TEMA 3. ANTICONCEPTIVOS

3.1 MÉTODO AMENORREA DE LA LACTANCIA (MELA o MAL)

El método de amenorrea de la lactancia (MELA) es un método anticonceptivo en el que se informa y apoya a la madre sobre cómo utilizar la lactancia para la anticoncepción. La lactancia sin alimentación complementaria retrasa el retorno de la fertilidad y los períodos menstruales, lo que constituye una protección normal (fisiológica) frente al embarazo. De forma más detallada, consiste en una lactancia exclusiva con tomas frecuentes espaciadas como mucho de 4 a 6 horas, incluso durante la noche y siempre que no haya menstruación.

El protocolo nº 13 de la ABM (American Breastfeeding Medicine) presenta el método MELA o MAL como un algoritmo (Fig. 1) e incluye tres criterios para definir el período de más bajo riesgo de embarazo. Si no se cumpliera con uno de estos criterios, las mujeres deben iniciar inmediatamente otro método. Se le hacen las siguientes tres preguntas a la madre:

“¿Está usted amenorreica?”, lo que significa que no ha menstruado ni ha tenido ningún sangrado de más de 2 días de duración (descontando el sangrado durante los primeros dos meses).
“¿Está amamantando completamente o casi completamente?”. Esto incluye no dar a su bebé ningún alimento ni líquido complementario además de la leche materna (más de una o dos veces por semana).
“¿Su bebé tiene menos de 6 meses de edad?”

Si responde “sí” a las tres preguntas, reúne los requisitos para este método anticonceptivo. Si cualquiera de las tres preguntas anteriores se responde con un “no”, entonces aumentan sus probabilidades de quedarse embarazada y es preciso aconsejarle comenzar con otra forma de anticoncepción para evitar un embarazo. Si la madre está interesada y cumple los criterios para seguir el método MAL/MELA, deberá repasar estas tres preguntas periódicamente. Los médicos deben asegurarse de que haya escogido su siguiente método de anticoncepción y que lo tenga a mano o sepa cómo obtenerlo si fuera un implante o un dispositivo intrauterino (DIU).

Una revisión de la bibliografía de Cochrane (Van der Wijden 2003) llegó a la conclusión de que los índices de fertilidad son bajos entre mujeres amenorreicas dedicadas a una lactancia completa. En estudios controlados del MAL, los índices de embarazo durante 6 meses variaron entre 0.45% y 2.45%. En seis estudios no controlados de usuarias del MAL, los índices de embarazo variaron entre 0% y 7.5%. La OMS llevó a cabo un ensayo prospectivo sobre la amenorrea durante la lactancia y el retorno de la fertilidad; si bien este no fue un estudio de mujeres que elegían y empleaban el MAL, las conclusiones confirmaron el potencial fisiológico de eficacia alta tal como se observó en los ensayos del MAL (OMS 1999, I&II). Posteriormente, los estudios sobre el uso del método descubrieron sistemáticamente un índice de embarazo a 6 meses que promediaba el 2% (Hatcher 2011).

3.2 ANTICONCEPTIVOS MECÁNICOS

3.2.1 Preservativo

El método de barrera más usado es el preservativo, el preservativo externo tiene una eficacia de alrededor del 98% con uso perfectoy unatasa de fallo del 13% en uso típico. Sí conviene remarcar que es el único método que además reduce el riesgo de ITS (CDC 2026).

Diafragma

El diafragma es un método muy poco usado en España. Requiere tomar medidas en la consulta ginecológica para encargarlo, aprender a usarlo correctamente y, para que sea más eficaz, se recomendaba usarlo junto con una crema espermicida.

Dispositivo intrauterino (DIU)

El DIU es uno de los anticonceptivos más frecuentemente utilizados en el mundo. El DIU se coloca en la consulta ginecológica, puede colocarse en cualquier momento del posparto, incluso de forma inmediata, también tras cesárea y durante lactancia, siempre que no haya sepsis posparto; cabe añadir que su expulsión es más frecuente cuando se coloca en el posparto inmediato (Curtis 2024).

