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U.S. Medical Eligibility Criteria for Contraceptive Use, 2016
Recommendations and Reports / July 29, 2016 / 65(3);1–104
Please note: An update has been published for this report. To view the update, please click here.
Kathryn M. Curtis, PhD1; Naomi K. Tepper, MD1; Tara C. Jatlaoui, MD1; Erin Berry-Bibee, MD1,2; Leah G. Horton, MSPH1; Lauren B. Zapata, PhD1; Katharine B. Simmons, MD1,2; H. Pamela Pagano, MPH1; Denise J. Jamieson, MD1; Maura K. Whiteman, PhD1 (View author affiliations)
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Summary
The 2016 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by women and men who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and consultation with national experts who met in Atlanta, Georgia, during August 26–28, 2015. The information in this report updates the 2010 U.S. MEC (CDC. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR 2010:59 [No. RR-4]). Notable updates include the addition of recommendations for women with cystic fibrosis, women with multiple sclerosis, and women receiving certain psychotropic drugs or St. John’s wort; revisions to the recommendations for emergency contraception, including the addition of ulipristal acetate; and revisions to the recommendations for postpartum women; women who are breastfeeding; women with known dyslipidemias, migraine headaches, superficial venous disease, gestational trophoblastic disease, sexually transmitted diseases, and human immunodeficiency virus; and women who are receiving antiretroviral therapy. The recommendations in this report are intended to assist health care providers when they counsel women, men, and couples about contraceptive method choice. Although these recommendations are meant to serve as a source of clinical guidance, health care providers should always consider the individual clinical circumstances of each person seeking family planning services. This report is not intended to be a substitute for professional medical advice for individual patients. Persons should seek advice from their health care providers when considering family planning options.
Introduction
Approximately 45% of all pregnancies that occur in the United States are unintended (1), with associated increased risks for adverse maternal and infant health outcomes (2) and increased health care costs (3). Women, men, and couples have increasing numbers of safe and effective choices for contraceptive methods, including long-acting reversible contraception methods such as intrauterine devices (IUDs) and implants, to reduce the risk for an unintended pregnancy. However, with these expanded options comes the need for evidence-based guidance to help health care providers offer quality family planning care to their patients, including choosing the most appropriate contraceptive method for individual circumstances and using that method correctly, consistently, and continuously to maximize effectiveness.
In 2010, CDC published the first U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC), which provided recommendations on safe use of contraceptive methods for women with various medical conditions and other characteristics (and was adapted from global guidance developed by the World Health Organization [WHO MEC]) (4,5). U.S. MEC is a companion document to the U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), which provides guidance on how to use contraceptive methods safely and effectively once they are deemed to be medically appropriate (6). WHO intended for the global guidance to be used by local or national policy makers, family planning program managers, and the scientific community as a reference when they develop family planning guidance at the country or program level. During 2008–2010, CDC participated in a formal process to adapt the global guidance for appropriateness for use in the United States, which included rigorous identification and critical appraisal of the scientific evidence through systematic reviews, and input from national experts on how to translate that evidence into recommendations for U.S. health care providers (5). At that time, CDC committed to keeping this guidance up to date and based on the best available evidence, with full review every few years (5).
This document updates CDC’s U.S. MEC 2010 (5), based on new evidence and input from experts. A summary of changes from U.S. MEC 2010 is provided (Appendix A). Notable updates include the following:
- addition of recommendations for women with cystic fibrosis, women with multiple sclerosis, and women receiving certain psychotropic drugs or St. John’s wort
- revisions to the recommendations for emergency contraception, including the addition of ulipristal acetate
- revisions to the recommendations for postpartum women; women who are breastfeeding; women with known dyslipidemias, migraine headaches, superficial venous disease, gestational trophoblastic disease, sexually transmitted diseases (STDs), and human immunodeficiency virus (HIV); and women who are receiving antiretroviral therapy
The goal of these recommendations is to remove unnecessary medical barriers to accessing and using contraception, thereby decreasing the number of unintended pregnancies. These recommendations are meant to serve as a source of clinical guidance for health care providers; health care providers should always consider the individual clinical circumstances of each person seeking family planning services. This report is not intended to be a substitute for professional medical advice for individual patients, who should seek advice from their health care providers when considering family planning options.
