Reviews
Return of Ovulation and Menses in
Postpartum Nonlactating Women
A Systematic Review
Emily Jackson, MD, MPH, and Anna Glasier, MD
OBJECTIVES: To estimate, from the literature, when
nonlactating postpartum women regain fertility.
DATA SOURCES: We searched PubMed and Cochrane
Library databases for all articles (in all languages) pub-
lished in peer-reviewed journals from database inception
through May 2010 for evidence related to the return of
ovulation and menses in nonlactating postpartum
women. Search terms included “Fertility” (Mesh) OR
“Ovulation” (Mesh) OR “Ovulation Detection” (Mesh)
OR “Ovulation Prediction” (Mesh) OR fertility OR ovulat*
AND “Postpartum Period” (Mesh) OR postpartum OR
puerperium AND Human AND Female.
METHODS OF STUDY SELECTION: We included articles
assessing nonlactating women’s first ovulation postpar-
tum. Studies in which women breastfed for any period of
time or in whom lactation was suppressed with medica-
tions were excluded.
TABULATION, INTEGRATION AND RESULTS: We iden-
tified 1,623 articles; six articles reported four studies met
our inclusion criteria. In three studies utilizing urinary
pregnanediol levels to measure ovulation, mean day of
first ovulation ranged from 45 to 94 days postpartum;
20%–71% of first menses were preceded by ovulation
and 0%– 60% of these ovulations were potentially fertile.
In one study that used basal body temperature to mea-
sure ovulation, mean first ovulation occurred on day 74
postpartum; 33% of first menses were preceded by
ovulation and 70% of these were potentially fertile.
CONCLUSION: Most nonlactating women will not ovu-
late until 6 weeks postpartum. A small number of women
From the World Health Organization, Geneva, Switzerland.
The findings and conclusions in this report are those of the authors and do not
necessarily represent the official position of the World Health Organization.
Corresponding author: Emily Jackson, World Health Organization, 20 Avenue
Appia, 1211 Geneva 27, Switzerland; e-mail: emilyjacksonmd@gmail.com.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© World Health Organization 2011. All rights reserved. The World Health
Organization has granted the Publisher permission for the reproduction of this
article.
ISSN: 0029-7844/10
VOL. 117, NO. 3, MARCH 2011
will ovulate earlier, potentially putting them at risk for
pregnancy sooner, although the fertility of these early
ovulations is not well-established. The potential risk of
pregnancy soon after delivery underscores the impor-
tance of initiating postpartum contraception in a timely
fashion.
(Obstet Gynecol 2011;117:657–62)
DOI: 10.1097/AOG.0b013e31820ce18c
A s part of the World Health Organization’s
(WHO) ongoing effort to maintain evidence-
based recommendations on contraceptive medical
eligibility, the WHO’s Medical Eligibility Criteria for
Contraceptive Use, 3rd edition1 provides guidance regard-
ing the use of combined hormonal contraceptives
during the postpartum period. When used during
lactation, combined hormonal contraceptives may
adversely affect milk production; for this reason, these
methods are generally not recommended for use
during breastfeeding. However, combined hormonal
contraceptives are an important contraceptive option
during the postpartum period for women not breast-
feeding. Current WHO recommendations state that
in women who are not breastfeeding, the risks of
combined hormonal contraceptive use before 21 days
postpartum usually outweigh the contraceptive bene-
fits of use (WHO category 3), and that there is no
restriction for the use of combined hormonal contra-
ceptives at or after 21 days postpartum (WHO cate-
gory 1). This guidance was based on evidence that
combined hormonal contraceptives increase venous
thromboembolism risk threefold to sevenfold in
healthy reproductive age women,2– 4 data from the
1980s that indicate that blood coagulation and fibri-
nolysis variables affected during pregnancy return to
normal in women by 21 days postpartum,5 and the
assumption that the elevated risk of venous thrombo-
embolism associated with pregnancy returns to non-
pregnant levels by that time. However, more recent
OBSTETRICS & GYNECOLOGY 657
data indicate that the risk of venous thromboembo-
lism during the first 6 weeks postpartum is signifi-
cantly higher than previously thought, 21.5- to 84-fold
greater than in nonpregnant, nonpostpartum, repro-
ductive age women.6 This risk is most pronounced
around the time of child birth, declining rapidly
during the first 3 weeks postpartum as coagulation
factors return to prepregnancy levels and nearing
normal levels by 6 weeks postpartum.