El DIU funciona creando un ambiente adverso a los espermatozoides y a la posible implantación de un óvulo fecundado, ya que provoca una reacción inflamatoria a cualquier cuerpo extraño. A algunas mujeres les causa reglas más largas y dolorosas.

Hay dos tipos de estos dispositivos: DIU hormonales que liberan levonorgestrel y los DIU no hormonales de cobre. Tienen distintos perfiles de efectos secundarios.

Los DIU liberadores de levonorgestrel están asociados con una reducción del flujo menstrual, si bien en torno al momento de la inserción las mujeres suelen experimentar un sangrado irregular.

En un estudio que comparó los resultados de lactancia en mujeres asignadas aleatoriamente para recibir un DIU de cobre u hormonal entre las 6 y las 8 semanas después del parto, los autores no encontraron ninguna diferencia en la duración total de la lactancia, en el crecimiento de los bebés ni el desarrollo hasta 1 año después del parto (Shaamash 2005). No obstante, en un análisis secundario de un ensayo controlado aleatorizado que comparaba mujeres que se colocaron un DIU de levonorgestrel inmediatamente después del parto con otras que se lo colocaron de 6 a 8 semanas después del parto, la colocación temprana del DIU de levonorgestrel se asoció con índices de lactancia inferiores (Chen 2011); en el grupo de colocación tardía, cuatro mujeres recibieron ADMP antes de su consulta a las 6 semanas.

En relación con los estudios del DIU de cobre, se ha asociado a un aumento de dismenorreas y menorragias. Por otro lado, no se detectaron cambios en la leche ni en los niveles de cobre en suero (Cunha 2001).

Las complicaciones relacionadas con el dispositivo en sí incluyen perforación uterina, fallo (embarazo), imposibilidad de visualizar los hilos en el cuello del útero, secreción vaginal, infección, dolor, que la pareja sienta los hilos, mala ubicación (que podría requerir de un procedimiento quirúrgico para retirar el DIU) y expulsión (de 2 a 10% dentro del primer año). Los datos sugieren que existe un mayor riesgo de perforación cuando se coloca cualquiera de los DIU a mujeres que amamantan.

Una revisión sistemática reciente sugirió que los DIU siguen siendo una opción anticonceptiva a largo plazo reversible para mujeres que amamantan y que tuvieron a sus bebés por cesárea.

3.3 ANTICONCEPTIVOS HORMONALES

3.3.1 Levonorgestrel

Los anticonceptivos con solo progestágeno —entre ellos el levonorgestrel— continúan considerándose los métodos hormonales de elección durante la lactancia. La evidencia actualmente disponible indica que, en general, no se asocian con efectos clínicamente relevantes sobre la composición de la leche, el crecimiento y desarrollo del lactante ni la duración de la lactancia, aunque debe reconocerse que una parte de los estudios presenta limitaciones metodológicas. En este contexto, el CDC 2024 clasifica en mujeres lactantes a las píldoras solo con progestágeno, los implantes y el acetato de medroxiprogesterona de depósito (DMPA) como métodos aceptables desde el posparto temprano, si bien el DMPA merece una valoración más cautelosa en algunos escenarios por su posible asociación con un incremento adicional del riesgo tromboembólico venoso en el posparto (Nguyen 2024, Lactmed 2026, OMS 2025).

En el caso específico del levonorgestrel, su transferencia a la leche materna es baja y la evidencia disponible no muestra efectos adversos clínicamente relevantes sobre la producción de leche, la composición de la leche ni el crecimiento y desarrollo del lactante. Por ello, LactMed lo sigue considerando uno de los progestágenos de elección durante la lactancia. Además de su empleo en formulaciones orales, implantes y dispositivos intrauterinos, el levonorgestrel puede utilizarse como anticoncepción de emergencia durante la lactancia; en este contexto, el CDC 2024 lo clasifica como categoría 1, es decir, sin restricciones.

