Cabergoline Safety for Lactation Suppression
by Anne Eglash MD, IBCLC, FABM
The typical recommendations for decreasing or stopping lactation include ice, tight bra, no milk expression, and tincture of time. For some, these recommendations lead to anxiety and discomfort, particularly for those who don’t easily down-regulate milk production in response to breast/chest fullness. For a lactating parent who lost their breastfeeding/chestfeeding child, breast/chest fullness and discomfort compound the heartache of such tremendous loss.
In my medical training in the 1980’s, it was routine to offer a menu of lactation suppression options postpartum, as most individuals didn’t choose to breastfeed. Bromocriptine, a dopamine agonist (increases dopamine) was the primary medication chosen, although other options included hydrochlorothiazide, a shot of estrogen, or a shot of testosterone.
Medications for lactation suppression fell out of favor after bromocriptine was removed from the market in 1994 due to its association with strokes, heart attacks, and 9 deaths. According to the US Food and Drug Administration, 'cabergoline is not indicated for the inhibition or suppression of physiologic lactation. Use of bromocriptine, another dopamine agonist for this purpose, has been associated with cases of hypertension, stroke, and seizures'.
This week I am addressing a systematic review on the use of cabergoline for lactation cessation or suppression, and whether cabergoline is associated with the same risks as bromocriptine. They have similar mechanisms of action, although their affinity for D1 and D2 receptors differ. Cabergoline works by primarily stimulating D2 receptors (D= dopamine), causing a decrease in prolactin secretion from the pituitary.
The authors identified 25 human research studies that investigated cabergoline for postpartum lactation inhibition or suppression in women aged 15 to 50. These studies included 8 randomized controlled trials, 9 cohort or non-randomized controlled trials and 6 case studies. Among a total of 757 women, 108 adverse effects were observed in 14.2% of participants. Most were short lived, self-resolving, dose dependent, and benign.
The authors discussed evidence that cabergoline use early postpartum might trigger or potentiate a psychotic event in individuals at risk such as those with schizophrenia or bipolar disorder. Although the evidence for this was low, because these individuals were already at high risk for psychosis, the authors recommend avoiding cabergoline in those at high risk for postpartum psychosis.
- Nausea and vomiting
See the Answer
This study sought to perform a systematic review of adverse events reported with the use of cabergoline for postpartum lactation inhibition or suppression in women aged 15 to 50. Following registration with PROSPERO (CRD42017049894), a comprehensive search of the Ovid databases Medline, Embase, and CENTRAL, along with PubMed, was conducted from January 1, 1985 to January 25, 2018. All study designs investigating cabergoline use for postpartum lactation inhibition or suppression in women aged 15 to 50 were included. A total of 695 articles were retrieved, and 25 articles were eligible for inclusion. Adverse events were then reported in terms of frequency, with percentages calculated according to the total number of women exposed to the intervention. A bias assessment of the articles was also performed. Among a total of 757 women, 108 adverse events were observed in 96 women (14.2%). The most common adverse events were dizziness (35 of 757), headache (30 of 757), and nausea or vomiting (19 of 757). These events were described as short-lived, self-resolving, and dose dependent. One pharmacovigilance study reported 29 “serious” events from a total of 175 events in 72 case reports, which included thromboembolic and neurologic events. Four case studies specifically addressed the psychiatric population, with one half reporting psychiatric symptoms following administration of cabergoline. In conclusion, this systematic review demonstrates that adverse events were generally benign and tolerable following the administration of cabergoline. However, pharmacovigilance data reveal that vigilance is still needed given the occurrence of rare but serious events.
I believe the medical community in the USA still views dopamine agonists as unsafe for lactation suppression because of the history of risks from bromocriptine. For several years I have heard reports of physicians unwilling to prescribe cabergoline for women with histories of no nipples, massive over production, sudden infant loss, etc. Instead, these individuals have had to endure painful swelling, edema, with the risk of mastitis and abscess. Lactating individuals have the right to be treated with compassion and evidence-based medicine, and this systematic review reassures us that cabergoline is safe for lactation suppression. This systematic review should be shared with physicians.
Unfortunately, the FDA still recommends not using it for lactation suppression, despite evidence that cabergoline does not have the same risks as bromocriptine. The FDA also states cabergoline is contraindicated for people who have elevated blood pressure, heart valve problems, or rare heart/lung/retroperitoneal fibrotic disorders.
Some people question whether cabergoline will work for people who are several months postpartum based on the theory that lactation switches from endocrine (prolactin messaging lactocytes to make milk) to autocrine (lactocytes make an independent decision on milk production based on supply/demand). The hormonal control of lactation is not clear cut. I have prescribed cabergoline to many lactating individuals who are at least 1 year postpartum for assistance with weaning, and it has been reliably effective. Metoclopramide (a medication that increases prolactin) also works beautifully for those who are close to 1 year postpartum who want to boost production. Based on my experience, I don’t believe that prolactin’s role is entirely surrendered at some point postpartum.