Methods
Since publication of U.S. MEC 2010, CDC has monitored the literature for new evidence relevant to the recommendations through the WHO/CDC continuous identification of research evidence (CIRE) system. This system identifies new evidence as it is published and allows WHO and CDC to update systematic reviews and facilitate updates to recommendations as new evidence warrants. Automated searches are run in PubMed weekly, and the results are reviewed. Abstracts that meet specific criteria are added to the web-based CIRE system, which facilitates coordination and peer review of systematic reviews for both WHO and CDC (7). In 2014, CDC reviewed all of the existing recommendations in U.S. MEC 2010 for new evidence identified by CIRE that had the potential to lead to a changed recommendation. During August 27–28, 2014, CDC held a meeting in Atlanta, Georgia, of 11 family planning experts and representatives from partner organizations to solicit their input on the scope of and process for updating both U.S. MEC 2010 and U.S. SPR 2013. The participants were experts in family planning and represented various types of health care providers, as well as health care provider organizations. A list of participants is provided at the end of this report. Meeting participants discussed topics to be addressed in the update of U.S. MEC based on new evidence published since 2010 (identified through the CIRE system), topics addressed at a 2014 WHO meeting to update global guidance, and suggestions CDC received from health care providers for the addition of recommendations for women with medical conditions not yet included in U.S. MEC (e.g., from provider feedback through e-mail, public inquiry, and questions received at conferences). CDC identified several topics to consider when updating the guidance, including revision of existing recommendations for certain medical conditions or characteristics (breastfeeding, postpartum, HIV, receiving antiretroviral therapy, obesity, dyslipidemia, increased risk for STDs, superficial venous thrombosis, gestational trophoblastic disease, and migraine headaches), addition of recommendations for new medical conditions (cystic fibrosis, multiple sclerosis, use of certain psychotropic drugs, and St. John’s wort), and addition of recommendations for new contraceptive methods (ulipristal acetate for emergency contraception). CDC determined that all other recommendations in U.S. MEC 2010 were up to date and consistent with the existing body of evidence for that recommendation.
In preparation for a subsequent expert meeting held during August 26–28, 2015, to review the scientific evidence for potential recommendations, CDC staff members and other invited authors listed at the end of this report conducted independent systematic reviews for each of the topics being considered. The purpose of these systematic reviews was to identify direct evidence about the safety of contraceptive method use by women with selected conditions (e.g., risk for disease progression or other adverse health effects in women with multiple sclerosis who use combined hormonal contraceptives [CHCs]). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for reporting systematic reviews (8,9), and strength and quality of the evidence were assigned using the system of the U.S. Preventive Services Task Force (10). When direct evidence was limited or not available, indirect evidence (e.g., evidence on surrogate outcomes or among healthy women) and theoretical issues were considered and either added to direct evidence within a systematic review or separately compiled for presentation to the meeting participants. Completed systematic reviews were peer reviewed by two or three experts and then provided to participants before the expert meeting. Reviews are referenced and cited throughout this document; the full reviews appear in the published literature and contain the details of each review, including the systematic review question, literature search protocol, inclusion and exclusion criteria, evidence tables, and quality assessments. CDC staff continued to monitor new evidence identified through the CIRE system during the preparation for the August 2015 meeting.
