and caused an increase in milk secretion exwas 56% of the women felt that they could have plained on the basis that it behaves as do the lactated longer if they had not been on the 1 9 nortestosterone derivatives, which pill. The author concluded that lactation sup-other have
results

been have

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pression component

was

dose of the

related medication:

to

the

progestogen

are

partly

metabolized

to

estrogen.

The

au-

thors conclude that the steroid had no inhibithe tory effects on the initiation of lactation. Aldose, the greater the amount of suppression. estrogens increase prolactin producThey also noted a relation between duration though tion and release in laboratory rats, the effect of lactation under therapy and lactation in on lactation in humans has been shown to previous pregnancy: the shorter the period of be on a dose-related basis. The lactation in the previous pregnancy, the inhibitory mechanism of inhibition is unknown but greater the suppression when a woman is thought to be either by suppression of a taking the pill. pituitary hormone necessary for lactation or Kaern (28) used placebos and 1 mg norby effect on the mammary gland (30). ethindrone with 0.05 mg mestranol in 451 direct lactating women from 1 to 8 days postparGarcia and Pincus (31) are also quoted as pointing out that the effect of the steroidal tum. Although cessation of lactation did not regimen depends to a considerable degree on occur during this period, the infants in the the time postpartum at which treatment is treated group required more supplementary They reported that a 10-mg/day feedings than the control group. This studyinitiated. of norethynodrel-mestranol initiated 5 documented the inhibitory effect of the prep- dose to postpartum did not produce comaration when administered during the first 8 weeks plaints of diminished lactation. postpartum week. Semm (29) administered Chinnatamby (27) noted that the lactation placebos and 2.5 mg lynestrenol combined effect of Enovid (norethynodrel with 0.075 mg mestranol to 100 lactating suppression mg and mestranol 0.1 mg) may be remothers from 1 to 10 days ostpartum p and 2.5
the higher

I 206

CHOPRA

results showed that the small-dose lated to the previous nursing history. For The pill had the least and the highwomen in whom lactation was depressed, lynestrenol Lyndiol 2.5 mg pill or deladroxate in78% had not lactated for more than or 6 dose 5 had the greatest inhibitory effects on months during previous pregnancies. Con-jections lactation. versely, in women in whom lactation was not and associates (34) studied a affected, 70% gave a history of previous lac- Rice-Wray new low-dosage, totally synthetic progestogen tation varying from 1 1 months to 2 years. It (0.5 mg) combined with ethinyl should also be noted that all these findings norgestrel (0.05 mg) (Ovral). From a group of were incidental to the original study objec- estradiol 300 women observed during a total of 3,175 tives, and in no instance were properly concycles, the authors were able to follow 20 trolled studies of the effects of the contracepwomen who began treatment while lactating. tive agents on lactation performed. women had already noted a tendency Since 1 966, more information on lactation Eleven a decrease in the amount of milk. Of performance has become available, and toward a the remaining nine, three reported diminished number of studies have been performed with lactation after starting treatment. Four conthis specific objective in mind. Frank and coworkers (32) at Michael Reese Hospital tinued in lactating as before for from five to nine cycles. Chicago studied 1 24 women started on 1 mg The same combined pill was studied for oral ethynodiol diacetate and 0. 1 mg mestranol, 72 hr postpartum. Sixteen mothers wereits effects on lactation and breast feeding by and El-Tawil (35). Ovral was given, desirous of breast feeding. Only four mothers Ibrahim to 32 multiparas and5 primi1 were able to do so for more than 2 months. postpartum, In the 12 others, lactation gradually disap- paras. Lactation was adversely affected. In pregnancies, .5 1% of the 7 multipeared. No adverse effects on the infants previous were noted. The authors conclude that in the paras in the study had nursed for more than 3 is months, 62% for more than 6 months, and small number of patients studied, lactation not well initiated or will soon be depressed 47% in for more than 1 year. On the low-dosthe majority of women on this regimen. Theyage pill, successful lactation stopped after 6 plan a control study to determine how manymonths in 8 1 % of the patients. The authors mothers from the same population who voiceconclude that previous satisfactory breast is no guarantee that lactation will not desire to breast feed are actually still doingfeeding be affected while a woman is on the pill. so after 1, 3, and 6 months. Kamal et al. (33) in a double-blind study Miller and Hughes (36) at the University gave different combinations of gestagen (Lyn- of Iowa, studied the effects on lactation of diol 2.5, Lyndiol 1.0, lynestrenol 0.5, and another low-dosage, oral, combined medicadeladroxate injections) to 120 subjects dition, 1 mg norethindrone and 0.8 mg mestravided into four groups, 6 to 10 weeks postnol, or a placebo, given daily for 21 days, partum; a fifth group (control) was given starting a 2 to 5 weeks postpartum and on a placebo. The subjects and their infants wererandomized double-blind basis. One hundred followed until weaning. The criteria used in mothers who wanted to nurse their infants for evaluating the results were: 1) age at suppleat least 3 months, one-half of whom wished mentation, 2) subjective impressions of the to use an oral contraceptive while nursing mothers, 3) amount of milk yield as obtained and one-half of whom did not use any prepaby mechanical suction and test feeding, 4) ration, comprised the study cohort. Three feed-to-weight adequacy, and 5) infant groups were developed for the study: 25 pagrowth curve. tients on oral contraceptives; 25 patients who The average amount of milk yieldas estihad expressed interest in using the pill startmated by mechanical suction, the feed-to- ing 6 weeks postpartum; and 50 patients who weight adequacy, and changes in infant did not desire any medication. During the weight were found to be the most useful 2nd and 3rd weeks after birth, infants of the parameters for studying the adequacy of lacmothers taking the pill exhibited a decrease tation. in the mean weekly weight gain. Infants in

