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.
- Dizziness
- Headache
- Tremors
- Seizures
- Nausea and vomiting
See the Answer
Abstract
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.
It is interesting to read about how USA’s approach to the use of these drugs differs from how they are commonly used, safely and successfully, in Australia.
Cabergoline is routinely offered to women who have had a fetal loss after 20 weeks gestation. It is effective and usually given within the first 48hrs postpartum.
Metoclopramide is not usually used to enhance lactation due to its extrapyramidal side effects, however Domperidone is frequently prescribed for this purpose. I realise the two countries’ FDA’s view these medications very differently.
I was wondering what you thought about having women take a couple doses of sudafed instead for milk suppression? It is easily available OTC and cheaper than a prescription med. Usually works well. I also recommend a supportive (not tight) bra and some gentle breast massage and some milk expression just to relieve discomfort, but not empty the breast. I also wondered your thoughts about potentially using something like lasix for women who have severe breast engorgement/edema. I’m thinking of women who typically are not breastfeeding but come to the ER with very swollen breasts and so much edema that if we do try to pump, nothing comes out. I’ve always wondered if maybe a short course of lasix could help?
Hi, most definitely there is a role for pseudoephedrine and other substances to decrease milk production, including the combined birth control pill, sage, peppermint, and chasteberry. I never found lasix to be helpful for engorgement, so stopped using it.
Therapeutic breast massage as a non pharmacological approach for the engorgement with early postpartum edema.
This is great systematic review. Thank you for sharing. Unfortunately i am unable to get online access to the full systematic review through my university library. what regimen does sys review recommend start and for how long when it is for a women 1 yr out of postpartum. Uptodate recommends an (off-label use): Oral: 1 mg as a single dose within 48 hours postpartum (Boucoiran 2021; Buhendwa 2008; Humphrey 2018; Nisha 2009). Im curious for those ready to wean what your starting regimen would be thank.
My doctor gave me a prescription for cabergoline to help with weaning. I am 4 months postpartum and have an oversupply of milk and postpartum anxiety stemming from the oversupply. I am afraid to use because I have read about all these crazy side effects. I also had postpartum preeclampsia, but blood pressure has been stable for a couple months without meds. It is difficult to determine how common some of these side effects are and how effective use is when you are already 4 months postpartum.
Emy, we cannot provide medical advice for individuals on this site. When I prescribe 0.25-0.5mg of cabergoline for my patients, they generally report no more than mild dizziness or headache the next day. I honestly have never had a patient report that they would never take a second dose due to side effects. However, I don’t know your medical history or the other meds you take, or the dose of cabergoline given to you, so you need to contact your physician with this question.
Thank you. Do you find it is effective in people several months postpartum. Do they need to take longer? My doctor just said to take .25 mg 2x a week until you don’t need it anymore, but didn’t know what a typical timeframe was. Do you have any idea how long it takes (on average)?
From my experience, cabergoline is always effective for weaning, no matter how many weeks, months or years someone is postpartum. I have found that 0.25mg taken twice a week generally will lead to complete weaning over 2 weeks, as long as the patient is also not excessively pumping or nursing. As the production declines, the patient should only just nurse or pump to comfort. Some patients find that 0.25mg is not strong enough and they need 0.5mg to respond, but most do fine with the 0.25mg dose. The first dose takes 3-5 days to be fully effective.
I am so grateful to have come across this article, 1 week postpartum choosing not to breastfeed, called the doctor’s office with breast engorged and pain, and they did not have any prescription suggestions for me, except the usual wear tight bra and don’t pump or stimulate. However after reading this, I told the dr’s office to call in for cabergoline 0.50 mg, and I picked it up.
I am hoping it would work even after 1 weeks post c-section. How long before I see any changes with let downs and engorgement?
The medication works slowly. Typically people notice a major drop in milk production 3-4 days after each dose. Some people need a dose every 3 days for 2 weeks to fully wean
Thank you. It has worked well, has helped pain and engorgement by day 5 of taking cabergoline 0.5.
i’m an over supply mum, 2 months post partum, exclusively pumping due to latching issues with my babe. I’ve been experiencing lots of problems like engorgment and plugged ducts in the past month. So i decided to stop.
I was prescribed Cabergoline 0.5mg, 2 tablets at half tablet BID. As i took the first dose. i got mastitis on both my breasts on the same day, so now i’m also on antibiotics and was advised by my doctor to continue pumping to clear out the mastitis.
So now, pumping every 4-5hours to trying to clear but is not working: I use to get about 220ml each pump. Now, i get only 10mls on one breast and 50ml on the other. However, I don’t think it’s the Cabergolin that’s working. i’m only on day 2. it’s the mastitis that’s not allowing the milk to flow. everything is stuck and tender.
So, my question is, would my pumping affect on how cabergoline will work?
Hi Cher, we are unable to give specific advice to individuals. However, in general, cabergoline takes 3-5 days to work. Overfullness along with poor milk removal can cause swelling and breast pain, and this is often diagnosed as infectious mastitis, whereas it is probably just inflammation from over fullness. If there are signs of infection such as fever, dizziness, weakness, nausea, then serious infection needs to be considered and a visit to the doctor is warranted. If there is a mass in the breast, then an ultrasound is needed to check for an abscess or other lesion.
When the breast is swollen and red from overfullness, cabergoline is an aggressive option to decrease milk production, usually given when the intent is to wean. It takes 3-5 days to work. In general excessive pumping just creates more inflammation because the milk cannot move due to the swelling around the ducts. Therefore, hand expression, ice and ibuprofen are recommended to cool down the inflammation. Pumping to completely empty is no longer the recommendation because it just makes things worse. Here is a link to the new Academy of Breastfeeding Medicine protocol on mastitis spectrum disorder, that discusses this in further detail- https://www.bfmed.org/assets/ABM%20Protocol%20%2336.pdf