During August 26–28, 2015, in Atlanta, Georgia, CDC held a meeting with 44 participants who were invited to provide their individual perspectives on the scientific evidence presented and potential recommendations. Twenty-nine of the participants represented a wide range of expertise in family planning provision and research, and included obstetricians/gynecologists, pediatricians, family physicians, nurse practitioners, epidemiologists, and others with research and clinical practice expertise in contraceptive safety, effectiveness, and management; these individuals participated in the entire meeting. Fifteen participants with expertise relevant to specific topics on the meeting agenda provided information and participated in the discussion (e.g., an expert in cystic fibrosis was asked to provide general information about the condition and to assist in interpreting the evidence and any theoretical concerns on the use of contraceptive methods in women with the condition); these participants provided input only during the session for which their topics were discussed. Lists of participants and any potential conflicts of interest are provided at the end of this report. During the meeting, the evidence from the systematic review for each topic was presented, including direct evidence and any indirect evidence or theoretical concerns. Participants provided their perspectives on using the evidence to develop recommendations that would meet the needs of U.S. health care providers. After the meeting, CDC determined the recommendations in this report, taking into consideration the perspectives provided by the meeting participants. Feedback also was received from three external reviewers, composed of health care providers and researchers who had not participated in the update meetings. These reviewers were asked to provide comments on the accuracy, feasibility, and clarity of the recommendations. Areas of research that need additional investigation also were considered during the meeting (11).
How to Use This Document
These recommendations are intended to help health care providers determine the safe use of contraceptive methods among women and men with various characteristics and medical conditions. Providers also can use the information in these recommendations when consulting with women, men, and couples about their selection of contraceptive methods. The tables in this document include recommendations for the use of contraceptive methods by women and men with particular characteristics or medical conditions. Each condition is defined as representing either an individual’s characteristics (e.g., age or history of pregnancy) or a known preexisting medical or pathologic condition (e.g., diabetes or hypertension). The recommendations refer to contraceptive methods being used for contraceptive purposes; the recommendations do not consider the use of contraceptive methods for treatment of medical conditions because the eligibility criteria in these situations might differ. The conditions affecting eligibility for the use of each contraceptive method are classified into one of four categories (Box 1).
Using the Categories in Practice
Health care providers can use the eligibility categories when assessing the safety of contraceptive method use for women and men with specific medical conditions or characteristics. Category 1 comprises conditions for which no restrictions exist for use of the contraceptive method. Classification of a method/condition as category 2 indicates the method generally can be used, although careful follow-up might be required. For a method/condition classified as category 3, use of that method usually is not recommended unless other more appropriate methods are not available or acceptable. The severity of the condition and the availability, practicality, and acceptability of alternative methods should be considered, and careful follow-up is required. Hence, provision of a contraceptive method to a woman with a condition classified as category 3 requires careful clinical judgement and access to clinical services. Category 4 comprises conditions that represent an unacceptable health risk if the method is used. For example, a smoker aged <35 years generally can use combined oral contraceptives (COCs) (category 2). However, for a woman aged ≥35 years who smokes <15 cigarettes per day, the use of COCs usually is not recommended unless other methods are not available or acceptable to her (category 3). A woman aged ≥35 years who smokes ≥15 cigarettes per day should not use COCs because of unacceptable health risks, primarily the risk for myocardial infarction and stroke (category 4). The programmatic implications of these categories might depend on the circumstances of particular professional or service organizations. For example, in some settings, a category 3 might mean that a special consultation is warranted.
The recommendations address medical eligibility criteria for the initiation and continued use of all methods evaluated. The issue of continuation criteria is clinically relevant whenever a medical condition develops or worsens during use of a contraceptive method. When the categories differ for initiation and continuation, these differences are noted in the Initiation and Continuation columns. When initiation and continuation are not indicated, the category is the same for initiation and continuation of use.
On the basis of this classification system, the eligibility criteria for initiating and continuing use of a specific contraceptive method are presented in tables (Appendices A–K). In these tables, the first column indicates the condition. Several conditions are divided into subconditions to differentiate between varying types or severity of the condition. The second column classifies the condition for initiation or continuation (or both) into category 1, 2, 3, or 4. For certain conditions, the numeric classification does not adequately capture the recommendation; in these cases, the third column clarifies the numeric category. These clarifications were determined during the discussions of the scientific evidence and are considered a necessary element of the recommendation. The third column also summarizes the evidence for the recommendation if evidence exists. The recommendations for which no evidence is cited are based on expert opinion from either the WHO or U.S. expert meeting in which these recommendations were developed, and might be based on evidence from sources other than systematic reviews. For certain recommendations, additional comments appear in the third column and generally come from the WHO meeting or the U.S. meeting.
