NDC Clinical Guidelines Induction of Lactation Part 2. Do hormonal medications improve breastmilk volumes in non-puerperal induction of lactation?
Non-puerperal induction of lactation: do hormonal medications actually prepare the breasts?
Protocols for the induction of lactation often (though not always) aim to mimic the hormones of pregnancy to prepare the breast, at the same time as the patient takes domperidone.
You can find out about the process of secretory activation in the human mammary gland here.
The Newman Goldfarb Protocol (NGP), discussed here, recommends up to nine months of hormone-mimicking drugs in an attempt to replicate the hormonal milieu of pregnancy, stating that 6-9 months of combined oral contraceptive pill (COCP) plus domperidone gives the best results.
But there is no research to show that preparation with reproductive hormones is more effective than domperidone and stimulation alone, or even breast stimulation alone. The dose of the recommended COCP is many times less than hormonal levels which occur in pregnancy.
Nevertheless, individuals without risk factors often choose, despite the absence of guiding evidence, to use hormone medication as they attempt to create a milk supply.
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Many have already taken the COCP for contraception or other reasons previously.
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The risks of COCP when taken for less than a year and when usual risk factors are excluded are minimal.
When there is minimal risk, many decide it's worth trying hormonal preparation, hoping for the best possible outcomes.
What hormonal regimes are used and for how long? NDC Clinical Guidelines, adapted from the Regular Newman Goldfarb Protocol
If the COCP is contra-indicated due to risk factors, it's helpful to know that there are research reports of successful induction of lactation resulting from nipple stimulation alone.
When a patient wishes to attempt to prepare or prime the breasts hormonally, you would prescribe a combined oral contraceptive pill (COCP) which contains both progesterone and oestrogen.
The NGP recommends
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A maximum of 35 micrograms of ethinyl oestradiol.
- NGP states, without evidence, that 20 micrograms of ethinyl oestradiol is as effective and reduces nausea, bloating, and breast tenderness. However, 20 micrograms does result in more irregular vaginal bleeding.
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At least 1 mg of norethisterone, also known as norethindrone. The NGP claims, despite the absence of research-based evidence, that 2-3 mg of progesterone is more effective.
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The oestrogen and progesterone doses are prescribed as a monophasic high dose COCP, ingested daily and continuously throughout the induction without pause for inactive pills.
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Levonorgestrel is considered more potent than norethisterone.
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Yasmin, containing drospirenone 3000 micrograms (mcg) + ethinylestradiol 30 mcg, is often a good option.
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Prepare the patient for the COCP by
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Checking the patient's blood pressure
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Informing the patient that continuous COCP active pills commonly results in irregular breakthrough bleeding, which is not a cause for concern.
When the combined oral contraceptive pill is contra-indicated
Contra-indications will become clear with a thorough medical history and assessment, and might include:
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Hypertension
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Thrombosis
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Cardiac conditions.
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The patient is over 35 years of age.
If the patient is unable to use a combined oral contraceptive pill, a progesterone-only pill, such as >provera 2.5 or prometrium 100 mg can be used.
Cessation of hormones: NDC Clinical Guidelines, adapted from the Regular Newman Goldfarb Protocol
The NGP recommends stopping the hormones six weeks before the baby is delivered or arrives. Ceasing the hormones
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Is intended to mimic the drop in oestrogen and progesterone that occurs with delivery of the placenta (even though the plasma levels have been multiple times less than is found in pregnancy)
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Occurs at six weeks to give the breasts one month of stimulation prior to the baby's arrival (including two weeks grace in case baby arrives before the due date)
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Can be expected to result in vaginal bleeding as a result of hormonal withdrawal.
When the hormones are ceased
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Domperidone ingestion continues, and
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Nipple and breast stimulation using an electric breast pump is commenced.
You can find out about nipple and breast stimulation for induction of lactation here.
You can find out about domperidone and other galactogue use and induction of lactation here.
Accelerated NGP protocol
If the patient does not have six months before the baby is delivered or arrives, the patient takes the COCP for as long as possible or ideally, until the breasts have increased one cup in size, and feel heavier, fuller, and tender.
The patient then ceases the COCP, ideally 6 weeks prior to the baby's arrival. Domperidone is commenced with the COCP, as soon as the decision to induced lactation is made.
Since breast and nipple stimulation is the most important aspect of induction of lactation, this needs to start at least four weeks prior to the baby's arrival.
You can find out about nipple stimulation in the induction of lactation here.
You can find out about use of domperidone and herbs as galactogogues in the induction of lactation here.
Recommended resources
Research about induction of lactation in transgender patients
Induction of lactation: taking a history and why each question matters
Case report of preparation for induction of lactation in a cisgender woman (NDC Clinical Guidelines)
NDC Co-lactation Feeding Plan (to be adapted adapted)
Selected references
McBride GM, Stevenson R, Zizzo G, Rumbold AR, Amir LH, Keir AK, et al. Use and experience of galactogogues while breastfeeding among Australian women. Plos One. 2021;16(7):e0254049
Other references available here.
The Newman Goldfarb Protocols for induction of lactation are found here.