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CONTRACEPTIVES

ON

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1207

after completing the first cycle of oral conthe placebo group had better weight gain and required fewer supplementary feedings. At traceptives. Additionally, 44.4% had a slight in lactation after completing six cythe end of 3 months, 73 % of mothers on decrease no medication were still nursing, whereas only des, 8.3 % had a marked decrease, and 20% cessation of lactation. Although 2 1 % of those who started the pill 2 weekshad complete postpartum were still breast feeding their there are several factors influencing lactation, babies. Asked why they stopped nursing, the percentage of lactation failure in these more mothers in the pill group gave made- 205 women was remarkably high. Lactation, quate milk supply as the reason than did the also according to the mothers observations, mothers in the control group. Mothers who did not change or changed very slightly in had successfully nursed an infant before had the control group. A study by the same authors (21) showed a higher success rate with the present infant. that 22 women on Ovulen (1 mg ethynodiol Medication had the least effect on these mothers. No deleterious effects were noted in diacetate and 0. 1 mg mestranol) or C-Quens ,g mestranol plus 2 mg chlormadinone any of the infants. The authors (36) imply (80 that the estrogen component is the lactation acetate), started at 6 weeks postpartum, suppressing agent. showed that the mean volume milk of exIn Bombay, Kora (37) studied the effect of pressed in cubic centimeters was slightly de1 mg oral ethynodiol diacetate combined creased after 1 to 2 months but was signifiwith 0. 1 mg mestranol (Ovulen) on a group cantly decreased after thehird t cycle as cornof low-income Indian mothers who were lacpared with the controls. These results concur tating satisfactorily and were breast feeding well with the subjective observation by the their infants between 4 and 24 weeks of age. mothers. The infants weight was only slightly Fifteen mothers served as a control group, lower than that of the controls and that of the receiving no medication, and 62 mothers average Thai baby. However, this finding is took the oral drug. Statistically significant not in agreement with the milk volume deresults showed that the infants from control crease. They speculate that this may be due group mothers received greater amounts of to the fact that babies whose mothers rebreast milk than the infants whose mothers ceived the pill sucked more frequently, thus were on the pill; the amount of milk obtained compensating for the decreased volume. from control mothers increased weekly, These same authors confirmed observation whereas medication mothers produced less by others that the pill had no significant milk than prior to taking the pill; and weight effect on the composition of the milk. gain per week was significantly less in the Hayden (38), who gave norethynodrel experimental infants than in the control inmestranol to 30 lactating women and had a fants. double control of the participants previous Bhiraleus et al. (21) reported on a study of lactation histories and a control series using women in which the control group used an a mechanical contraceptive, found that the IUD, tubal ligation, or nothing; the experi- length of lactation was, if not actually inmental group of 205 women were put on creased, then certainly not adversely affected. oral, combined, or sequential contraceptives Pincus (39) reported that lactation fails in 6 weeks after delivery. The childs age when subjects using Enovid E (2.5 mg norethynomothers started oral contraceptives ranged drel plus 0.1 mg mestranol) in large doses. from I to 12 months. All mothers in this Mazhar and associates (40) compared the group stated that they had good or adequate ages at supplementation and weaning of 51
breast milk at the beginning of medication, mothers (who were given different gestagens)

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more than enough and with the subjects previous lactation history. some had just enough milk for infantile They reported that, although supplementation needs. The results, based on the mothers was earlier in onset the present in study, the own observations, showed that 27.3% of the total duration of lactation was approximately mothers had no change at all months 6 after the same. medication and 55% had decreased lactation The inhibition of lactation occurs only

