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Lactational amenorrhea: fertility, birth control and breastfeeding

Kelly Durbin, Austin, Texas, USA

Lactational amenorrhea is a period of temporary infertility that accompanies breastfeeding and is marked by the absence of monthly periods. Postpartum fertility is an important topic and many mothers who seek breastfeeding support have questions about using lactation as a means of birth control.

The physiology of lactational amenorrhea involves a highly sensitive hormonal feedback loop between the brain and ovaries (or hypothalamus-pituitary-ovarian axis). When the infant is at the breast, the suckling action triggers nerve signals that travel from the breast to the brain. This causes the hypothalamus to alter the hormones released from the pituitary gland. This state of altered hormones disrupts normal activity in the ovaries, triggering a temporary period of infertility because ovulation is suppressed. This period of infertility is often referred to as LAM, or the Lactational Amenorrhea Method and can provide very effective birth control. 

In 1988, scientists and fertility specialists gathered in Italy at the Bellagio Consensus Conference to define the conditions for using lactation amenorrhea as birth control. They established that in order for LAM to be effective three important conditions must be met: 

  1. The infant is less than six months old,
  2. The menstrual cycle is absent, and
  3. The baby is exclusively breastfeeding. 

Once any of these conditions are not met, the effectiveness of LAM begins to wane (Kennedy et al., 1996). The Bellagio Consensus established the risk of pregnancy to be less than 2% in the first six months postpartum while using LAM (Lancet, 1988). According to the World Health Organization, the risk of pregnancy while using this method correctly is less than 1% (WHO, 2020). 

There are many benefits to using LAM as birth control in the first six months postpartum. LAM requires no special equipment, no pills, prescriptions or supplements, and is universally available. Unlike hormonal birth control such as the contraceptive pill, some intra uterine devices (IUDs) and implants, the LAM method does not involve synthetic hormones, which for many nursing parents can interfere with milk supply. In addition, using the LAM method is highly cost effective as it is free. 

LAM provides excellent birth control for six months but also enhances positive maternal and infant health outcomes. For example, one of the LAM requirements is full or exclusive breastfeeding. Exclusive breastfeeding for six months, aside from promoting LAM, is known to optimize infant gut health, support normal infant weight gain, and protect against certain respiratory illnesses and diarrhea. Exclusive breastfeeding also promotes positive outcomes for maternal health as well. Breastfeeding decreases the risk of developing certain cancers and conditions. For example, breastfeeding decreases the risks for breast and ovarian cancers as well as the risk of developing type 2 diabetes (Chowdhury et al., 2015). 

Artwork courtesy Ken Tackett

 

There are some ways to enhance the use of LAM. LAM appears to be associated with the intensity and duration of feeding, not just in terms of duration of months, but also duration of minutes throughout the day. The period of ovulation suppression and infertility can therefore be enhanced by:

  • Offering the breast whenever baby displays feeding cues (nursing on demand)
  • Nursing frequently throughout the day
  • Nursing baby on demand at night as long stretches without nursing can impact LAM (Gross & Eastman, 1985.)
  • Allowing baby to determine the end of the feeding instead of using arbitrary time limits
  • Allowing babies to meet all their sucking needs at the breast (no dummies or pacifiers)
  • Waiting until mid-way through the first year to introduce solid foods

Research shows that the physical stimulus of suckling at the breast directs suppression of ovulation (McNeilly, 2002). Therefore, it is important to maximize the infant’s time at the breast for suckling, even for comfort. The Bellagio Consensus did not expressly state that dummies or pacifiers be prohibited, and it is very likely that some people have success with LAM even while occasionally using a pacifier (dummy or soother). However, it may be best to minimize the use of pacifiers in order to protect the action of LAM. Minimizing the use of pacifiers also enhances milk production. 

Lactational amenorrhea as birth control might not be the best option for everyone. For some, it can be hard to practice exclusive breastfeeding. In addition, there is some evidence that the risk of pregnancy is slightly higher for working mothers who practice LAM (Valdés et al., 2000). Another consideration for this method is that it is less reliable after six months, making it necessary to use alternative birth control after that time. 

Some mothers or nursing parents who have purposefully used LAM or others who are meeting the LAM criteria for other reasons (promoting good milk supply, using responsive feeding techniques, or when cultural norms promote exclusive breastfeeding) have noticed that they experience a longer period of sub-fertility than they would prefer. Sometimes, for those with intense duration of breastfeeding, fertility has not yet returned when they are ready to conceive another child. There is evidence that the pattern of breastfeeding is a factor when it comes to fostering the return of fertility. For those who take months to gradually wean, the return of fertility could be stalled. On the other hand, abrupt changes to the nursing pattern can bring on ovulation more quickly (Andersen, & Schiøler, 1982) but stopping breastfeeding completely is not usually necessary. There are anecdotal stories about ovulation returning for women who experience temporary separation from their toddler, for example, after a weekend away. Reducing feed frequency, longer stretches between certain feeds or night weaning have triggered ovulation for some mothers.

Further reading

Taking Charge of Your Fertility by Toni Weschler. 

References 

  • Andersen, A. N., & Schiøler, V. (1982). Influence of breast-feeding pattern on pituitary-ovarian axis of women in an industrialized community. American Journal of Obstetrics and Gynecology, 143(6), 673-677.
  • Breastfeeding as a family planning method. (1988). Lancet (London, England), 2(8621), 1204–1205.
  • Chowdhury, R., Sinha, B., Sankar, M. J., Taneja, S., Bhandari, N., Rollins, N., … & Martines, J. (2015). Breastfeeding and maternal health outcomes: a systematic review and meta‐analysis. Acta paediatrica, 104, 96-113.
  • Gross, B. A., & Eastman, C. J. (1985). Prolactin and the return of ovulation in breast-feeding women. Journal of Biosocial Science, 17(S9), 25-42.
  • Kennedy, K. I., Labbok, M. H., & Van Look, P. F. A. (1996). Lactational amenorrhea method for family planning. International Journal of Gynecology & Obstetrics, 54(1), 55-57.
  • McNeilly, A. S. (2001). Lactational control of reproduction. Reproduction, Fertility and Development, 13(8), 583-590.
  • Valdés, V., Labbok, M. H., Pugin, E., & Perez, A. (2000). The efficacy of the lactational amenorrhea method (LAM) among working women. Contraception, 62(5), 217-219.
  • Family planning/contraception methods. (2020, June 22). WHO | World Health Organization. https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception

Kelly Durbin has been a Leader for about ten years in the United States with experience leading meetings in five different states across the country. She, her husband and their two daughters now live in Austin, Texas, USA.