Recommendations for Use of Contraceptive Methods
The classifications for whether women with certain medical conditions or characteristics can use specific contraceptive methods are provided for intrauterine contraception, including the copper-containing IUD and levonorgestrel-releasing IUDs (Appendix B); progestin-only contraceptives (POCs), including etonogestrel implants, depot medroxyprogesterone acetate injections, and progestin-only pills (Appendix C); CHCs, including low-dose (containing ≤35 μg ethinyl estradiol) COCs, combined hormonal patch, and combined vaginal ring (Appendix D); barrier contraceptive methods, including male and female condoms, spermicides, diaphragm with spermicide, and cervical cap (Appendix E); fertility awareness–based methods (Appendix F); lactational amenorrhea method (Appendix G); coitus interruptus (Appendix H); female and male sterilization (Appendix I); and emergency contraception, including emergency use of the copper-containing IUD and emergency contraceptive pills (Appendix J). A table at the end of this report summarizes the classifications for the hormonal and intrauterine methods (Appendix K).
Contraceptive Method Choice
Many elements need to be considered by women, men, or couples at any given point in their lifetimes when choosing the most appropriate contraceptive method. These elements include safety, effectiveness, availability (including accessibility and affordability), and acceptability. The guidance in this report focuses primarily on the safety of a given contraceptive method for a person with a particular characteristic or medical condition. Therefore, the classification of category 1 means that the method can be used in that circumstance with no restrictions with regard to safety but does not necessarily imply that the method is the best choice for that person; other factors, such as effectiveness, availability, and acceptability, might play an important role in determining the most appropriate choice. Voluntary informed choice of contraceptive methods is an essential guiding principle, and contraceptive counseling, when applicable, might be an important contributor to the successful use of contraceptive methods.
In choosing a method of contraception, dual protection from the simultaneous risk for HIV and other STDs also should be considered. Although hormonal contraceptives and IUDs are highly effective at preventing pregnancy, they do not protect against STDs, including HIV. Consistent and correct use of the male latex condom reduces the risk for HIV infection and other STDs, including chlamydial infection, gonococcal infection, and trichomoniasis (12). Although evidence is limited, use of female condoms can provide protection from acquisition and transmission of STDs (12). All patients, regardless of contraceptive choice, should be counseled about the use of condoms and the risk for STDs, including HIV infection (12). Additional information about prevention and treatment of STDs is available from the CDC Sexually Transmitted Diseases Treatment Guidelines (http://www.cdc.gov/std/treatment) (12).
Contraceptive Method Effectiveness
Contraceptive method effectiveness is critical for minimizing the risk for an unintended pregnancy, particularly among women for whom an unintended pregnancy would pose additional health risks. The effectiveness of contraceptive methods depends both on the inherent effectiveness of the method itself and on how consistently and correctly it is used (Figure). Methods that depend on consistent and correct use have a wide range of effectiveness. IUDs and implants are considered long-acting, reversible contraception (LARC); these methods are highly effective because they do not depend on regular compliance from the user. LARC methods are appropriate for most women, including adolescents and nulliparous women. All women should be counseled about the full range and effectiveness of contraceptive options for which they are medically eligible so that they can identify the optimal method.
Unintended Pregnancy and Increased Health Risk
For women with conditions that might make pregnancy an unacceptable health risk, long-acting, highly effective contraceptive methods might be the best choice to avoid unintended pregnancy (Figure). Women with these conditions should be advised that sole use of barrier methods for contraception and behavior-based methods of contraception might not be the most appropriate choice because of their relatively higher typical-use rates of failure (Figure). Conditions included in U.S. MEC that are associated with increased risk for adverse health events as a result of pregnancy are identified throughout the document (Box 2). Some of the medical conditions included in U.S. MEC recommendations are treated with teratogenic drugs. While the woman’s medical condition may not affect her eligibility to use certain contraceptive methods, women using teratogenic drugs are at increased risk for poor pregnancy outcomes; long-acting, highly effective contraceptive methods might be the best option to avoid unintended pregnancy or delay pregnancy until teratogenic drugs are no longer needed.