although

some

had

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when the preparation contains estrogen, and nificant impairment of the ability to breast that it was dramatic when using the sequen- feed. tial regimen (41). Brannon published a paper (50) concerning the use of combined oral contraceptives Rice-Wray et al. (42) have reported that in which he compared the effectiveness of 10 mg Ortho-Novum (10 mg norethindrone, 0.06 mg mestranol) caused diminution norethindrone-mestranol or combination with (testosterone ethanate plus esstoppage of lactation in 32.5% of the women. deladumone valerate) insuppression of lactation. Satterthwaite and Gamble (43), using nor-tradiol ethynodrel from the 3rd week postpartum, Burstein et al. (5 1) also employed norethinfound decreases in lactation: with 20 mg/day, drone mestranol in the immediate postpartum 77% of the mothers; with 10 mg/day, 38%;period but noted that lactation suppression with 5 mg/day, 45 % ; and with 2.5 mg/day, may not be effective unless therapy is started on the day of delivery. 15%. The inhibition of suppression of the initiaBeunslinck reports that 0.5 mg Organon 1043 (6a-rnethyl lynestrenol) given daily tion to of lactation in 136 patients followed up lactating women, starting at the 6th week for six weeks after delivery was studied by postpartum, did not inhibit but probably Giffibrand and Huntingford (52). They report that quinestrol (estrovis) failed to supfavored lactation. Adverse effects on the lactation within 8 days of delivery in mothers and the increment in babies weights press were not observed. 78% of the subjects. The combined use of estrogen and progestogen (Enovid E) gave As gauged by complete breast feeding by lowest failure rate (1 7 %) and this conthe mothers and the growth curve of the firms the previous report. The authors conbaby, Fern and associates (45), using 2.5 mg elude that usual absence of lactation before lynestrenol, found no effect on lactation. It is not solely due to inhibition of estrohas been reported that anovular did not affectlabor lactation (25), but Goldzieher and Rice-Wray gens. The combination of estrogen and prosuppresses the initiation of lactation (26) found an effect in 45% of their patients. gestogen percentage of subjects. Having given Lyndiol 2.5 (2.5 mg lynestre- in a greater Karim et al. (53) report that norethisterone nol, 0.1 mg mestranol) to 12 lactating mothers ethanate (200 mg every 84 days) and mefor four cycles, Turabi and associates (46) droxy-progesterone acetate (150 mg every 3 noticed a drop in milk volume. Kubba (47) were found to be completely effecsaid that lactation was not affected in a group months) in fertility control when started in the kept on continuous administration of 2.5 tive to puerperium. Neither agent had any ill effects 5.0 mg lynestrenol daily for 6 months, but on the amount of milk nor on the duration that Lyndiol 2.5 caused marked reduction in of lactation. From the 3rd month onward, the milk secretion. hourly available milk and the infant weight Borglin and Sandholm (48) studied the per month were statistically higher in effect on lactating women of the oral contra- gain the treated than in the controls. Milk proceptive Lyndiol 2.5 (2.5 mg lynestrenol plus showed a slight decrease in most groups, 0.075 mg mestranol) and of the estrogens, teins including the controls, perhaps due to a low 0.08 mg mestranol and 0.05 mg ethinyl esprotein diet. No important side effects were tradiol, on milk production. This was comproduced by these agents other than amenorpared with the effect of one placebo tablet rhea. given once a day for 1 week. Lyndiol, but not The effects on lactation of a daily dose of the estrogen, had a statistically inhibitory ef0.5 mg chlormadinone acetate, starting on fect in the production of milk. the 2nd day of puerperium in 25 women, Kates et al. (49) started 106 patients on showed that the small dose of progestogen oral sequential contraceptives on the 5th did not have any inhibitory effect in 86.3%. postpartum day. Side effects of the medica- The results were evaluated in terms of gain in tion were minimal, and effective inhibition of weight of infants and test feed weighing (54). ovulation was observed; there was no sig- Gonzalez (55), studying the effects of 0.5

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EFFECT

OF

STEROID

CONTRACEPTIVES

ON

LACTATION

1209

the mothers with an IUD was statistically mg chlormadinone on 50 women when administered 5 to 40 days postpartum, statessignificantly greater than in the 1 50 control group mothers. The authors point out that that this did not have any inhibitory effect on the longer duration of lactation in those who milk secretion, as judged by the infants gain use an IUD may be related to the mechanical in weight in a 6- to 10-month period; howstimulus of the IUD evoking a neuroendoever, Rudel and co-workers (56) have rereflex, which increases the secretion of ported that chlormadinone does not inhibit crine endogenous oxytocin. lactation. latter observation is particularly noteHoward et al. (57), in clinical trials of con- This worthy in light of Corfman and Segals (59) tinuous low-dose 0.5 mg chiormadinone acecalling attention to an independent unpubtate on 260 women who completed 2,050 cystudy by Chaudhury that revealed eledes, found that lactation did not seem to lished be vated blood levels of oxytocin or oxytocinaffected by the medication; 71 patients were like substances in IUD users who may have breast feeding when the tablets were cornbeen lactating. (The work was performed in menced, and 38 were still lactating and where a high percentage of women amenorrheic at 3 months. The initial failure India who use an IUD have it inserted while they to continue breast feeding seemed adequately are lactating.) Further confirmation of this explained by poor motivation; the determined thesis is proposed by Meites (60). He states breast feeders continued successfully, and lactation is initiated at the time of partuone patient continued for 1 1 months. There that rition, primarily as a result of the marked inare two drawbacks to this method of concrease in prolactin and adrenal cortical hortraception, irregular bleeding and a high mones, both of which are essential for initiapregnancy rate, with use effectiveness of 8.6 and maintenance of milk secretion. The and a method failure of 5.2 per 100 women- tion stimulus by the infant on the nipples years. This method may have a place in con- suckling and surrounding skin results in a reflex retraceptive practice for women who are laclease of prolactin and ACTH from the antetating and wish to use an oral contraceptive, pituitary and oxytocin from the posteor for those who are spacing their families nor pituitary. Oxytocin acts to increase the and are not overanxious about further preg-nor
nancies. pressure within the breast and elicits milk