Con respecto al dispositivo intrauterino con levonorgestrel, la evidencia más reciente no apoya presentar como conclusión firme que su inserción precoz en el posparto reduzca la duración de la lactancia. Los ensayos clínicos disponibles muestran resultados conflictivos sobre los desenlaces de lactancia cuando se compara la inserción inmediata posparto con la inserción diferida, aunque no se han observado efectos perjudiciales sobre la salud, el crecimiento o el desarrollo del lactante. En consecuencia, las guías actuales consideran que puede utilizarse durante la lactancia, si bien el momento de inserción debe valorarse de forma individualizada.”(Lactmed 2026, CDC 2026).

Otros progestágenos, como desogestrel, etonogestrel y noretindrona, también se asocian a una exposición infantil baja a través de la leche materna. En el caso del desogestrel, la dosis estimada recibida por el lactante a partir de su metabolito activo, etonogestrel, es reducida y no se han observado diferencias clínicamente relevantes en el crecimiento infantil en los estudios disponibles. Para el implante de etonogestrel, la evidencia no muestra efectos consistentes sobre la lactogénesis, la duración de la lactancia ni el crecimiento del lactante, aunque LactMed recoge una pequeña posibilidad de supresión de la lactancia, estimada en torno al 0,9%. En cuanto a la noretindrona, los niveles en leche son bajos y tampoco se han descrito efectos adversos consistentes en lactantes amamantados.

3.3.2 Anticonceptivos combinados: progestágenos y estrógenos

Los anticonceptivos combinados, son aquellos que incluyen un estrógeno y un progestágeno derivado de la 19-nortestosterona como el desogestrel, drospirenona, etonogestrel, levonorgestrel, norelgestromina o noretindrona. Este tipo de anticonceptivos se comercializan en forma de píldoras de uso oral, anillos vaginales, parches transdérmicos (ambos con una duración de 3 semanas) o implantes subcutáneos (con 3 años de duración).

Con respecto a los estrógenos, los de uso común son los siguientes:

Valerato de estradiol

El valerato de estradiol es un estrógeno natural cuya excreción en leche materna parece ser baja y dependiente de la vía de administración (Nilsson 1978). La evidencia disponible indica que la administración vaginal puede dar lugar a concentraciones medibles en leche, mientras que tras el uso de parches transdérmicos los niveles en leche han sido indetectables. En lactantes amamantados por madres tratadas con estradiol transdérmico, las concentraciones séricas de estradiol y estrona fueron indetectables o muy bajas, sin observarse diferencias en el crecimiento infantil. No obstante, aunque no se han demostrado efectos adversos consistentes en el lactante, los estrógenos pueden disminuir la producción de leche, especialmente cuando se inician antes de que la lactancia esté bien establecida. En este contexto, un caso aislado asoció el inicio de estradiol transdérmico el primer día posparto con ictericia y escasa ganancia ponderal, probablemente en relación con una ingesta insuficiente secundaria a reducción de la producción láctea; sin embargo, este hallazgo no se confirmó en pequeños estudios realizados cuando la lactancia ya estaba instaurada.

Etinilestradiol

El etinilestradiol se excreta en la leche materna en cantidades muy bajas (Nilsson 1978, Betrabet 1986); de hecho, un estudio reciente publicado por Segev y col. (2025) que evaluó anticonceptivos hormonales combinados de dosis bajas (15–35 μg/día de etinilestradiol) no detectó concentraciones medibles en leche, lo que respalda que la transferencia al lactante sea mínima. Aunque se han descrito casos aislados y antiguos de aumento mamario transitorio en lactantes expuestos a anticonceptivos combinados, la evidencia disponible no ha demostrado efectos adversos consistentes sobre el crecimiento o la salud del lactante (Nilsson 1978, Betrabet 1986). En la práctica clínica actual, el principal motivo de cautela no es tanto la exposición del lactante como el posible descenso de la producción de leche, especialmente con preparados que contienen ≥30 μg de etinilestradiol y cuando se inician antes de que la lactancia esté bien establecida.

Sin embargo, numerosas publicaciones que estudiaron la administración de anticonceptivos combinados a dosis más bajas (30 microgramos de etinilestradiol o su profármaco mestranol) no detectaron ningún efecto en la producción de leche materna (Madhavapeddi 1985, Mandel 1985, Nilsson 1986) ni en la ganancia ponderal de lactantes amamantados de madres que tomaban anticonceptivos combinados respecto a otros métodos anticonceptivos (dispositivos intrauterinos, progestágenos aislados).