Keeping Guidance Up to Date
Updating the evidence-based recommendations as new scientific evidence becomes available is a challenge. CDC will continue to work with WHO to identify and assess new relevant evidence as it becomes available and to determine whether changes in the recommendations are warranted (7). In most cases, U.S. MEC follows the WHO guidance updates, which typically occur every 5 years (or sooner if warranted by new data). However, CDC will review all WHO updates for their application in the United States. CDC also will identify and assess any new literature for the recommendations and medical conditions that are not included in the WHO guidance. CDC will completely review U.S. MEC every 5 years as well. Updates to the guidance will appear on the CDC U.S. MEC website (http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm).
Acknowledgments
This report is based, in part, on the work of the Promoting Family Planning Team, Department of Reproductive Health and Research, World Health Organization, and its development of Medical Eligibility Criteria for Contraceptive Use, 5th edition.
U.S. Medical Eligibility Criteria for Contraceptive Use Participants
CDC Guideline Development Group for U.S. Medical Eligibility Criteria for Contraceptive Use and U.S. Selected Practice Recommendations for Contraceptive Use
Kathryn M. Curtis, PhD (Chair), Erin Berry-Bibee, MD, Suzanne G. Folger, PhD, Leah G. Horton, MSPH, Denise J. Jamieson, MD, Tara C. Jatlaoui, MD, Polly A. Marchbanks, PhD, H. Pamela Pagano, MPH, Halley E.M. Riley, MPH, Mirelys Rodriguez, Katharine B. Simmons, MD, Naomi K. Tepper, MD, Maura K. Whiteman, PhD, Lauren B. Zapata, PhD, CDC, Atlanta, Georgia.
Invited Meeting Participants, August 27–28, 2014, Atlanta, Georgia
Herbert Peterson, MD, University of North Carolina, Chapel Hill, North Carolina (Chair); Gale Burstein, MD, Erie County Department of Health, Buffalo, New York; Alison Edelman, MD, Oregon Health and Science University, Portland, Oregon; Eve Espey, MD, University of New Mexico, Albuquerque, New Mexico; Emily Godfrey, MD, University of Washington, Seattle, Washington; Andrew Kaunitz, MD, University of Florida, Jacksonville, Florida; Susan Moskosky, MS, U.S. Department of Health and Human Services, Rockville, Maryland; Kavita Nanda, MD, FHI360 and American College of Obstetricians and Gynecologists, Durham, North Carolina; Deborah Nucatola, MD, Planned Parenthood Federation of America, New York, New York; Michael Policar, MD, University of California, San Francisco, California; Carolyn Westhoff, MD, Columbia University, New York, New York.
Systematic Review Presenters and Authors, Meeting, August 26–28, 2015, Atlanta, Georgia
Erin Berry-Bibee, MD, Kathryn M. Curtis, PhD, Leah G. Horton, MSPH, Denise J. Jamieson, MD, Tara C. Jatlaoui, MD, Polly A. Marchbanks PhD, Titilope Oduyebo, MD, Pamela Pagano, MPH, Halley E.M. Riley, MPH, Katharine B. Simmons, MD, Naomi K. Tepper, MD, Maura K. Whiteman, PhD, Lauren B. Zapata, PhD, CDC, Atlanta, Georgia; Monica Dragoman, MD, Mary E. Gaffield, PhD, Sharon J. Phillips, MD, Marleen Temmerman, MD, World Health Organization, Geneva, Switzerland; Andra James, MD, Duke University Medical Center, Durham, North Carolina; Nathalie Kapp, MD, HRA Pharma, Paris, France; Kavita Nanda, MD, FHI360, Durham, North Carolina; Seth Walker, MD, Emory University, Atlanta, Georgia.