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ejection, so that the infant can easily obtain IUD and lactation the stored milk. Likewise, the WHO Scientific Group Report (61) on IUDs states that Studies related to the effect of IUD on lacof oxytocin-like substances in the tation performance on the breast-fed infant elevation plasma of women using IUDs has been reare reviewed in the following paragraphs. ported in one study, although the number of Gomez-Rogers (58) and associates at the is small. The group report conUniversity of Chile studied the effect of the observations IUD and other contraceptive methods cludes in that probably the only systemic effects lactation in 276 multigravid women comof the IUD are of neurogenic origin, due to influence of the uterus on the hypopared with a control group of 150 similar the multiparas not undergoing contraceptive ther- thalamohypophyseal centers in the human. apy postpartum. All mothers had more than In the female rat, neither oxytocin production one child and had nursed one or more chiland release nor oxytocin sensitivity of the dren previously. All patients were studied for uterus is influenced by the presence of an at least 1year. The 81 mothers with an IUD IUD. had the highest average duration of lactation Kamal et al. (33) report on 24 women with (7 months and 21 days). The mothers on se- IUD and who an were given a placebo for 22 quential therapy averaged 3 months. days per cycle; the infants were followed biLactation duration in the combined and monthly until 24 weeks, then monthly until weaning. The group showed no change in sequential groups was 50% less than the mothers had achieved in a prior pregnancy feed-to-weight adequacy (the adequacy of without the pill. The duration of lactation in test feed in relation to babys weight). It

1210

CHOPRA

should be pointed out that the feed-to-weight reported decreased lactation after the completion of the first cycle. adequacy does not quantify the amount of milk secreted but merely indicates the ade- From the data reviewed, it seems reasonaquacy in relation to the gain of weight by the ble to conclude that in general some forms of baby. contraceptive pills, especially those which To determine the effects of postpartum rely chiefly upon estrogen action, may have IUD insertions on lactational amenorrhea some adverse effect on lactational efficiency. and lactation, 185 postpartum women were On the other hand, the IUD appears to fitted with a 30-mm Lippes loop using stimulate a lactation, possibly through its memodified inserter on the 3rd to 7th day post-chanical action provoking a neuroendocrine partum, and another 106 postpartum women reflex that increases the excretion of endogewere observed as a control group. Hingorami nous oxytocin. and Bai (62) discovered that the duration of Other questions that need clarification are the following: Are hormones in oral contralactation in the study group varied between 0 ceptives secreted in breast milk, and, if so, and 36 months, the average being 10.86 months, with 82% of the women lactating can this affect the baby? Do they alter the for more than 1 month. In the control group, composition of milk? groups have attempted a direct study the lactation period varied between 0 and 30 Two months, the average being 9.9 months, with the excretion of in breast milk of the steroids contraceptives. Laumas et al. (64) 84% of these women lactating for more thanof oral 1 month. The difference in the duration of lac-found that .1 % 1 of the radioactivity present tation in the two groups was not statistically in a single dose of tritiated norethynodrel was in breast milk in the subsequent 5 significant (P > 0.05). In the study group, excreted On the other hand, Pincus et al. (65) menstruation resumed 1 to 16 months (aver- days. found only 0.004 to 0. 1 3 % of the radioacage 4.7 months) after delivery, whereas in of orally administered tritiated northe control group it began again after 1 to tivity 14 and ethynodiol in the breast milk months (average 5.2 months). The differ-ethynodrel over the course of 4 days. The disadvantage ence in the period of lactational amenorrhea studies is that they do not distinguish between the two groups was not statistically of these whether the radioactive label was still in the significant. They concluded that the postof the original steroid or of an inactive partum IUD insertion did not affect the dura- form metabolite. Because the fetal breast is a sensition of lactation or lactation amenorrhea. organ for estrogen, as evidenced by Snidvongs et al. (63) found that almost tive target hypertrophy secondary to endogenous estro100% of the women who were lactating at in utero, a built-in biologic assay for time of insertion of IUD continued breast gens estrogen was present in the study of infants feeding for 8 to 10 months or longer. They reported by Miller and Hayes (36). No effect conclude that IUD insertion has no effect on breasts during the period lactation or upon intrauterine involution. Thewas noted on infant of observation. incidence of puerperal complications of and van der Molen (66) adminbleeding and infection is not increased. The Wijmenga istered 14C mestranol orally in a Lyndiol tabadjustment of the uterus to the IUD is con0, 150 g mestranol) to current with the usual puerperal involution, let (5 mg lynestrenol four women using Lyndiol during the lactaand consequently the women have very few tion period shortly after delivery. They studcomplaints. Thus, such studies are not only the concentration of radioactivity inthe of considerable importance, but also warrant ied plasma and excretion in the urine and milk. further investigation and confirmation. During a collection period of 4 days after Bhiraleus et al. (21) conducted a study to determine the effects of contraceptives uponoral administration of a 14C mestranol-conlactation and reported that lactation was not taming tablet, 0.0002-0.013% of the adminaffected in control subjects who either had istered dose was excreted in the milk. These an IUD, tubal ligation, or nothing, whereas very low values were due in part to the low 55% of the subjects who were on a gestagen amount of milk that could be collected. It

