If you believe that both you and your baby have all the right equipment and yet you aren’t mak ng enough milk, what could be going on? It 1S especially frustrating if well-meaning friends or relatives tell you that you just need to try a little harder, or that maybe you’re just too high- strung. Read on! You may find some clues here that will help you solve your personal mystery.

The piece of the equation least addressed by research is the active physiological process of making milk-having the right ingredients and instructions. This refers not to your diet but rather to your hormones and their complex interactions that bring everything together and direct milk production.

The Milk Supply Equation

 Sufficient glandular tissue

Intact nerve pathways and ducts

+ Adequate hormones and hormone receptors

+ Adequately frequent, effective milk removal and stimulation  

= GOOD MILK PRODUCTION 

Hormonal Issues: The Big Spider Web

Probably the most confusing and confounding aspect of trying to understand problems related to hormonal issues is the many complex interrelationships between conditions. Sometimes the question becomes, “Which came first; the chicken or the egg?” Is the hormone problem the cause of low milk production, or is it a symptom of another issue?

Hormones are complex and difficult to study because they interrelate like a giant spider web. They can affect their own receptors, other hormones, and other hormone receptors. Timing can determine whether lactation is affected or not. For instance, problems with key hormones during the critical window of puberty could affect the developing breast structures, resulting in hypoplasia (SEE_BLOG_8 )

Certain conditions that affect various mammary and lactation hormones will be discussed individually in this blog, but it also helps to look at the big picture as you try to understand what may be asked in your body when milk production doesn’t seem to be working right. For instance, if your body doesn’t make enough progesterone, it’s possible that this could affect the development of your milk factory and your eventual milk supply. A problem with any of the three major milk hormones, prolactin, insulin, and cortisol, could certainly throw a monkey wrench into your milk production machinery. If there is a problem with oxytocin, it could cause a decrease in your ability to release milk, which would automatically lead to decreased milk production.

Actual hormonal deficits are possible, though not common, and in rare instances can be an inherited condition. In one documented case, a mother with no detectable milk also had almost no measurable prolactin, a problem that apparently ran in her family. Prolactin replacement, now being researched, will be helpful when it becomes available.

The receptor side of hormone function has been the neglected element in the Milk Supply Equation, yet having a receptor problem is the same as not having enough hormone because the hormone can’t get where it needs to go. At least one study has looked at whether prolactin resistance can happen and interfere with normal milk production. Insulin resistance is certainly known, and cortisol resistance also may not be as rare as previously thought.

 Edema

Water retention in the body, called edema, is common toward the end of pregnancy. Nurses and lactation consultants report that a growing number of women are now also experiencing water retention and swelling that seems to develop or worsen during and after hospital deliveries. Their breasts may feel hard and swollen to the point that the nipple and areola flatten out as if engorged with milk. So far there is no good research, but some believe that it may be due to intravenous (IV) fluids building up in the body, while others think that Pitocin (artificial oxytocin), which is chemically similar to antidiuretic hormone (ADH), may bind to or increase the number of ADH receptors and temporarily cause more water retention. Whatever the reason, there seems to be a connection between this edema and delayed milk production; often the milk doesn’t come in fully until the swelling subsides.

Diuretic drugs are rarely prescribed because edema is usually a self-correcting condition. If you are anxious to speed the process of eliminating the excess water to help your milk come in, there are foods with diuretic properties, such as dandelion greens, dandelion tea, watermelon, cucumbers, asparagus, cabbage, and celery, that you can try, though you’ll need to eat a lot of them!

Obesity

Obesity, defined as a prepregnancy body mass index (BMI) greater than twenty-six, is a risk factor for both delayed lactation and low milk production. In animal experiments, overfeeding and excessive weight has been related to poor mammary growth both before and during pregnancy. Research hasn’t examined this possibility in humans, but a study of obese mothers who weren’t making enough milk found that they often had lower prolactin surges in response to nursing or pumping even though they started with levels similar to nonobese mothers. It’s quite possible that mammary gland development during puberty or pregnancy also may be affected in a manner similar to the animal studies, and excessive weight gain during pregnancy could also alter breast growth during that time.

Exploring the underlying cause of obesity may provide additional clues for milk supply problems. Many people assume that obesity is simply the result of overeating, but there are metabolic disorders that affect milk production such as hypothyroidism and polycystic ovary syndrome (PCOS) that also cause eight gain Obese women also frequently suffer from insulin resistance and diabetes, which are often reversible with weight loss.

Diabetes

The breast is a major consumer of insulin, a key hormone that plays a role in mammary development and milk production. Insulin receptors in the breast are normally somewhat resistant but become more sensitive to insulin during pregnancy in preparation for making milk. Diabetes is a disease or condition in which the body either does not produce enough insulin or does not use it properly. There are two major forms of diabetes.

Type 1 Diabetes

Insulin-dependent diabetes mellitus (IDDM), also known as type 1 diabetes, occurs when the pancreas is unable to manufacture enough insulin to meet the body’s needs. As a result, additional insulin is required to make up the deficit. During pregnancy, prolactin and human lactogen can be lower in type 1 diabetic mothers, possibly affecting mammary gland development and lactation. As milk production begins after birth, the body’s metabolic needs change dramatically, altering insulin requirements. This can slow the milk coming in up to twenty-four hours, depending on how quickly adjustments to insulin replacement are made.4 Any significant fluctuations in insulin can cause a decrease in milk production at any time during lactation. Tight control of blood sugar and insulin levels can help women with this type of diabetes maintain consistent milk production for baby. Insulin therapy is safe for lactation because the molecule is too large to pass into the milk. Type 1 diabetes may also affect thyroid function, another issue described later.

Type 2 Diabetes

Also called non-insulin-dependent diabetes mellitus (NIDDM), type 2 diabetes does not require insulin therapy. Instead, your body makes enough insulin but is not able to use it well because of a problem with receptor binding. The resulting insulin resistance creates a ‘rusty lock” effect that makes getting enough insulin and glucose into the cells more difficult. The body’s response is to compensate by increasing insulin production further, resulting in hyperinsulinemia. When the effort of overproducing insulin wears the pancreas out, type 1 diabetes results. Insulin receptors naturally become slightly more resistant than usual as a normal process of pregnancy, but when they become too resistant, a temporary form of type 2 diabetes called gestational diabetes can occur. Many mothers with type 2 or gestational diabetes make plenty of milk, but some don’t. Women with milk supply problems and confirmed insulin resistance often have breast hypoplasia as well.2More research is needed on the relationship between insulin resistance and breast development.

Hypertension

Hypertension is diagnosed when blood pressure is higher than normal. Mothers who have hypertension before pregnancy are said to have chronic hypertension. High blood pressure that starts after twenty weeks gestation is called gestational hypertension. Pregnancy-induced hypertension (PIH), also known as toxemia or preeclampsia, is a form of gestational hypertension accompanied by protein in the urine and sudden swelling of the hands, feet, or face. HELLP syndrome (named for its main symptoms: hemolytic anemia, elevated liver enzymes, and low platelet count) is a severe variation of PIH. Whatever the origin, hypertension is considered a risk factor for poor milk production.6 The exact mechanism is not well understood, especially because not all women with high blood pressure have difficult making milk. But it is known that hypertension can affect the placenta, which in turn could affect breast development (see the section “Placental Problems” later in this blog). Questions also have been raised about the drugs used to treat hypertension, especially in pregnancy, but so far we don’t have any definite answers.

Anemia

Anemia, a low red blood cell count, can be an inherited condition or caused by disease, infection, drug exposure inadequate nutrition, or excessive blood loss. Most cases are related to iron deficiency and may not have obvious signs Fatigue is the most common symptom, but as anemia becomes progressively worse, weakness pale skin (especially the inner lining of the eyelids), rapid heartbeat, shortness of breath, chest pain, dizziness, irritability, numbness or coldness in hands and feet, or headache may occur. Mild anemia is common during pregnancy and rarely a problem, but if there is a large loss of blood during delivery, anemia can develop or worsen. Sleep-deprived new mothers may not always realize that anemia may be contributing to their fatigue.

There 1s some evidence that anemia can affect lactation, though research has been limited. If you have low iron, researchers believe that it’s best to treat it whether or not you have obvious symptoms in order to optimize milk production. Share this with your doctor and ask him what he recommends. In the meantime, eat high iron foods together with food or drinks high in vitamin C to help your body to absorb more iron and rebuild your stores. Galactogogue herbs that contain iron may be useful (See_BLOG_12)

Postpartum Hemorrhage and Sheehan’s Syndrome

Severe bleeding after delivery can pose two risks to milk production. Most obvious is the large loss of red blood cells and possible anemia. The loss of up to a pint (500 cubic centimeters) of blood with vaginal births and up to 2 pints (1,000 cubic centimeters) with cesarean surgery is considered within normal limits. Higher amounts of blood loss have been associated with poor milk production.

The second risk from postpartum hemorrhage involves the pituitary gland, which enlarges during pregnancy. If there is a sudden loss of a large amount of blood, hypovolemia (decrease in blood plasma volume) may ensue and the pituitary gland may collapse. Mild to moderate damage is referred to as a pituitary insult and causes reduced functioning, depending on the severity. Severe damage is known as a pituitary infarction or Sheehan’s syndrome. Resulting problems may be immediately obvious or may occur over time, and hypothyroidism eventually occurs in half of all cases of pituitary damage. Prolactin and milk production can be moderate to completely suppress. Galactogogue drugs that stimulate prolactin can be only as effective as the pituitary’s ability to respond to Prolactin replacement therapy, once developed has the potential to restore milk production.

Mona Gabbay, M.D., IBCLC, a physician with a breastfeeding medicine practice in New York, finds that baseline prolactin levels are often below 30 nanograms per milliliter in mothers who have experienced postpartum hemorrhage and low milk supply. She reports improved milk production with domperidone treatment (See_BLOG_12)

Measuring Prolactin

Prolactin is tricky to measure and interpret because it varies depending on your stage of lactation. It’s highest around birth and then declines over the next few months to a lower plateau. Baseline measurements are those taken when there hasn’t been nipple stimulation for at least ninety minutes. Prolactin is lower in the daytime and rises at night during sleep. A prolactin surge is a rise above the baseline in response to stimulation Ideally, blood is drawn before feeding for a baseline measurement and then again forty- five minutes after starting to nurse or pump to measure the surge. In the early months, it will at least double, sometimes reaching ten to twenty times the baseline. Some experts believe that the prolactin response to suckling is more significant than the actual baseline number. If cost prohibits two separate tests, a baseline taken right before feeding is the bet- ter choice.

Some women have been told that their pro- lactin level was normal when in fact it was quite low for lactation. Standard lab reports list only the normal range for nonpregnant nonlactating females, and physicians may not always remember this. If testing is done while you are taking a prolactin-increasing drug, the results may be much higher than expected and there will be little or no rise with suckling or pumping.

Placental Problems

Joan had successfully breastfed two other children, but her third baby, born prematurely due to a separating placenta, was not thriving. She reported that her breasts didn’t grow or change much this pregnancy, nor did milk come in well despite excellent management.

Anything that compromises placental function can also affect breast development during pregnancy.10 A diagnosis of “placental insufficiency is a red flag, as is any significant separation of the placenta, referred to as placental abruption, occurring earlier on, especially if that led to more complications. (A compromised placenta can be the reason a baby is born small for his gestational age.) Poor glandular development caused by a poorly functioning placenta is difficult to remedy, but not impossible; you can still build breast tissue with frequent stimulation by nursing or pumping just as adoptive mothers do. Galactogogues that stimulate breast growth are the best choice in this situation.

Progesterone also may be lower during a pregnancy with placental problems. In rats, this has caused premature labor and sometimes even the start of milk production before birth. Involution then began because milk was not being removed; the milk factory literally began to tear down before it even opened for business! There have been a few cases reported of women who had preterm labor followed by engorgement and milk leakage. Once the baby was born, their milk did not come in at all. Though not tested, supplemental progesterone therapy at the first sign of placental problems might be able to rescue some of these situations by allowing continued breast development and stopping the premature initiation of full milk production.

A different type of placental problem is retained placenta. Once the baby is born and the placenta is delivered, progesterone levels drop rapidly and the milk comes in. On rare occasions, a piece of tissue may break off from the placenta and remain attached to the uterine wall. This will often cause heavy bleeding or even hemorrhaging, so it is usually discovered and treated quickly. But if symptoms are more subtle and the piece stays inside, continued progesterone can interfere with the start-up of milk production. Sometimes lack of milk may be the first clue that a piece of placenta remains. This is more likely to happen in deliveries where the placenta was slow to expel or tension was applied to help the placenta come out. It can even happen with a cesarean delivery.

Marie had previously breastfed four other children, but her new baby was not getting enough milk to grow well. A plan was developed to continue nursing, pumping, and supplementing. Two weeks later, the baby was suddenly gulping milk contentedly at the breast. When asked if there were any significant changes that week, Marie responded, “Well, I did have this really weird thing happen a couple of days ago. I had a lot of cramping and then I passed these big clots.” The improvement in milk production occurred soon after this event. Marie remembered that her obstetrician had kept traction on the umbilical cord until the placenta came out. Case solved.

When a mother’s postpartum bleeding is in the normal range but milk production is sluggish to start, Pamela Berens, M.D., suggests ruling out retained placental tissue with a blood test for beta human chorionic gonadotropin (ß-hCG), a placental hormone that normally decreases rapidly after birth. A transvaginal ultrasound is another possible screening test; a negative result is usually correct, but a positive result could wrongly interpret post-birth debris as placental tissue. As in Marie’s case, retained tissue can clear out on its own, but when identified earlier, it’s usually removed surgically to avoid the risk of hemorrhage. Increased milk production usually occurs within forty-eight hours.

In rare cases, a more severe version of placental retention can occur. Rather than merely attaching to the uterine wall, the placenta may grow into the wall and sometimes through the wall and even to other organs. This often causes hemorrhaging because the pieces cannot easily let go and come out after birth. Manual removal of the placenta may be attempted, and medications such as Methergine or methotrexate may be used to help complete the job and control bleeding. These drugs carry some risk of suppressing or reducing milk production, though short-term use is considered less risky.

Your physicians, working in tandem with a lactation consultant, are the best resources to help sort through this difficult problem. However, not all are aware of the connection between the placenta and the start of milk production or may not be open to the possibility because they feel that it implies error on their part. This can make it difficult to receive a serious, thorough evaluation if the symptoms are subtle. You may need a second opinion if your caregiver does not fully explore this possibility with you.

Thyroid Dysfunction

Thyroid hormones come from the butterfly-shaped thyroid gland in your neck and are vital to the proper regulation of lactation hormones  Thyroid function involves a complex interaction between the hypothalamus, pituitary, and thy roid glands. Thyroid-releasing hormone (TRH) from the hypothalamus tells the pituitary when to release thyroid-stimulating hormone (TSH) which directs the thyroid gland in the production of thyroxine (T4) and triiodothyronine (T3) Dysfunctions in this process can affect milk production.11 Problems with your thyroid gland can be hard to detect and diagnose if the symptoms or lab results are not obvious and straightfor- ward. They can also occur together with other conditions such as polycystic ovary syndrome (PCOS), which is discussed later in this blog and even cause PCOS-type symptoms.

Thyroid dysfunctions generally fall into two main categories. Hyperthyroidism, most often associated with Graves’ disease, involves overproduction of thyroid hormones that is usually caused by an overactivity of the thyroid gland In hypothyroidism, frequently associated with Hashimoto’s disease, the problem is inadequate production of thyroid hormones caused by under-activity of the thyroid gland. Postpartum thyroiditis, or postpartum thyroid dysfunction, often doesn’t show up until some time after baby 1s born. Little research exists on the effects of hypothyroidism and hyperthyroidism on human lactation, but animal research provides some insights.

Hypothyroidism

This is diagnosed when there are high lev els of TSH and low levels of T3/T4 (thyroid hormones), typical causing weight gain and even depression, Hv- pothyroidism may exist before pregnancy but occurs for the first time during pregnancy in a small percentage of women. Slightly lower levels of thyroid hormones are normal during pregnancy because some go to the developing baby. This isn’t usually a problem, but if you’re already hypothyroid, this additional burden can make your condition worse. Untreated hypothyroidism can cause pregnancy-induced hypertension, preeclampsia, placental abruption, anemia, postpartum hemorrhage, and low birth weight. For this reason, hypothyroid mothers are usually monitored carefully, and their medication is often increased during pregnancy. Until recently, it was believed that hypothyroidism affected only milk synthesis, but rat research suggests that poor milk ejection due to impaired oxytocin may be another problem. Poorly controlled hypothyroidism during pregnancy may also reduce the amount of food fats normally manufactured during pregnancy for making milk after baby comes.

Not all thyroid problems show up with the usual tests. Women with low milk productiorn and”low normal” thyroid levels may not be treated because their levels aren’t considered low enough. Some women whose TSH and T3 are considered normal, even though they don’t feel well, are eventually diagnosed with subclinical hypothyroidism by more thorough testing It can be difficult to find a provider who will pursue borderline cases, so you may need to be persistent. Mothers treated during pregnancy should have their thyroid checked within a couple of weeks after birth and again a few weeks later. Hormone needs often decrease after birth, and if medications are not quickly adjusted, this can lead to overmedication and hyperthyroidism which can also be a problem for milk supply.

Hyperthyroidism

This is diagnosed when TSH is low and T3/T4 are high, and it causes accelerated metabolism and weight loss. Hyperthyroidism occurs less commonly in pregnancy than hypothyroidism. If you were already hyperthyroid, you will usually experience improvement because the baby takes some of your hormones, pulling you closer to normal As a result, you may need less suppressing medication during pregnancy, though symptoms usually rebound shortly after birth. Poorly controlled hyperthyroidism can cause premature delivery preeclampsia and fetal growth restriction.

Studies of rats hyperthyroid during preg- nancy show multiple problems. First, while they had rapid mammary gland growth, they also were using up mammary fat stores before birth, affecting the amount left to make milk. Second, they had lower prolactin and oxytocin levels during lactation. Because of significant problems with milk ejection, little or no milk came out, depending on the severity of the hyperthyroidism.

There are no published human case reports of hyperthyroidism affecting lactation, but Chris- tine Betzold, NP, IBCLC, M.S.N., from California tells of two mothers with whom she has worked The first had been hyperthyroid for several years and had a history of good breast growth during pregnancy but premature delivery, severe engorgement, and mastitis with her first two children. Her third baby was also born prematurely, and although she tried to pump, not a drop of colostrum or milk ever came out. She tried galactagogues, but still nothing came out, so she stopped. The second mother had successfully breastfed her first two children, though she had a history of toxemia with each one. During her third pregnancy, she became very hyperthyroid and experienced severe hypertension along with other serious complications that forced a very premature delivery. She didn’t start pumping for almost two weeks but also never saw a drop of milk. Both of these mothers had pregnancy and lactation experiences that strongly resemble the rat research. It must be mentioned that a few isolated cases of hyperlactation in hyperthyroid mothers have been informally reported as well. If occurring as postpartum thyroiditis, it’s possible that increased metabolism may drive high production because the breast was not affected during pregnancy, but until we have more detailed information, we can’t fully explain the paradox.

Postpartum Thyroiditis

Postpartum thyroid dysfunction (PPTD) occurs in up to 7.5 percent of all pregnancies. Type 1 di abetes or smoking (especially more than twenty cigarettes per day) triples this risk. Diagnosis of PPTD often takes time because it can take differ ent patterns. It may start with hyperthyroidism that lasts for a few to several weeks and then transitions to hypothyroidism that continues for a few to several months. In some cases, the hyperthyroid stage starts just days after birth, accompanied by severe hypertension. But PPTD can also start with hypothyroidism and change to hyperthyroidism, or it can stay just one or the other. When hyperthyroidism occurs first, it is often not caught until the swing to the hypothyroid phase, which has more obvious symptoms Even when postpartum hyperthyroidism is detected, many doctors will treat only the hypothyroid phase if it occurs.

Galactogogues may be helpful but probably won’t make much difference if the thyroid dysfunction isn’t corrected at the same time. For herbal galactogogues, consider those that are reputed to support thyroid function or help with milk ejection (see_Blog_12).

Testing for Thyroid Problems

What’s a normal thyroid level? This is currently under debate, with some experts leaning toward tightening the range for TSH from 0.5-5 mIU/L (milli-international units per liter) to 0.5-2.5 mIU/L for preconception and pregnancy. 14 This may be better for lactation as well. Each individual has her own unique hormone profile that doesn’t always fit the standards, so explain your concerns to your doctor and ask for an in-depth assessment.

Infertility

A long-standing assumption has been that if a woman can become pregnant, lactation should follow successfully as well. But is this really the case? There has been surprisingly little professional discussion as to whether infertility could be related to low milk production, even though lactation consultants consider it a risk factor.

Causes of infertility vary, of course. When it’s related to an underlying hormonal issue on your side, there is potential for interference with breast development before or during pregnancy, or with the milk-making process after delivery. Quite often infertility treatments don’t directly correct a problem but “leapfrog” over it to achieve pregnancy. The breasts are ignored, yet they may be missing some of the materials needed to build your milk factory. If you had difficulty getting pregnant and haven’t found any other reasons for your low milk production, try to learn as much about the cause of your infertility as possible. Any clues you collect could give you a starting point for what might be wrong and then what you might be able to do about it, as you’ll read next.

Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOs) affects up to 15 percent of all women and is considered the leading cause of female infertility. It seems to be on the rise at the same time that milk supply problems in general appear to be increasing. Many women with PCOS have good milk supplies, and some even complain of overproduction, but Pcos mothers seem to struggle with low milk supply more often than other women do.

PCOS often causes higher levels of androgens (male hormones), estrogen, cholesterol, and insulin (due to insulin resistance); it also causes lower progesterone (due to lack of ovulation) and disrupts other reproductive hormones as well. Hypothyroidism may also be present.

These hormonal problems cause numerous symptoms. High levels of male hormones can result in excess body hair growth, male- pattern balding and persistent acne. Insulin resistance may cause brown, velvety patches of skin located around the neck, underarms, and groin area, and women with PCOS often develop type 2 diabetes in their thirties and forties. Half of women with PCOS are obese, which may be related to problems with carbohydrate metabolism. Infrequent ovulation is common, which in turn may cause ovarian cysts, irregular menstrual cycles, endometriosis, infertility, and miscarriage. Pregnancy complications such as hypertension, gestational diabetes, preeclampsia, and preterm birth occur more frequently in women with PCOS, who also seem more vulnerable to depression as a result of their hormonal imbalances. Because PCOS is a syndrome rather than a disease, every case is unique and any combination of problems can be found, making diagnosis tricky. For this reason, some health care providers skip the formality of a diagnosis and simply treat the patient’s individual problems and symptoms.

A connection between PCOS and milk supply problems was first proposed in a case study of three women with low milk production and common symptoms of PCOS.1 Researchers have largely overlooked the breast in women with PCOs, but over the years a few have written about underdevelopment of the glandular tissue within the breast, underdevelopment of the outward appearance of the breast, and both. They also mention women who had very large breasts that “simulated [excessive growth]” yet were mostly filled with fat, rather than glandular, tissue.18 These findings do not apply to all women with PCOS but are significant for PCOS mothers with breastfeeding problems.

How might PCOS affect milk production? If the symptoms start very early, around the time of a girl’s first period, the breast development that normally happens during puberty may be arrested, especially when the menstrual cycle is never established, resulting in hypoplasia. A lack of normal breast growth during pregnancy is also possible, though whether due to hormonal interference during pregnancy or simply from not starting with enough glandular tissue 1s uncertain. There is also the possibility that sufficient glandular tissue may be present but hormonal problems are interfering with the nor- mal milk-making process.

To date, two retrospective studies have looked at PCOS and milk production. The first, conducted in the United States, concluded that PCOS didn’t cause a higher rate of milk supply problems than that of the general population. However, all the mothers had metformin therapy during the first trimester of pregnancy and some longer, which could positively affect their outcome (discussion coming up). Also, results from PCOS mothers who gave birth prematurely or had multiples, and who may have had more hormonal problems than the average PCos mother, were excluded.

The second, and most recent, a study looked at thirty-six m non-PCOS control mothers in Norway, a country with excellent support and high breastfeeding rates.20 Half of the PCOS mothers were given 1,700 milligrams of metformin daily during others with PCOS and ninety-nine pregnancy, and the other half none; the medication was stopped after birth. At one month, 75 percent (27) of the PCOS mothers were exclu- sively breastfeeding versus 89 percent (88) of the non-PCOS mothers, a 14 percent difference. Five PCOS mothers but only two control moth- ers did not breastfeed at all. By three months, breastfeeding rates were equal between the two groups. The researchers also discovered a mild negative relationship between third-trimester pregnancy levels of DHEAS, a “pre-androgen,” and breastfeeding rates for PCOS mothers, providing a clue to one hormonal problem that might interfere with milk production. They did not look at other hormones besides androgens.

lf you have PCOS and are struggling to produce enough milk, first make sure that the problem isn’t something else easier and more obvious. If PCOS really seems to be the only explanation, pumping and galactogogues (see_blog_12 for more information on the galactogogues mentioned here) help in some situations, but quite often aren’t enough. Identifying and addressing an underlying hormonal problem such as insulin resistance, high androgens, low prolactin levels, or thyroid problems is likely to result in the greatest milk production capability. Metoclopramide is probably not a good idea for depression-prone mothers with PCOs, but domperidone may help get more from your breasts.

One medication being explored for increasing milk production is metformin, which improves PCOS symptoms for many women even when they aren’t insulin resistant.21 There has been informal feedback that it has helped some women significantly, some modestly, and some not at all. Dosages vary, typically starting at 500 milligrams and working up to 1,000 to 2,500 milligrams daily; if you have taken metformin previously, ask your doctor about trying the dosage that was initially needed to improve your symptoms. Metformin during pregnancy re- duces the incidence of miscarriage, gestational diabetes, pregnancy-induced hypertension, and premature delivery. It may also reduce hormonal interferences and has been reported by one infertility specialist to improve pregnancy breast growth and lactation for many of his patients.

Goat’s rue is one herb that seems especially appropriate for PCOS-related low milk producing- It contains galegin and is the herb from which metformin was originally developed Saw palmetto is reputed to reduce excessive body hair, a symptom of high testosterone. One PCOS mother who tried saw palmetto reported a tripling of her low milk production. Chaste- berry has long been used for PCOS and for milk production, and a few PCOS mothers feel it has helped them, but it must be dosed carefully by an herbal practitioner as too much may decrease prolactin.

Luteal Phase Defect

Luteal phase defect (LPD) is a condition in which the second half of a woman’s monthly menstrual cycle does not proceed normally, and it is another common cause of infertility. As a result of its effect on the menstrual cycle, not enough progesterone is produced. LPD is to blame for many pregnancies that are confirmed early but lost in the days or weeks after the period was due to start.

One reported case of low milk supply was attributed to insufficient mammary gland tissue.23 when the mother had difficulty conceiving another baby, she was diagnosed with luteal phase defect. After being treated with natural progesterone suppositories from ovulation until twelve weeks into the pregnancy, her milk supply came in normally, and she was able to provide milk fully for her second baby.

When deficiencies exist, extra progesterone throughout pregnancy may allow the breast tissue to develop more normally, resulting in better milk production (see Irene’s story in see_blog_16). Unfortunately, progesterone will not help after the baby is born because of its role in suppressing milk production during pregnancy.

Gestational Ovarian Theca Lutein Cysts

Your ovaries produce some testosterone, and a small amount is normally present during pregnancy. Rarely, an ovarian cyst called a gestational ovarian theca lutein cyst (GOTLC) may develop during pregnancy and secrete up to 10 to 150 times the normal amount. Some women experience a dramatic increase in body or facial hair, balding at the temples, deepening of the voice, or an enlarged clitoris, but if symptoms are mild or absent, the condition may not be noticed and the diagnosis may be missed completely unless your ovaries are inspected during a cesarean surgery or tubal ligation. The cure for GOTLC is birth, after which testosterone levels gradually decline without treatment.

We’ve known that high levels of testosterone can suppress milk production by interfering with prolactin, but the fact that GOTLC can interfere with milk production was only recently recognized. If you and your caregivers are not aware of the possibility, you may give up too early, assuming that you’re “one of those mothers who just can’t make enough milk.”24 This is a good reason to have your testosterone checked when there aren’t any other explanations. The milk will come in so long as breast stimulation by baby or pump is continued until your testosterone level has dropped low enough. In four reported cases, that was around 300 nanograms per deciliter and took two to four weeks.

Menstruation

Mothers sometimes complain of lower milk production prior to or during their periods, once their cycles have returned. This hasn’t been formally studied, but Patricia Gima, IBCLC, reports that a daily dose of 500 to 1,000 milligrams of a calcium/magnesium supplement has helped several of her clients, often within twenty-four hours. Gima recommends taking the supplements from ovulation (midcycle) through about three days into menstruation.

Before jumping to the cor periods are causing your low milk production. keep in mind that the return of menstruation may actually be a symptom and not a cause. A drop in the number of breastfeedings a day or long periods without stimulation (such as baby sleeping through the night) can trigger the return of menstruation. Hormonal birth control can also artificially induce periods in a nursing mother before she might otherwise have started. We don’t understand all of the hormonal changes during lactation that cause a woman’s body to resume ovulation, but one of the results of low production can be the return of menstruation. Did your milk production decrease before your periods came back, or after? If it decreased beforehand, then low production triggered the periods, not the other way around. A second question is whether you believe your production drops immediately prior to and during menstruation or if it is low all the time If it’s consistently low, then your period isn’t the likely cause.

The Age Factor

The relationship between age and milk produc tion has often been debated but studied very little. There are plenty of mothers in their later thirties or forties (and sometimes beyond) who make lots of milk for their babies. On the other hand, there are also older mothers who have had problems with milk production with no apparent explanation. Most perplexing are the cases of women who previously breastfed other children and then find themselves facing inexplicable low milk production for the first time.

At age forty-two, eight years after the birth of her fifth child, Laura gave birth to Janette. For the first time in her life, Laura struggled with milk production. Her lactation consultant noted that Janette’s suck was weak, though it was unclear whether this was due to not getting enough milk or because of a true sucking problem. Pumping and herbal galactogogues were begun, and milk production rose slowly, but still not enough. Laura decided to try domperidone, and finally her supply reached and then surpassed Janette’s needs. It became clear over time that Laura’s breasts weren’t functioning as enthusiastically as they had with her other children and needed a boost.

A key question to ask first is, “What are the surrounding circumstances of the baby’s birth? Is this your first baby after fertility problems or years of health or hormonal problems, or did you simply wait until now to have a baby for other reasons? If the new baby was conceived in the midst of long-term health or reproductive problems, those factors-not age directly-may be the culprit. However, the problem could also be the reverse: health or reproductive problems could be the natural result of an aging process that is now extending to milk production as well.

The high fertility that nature programs into younger women slowly but progressively wanes as we enter our thirties and forties. We all age at different rates, and menopause, the natural end of the fertility road, can happen anywhere from the late thirties to the mid-fifties. Preceding this is perimenopause, a time of hormonal fluctuation as the body prepares for this change. The effects of approaching menopause catch up to some of us sooner than others, perhaps causing some problems making enough milk. On the other hand, women who are past menopause have been known to relactate for a grandchild! And mothers who are nursing at the time of a complete hysterectomy, the removal of uterus and ovaries, have continued to nurse uneventfully. These facts cast some doubt on the theory that hormonal changes due to menopause are the key problem.

Another intriguing possibility is the effects of aging itself. Some researchers believe that hormone receptors become resistant to binding with their own hormones as we age. Might this be an issue when older nursing mothers experience low milk supply?

What Do I Do Now?

You may have identified yourself in one or more of the scenarios that were discussed in this blog. Now what do you do? Read the blogs on increasing milk production so that you know all your options. Then, if needed, discuss your concerns with your health care practitioners and share the relevant parts of this blog. In some offices, a nurse practitioner may have more time to explore your concerns. Finally, share this information with a skilled lactation consultant so she can help you sort through your options and decide which plan is best for you and your baby.

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