In light of this evidence, WHO convened a
meeting of international experts in family planning
and hematology to reevaluate their recommendations
regarding initiation of combined hormonal contra-
ceptives during the postpartum period. These experts
weighed evidence regarding the risk of venous throm-
boembolism associated with combined hormonal
contraceptives and the high risk of venous thrombo-
embolism present during the postpartum period
against the risks of becoming pregnant if contracep-
tion were not initiated in a timely fashion. This
systematic review was prepared to estimate when
nonlactating women return to fertility postpartum to
better inform this discussion. This report describes the
evidence obtained from the systematic review and
provides the revised WHO recommendations that
were derived in part from this evidence.
SOURCES
PubMed and Cochrane databases were searched for
all articles (in all languages) published in peer-re-
viewed journals between database inception through
May 2010 describing the return to fertility in postpar-
tum, nonlactating women. Search terms included
“Fertility” (Mesh) OR “Ovulation” (Mesh) OR “Ovu-
lation Detection” (Mesh) OR “Ovulation Prediction”
(Mesh) OR fertility OR ovulat* AND “Postpartum
Period” (Mesh) OR postpartum OR puerperium
AND Human AND Female. Reference lists for arti-
cles retrieved using this strategy were manually
searched to identify additional articles. Neither un-
published articles nor abstracts from scientific confer-
ences were sought. Experts in the field were not con-
tacted in the preparation of the review. Article titles and,
when necessary, abstracts or full articles were reviewed
to identify studies for inclusion (Box 1).
STUDY SELECTION
Studies documenting women’s first ovulation postpar-
tum were included; those studies that only docu-
mented ovulation after the first menses were ex-
cluded. Two reviewers evaluated articles for
inclusion; there were no disagreements between re-
viewers. When available, data assessing the likely
658 Jackson and Glasier Postpartum Return of Menses
Box 1. Reasons for Excluding Studies From
Review 1,623 Citations Returned
394 review articles
1,214 with topics not pertinent to review
Three included breastfeeding and nonbreastfeeding mixed
Two ovulations documented only after first menses
One included suppressed lactation using hormonal methods
Three contained data not usable in current review
Six articles (four studies) included
fertility of first ovulations were included. In addition,
when possible, we assessed median time to ovulation
and menses and compared these data to the mean
data commonly presented in the included studies to
assess whether data were skewed. Studies in which
women had breastfed for any period of time or in
which lactation was prevented with medications were
excluded. All data were assessed systematically using
a standardized abstraction form,7 and quality of evi-
dence was rated by two evaluators using the U.S.
Preventive Services Task Force system.7,8 Data re-
ported in weeks were converted to days9,10 to facilitate
comparison across studies. In one study,9 standard
error was converted to standard deviation.
RESULTS
The search strategy identified 1,623 articles. Six arti-
cles reporting four studies met our inclusion criteria
(Table 1). All studies reported data regarding the
resumption of ovulation and menstruation in postpar-
tum nonlactating women and analysis of the fertility
of ovulatory first menses.