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EFFECT

OF

STEROID

CONTRACEPTIVES

ON

LACTATION

1211

that with regular administragens or their metabolites into maternal milk, Lyndiol tablet daily with 150 and tg subsequent effects on the composition per tablet, about 0.03-0.035 and upon g the baby, require further study. evidence suggests that certain (0.02 to 0.04%) of the administered dose of Current types of contraceptive pills do interfere with mestranol or its metabolites could be excreted especially those containing high per 100 ml of milk. This has much relevance lactation, doses of estrogens and administered shortly to the infants being breast fed (66). delivery (1 7, 70). They have a smaller Chinnatamby et al. (27) studied the effects after inhibitory effect on established lactation. At of gestagens on 1 50 postpartum women and ovulation-inhibiting doses currently their breast-fed infants. She reported gyneco- the lower in oral contraception, lactation may be mastia or no withdrawal vaginal bleeding in used but rarely stops altogether (71). any of the infants. One often-quoted case of diminished it is unaffected (72), particularly if infant breast hypertrophy in a nursing infant Usually whose mother was receiving an oral contrathe contraceptive therapy is not started before the appearance of breast milk and breast ceptive is open to question (67). The breast feeding continues (73). hypertrophy was first documented 5 at weeks Progestogens, such as the orally active postpartum when residual neonatal breast progestogen 6a-methyl1 7a-hyhypertrophy is not uncommon. The involu- synthetic acetate, which is devoid tion described following cessation of nursing droxyprogesterone was calculated

tion of mestranol

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might

well

represent

normal

neonatal

breast of

estrogenic

action,

have

been

shown

to

in-

involution. Pincus
strate milk orally mg of with daily) any

et

al.

(64)
taking estrogen a

estrogenic mothers

hibit lactogenesis quite effectively in high doses in the were unable to demon- ministered activity in the breastpostpartum period to nonnursing
Enovid E. (74).

when adimmediate mothers

Healthy
or

nursing
an

mothers
(ethinyl progestogen

were
estradiol, 30

treated

Further

work on
seems

hydroxyprogesterone for 5 full days

affected. tein A

after
highly

acetate, birth.
significant

(6a-methyl-17amg daily)

of world 0.3 the ship, and it

gestogen

is under way this important

likely do that not

in various parts interrelationlow-dose interfere prowith

compounds

Milk in

yield
increase

was
in

notlactation
pro-administered

to

the

orally

content et on

was al. the

observed (68). (69) studied quantitative

estrogen-treated

mothers

Kadar gestagens

(76). Depot of has been shown the effects of lating lactation action and qualitative ceptive the milk
For less showed seems as com-tion rate successful, of

same extent as estrogen when (70, 75) or by injection medroxyprogesterone acetate to be of great value in stimuquite apart from its contra(77).
areas, present the following lactation informasequence: alone

exfor 6 to 8 weeks, followed by continued lactawith the use of low-dose progestogen perimental groups as compared with the con-tion, (although the side effects on the breasttrols. The milk fats and protein dropped (77) gradually; lactose showed minor variation, fed baby need clarification); or with an intrawhereas changes in minerals were inconsist- uterine device, which has the advantage of ent. The author concludes that gestagens havenot interfering with lactation, but may even it, because of the raised oxytocin an adverse effect on the quantity and quality enhance levels found (78). of milk when administered after established
lactation. The

changes of milk in goats. The results a decrease in total quantity per 24 hr pared with the control groups. The growth of the kids was also slowerin the

developed to suggest unsupplemented

An Enovid
shown ture that

extract prepared from E was administered

to mice. have estrogenic

goat milk to the goat

activity for

afterhormonal was tation

immanology,

problem of contraceptive is a

the side preparations

effects on

of oral lac-

recent

especially

family

planning

From
the

the

data

at
of

hand,
excretion

one

can
of

possibility

in conclude objectives programs oral gesta- health

techboth and breast feeding are major practical maternal and child (33, 37). Investigations into
in communities where

concern

of

modern

1212

CHOPRA

both reproductive functions and lactation in have in relation to lactation performance the human are notoriously difficult. For exwhile the woman is using a contraceptive ample, practical objective measures of milk agent, for example, the desire to nurse versus output and also other factors responsible, desire for conception protection? especially psychologic influences, lead to In addition, further study of the role the varying degrees of motivation and assurance, IUD plays in oxytocin levels and whether or with consequent effects on the key let-down not significant amounts of hormonal contrareflex. ceptives are excreted in breast milk is reIn addition, the effect of oral contracep- quired. Finally, all future studies relating to tives on lactation has been inadequately stud- lactation performance and contraceptive ied because in most of the reports the basis practice should be predesigned, double-blind, for comparison has been the womens own controlled studies, incorporating sufficient recollection of their previous performance. numbers of women so that statistically valid Furthermore, there are a large number of data may be assembled for critical analysis. ] ( oral contraceptive preparations that differ considerably in their formulation and hence References in their The of oral
observations

Downloaded from ajcn.nutrition.org by guest on September 11, 2012

possible available contraceptives

ranging

effects literature

lactation. describing during lactation

an

on

1.