Las guías vigentes no son completamente uniformes respecto al momento de inicio: el CDC 2024 clasifica los anticonceptivos hormonales combinados en mujeres lactantes como categoría 4 antes de los 21 días posparto, categoría 3 entre 21 yFaculty of Sexual & Reproductive Healthcare (FSRH) para evaluar la seguridad en el uso de anticonceptivos según condiciones médicas o características personales, los clasifica como categoría 4 antes de 6 semanas, 2 entre 6 semanas y

3.3.3 Anticonceptivos de emergencia (píldora del día después)

Acetato de Ulipristal

El acetato de ulipristal es un modulador selectivo de los receptores de la progesterona. Como anticonceptivo de emergencia, su mecanismo principal de acción es la inhibición o el retraso de la ovulación, y puede utilizarse hasta 120 horas (5 días) después de una relación sexual no protegida.

Los datos farmacocinéticos disponibles indican que el acetato de ulipristal y su metabolito activo se excretan en la leche materna en cantidades bajas. Se estima que un lactante alimentado exclusivamente al pecho recibiría aproximadamente un 0,8% de la dosis materna ajustada por peso durante el primer día y alrededor del 1% en 5 días. Aunque la evidencia clínica en lactantes expuestos sigue siendo limitada y no se dispone de datos sobre sus niveles plasmáticos ni sobre el efecto en la producción de leche, no existe evidencia publicada de efectos perjudiciales tras una dosis única utilizada como anticoncepción de emergencia. La novedad principal frente a textos antiguos es que ya no se mantiene la recomendación de extraer y desechar la leche durante una semana tras la administración de ulipristal. En 2025, la Faculty of Sexual & Reproductive healthcare (FSRH) publicó una declaración específica en la que señala que no es necesario interrumpir la lactancia tras una dosis única de ulipristal como anticonceptivo de emergencia, en línea con la Specialist Pharmacy Service y con LactMed. En consecuencia, las recomendaciones previas de suspender temporalmente la lactancia durante 24 horas o una semana deben considerarse desactualizadas.

El acetato de ulipristal también se emplea en el tratamiento de los miomas lo que podría plantear un mayor riesgo por la larga duración del tratamiento (una toma diaria en máximo 4 ciclos de 3 meses con dos meses de descanso entre ciclos). Teóricamente la dosis relativa ingerida diariamente por el lactante es del 1%, es decir, que en cada ciclo completo (90 días) el lactante no habría llegado a ingerir ni la dosis (correspondiente a su peso) de un día. No obstante, como no hay
datos publicados de su excreción en leche materna, pueden valorarse a criterio médico alternativas conocidas más seguras.

Levonorgestrel

Levonorgestrel también se usa como anticonceptivo de emergencia hasta 72 horas postcoital. La pauta de administración oral es de una dosis aislada de 1,5 mg (varias veces superior a la usada como anticonceptivo diario).

Aunque el fabricante (Sandoz) y algún autor (Gainer 2007) aconsejan una interrupción de la lactancia de unas 8 horas tras la toma del medicamento, la escasa cantidad excretada en leche no justifica esta interrupción y otros autores expertos indican que no se precisa ningún tiempo de interrupción de la lactancia tras la toma de levonorgestrel como anticonceptivo de emergencia (Polakow 2013, FFPRHC 2004).

Diversas guías clínicas y consensos actuales consideran que el levonorgestrel como anticonceptivo de emergencia es compatible con la lactancia. En mujeres lactantes, el CDC lo clasifica como categoría 1 (sin restricciones), y la evidencia disponible muestra una transferencia mínima a la leche materna, sin efectos adversos clínicamente relevantes sobre la lactancia ni sobre el lactante; por ello, no es necesario interrumpir la lactancia tras una dosis única (Nguyen 2024, Jatlaoui 2016, Berens (ABM) 2015, WHO/OMS 2015, Polakow 2013, Shaaban 2013, FFPRHC 2004).

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