Articles by Campbell et al11 and Gray et al12
utilized urinary pregnanediol (the urinary metabolite
of progesterone) or luteinizing hormone levels or
both, and a reversal of pregnanediol-to-estradiol ratio
to determine postpartum ovulation in the same cohort
of 22 nonlactating postpartum women. Mean day of
ovulation was 45 days postpartum (standard deviation
[SD] 16.9 days). The median day of ovulation, calcu-
lated by review authors, was slightly less at 39 (min-
imum 25; quartile 1: 32.8; quartile 3: 69; maximum
not known because two participants had not ovulated
at time of study closure). Mean day of first menstru-
ation also occurred on day 45 postpartum (SD 10.1
days). Median day was 44 (minimum 30; quartile 1:
38.5; quartile 3: 48.5; maximum 81). Sixty-eight per-
cent of first menses were preceded by ovulation;
however, based on pregnanediol level and length of
luteal phase, authors estimated that more than half of
OBSTETRICS & GYNECOLOGY
Table 1. First Ovulation and Menstruation in Postpartum Nonlactating Women
Methods of Menstruation, Ovulation, Days Assessment of Quality
Study/Year N Measurement Days Postpartum Postpartum Fertility Grading

Campbell 1993, 22 Menstruation: weekly 45.2 ⫾ 10.1 (30–81) 45 ⫾ 16.9 (25–unknown)* 32% of first Level III
Gray 1987, questionnaire Median 44 (min 30, Q1 Median 39 (min 25, Q1 menstruation Fair
United States Ovulation: daily first 38.5, Q3 48.5, 32.8, Q3 69, max anovulatory
morning urine max 81) unknown)* 67% of ovulatory first
pregnanediol 3a- menses with
glucoronide (4 mg/L or defective or
more) and luteinizing equivocal luteal
hormone phase
Fertility: luteal phase levels
of smoothed
pregnanediol 3a-
glucoronide excretion
(area under curve more
than 20 mg/L)
Glasier 1983, 7 Menstruation: daily patient 63.7 ⫾ 13.0 (49–84) 93.8 ⫾ 37.0 (77–84 [sic]) 29% (2/7) of first Level III
United diary menstruation Poor
Kingdom Ovulation: once-weekly anovulatory
24-h urine or early 40% (2/5) of ovulatory
morning urine first menses with
pregnanediol (more defective luteal
than 1 mg/24 h) or phase
pregnanediol-to-
creatinine ratio (more
than 1)
Fertility: two urinary
pregnanediol levels
collected in the 2 wk
before menstruation; if
both less than 1 mg/24
h, luteal phase
considered absent
McNeilly 1982, 10 Menstruation: biweekly 56.7 ⫾ 7 (range not 75.6 ⫾ 7 (range not 80% (8/10) of first Level III
Howie 1982, data cards collected by reported) reported) menstruation Poor
United research nurses anovulatory
Kingdom Ovulation: once-weekly 100% (2/2) of
24-h urinary ovulatory first
pregnanediol (1 mg/24 menses with
h or more) defective luteal
Fertility: two urinary phase
pregnanediol levels
collected in the 2 wk
before menstruation; if
both less than 1 mg/24
h, luteal phase
considered absent
Cronin 1968, 93 Menstruation: daily patient 58.9 (SD and range not 73.5 (SD and range not 67% (60/90) of first Level III
United diary reported) reported) menstruation Poor
Kingdom Ovulation: daily basal body No. (%) of women who No. (%) of women who anovulatory
temperature menstruated on ovulated on day: 70% (21/30) of
Fertility: hyperthermic day: 0–28: 2 (2.2) ovulatory first
postovulatory plateau 0–28: 3 (3.2) 29–56: 24 (26.7) menses were
more than 7 days 29–56: 43 (46.2) 57–84: 31 (34.4) likely fertile
57–84: 38 (40.9) 85–112: 25 (27.8) ovulations
85–112: 7 (7.5) 113–140: 8 (8.9)
113–140: 2 (2.2)

max, maximum; min, minimum; Q1, first quartile; Q3, third quartile; SD, standard deviation.
Data are mean⫾SD (range) unless otherwise specified.
Calculated by E.J. from data provided in article.
* Maximum is unknown because two women did not ovulate by the close of the study.

these first ovulations (67%) had defective or equivo- urine measurements of pregnanediol to estimate ovu-
cally effective luteal phases, with consequent likely lation in seven nonlactating postpartum women. Au-
decreased fertility. Glasier et al9 used once-weekly thors found that menstruation occurred on day 64

VOL. 117, NO. 3, MARCH 2011 Jackson and Glasier Postpartum Return of Menses 659
postpartum (SD 13 days) on average; ovulation oc-
curred on day 94 postpartum (SD 37 days). McNeilly
et al13 and Howie et al10 estimated menstruation at 57
days postpartum (SD 7) and ovulation at 76 days (SD
7) in 10 women using once-weekly urinary pregnane-
diol measurements. They found that two of 10 first
menses were ovulatory, but both had defective luteal
phases. Seventy one percent of first menses were
preceded by ovulation, but 40% of these ovulations
had defective luteal phases. In these three studies
utilizing urinary pregnanediol levels to measure ovu-
lation, mean day of first ovulation ranged from 45 to
94 days postpartum; 20%–71% of first menses were
preceded by ovulation, and 0%– 60% of these ovula-
tions were potentially fertile.