TAYLOR,

the use reports

inhibitory

lated

to

H. C. maternity

Family

planning

programs

re-

service.
Programs:

In: Family
A Review

between

effect on milk production to an increase in milk output (68). The number of women on oral contracep2. tives is increasing rapidly. Therefore, a study that would enable physicians to advise their 3. nursing patients intelligently regarding the effects of oral contraceptives seems advisable. 4. This question is of vital importance to the underdeveloped and overpopulated countries that are instituting contraceptive programs in areas where breast milk remains the main source of infant nutrition. 5. From the data at hand one may conclude 6. that the relation between lactation performance and contraceptive practice requires 7. further elucidation and study. Many stimulating questions are raised. Is there a dose relationship between oral and parenteral contraception and lactation 8. performance? If a relationship does exist, is it related to the estrogen or the progestogen component 9. of the contraceptive agent? 10. Is lactation performance related to the time contraception is started in relation to termination of pregnancy and initiation of 11. lactation? Is previous lactational performance related 12. to the lactational history of the patient using a contraceptive, and what is the relation to 13. milk supply and composition, if any? What influence do psychogenic factors

edited by B. Berelson (Proc. Intern. Conf. Family Planning Programs, Geneva, August 1965). Chicago: Univ. Chicago Press, 1966, chapt. 35. DAS, S. K., AND A. Mrra.&. A clinico-pathological study of lactational amenorrhea. I. Obstet. Gynaecol. (India) 16: 156, 1966. TIETZE, D. Manual of Contraceptive Practice. Baltimore: Williams & Wilkins, 1964. KAMAL, I., F. HEFNAWI, M. GHONEIM, M. TALAT, N. YOUNIS, A. TAGNI AND M. ABDALLA. Clinical, biochemical, and experimental studies on lactation. I. Lactation patterns in Egyptian women. Am. I. Obstet. Gynecol. 105: 325, 1969. JANNEY, D. C. Medical Gynecology. Philadelphia: Saunders, 1945. PUNDEL, J. P. Les Froths Vaginaux Endocriniens. Paris: Masson, 1952. ENGEL, S., S. K. KON, E. H. MAWSON AND S. J.
FOLLEY. ment in Discussion knowledge on of some physiology recent of developbreast.

and Population Developments,

Planning of

World

Proc.

Soc. Med. 40: P. Histologic metrium during lactation relationship to ovarian Gynecol. 45: 45, 1943. DAVIS, M. E. Clinical peratures. I. Am. Med.
TOPKINS, ELSNER,

Roy.

899, 1947. appearance of endoamenorrhea and its function. Am. J. Obstet. use of oral basal temAssoc. 130: 929, 1946.
Partus

P.

und Abortus. 1948.

SHARMAN,

Erste Wein. Ovulation

Menstruation nach Klin. Wochschr. after

60:

433, Fer-

A.

pregnancy.

2: 371, 1951. MALKANI, P. K., AND J. J. MIRCHANDANI. struation during lactation. I. Obstet. (India) 11: 1221, 1960. EL-MINAWI, M. F., AND M. S. FODA. turn lactation amenorrhea. Am. J. necol. 111: 19, 1970.
tility Sterility

MenGynaecol.
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Obstet.

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14.