Invited Meeting Participants, August 26–28, 2015, Atlanta, Georgia
Herbert Peterson, MD, University of North Carolina, Chapel Hill, North Carolina (Chair); Rebecca Allen, MD, American Society for Reproductive Medicine and Women and Infants Hospital, Providence, Rhode Island; Jean Anderson, MD, Johns Hopkins University, Baltimore, Maryland; Abbey Berenson, MD, University of Texas Medical Branch, Galveston, Texas; Amanda Black, MD, University of Ottawa, Ontario, Canada; Cora Collette Breuner, MD, American Academy of Pediatrics and Seattle Children’s Hospital, Seattle, Washington; Gale Burstein MD, Erie County Department of Health, Buffalo, New York; Anne Calhoun, MD, University of North Carolina, Chapel Hill, North Carolina; Nahida Chakhtoura, MD, National Institutes of Health, Rockville, Maryland; Alicia Christy, MD, National Institutes of Health, Rockville, Maryland; Mitchell D. Creinin, MD, University of California, Davis, California; Linda Dominguez, Southwest Women’s Health, Albuquerque, New Mexico; Alison Edelman, MD, Oregon Health and Science University, Portland, Oregon; Eve Espey, MD, University of New Mexico, Albuquerque, New Mexico; Emily Godfrey, MD, University of Washington, Seattle, Washington; Marji Gold, MD, Albert Einstein College of Medicine, Bronx, New York; Donald Goldstein, MD, Harvard Medical School, Boston, Massachusetts; Robert Hatcher, MD, Emory University, Atlanta, Georgia; Mark Hathaway, MD, JHPIEGO and Unity Healthcare, Washington, DC; Stephen Heartwell, MD, Susan Thompson Buffett Foundation, Omaha, Nebraska; Paula Hillard, MD, Stanford University, Palo Alto, California; Maria Houtchens, MD, Harvard Medical School, Boston, Massachusetts; Andra James, MD, Duke University Medical Center, Durham, North Carolina; Andrew Kaunitz, MD, University of Florida, Jacksonville, Florida; Myong-Jin Kim, Pharm-D, Food and Drug Administration, Rockville, Maryland; Barbara Konkle, MD, Bloodworks Northwest, Seattle, Washington; Tobias Kurth, MD, INSERM, Bordeaux, France; Miriam Labbok, MD, Academy of Breastfeeding Medicine and University of North Carolina, Chapel Hill, North Carolina; Reagan McDonald-Mosley, MD, Planned Parenthood Federation of America, New York, New York; Joan Meek, MD, American Academy of Pediatrics and Florida State University College of Medicine, Orlando, Florida; Mark Mirochnick, MD, Boston University, Boston, Massachusetts; Susan Moskosky, MS, U.S. Department of Health and Human Services, Rockville, Maryland; Kavita Nanda, MD, FHI360, Durham, North Carolina; Jeffrey Peipert, MD, Washington University, St. Louis, Missouri; Michael Policar, MD, University of California, San Francisco, California; Sarah Prager, MD, University of Washington, Seattle Washington; David Soper, MD, Medical University of South Carolina, Charleston, South Carolina; Lisa Soule, MD, Food and Drug Administration, Rockville, Maryland; Alison Stuebe, MD, American College of Obstetricians and Gynecologist and University of North Carolina, Chapel Hill, North Carolina; James Trussell, PhD, Princeton University, Princeton, New Jersey; Seth Walker, MD, Emory University, Atlanta, Georgia; Nanette Wenger, MD, Emory University, Atlanta, Georgia; Carolyn Westhoff, MD, Columbia University, New York, New York; Christopher Zahn, MD, American College of Obstetricians and Gynecologists, Washington, DC.
CDC Attendees
Wanda D. Barfield, MD, Peter Briss, MD, W. Craig Hooper, PhD, Jill Huppert, MD, Caroline King, PhD, Michele Mandel, Titilope Oduyebo, MD, Cria Perrine, MD, Sam Posner, PhD.
