Cabergoline for Lactation Inhibition After 2nd Trimester Abortion or Pregnancy Loss
by Anne Eglash MD, IBCLC, FABM
Is cabergoline effective in reducing postpartum breast engorgement, and how does it work?
According to the authors of this week’s study, approximately 45% of people who undergo a 2nd trimester pregnancy termination or loss will experience either breast tenderness, engorgement, or milk leakage.
These symptoms can trigger emotional distress, and many physicians/providers are not familiar with preventive interventions. Many individuals who experience breast engorgement after such procedures are advised to use ice, cabbage leaves, a supportive bra, and some are referred for acupuncture, massage, and/or are advised to use herbs.
A Cochrane review of treatments for breast engorgement during lactation found that nonpharmacologic interventions for engorgement had low quality evidence and the review did not include cabergoline as an option.
Cabergoline is a prescription medication that is a dopamine agonist. Because dopamine agonists decrease prolactin, it is FDA approved for treatment of high prolactin levels due to pituitary growths.
A systematic review of the use of cabergoline for postpartum lactation inhibition concluded that cabergoline is generally safe and effective for postpartum women who wish to suppress lactation. In the United States, cabergoline use for lactation suppression is considered off-label, which often deters physicians and other providers from offering this option for the prevention of postpartum or post-procedural engorgement.
This week’s study is a randomized double-blind placebo-controlled trial on the use of a single 1mg dose of cabergoline vs placebo among 72 individuals who had undergone a 2nd trimester pregnancy abortion or management of fetal death.
The average gestational age was 21 weeks, and approximately 35-38% of subjects were insured by Medicaid, 39% were Asian, 35% white, and 34% Hispanic.
The participants were given either cabergoline 1mg or placebo within 4 hours of the procedure or loss of the fetus. All were given standard care instructions including breast support and ice packs as needed.
The participants were surveyed on days 2,3,4,7, and 14 post-procedure and asked to rate their overall experience with engorgement. At each time point, the participants who received cabergoline reported fewer breast symptoms (engorgement, breast tenderness, leaking milk, and requiring pharmacologic pain relief).
What else? See the question!
- The prolactin levels on day 4 were similar between the cabergoline and placebo groups.
- Among people who received a placebo, breast discomfort peaked on day 7.
- Side effects for cabergoline were much higher as compared to placebo.
See the Answer
To assess cabergoline’s efficacy at decreasing breast symptoms after second-trimester abortion or pregnancy loss.
This was a double-blinded, block-randomized superiority trial comparing cabergoline 1 mg once to placebo for preventing bothersome breast engorgement after second-trimester uterine evacuation. We enrolled pregnant people at 18–28 weeks of gestation who were English- or Spanish-speaking and without contraindication to the study drug. Participants completed a validated, piloted, electronic survey at baseline and at multiple timepoints through 2 weeks postprocedure to assess breast symptoms, side effects, and bother. Our primary outcome was any breast symptoms (a composite of engorgement, milk leakage, tenderness, and need for pain relief) on day 4; we planned to enroll 80 patients to show a 30% difference in breast symptoms (80% power,α=0.049). A subgroup of participants returned for serum prolactin levels.
After screening 150 patients from April 2021 to June 2022, we enrolled 73 participants. Baseline demographics were balanced between groups: median gestational age was 21 weeks (range 18–26 weeks), 56.2% of participants were nulliparous, 34.2% self-identified as Hispanic, and 37.0% had public insurance. At baseline, reported breast symptoms were similar between groups. Among 69 participants who returned surveys on day 4, significantly fewer participants receiving cabergoline re-ported any breast symptoms compared with placebo (27.8% vs 97.0%, P,.001) (primary outcome) and fewer reported significant bother (2.8% vs 33.3%, P5.001) (secondary outcome). These differences persisted through day 14. Reported incidence and severity of bother from side effects were similar between groups: most common were constipation, fatigue, and headache. Serum prolactin levels were similar at baseline. On day 4, mean serum prolactin level was 6.5 ng/mL (SD 2.2) for those who received cabergoline and 18.0 ng/mL (SD 5.9) for placebo (P5.049).
Cabergoline is an effective and well-tolerated strategy to prevent breast symptoms after second-trimester abortion or pregnancy loss.
This study demonstrated lower prolactin levels on days 4 and 7 for people who were given cabergoline vs placebo. By day 14, the prolactin levels were similar.
Among participants who were given placebos, breast discomfort symptoms peaked on day 4, not day 7.
Interestingly, the participants in the placebo group had very similar side effects when compared to those in the cabergoline group. There was no significant difference between cabergoline and placebo for the most common complaints, which included headache, constipation, fatigue, anxiety, and insomnia.
A 2020 systematic review of cabergoline safety concluded that adverse effects were benign and tolerable.
This is a convincing study to share with physicians and other providers who are skeptical regarding the safety and effectiveness of offering preventive lactation suppression treatment. We need professional societies such as the American College of OB/Gyn to support proactive shared decision-making for prevention of post-procedure lactational breast discomfort, as an aspect of reproductive justice.