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Postpartum contraception: Initiation and methods

Andrew M Kaunitz, MD
Section Editor
Courtney A Schreiber, MD, MPH
Deputy Editor
Kristen Eckler, MD, FACOG


Contraceptive selection requires consideration of patient preferences and medical factors unique to this period. For postpartum women, additional issues include the timing of contraceptive initiation, risk of venous thromboembolism, resumption of ovulation, and impact on lactation. Prompt initiation of postpartum contraception increases utilization and continuation and thus reduces the risk of unintended pregnancy. The woman's preferences and the risks and benefits of various contraceptive options are ideally discussed during prenatal care so the woman has adequate time to consider her options and have her questions answered.

This topic will review contraception issues specific to postpartum women. Discussions on contraceptive counseling and selection and postabortion contraception are presented separately. (See "Contraceptive counseling and selection" and "Postabortion contraception".)


In postpartum women who do not breastfeed, ovulation returns at a mean of 39 days postpartum (earliest ovulation reported 25 days after delivery) [1,2]. As many as 60 percent of these ovulations are potentially fertile [1]. Since the first ovulation often occurs before the first menses, we educate women that return of menses cannot be used as a reliable marker for when to initiate contraception.

For breastfeeding women, the resumption of ovulation appears to be influenced by the frequency and duration of breastfeeding. In an observational study of 200 postpartum women, the women who breastfed less had a quicker resumption of ovulation compared with women who breastfed exclusively [3]. In addition, exclusively breastfeeding women typically ovulated after the first menses as compared with non-breastfeeding women, who typically ovulated prior to the resumption of menses. In a different study of 101 breastfeeding women (60 women in Baltimore, Maryland, United States and 41 women in Manila, Philippines), the resumption of ovulation occurred at a mean of 27 and 38 weeks, respectively [4]. In this study, the women in Baltimore tended to breastfeed less frequently, but for a longer duration at each episode, compared with the women in the Philippines. During the first six months postpartum, approximately 10 percent of all amenorrheic women ovulated. Among women who were exclusively breastfeeding, 1 to 5 percent of amenorrheic women ovulated.

Impact of lactation — Women who exclusively breastfeed typically have a delay in resumption of ovulation postpartum due to prolactin-induced inhibition of pulsatile gonadotropin-releasing hormone release from the hypothalamus. The degree to which breastfeeding suppresses ovulation is modulated by the intensity of the breastfeeding, the basal nutritional status of the mother, and the body mass index of the mother. While breastfeeding is associated with subfertility, anovulation is likely only when all of the following specific conditions are met [5]:

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Literature review current through: Nov 2017. | This topic last updated: Dec 05, 2017.
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