Using daily basal body temperature measure-
ments, Cronin14 reported that in a sample of 93
women, menstruation resumed at 59 days and ovula-
tion resumed at 74 days (SD not reported) postpartum;
these data are normally distributed. Although in only
one-third of women were first menses preceded by
ovulation, the authors suggested that 70% of these
ovulations were likely fertile based on the duration of
the increase in basal body temperature.
In two studies,12,14 the earliest ovulation among
the patient population was also reported; these oc-
curred on day 25 and day 27 postpartum, respec-
tively. One of these ovulations was estimated to be
fertile by investigators.
DISCUSSION
In these six articles presenting the results of four
studies, the average time to first menstruation in
nonlactating women ranged from 45 to 64 days
postpartum. The time to first ovulation varied from 45
to 94 days postpartum. First menses were anovulatory
29%– 80% of the time. Of those first menses with
evidence of ovulation, data indicate that 30%–100%
may have had compromised fertility. Although the
mean time of ovulation was after 6 weeks postpartum
and evidence indicates that many first ovulations may
be subfertile, in two studies12,14 ovulation before 6
weeks was reported. Some of these ovulations were
estimated to be fertile by study investigators, under-
scoring the need for timely initiation of contraception
postpartum to prevent unintended pregnancy.
Overall, this body of evidence is limited to few
studies with small numbers of women included in
study samples. No studies provide sample size calcu-
lations or discuss adequacy of their sample sizes. In
addition, measures used to determine ovulation in the
included studies are of varying accuracy. Most nota-
bly, basal body temperature measurement14 is signif-
660 Jackson and Glasier Postpartum Return of Menses
icantly less accurate than ultrasonography15 or urinary
luteinizing hormone level16 in predicting ovulation.
Several studies used the more reliable measurement
of urinary luteinizing hormone levels to determine
ovulation; however, in three studies measurements
were made infrequently,9,10,13 likely overestimating
the date of ovulation because short luteal phases
could be missed. The only study measuring these
hormones daily11,12 also reported the earliest average
day of ovulation postpartum. Although detection of
urinary luteinizing hormone is a reliable method of
determining ovulation, prospective studies demon-
strating a positive effect on pregnancy rates are lack-
ing, indicating that detecting ovulation alone is not
necessarily adequate to determine fertility. All studies
in this review attempted to assess fertility in addition
to ovulation, albeit indirectly by determining luteal
phase adequacy. The ability to assess adequacy of the
luteal phase via basal body temperature has been
called into question because some women may have
a poor thermogenic response to progesterone, giving
the impression of a luteal phase defect when none
exists, given that women with a luteal phase defect
may have a normal basal body temperature chart, and
given that short luteal phases may not be clinically
significant.17 In addition, controversy exists regarding
the criteria to assess adequacy of luteal phase via this
method.18,19 Validity of urinary pregnanediol levels to
assess luteal phase adequacy has been established;20,21
however, two of the three studies that utilized this
measure collected specimens relatively infrequently.
Although luteal phase inadequacy is believed to ac-
count for as much as 3%–10% of cases of infertility,18
its importance in otherwise fertile women is less clear
because it has been identified in women with proven
fertility at rates similar to those seen in women with
decreased fecundity.22,23 Furthermore, adequacy of
luteal phase is not, in and of itself, tantamount to a
fertile ovulation.
Only one study11,12 provided data from which a
median value could be generated. Comparison of the
mean and median data in this study indicate that the
distribution of data may be skewed to the right,
potentially resulting in a later estimated first day of
ovulation. Thus, women may ovulate and may be at
risk for pregnancy earlier. However, the study sample
was too small to draw a final conclusion regarding the
distribution of the data. Data from Cronin,14 who
provided information regarding the distribution of his
sample, appear to be normally distributed. This study
contained more participants than the studies by Gray
et al12 and Campbell et al;11 however, methodology
OBSTETRICS & GYNECOLOGY
for measuring ovulation (basal body temperature)
used in this study is much less precise.