External Reviewers
Abigail R.A. Aiken, PhD, Princeton University, Princeton, New Jersey; Linda Burdette, PA-C, Premier Women’s Health of Yakima, Yakima, Washington; Mimi Zieman, MD, Planned Parenthood Southeast, Atlanta, Georgia.
Conflicts of Interest for Invited Meeting Participants, August 26–28, 2015, Atlanta, Georgia
Rebecca Allen, Nexplanon trainer for Merck and Liletta trainer for Actavis, consultant, advisory board and education grant from Bayer; Mitchell D. Creinin, Nexplanon trainer for Merck, litigation consultant for Bayer, advisory board for Merck and Teva Pharmaceutical Industries, Ltd., consultant for Lemonaid – PolkaDoc app, research support to University of California, Davis from Medicines360, Contramed, Merck, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Society of Family Planning; Linda Dominguez, speaker for Bayer, Merck, and Actavis; Alison Edelman, royalties from Up to Date, Inc., consultant for Genzyme, grant support from the National Institutes of Health and the Gates Foundation, travel funds from the World Health Organization, grant support and honorarium from Society of Family Planning, honorarium and travel funds from Contemporary Forum, trainer for Merck, consultant for Gynuity Health Projects, honorarium from CDC, Projects In Knowledge, and American Congress of Obstetricians and Gynecologists, advisory board for Agile Therapeutics; Eve Espey, travel funds from the American Congress of Obstetricians and Gynecologists, Society for Family Planning, and U.S. Food and Drug Administration, Reproductive and Drug Advisory Committee for U.S. Food and Drug Administration, travel funds and honoraria from Wayne State University, Telluride Conference, New Mexico Department of Health Clinician Conference, Planned Parenthood National Medical Conference and Society of Family Planning, British Columbia Contraception Access Research Team Conference, and American Congress of Obstetricians and Gynecologists annual meeting; Emily Godfrey, research funding from Bayer Women’s Health, Prima-Temp, and Teva Pharmaceutical Industries, Ltd., trainer for Merck and Upstream USA, grant reviewer for Fellowship of Family Planning and Society of Family Planning Research Fund; Mark Hathaway, Liletta trainer and speaker for Actavis and Medicines360, Nexplanon trainer for Merck, advisory board for Contramed and Afaxys Pharmaceuticals; Paula Hillard, consultant for American Civil Liberties Union, Advanced Health Media, CMEology, National Sleep Foundation, and Planned Parenthood Federation of America, honoraria from National Sleep Foundation, Dignity Health, CMEology, Advance Health Media, and Medscape, editorial board for Advanstar–Contemporary OB/GYN, board examiner for the American Board of Obstetrics and Gynecology, contract reviewer for the U.S. Department of Health and Human Services, editorial board for EBSCO–PEMSoft, Nexplanon trainer for Merck, scientific advisor to Proctor and Gamble, publication royalties from Wiley Blackwell Publishing; Andrew Kaunitz, advisory board participant of Allergan, Bayer, Merck, and Pfizer, clinical trial funding to University of Florida from Agile Therapeutics, Bayer, Merck; Mark Mirochnick, data and safety monitoring board for Merck and ViiV Healthcare, advisory board for Merck; Jeffrey Peipert, research funding from Bayer and Teva Pharmaceutical Industries, Ltd., advisory board for Perrigo; Michael Policar, litigation consultant for Bayer; James Trussell, advisory board for Merck and Teva Pharmaceutical Industries, Ltd., consultant for Bayer; Nanette Wenger, research grants from Alnylam Pharmaceuticals, Gilead Sciences, National Heart, Lung, and Blood Institute, Pfizer, and Society for Women’s Health Research, consultant for Amgen, AstraZeneca, Gilead Sciences and Merck; Carolyn Westhoff, data and safety monitoring board for Merck and Bayer, advisory board for Agile Therapeutics, MicroChips Biotech, and Actavis, research support to Columbia University from Medicines360, León Farma, and ContraMed.