JiN,

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BAUGH. Advances in Planned Parenthood. AmA. K., T. C. Hsu AND M. C. CHANG. Demsterdam: Excerpta Medica, Intern. Congr. Ser ographic aspects of lactation and postpartum No. 138, 1967. amenorrhea. Demography 7: 255, 1970. 33. KL, I., F. HEFIAw, M. GHONEIM, M. DEL MUNDO, F., AND A. C. ADIAO. Lactation T&LAT, N. Yotmis, A. TAGNI AND M. ABDALLA. and child spacing as observed among 2,102 Clinical, biochemical, and experimental studies rural Filipino mothers. Philippine I. Pediat. 19: on lactation. II. Clinical effects of gestagens on 128, 1970. lactation. Am. I. Obstet. Gynecol. 105: 325, BONT, M. M., AND H. VAN BELEN. Prolonged 1969. lactation and family spacing in Rwanda.I. 34. RICE-WRAY, E., C. AVILA AND J. GUTIERREZ. Biosoc. Sci. 1: 97, 1969. Norgestrel and ethinyl estradiol: a new lowCRONIN, T. J. Influence of lactation on ovuladose oral agent for fertility control. I. Obstet. tion. Lancet 2: 422, 1968. Gynecol. 31: 368, 1968. MCKEOWN, T., J. R. GIBSON AND T. DOUGLAY. A., AND N. Z. EL-TAWIL. The effect Study of the variation in length of menstrual 35. Iaiiu, of low dosage oral contraceptive pill on lactacycle. J. Obstet. Gynaecol. 61: 678, 1952. tion. Intern. Surgery 49: 561, 1968. KAVA, H. W., H. P. KLINGER, J. I. MOLNAR 36. MILLER, G. H., AND L. R. HUGHES. Lactation AND S. L. ROMNEY. Resumption of ovulation and genital involution: effects of a new lowpostpartum. Am. I. Obstet. Gynecol. 102: 122, dose oral contraceptive on breast-feeding moth1968. ers and their infants. Obsiet. Gynecol. 35: 44, GIACOSA, R. Incidence of pregnancy during 1970. lactation. Am. I. Obstet. Gynecol. 70: 162, 37. K0RA, S. J. Effect of oral contraceptives on 1955. lactation. Fertility Sterility 20: 419, 1969. BHIRALEUS, T. C., AND S. KOETSAWANG. Effects 39. PINCUS, G. The Control of Fertility. New of oral gestagens upon lactation. Postpartum In: York: Academic, 1965, vol.I, p. 26 1-262. I Family Planning: A Report of International the 40. MtzHit, K., F. HEFNAWI, B. GANZOURI AND Program (A Population Council Book), edited H. ASHALANI. I. Egyptian Med. Assoc. 10: 117, by G. I. Zatuchni. New York: McGraw-Hill, 1965. 1970. 41. GOMEZ-ROGERS, C., P. A. IBARRA, A. FAUNDES Studies on family planning. Population CounAND E. GUILOFF E. Effect of IUD and other cil Bull. 24: 1, 1967. contraceptive methods on lactation. Proc. Viii Report of a World Health Organ. Scientific Conf. intern. Planned Parenthood Federation, Group. Physiology of lactation. WHO Tech. Santiago, Chile, 1967, p. 328. Repi. Ser. No. 305, Geneva, 1965. J. W., E. RICE-WRAY, M. SCHULZReport of a World Health Organ. Scientific 42. GOLDZIEHER, CONTRERAS AND A. ARANDA-COSELL. Fertility Group. Clinical aspects of oral gestagens. WHO Tech. Rept. 5cr.No. 326, Geneva, 1966. following termination of contraceptives with norethindrone. Endometrial morphology and DRILL, V. A. Oral Contraceptives. New York: conception rate. Am. J. Obstet. Gynecol. 84: McGraw-Hill, 1966. 1474, 1963. GOLDZIEHER, J. W., AND E. RICE-WRAY. Oral 43. SATTERTHWAITE, A. P., AND G. J. GAMBLE. ConContraception. Springfield, Illinois: Thomas, ception control with norethynodrel. Progr. 1966. Rept. of a Five-year Field Study, Humacao, CHINNATAMBY, S. Effect of oral contraception Puerto Rico. Am. Med. Womens Assoc. 17: on lactation. Proc. VII! Conf. Intern. Planned Parenthood Federation, Santiago, Chile, 1967, 797, 1962. 44. BEUNSLINCK, A. Klinische resultaten bekomen p. 263-267. KAERN, T. Effect of an oral contraceptive immet het 6a-methyl-17a-ethinyl oestrenol tijdens volledige borstvoeding. Bull. Soc. Roy. Beig. mediately postpartum on initiation of lactation. Brit. Med. J.3: 644, 1967. Gynecol. Obstet. 37: 365, 1967. SEMM, K. Contraception and lactation. In: 45. FERIN, J. Hypoestrogenic amenorrhea and/or Social and Medical Aspects of Oral Contrasterility induced by lynestrenol. Intern. I. Ferception (Round Table Conf., Scheveningen, tility 9: 29, 1964. The Netherlands). Amsterdam: Excerpta Med- 46. TURABI, B., M. S. DIxON, KIIAN INAYAT, A. ica, 1966, p. 98-102. AMINA, N. N. GHANI AND S. WHISKIK. A study KAMAL, I., F. HEFNAWI, M. GHONEIM, M. ABof the effects of an oral contraceptive on lactaDALLA AND S. ABDEL RAZEK. Clinical, biochemition. Proc. ii Biannual Seminar Research in cal, and experimental studies on lactation. V. Family Planning, Karachi, Pakistan, 1966. Clinical effects of steroids on the initiation of 47. KUBBA, K. I. Fac. Med. (Baghdad) 8: 16, 1961. lactation. Am. I. Obstet. Gynecol. 108: 655, 48. BORGLIN, N. E., AND L. E. SANDHOLM. Effect of 1970. oral contraceptives on lactation. Fertility SteGARCfA, C. R., AND G. PINCUS. Clinical conrility 22: 39, 1971. siderations of oral hormonal control of human 49. KATES, R. B., D. PEBI AND J. TOWNES. Immedifertility. Cli,z. Obsiet. Gynecol. 7: 844, 1964. ate postpartum use of sequential oral contraFRANK, R., W. R. ALPERN AND D. E. ESHceptives. Southern Med. 1. 2: 694, 6 1969.

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1214 50.
BRANNON,

CHOPRA

R.

Paper Fellow

presented

at Meeting,

the

District Houston,

women

after

oral

administration

of

3H-norethy-

VII 5 1.