Precise studies using currently easily available
criteria for determining ovulation are lacking. Avail-
able data indicate that few nonlactating postpartum
women will ovulate before 6 weeks postpartum, and
that many first ovulations may have compromised
fertility. However, a small number of women may
experience a fertile ovulation as early as 25 days
postpartum. Some data indicate that younger women
may return to fertility more quickly than their older
counterparts.24 We limited the included studies to
those enrolling women who were not breastfeeding to
obtain the most conservative estimate of when a
woman may return to fertility postpartum. Return to
fertility in fully or nearly fully breastfeeding women
occurs much later in the postpartum period,9 –14,25–29
and lactational amenorrhea has proven to be a reli-
able method of contraception for many such women.
In January 2010, WHO convened a group of
family planning and hematology experts to review
these data together with evidence regarding the inci-
dence of venous thromboembolism during the post-
partum period to compare the theoretical risks of
using combined hormonal contraceptives during the
postpartum with the risk of pregnancy. In light of
evidence indicating that the risk of venous thrombo-
embolism development during the postpartum period
was much higher than previously thought and de-
clines gradually after delivery, the group changed the
earlier WHO recommendation to more closely fit the
available data. The new guidance states that before 21
days postpartum, when risk of pregnancy is very low,
risk of use of combined hormonal contraceptives
generally outweigh the contraceptive benefits (WHO
category 3), even in women who are not breastfeed-
ing. For some women with additional risk factors for
venous thromboembolism other than being postpar-
tum, combined hormonal contraceptives should not
be used (WHO category 3/4). Between 21 and 42
days postpartum, as risk of pregnancy increases and
risk of venous thromboembolism decreases, the ben-
efits of using combined hormonal contraceptives gen-
erally outweigh the risks (WHO category 2), although
for some women with additional risk factors for
venous thromboembolism the method should not be
used unless other more appropriate methods are not
available or acceptable (WHO category 2/3). Finally,
in nonlactating women beyond 42 days postpartum,
combined hormonal contraceptives may be used
without restriction (WHO category 1). These recom-
mendations have important implications in those
settings in which combined hormonal contraceptives
VOL. 117, NO. 3, MARCH 2011
are routinely instituted before day 21 and, for women
with additional risk factors for venous thromboembo-
lism, before 42 days postpartum. No studies have
directly evaluated risk of venous thromboembolism
in postpartum women using combined hormonal
contraceptives,6 and thus data specifically delineating
any additional risk posed by combined hormonal
contraceptive use during the postpartum are lacking.
Risk of venous thromboembolism in users of com-
bined hormonal contraceptives is threefold to seven-
fold higher than that of healthy nonusers,30 –34 render-
ing their use during the early postpartum, when risk of
pregnancy is low and venous thromboembolism is
high, unacceptable.
Progestogen-only contraceptives, which are not
associated with an increased risk of venous thrombo-
embolism in nonpregnant, nonpostpartum women
and have no deleterious effects on hemostasis,30,32 are
an important alternative to combined hormonal con-
traceptives during the early postpartum period. Pro-
gestogen-only contraceptives may be used by non-
breastfeeding women at any time during the
postpartum period; however, because of lack of data
regarding possible effects on infants exposed to pro-
gestogens in breast milk, current guidelines disagree
regarding the optimal time to initiate progestogen-
only contraceptives in breastfeeding women. The
WHO Medical Eligibility Criteria1 generally recom-
mend against use of progestogen-only contraceptives
before 6 weeks postpartum because of these theoret-
ical risks (WHO Medical Eligibility Criteria category
3), whereas both the U.S. Medical Eligibility Criteria35
and U.K. Medical Eligibility Criteria36 are more le-
nient. During the first postpartum month, the U.S.
Medical Eligibility Criteria advises that advantages
generally outweigh risks of using progestogen-only
contraceptives (U.S. Medical Eligibility Criteria cate-
gory 2), whereas the U.K. Medical Eligibility Criteria
has no restrictions on use of progestogen-only contra-
ceptives by breastfeeding women at any point during
the postpartum period (U.K. Medical Eligibility Cri-
teria category 1). A significant number of women,
20% in one study,37 will resume sexual activity before
4 weeks postpartum, and some of those women will
be fertile. Safe, effective, and timely postpartum con-
traception is necessary to prevent unwanted pregnan-
cies in these women.
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