Handling Conflicts of Interest
To promote transparency, all participants were asked to disclose any potential conflicts of interest to CDC prior to the expert meeting and to report any potential conflicts of interest during the introductory portion of the expert meeting. All potential conflicts of interest are listed above. No participants were excluded from discussion based on potential conflicts of interest. CDC staff who ultimately decided and developed these recommendations have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters relevant to these recommendations.
Corresponding author: Kathryn M. Curtis, PhD, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-5200; E-mail: [email protected].
1Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia; 2Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Disclosure of Relationship CDC, our planners, and our content experts wish to disclose they have no financial interest or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Planners have reviewed content to ensure there is no bias. This document will not include any discussion of the unlabeled use of a product or a product under investigational use, with the exception that some of the recommendations in this document might be inconsistent with package labeling.
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| ARV = antiretroviral [therapy] BMD = bone mineral density BMI = body mass index CHC = combined hormonal contraceptive COC = combined oral contraceptive Cu-IUD = copper-containing intrauterine device DMPA = depot medroxyprogesterone acetate DVT = deep venous thrombosis ECP = emergency contraceptive pills FAB = fertility awareness–based [methods] hCG = human chorionic gonadotropin HDL = high-density lipoprotein HIV = human immunodeficiency virus IBD = inflammatory bowel disease IUD = intrauterine device LARC = long-acting reversible contraception LDL = low-density lipoprotein |
LNG = levonorgestrel LNG-IUD = levonorgestrel-releasing intrauterine device NET-EN = norethisterone enantate NNRTI = nonnucleoside reverse transcriptase inhibitor NRTI = nucleoside reverse transcriptase inhibitor PE = pulmonary embolism PID = pelvic inflammatory disease POC = progestin-only contraceptive POP = progestin-only pill SLE = systemic lupus erythematosus SSRI = selective serotonin reuptake inhibitors STD = sexually transmitted disease UPA = ulipristal acetate U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use U.S. SPR = U.S. Selected Practice Recommendations for Contraceptive Use VTE = venous thromboembolism |
BOX 1. Categories of medical eligibility criteria for contraceptive use
1 = A condition for which there is no restriction for the use of the contraceptive method.
2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks.
3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
4 = A condition that represents an unacceptable health risk if the contraceptive method is used.
FIGURE. Effectiveness of family planning methods*
Sources: Adapted from World Health Organization (WHO) Department of Reproductive Health and Research, Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP). Knowledge for health project. Family planning: a global handbook for providers (2011 update). Baltimore, MD; Geneva, Switzerland: CCP and WHO; 2011; and Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397–404.
* The percentages indicate the number out of every 100 women who experienced an unintended pregnancy within the first year of typical use of each contraceptive method.
BOX 2. Conditions associated with increased risk for adverse health events as a result of pregnancy*
Breast cancer
Complicated valvular heart disease
Cystic fibrosis
Diabetes: insulin dependent; with nephropathy, retinopathy, or neuropathy or other vascular disease; or of >20 years’ duration
Endometrial or ovarian cancer
Epilepsy
Hypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg)
History of bariatric surgery within the past 2 years
HIV: not clinically well or not receiving antiretroviral therapy
Ischemic heart disease
Gestational trophoblastic disease
Hepatocellular adenoma and malignant liver tumors (hepatoma)
Peripartum cardiomyopathy
Schistosomiasis with fibrosis of the liver
Severe (decompensated) cirrhosis
Sickle cell disease
Solid organ transplantation within the past 2 years
Stroke
Systemic lupus erythematosus
Thrombogenic mutations
Tuberculosis
*Long-acting, highly effective contraceptive methods might be the best choice for women with conditions that are associated with increased risk for adverse health events as a result of pregnancy. These women should be advised that sole use of barrier methods for contraception and behavior-based methods of contraception might not be the most appropriate choice because of their relatively higher typical-use rates of failure.
Suggested citation for this article: Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-3):1–104. DOI: http://dx.doi.org/10.15585/mmwr.rr6503a1.
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