Junior

ACOG
WrrL0W

nodrel. 65.

Texas, 1 June 1968.

BURSTEIN,

R.,

G.

AND

H. Obstet. J.

WASSERMAN. in the

The
mediate Digest

use of norethindrone,
postpartum

mestranol

period.
AND

imGynecol.

66.

1: 34,
of

52.

GILLLBRAND, Inhibiflon

1968. P. N.,
lactation

P.
with

HUNTINGFORD. oestrogen

combined

and 53.

progestogen. KARIM, M., R. GANZOURY, F.

progestogen and CASARES,

Med. J.4: 769, l96o. AMMAR, S. EL MAHGOUB, B. EL FIIcRi AND 1. ABrou. Injected lactation. Brit. Med. J. 1: 200,
of on

Brit.

67.

Am. J. Obstet. Gynecol. 98: 411, 1967. PINCUS, G., G. BIALY AND D. S. LAYNE. Radioactivity in the milk of subjects receiving radioactive 19-norsteroids. Nature 212: 924, 1966. WIJMENGA, H. G., AND H. J. VAN DER MOLEN. Studies with 4-14 C mestranol in lactating women. N. V. Organon OSS, cta A Lndocrino.. (Netherlands) 16: 665, 1969. CURTIS, E. N., N. H. NEWSOM AND R. P.
GRANT. Oral contraceptives in the immediate

puerperium. 1963. 68.

TOAFF, HERZBERG.

J. R., A.

Med.
ASHENZI,

Assoc. A.
of

Georgia
SCHWARTZ

52: 425,
AND

1971.

M.

54.

H. J. Daily administration microdoses of chiormadinone and effects its breast feeding. Ginecol. Obstel. Mex. 25:
PONCE

Effects

oestrogen

and

progesta-

gen 69.

295,

19o9.

55.

GONZALEZ, nladlnone

C. Continuous
during lactation.

microdoses Ginecol.

of chiorObstet.
AND

Mex. 56.
1(UDEL, MAQUES the

2&

563, 19/U. H. W., J. MARTINEZ-MANAUTOU

TOPETI. The control role of of fertility. Fertility

M.
in

progestogens

hormonal

Ste-

57.

rility 16: Howxiw,

dose

156, 19o5. G., M.

70. GLAiR AND a M.

ELSTEIN. Lowas an chiormadinone-acetate

continuous

oral 24, 58.

AND

contraceptive: 1969. C., E.

GUILOFF

clinical

trial. Lancet

2:

71.

G#{212}MEZ-ROGERS, contraceptive

P. A. Lnxiut, A. FAUNDES E. Effect of IUD and other methods on lactation.roc. P Viii Federation,
Advances

72.

59.

60.

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74. Ser. No. 156, 1968, vol.in. Report of a World Health Organ. Scientific Group. Intrauterine devices: physiological and 75. clinical aspects. Wi-JO Tech. Rept. Ser. No. 397, 1968. HINGORANI, V., AND G. R. BAI. Lactation and lactational amenorrhea with postpartum IUCD insertions. I. Reprod. Fertility 23: 513, 1970. 76. SNIDVONGS, M. L. K., C. ISRANGUN, A. S0MBOONSUK, D. RIEPRAYURA AND A. P. SATTERTHWAITE. Immediate postpartum IUD inser- 77. tions. In: Postpartum Family Planning: A Re78. port of the international Program (A Population Council Book), edited by G. I. Zatuchni. New York: McGraw-Hill, 1970, chapt. 18. LAUMAS, K. R., P. K. MALKANI AND S. BHATNAGAR. Radioactivity in the breast milk of lactating

the composition of milk. . Reprod. J 19: 475, 1968. KADAR, M. M. A., A. ABDEL HAY, A. T. ABDEL Aziz, S. El SAJOURI, J. SAAD EL-DIN, 1. KAMAL, F. HEFNAWI AND M. ABDALLA. Clinical, biochemical, and experimental studies on lactation. IV. Quantitative and qualitative changes induced in goats milk by gestagens. Ani. J. Obstet. Gynecol. 105: 1 168, 1969. BONTi, M. Family planning by prolonged lactation and hormones. J. Trop. Pediat. 2: 56, 1966. RICE-WRAY, E., J. W. GOLDZIEHER AND A. A. RUSSELL. Oral prestins in fertility control. A comparative study. Fertility Sterility 14: 402, 1963. GARCiA, C. R., AND G. PINCUS. Clinical consideration of oral hormonal control of human fertility. Clin. Obstet. Gynecol. 7: 844, 1963. KISTNER, R. W. Therapeutic application of progestational compounds. In:Advances of Obstetrics amid Gynecology, edited by S. L. Marcus and C. C. Marcus. Baltimore: Williams & Williams, 1967, vol. . TOAFF, R., AND R. JEWELEWICZ. Inhibition of lactogenesis by combined oral progestogens and oestrogens. Lancet 2: 322, 1963. SAXTON, G. A. A review of recent research related to family planning in Africa. Paper presented at Ford Found. Workshop on Need of
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Nairobi, Contra-

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Jet

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