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Appendix E

Classifications for Intrauterine Devices


Classifications for intrauterine devices (IUDs) are for the levonorgestrel-releasing (20 μg/24 hours) IUD and the copper-bearing IUD (Box). IUDs do not protect against sexually transmitted infections (STIs) or human immunodeficiency virus (HIV).

BOX. Categories for Classifying Intrauterine Devices

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.

TABLE. Classifications for intrauterine devices, including the LNG-IUD and the Cu-IUD*†

Condition

Category

Clarifications/Evidence/Comments

LNG-IUD

Cu-IUD

Personal Characteristics and Reproductive History

Pregnancy

4

4

Clarification: The IUD is not indicated during pregnancy and should not be used because of the risk for serious pelvic infection and septic spontaneous abortion.

Age

a. Menarche to <20 yrs

2

2

Comment: Concern exists about both the risk for expulsion from nulliparity and for STIs from sexual behaviour in younger age groups.

b. ≥20 yrs

1

1

Parity

a. Nulliparous

2

2

Evidence: Data conflict about whether IUD use is associated with infertility among nulliparous women, although well-conducted studies suggest no increased risk (1--9).

b Parous

1

1

Postpartum (breastfeeding or nonbreastfeeding women, including post-Cesarean section)

a. <10 minutes after delivery of the placenta

2

1

Evidence: Immediate postpartum Cu-IUD insertion, particularly when insertion occurs immediately after delivery of the placenta, is associated with lower expulsion rates than is delayed postpartum insertion up to 72 hours postpartum; no data exist that examine times >72 hours postpartum. In addition, postplacental placement at the time of Cesarean section has lower expulsion rates than does postplacental vaginal insertions. Insertion complications of perforation and infection are not increased by Cu-IUD placement at any time during the postpartum period (10--23). No evidence is available that compares different insertion times for the LNG-IUD.

b. 10 minutes after delivery of the placenta to <4 wks

2

2

c. ≥4 wks

1

1

d. Puerperal sepsis

4

4

Comment: Insertion of an IUD might substantially worsen the condition.

Postabortion

a. First trimester

1

1

Clarification: IUDs can be inserted immediately after first trimester spontaneous or induced abortion.

Evidence: Risk for complications from immediate versus delayed insertion of an IUD after abortion did not differ. Expulsion was greater when an IUD was inserted after a second trimester abortion than when inserted after a first trimester abortion. Safety or expulsion for postabortion insertion of an LNG-IUD did not differ from that of a Cu-IUD (24--37).

b. Second trimester

2

2

c. Immediate postseptic abortion

4

4

Comment: Insertion of an IUD might substantially worsen the condition.

TABLE. (Continued) Classifications for intrauterine devices,*† including the LNG-IUD and the Cu-IUD

Condition

Category

Clarifications/Evidence/Comments

LNG-IUD

Cu-IUD

Past ectopic pregnancy

1

1

Comment: The absolute risk for ectopic pregnancy is extremely low because of the high effectiveness of IUDs. However, when a woman becomes pregnant during IUD use, the relative likelihood of ectopic pregnancy increases greatly.

History of pelvic surgery (see Postpartum, including post-Cesarean section)

1

1

Smoking

a. Age <35 yrs

1

1

b. Age ≥35 yrs

i. <15 Cigarettes/day

1

1

ii. ≥15 Cigarettes/day

1

1

Obesity

a. ≥30 kg/m2 BMI

1

1

b. Menarche to <18 yrs and ≥30 kg/m2 BMI

1

1

History of bariatric surgery§

a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy)

1

1

b. Malabsorptive procedures: decrease absorption of nutrients and calories by shortening the functional length of the small intestine (Roux-en-Y gastric bypass, biliopancreatic diversion)

1

1

Cardiovascular Disease

Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)

2

1

Hypertension

For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, risk for cardiovascular disease might increase substantially. A single reading of blood pressure level is not sufficient to classify a woman as hypertensive.

a. Adequately controlled hypertension

1

1

b. Elevated blood pressure levels (properly taken measurements)

i. Systolic 140--159 mm Hg or diastolic 90--99 mm Hg

1

1

ii. Systolic ≥160 mm Hg or diastolic ≥100 mm Hg§

2

1

Comment: Theoretical concern exists about the effect of LNG on lipids. Use of Cu-IUDs has no restrictions.

c. Vascular disease

2

1

Comment: Theoretical concern exists about the effect of LNG on lipids. Use of Cu-IUDs has no restrictions.

History of high blood pressure during pregnancy (where current blood pressure is measurable and normal)

1

1

Deep venous thrombosis (DVT)/pulmonary embolism (PE)

a. History of DVT/PE, not on anticoagulant therapy

i. Higher risk for recurrent DVT/PE (≥1 risk factors)

• History of estrogen-associated DVT/PE

• Pregnancy-associated DVT/PE

• Idiopathic DVT/PE

• Known thrombophilia, including antiphospholipid syndrome

• Active cancer (metastatic, on therapy, or within 6 mos after clinical remission), excluding non-melanoma skin cancer

• History of recurrent DVT/PE

2

1

ii. Lower risk for recurrent DVT/PE (no risk factors)

2

1

TABLE. (Continued) Classifications for intrauterine devices,*† including the LNG-IUD and the Cu-IUD

Condition

Category

Clarifications/Evidence/Comments

LNG-IUD

Cu-IUD

b. Acute DVT/PE

2

2

Evidence: No direct evidence exists on the use of POCs among women with acute DVT/PE. Although findings on the risk for venous thrombosis with the use of POCs in otherwise healthy women are inconsistent, any small increased risk is substantially less than that with COCs (38--40).

c. DVT/PE and established on anticoagulant therapy for at least 3 mos

Evidence: No direct evidence exists on the use of POCs among women with acute DVT/PE. Although findings on the risk for venous thrombosis with the use of POCs in otherwise healthy women are inconsistent, any small increased risk is substantially less than that with COCs (38--40).

Evidence: Limited evidence indicates that insertion of the LNG-IUD does not pose major bleeding risks in women on chronic anticoagulant therapy. (41--44)

Comment: The LNG-IUD might be a useful treatment for menorrhagia in women on long-term chronic anticoagulation therapy.

i. Higher risk for recurrent DVT/PE (≥1 risk factors)

• Known thrombophilia, including antiphospholipid syndrome

• Active cancer (metastatic, on therapy, or within 6 mos after clinical remission), excluding non-melanoma skin cancer

• History of recurrent DVT/PE

2

2

ii. Lower risk for recurrent DVT/PE (no risk factors)

2

2

d. Family history (first-degree relatives)

1

1

e. Major surgery

i. With prolonged immobilization

2

1

ii. Without prolonged immobilization

1

1

f. Minor surgery without immobilization

1

1

Known thrombogenic mutations§ (e.g., factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)

2

1

Clarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening.

Superficial venous thrombosis

a. Varicose veins

1

1

b. Superficial thrombophlebitis

1

1

Current and history of ischemic heart disease§

Initiation

Continuation

Comment: Theoretical concern exists about the effect of LNG on lipids. Use of Cu-IUDs has no restrictions.

2

3

1

Stroke§ (history of cerebrovascular accident)

2

1

Comment: Theoretical concern exists about the effect of LNG on lipids. Use of Cu-IUDs has no restrictions.

Known hyperlipidemias

2

1

Clarification: Routine screening is not appropriate because of the rarity of the condition and the high cost of screening.

Valvular heart disease

a. Uncomplicated

1

1

Comment: According to the American Heart Association, administration of prophylactic antibiotics solely to prevent endocarditis is not recommended for patients who undergo genitourinary tract procedures, including insertion or removal of IUDs (45).

b. Complicated§ (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)

1

1

Comment: According to the American Heart Association, administration of prophylactic antibiotics solely to prevent endocarditis is not recommended for patients who undergo genitourinary tract procedures, including insertion or removal of IUDs (45).

Peripartum cardiomyopathy§

a. Normal or mildly impaired cardiac function (New York Heart Association Functional Class I or II: patients with no limitation of activities or patients with slight, mild limitation of activity) (46)

Evidence: No direct evidence exists on the safety of IUDs among women with peripartum cardiomyopathy. Limited indirect evidence from noncomparative studies did not demonstrate any cases of arrhythmia or infective endocarditis in women with cardiac disease who used IUDs (47,48).

Comment: IUD insertion might induce cardiac arrhythmias in healthy women; women with peripartum cardiomyopathy have a high incidence of cardiac arrhythmias.

i. <6 mos

2

2

ii. ≥6 mos

2

2

TABLE. (Continued) Classifications for intrauterine devices,*† including the LNG-IUD and the Cu-IUD

Condition

Category

Clarifications/Evidence/Comments

LNG-IUD

Cu-IUD

b. Moderately or severely impaired cardiac function (New York Heart Association Functional Class III or IV: patients with marked limitation of activity or patients who should be at complete rest) (46)

2

2

Evidence: There is no direct evidence on the safety of IUDs among women with peripartum cardiomyopathy. Limited indirect evidence from noncomparative studies did not demonstrate any cases of arrhythmia or infective endocarditis in women with cardiac disease who used IUDs (47,48).

Comment: IUD insertion might induce cardiac arrhythmias in healthy women; women with peripartum cardiomyopathy have a high incidence of cardiac arrhythmias.

Rheumatic Diseases

Systemic lupus erythematosus (SLE)§

Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Categories assigned to such conditions in the MEC should be the same for women with SLE who have these conditions. For all categories of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors.

Many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives (43,49--66).

Initiation

Continuation

a. Positive (or unknown) antiphospholipid antibodies

3

1

1

Evidence: Antiphospholipid antibodies are associated with a higher risk for both arterial and venous thrombosis (67,68).

b. Severe thrombocytopenia

2

3

2

Clarification: Severe thrombocytopenia increases the risk for bleeding. The category should be assessed according to the severity of thrombocytopenia and its clinical manifestations. In women with very severe thrombocytopenia who are at risk for spontaneous bleeding, consultation with a specialist and certain pretreatments might be warranted.

Evidence: The LNG-IUD might be a useful treatment for menorrhagia in women with severe thrombocytopenia (43).

c. Immunosuppressive treatment

2

2

1

d. None of the above

2

1

1

Rheumatoid arthritis

Initiation

Continuation

Initiation

Continuation

a. On immunosuppressive therapy

2

1

2

1

b. Not on immunosuppressive therapy

1

1

Neurologic Conditions

Headaches

Initiation

Continuation

Clarification: Any new headaches or marked changes in headaches should be evaluated.

a. Non-migrainous (mild or severe)

1

1

1

b. Migraine

i. Without aura

Comment: Aura is a specific focal neurologic symptom. For more information about this and other diagnostic criteria, see: Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders. 2nd ed. Cephalalgia 2004;24(Suppl 1):1-- 150. Available from http://www.i-h-s.org/upload/ct_clas/ihc_II_main_no_print.pdf.

• Age <35 yrs

2

2

1

• Age ≥35 yrs

2

2

1

ii. With aura, at any age

2

3

1

Epilepsy§

1

1

Depressive Disorders

Depressive disorders

1

1

Clarification: The classification is based on data for women with selected depressive disorders. No data were available on bipolar disorder or postpartum depression. Drug interactions potentially can occur between certain antidepressant medications and hormonal contraceptives.

Reproductive Tract Infections and Disorders

Vaginal bleeding patterns

Initiation

Continuation

a. Irregular pattern without heavy bleeding

1

1

1

b. Heavy or prolonged bleeding (includes regular and irregular patterns)

1

2

2

Clarification: Unusually heavy bleeding should raise suspicion of a serious underlying condition.

Evidence: Evidence from studies examining the treatment effects of the LNG-IUD among women with heavy or prolonged bleeding reported no increase in adverse effects and found the LNG-IUD to be beneficial in treating menorrhagia (69--76).

Unexplained vaginal bleeding (suspicion for serious condition)

Clarification: If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation. The IUD does not need to be removed before evaluation.

Initiation

Continuation

Initiation

Continuation

Before evaluation

4

2

4

2

TABLE. (Continued) Classifications for intrauterine devices,*† including the LNG-IUD and the Cu-IUD

Condition

Category

Clarifications/Evidence/Comments

LNG-IUD

Cu-IUD

Endometriosis

1

2

Evidence: LNG-IUD use among women with endometriosis decreased dysmenorrhea, pelvic pain, and dyspareunia (77--81).

Benign ovarian tumors (including cysts)

1

1

Severe dysmenorrhea

1

2

Comment: Dysmenorrhea might intensify with Cu-IUD use. LNG-IUD use has been associated with reduction of dysmenorrhea.

Gestational trophoblastic disease

a. Decreasing or undetectable β--hCG levels

3

3

Evidence: Limited evidence suggests that women using an IUD after uterine evacuation for a molar pregnancy are not at greater risk for postmolar trophoblastic disease than are women using other methods of contraception (82--84).

b. Persistently elevated β-hCG levels or malignant disease§

4

4

Evidence: Limited evidence suggests that women using an IUD after uterine evacuation for a molar pregnancy are not at greater risk for postmolar trophoblastic disease than are women using other methods of contraception (82--84)

Cervical ectropion

1

1

Cervical intraepithelial neoplasia

2

1

Comment: Theoretical concern exists that LNG-IUDs might enhance progression of cervical intraepithelial neoplasia.

Cervical cancer (awaiting treatment)

Initiation

Continuation

Initiation

Continuation

Comment: Concern exists about the increased risk for infection and bleeding at insertion. The IUD most likely will need to be removed at the time of treatment, but until then, the woman is at risk for pregnancy.

4

2

4

2

Breast disease

a. Undiagnosed mass

2

1

b. Benign breast disease

1

1

c. Family history of cancer

1

1

d. Breast cancer§

Comment: Breast cancer is a hormonally sensitive tumor. Concerns about progression of the disease might be less with LNG-IUDs than with COCs or higher-dose POCs.

i. Current

4

1

ii. Past and no evidence of current disease for 5 yrs

3

1

Endometrial hyperplasia

1

1

Evidence: Among women with endometrial hyperplasia, no adverse health events occurred with LNG-IUD use; most women experienced disease regression (85--93).

Endometrial cancer§

Initiation

Continuation

Initiation

Continuation

Comment: Concern exists about the increased risk for infection, perforation, and bleeding at insertion. The IUD most likely will need to be removed at the time of treatment, but until then, the woman is at risk for pregnancy.

4

2

4

2

Ovarian cancer§

1

1

Comment: Women with ovarian cancer who undergo fertility sparing treatment and need contraception may use an IUD.

Uterine fibroids

2

2

Evidence: Among women with uterine fibroids using an LNG-IUD, most experienced improvements in serum levels of hemoglobin, hematocrit, and ferritin (73,94--100) and menstrual blood loss (73,75,94--101). Rates of LNG-IUD expulsion were higher in women with uterine fibroids (11%) than in women without fibroids (0%--3%); these findings were not statistically significant or significance testing was not conducted (75,101). Rates of expulsion from noncomparative studies ranged from 0%--20% (94,96--100).

Comment: Women with heavy or prolonged bleeding should be assigned the category for that condition.

Anatomical abnormalities

a. Distorted uterine cavity (any congenital or acquired uterine abnormality distorting the uterine cavity in a manner that is incompatible with IUD insertion)

4

4

Comment: An anatomic abnormality that distorts the uterine cavity might preclude proper IUD placement.

b. Other abnormalities (including cervical stenosis or cervical lacerations) not distorting the uterine cavity or interfering with IUD insertion

2

2

TABLE. (Continued) Classifications for intrauterine devices,*† including the LNG-IUD and the Cu-IUD

Condition

Category

Clarifications/Evidence/Comments

LNG-IUD

Cu-IUD

Pelvic inflammatory disease (PID)

Initiation

Continuation

Initiation

Continuation

a. Past PID (assuming no known current risk factors for STIs)

Comment: IUDs do not protect against STI/HIV/PID. In women at low risk for STIs, IUD insertion poses little risk for PID. Current risk for STIs and desire for future pregnancy are relevant considerations.

i. With subsequent pregnancy

1

1

1

1

ii. Without subsequent pregnancy

2

2

2

2

b. Current PID

4

2

4

2

Clarification for continuation: Treat the PID using appropriate antibiotics. The IUD usually does not need to be removed if the woman wishes to continue using it. Continued use of an IUD depends on the woman's informed choice and her current risk factors for STIs and PID.

Evidence: Among IUD users treated for PID, clinical course did not differ regardless of whether the IUD was removed or left in place (102--104).

STIs

Initiation

Continuation

Initiation

Continuation

a. Current purulent cervicitis or chlamydial infection or gonorrhea

4

2

4

2

Clarification for continuation: Treat the STI using appropriate antibiotics. The IUD usually does not need to be removed if the woman wishes to continue using it. Continued use of an IUD depends on the woman's informed choice and her current risk factors for STIs and PID.

Evidence: No evidence exists about whether IUD insertion among women with STIs increases the risk for PID over that of women with no IUD insertion. Among women who had an IUD inserted, the absolute risk for subsequent PID was low among women with STI at the time of insertion but greater than among women with no STI at the time of IUD insertion (105--111).

b. Other STIs (excluding HIV and hepatitis)

2

2

2

2

c. Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)

2

2

2

2

d. Increased risk for STIs

2/3

2

2/3

2

Clarification for initiation: If a woman has a very high individual likelihood of exposure to gonorrhea or chlamydial infection, the condition is a Category 3.

Evidence: Using an algorithm to classify STI risk status among IUD users, 1 study reported that 11% of women at high risk for STIs experienced IUD-related complications compared with 5% of those not classified as high risk (107).

HIV/AIDS

High risk for HIV

Initiation

Continuation

Initiation

Continuation

2

2

2

2

Evidence: Among women at risk for HIV, Cu-IUD use did not increase risk for HIV acquisition (112--122).

HIV infection§

2

2

2

2

Evidence: Among IUD users, limited evidence shows no higher risk for overall complications or for infectious complications in HIV-infected than in HIV-uninfected women. IUD use did not adversely affect progression of HIV when compared with hormonal contraceptive use among HIV-infected women. Furthermore, IUD use among HIV-infected women was not associated with increased risk for transmission to sex partners (112,123--130).

AIDS§

3

2

3

2

Clarification for continuation: IUD users with AIDS should be closely monitored for pelvic infection.

Clinically well on ARV therapy

2

2

2

2

Other Infections

Schistosomiasis

a. Uncomplicated

1

1

b. Fibrosis of the liver§ (if severe, see cirrhosis)

1

1

Tuberculosis§

Initiation

Continuation

Initiation

Continuation

a. Nonpelvic

1

1

1

1

b. Pelvic

4

3

4

3

Comment: Insertion of an IUD may substantially worsen the condition.

Malaria

1

1

TABLE. (Continued) Classifications for intrauterine devices,*† including the LNG-IUD and the Cu-IUD

Condition

Category

Clarifications/Evidence/Comments

LNG-IUD

Cu-IUD

Endocrine Conditions

Diabetes

a. History of gestational disease

1

1

b. Nonvascular disease

Evidence: Limited evidence on the use of the LNG-IUD among women with insulin-dependent or noninsulin-dependent diabetes suggests that these methods have little effect on short-term or long-term diabetes control (e.g., glycosylated hemoglobin levels), hemostatic markers, or lipid profile (131,132).

i. Noninsulin-dependent

2

1

ii. Insulin-dependent§

2

1

c. Nephropathy/retinopathy/neuropathy§

2

1

d. Other vascular disease or diabetes of >20 yrs' duration§

2

1

Thyroid disorders

a. Simple goiter

1

1

b. Hyperthyroid

1

1

c. Hypothyroid

1

1

Gastrointestinal Conditions

Inflammatory bowel disease (IBD) (ulcerative colitis, Crohn disease)

1

1

Evidence: Although two case reports described three women with IBD who experienced exacerbation of disease 5 days--25 months after LNG-IUD insertion (133,134), no comparative studies have examined the safety of IUD use among women with IBD.

Gallbladder disease

a. Symptomatic

i. