Ovarectomy, HRT and Breastfeeding Adopted Infants

A review of the risks versus benefits of hormone replacement therapy (HRT) for ovarectomized women contemplating breastfeeding adopted infants

     by  Jimmie Lynne Scholl Avery

As breastfeeding has increased within the U.S.A. since the early 1970s, a comparable increase has developed of women breastfeeding their adopted infants. The major reason for adoption is infertility. Among some of these women, infertility is due to hysterectomy and removal of the ovaries. Hormone replacement therapy, HRT, has traditionally been recommended for women who have experienced such surgical menopause. It has also been recommended for women born without ovaries.

The controversy: When a woman in this situation contemplates breastfeeding an adopted infant, these questions usually arise-

    * Shall I continue HRT during breastfeeding?
    * Shall I discontinue HRT during breastfeeding?
    * Should my endeavor to breastfeed be ruled out entirely?

The ultimate decision rests with the prospective adoptive mother, of course. In keeping with the philosophy of informed choice, various facts about this controversy are explored here for consideration.

Reasons for controversy: Much of the concern centers on the known facts about the risks associated with using oral contraceptives. There are risks recognized in general, which include unpleasant side effects of nausea, fluid retention, headache, and increased risk of liver cancer. Special issues of concern for lactating women are whether the contraceptives will diminish lactation, or will compromise, alter, or reduce the quality or composition of the milk, and whether hormones will pass through the milk to the infant, and ultimately have a negative effect on the infant's health.

Differences between oral contraception and hormone replacement therapy: The effect of contraception is achieved by providing hormones to supplement, add to, those already being produced by fertile women, with the object being to suppress ovulation. In hormone therapy, hormones are supplied to replace those no longer being produced by the ovaries, which have been removed. In ovarectomized women, the trend is to provide only minimal dosage levels, which are adequate for maintaining their health needs. These include protection from bone loss of osteoporosis, and reduced risk of heart disease. Hormone levels are usually much LESS than the levels that would be produced by a single functioning ovary.

Comparative hormone levels: Studies of women breastfeeding homemade babies (not adopted) and using oral contraceptives, show that an infant who consumes 600 ml (20.29 ounces) of breast milk daily, from a mother taking 50 ug (micrograms) of ethinyl estradiol daily, receives about 10 ng (nanogram, or billionth of a gram), or 0.02% of the mother's dose. This amount is comparable to amounts of estradiol breastfeeding infants consume in milk from mothers who are NOT taking oral contraceptives. Before ovulation resumes postpartally, it is estimated a suckling infant receives from 3 to 6 ng a day of estradiol in his mother's milk. After ovulation resumes, a baby might receive 6 to 12 ng a day in breast milk, depending on the phase of his mother's menstrual cycle.

Unanswered questions: The actual levels of hormones secreted by lactating adoptive mothers on hormone replacement therapy are unknown. There has not been sufficient interest within the scientific community for investigation. The actual volume of milk production in adoptive women is highly variable, ranging from practically nil, to 50-75% of an adopted infant's nutritional intake. Even these volumes are estimates, based on standard nutritional requirements for infants of comparable ages, and subtracting the volume of supplemental formula and solid foods being consumed by infants. The result is the estimated volume of breast milk supplied by the adoptive mother.

In a study of 240 adoptive women, about 2/3 of the women who breastfed indicated they thought their infants received 50 to 75% of their nutrition as breast milk. Stated simply, no one knows how much breast milk adopted infants, in general, consume. And, among the mothers who receive replacement hormones, no one knows how much hormone is passed through the milk to infants.

Experiences to date: More women have elected to breastfeed while taking HRT than have decided to discontinue hormones, or to abandon the idea of attempting to breastfeed their adopted infants. Some have done so with the support of their primary care physicians, and others have disregarded advice against it.

BREASTFEEDING WITH HRT: The rationale given by most who elected to breastfeed while continuing hormone replacement therapy is:

    * Hormone levels being taken by the mother are less than she would produce with a single, functioning ovary.
    * It is assumed, then, that the levels secreted in milk are likely less than levels among non-adoptive lactating women with functioning ovaries, and not receiving oral contraceptives.
    * Overall milk volume an adoptive mother might expect to produce will be significantly less than volume of non-adoptive lactating women.
    * Thus, hormones passed to the infant over a period of time will likely also be less than for non-adoptive breastfed infants.

BREASTFEEDING WITHOUT HRT: Of those who elect to breastfeed adopted infants, but discontinue replacement hormones, their rationale they give is:

    * The volume of hormones secreted in milk is unknown.
    * The risks, if any, to adopted infants is unknown.
    * Breastfeeding is considered important from a bonding perspective.
    * Therefore the adoptive mother considers it worth sacrificing her HRT during the breastfeeding period.

Some women also cite their doubts in the value of such therapy, in view of risks publicized for hormone replacement therapy in women experiencing normal menopause (non-surgically induced).

ABANDONING BREASTFEEDING: Those who elect to abandon the idea of attempting to breastfeed tend to approach it from the point of view that they are unable to do so. They often have made statements like,

    * ...I can't. My doctor won't let me.
    * ...I wanted to so badly, but now I'm not able to.

Such women have generally not had much information, so that the decision seems to be one in which events happen, rather than a conscious, informed choice being made. Only a few women, thus far, have made a clear choice to abandon breastfeeding their adopted infants, after being informed of facts pertinent to this issue.

REFERENCES

Auerbach KG & Avery JL: Nursing the Adopted Infant: report from a survey. Monograph No. 5. Denver, 1979, Resources in Human Nurturing, International, Inc. (Now available as Monograph # M005, from Lact-Aid International, Inc.

Avery JL: Relactation and induced lactation, Chapter 13, in Riordan J: A Practical Guide to Breastfeeding. St. Louis, 1984, CV Mosby Co.

Avery JL: Unpublished Data from Lact-Aid International, Inc. client files, 1969 to 1984.

Bowes WA, Jr, MD: Personal communications 1979 (while serving as Editorial Advisor for Keeping Abreast Journal of Human Nurturing.)

Hormann E: Breastfeeding the adopted baby, in Birth & the Family Journal. Volume 4:p165, 1977.

Kleinman R, et al: Protein values of milk samples from mothers without biologic pregnancies, in Journal of Pediatrics. Vol. 97: p 612, 1980.

McGregor JA: Lactation: Physiology, Nutrition, and Breast-Feeding. New York, 1983, Plenum Press.


NOTE: This report is adapted from an article appearing in Lact-Aid Bulletin, No. 10, Nov/Dec 1984. © Copyright 1996, 1993 & 1984, by Jimmie Lynne Avery, All rights reserved. This publication may not be modified nor altered in any way, nor reproduced in whole, nor any part, by any means, photographic, electronic or otherwise, without the express permission of the author, except for free distribution for educational purposes only.

Disclaimer: The information presented here is for educational purposes only, and is not intended to provide or substitute for medical advice in any way. Anyone contemplating HRT, while breastfeeding or for any other reason should discuss it with their physician.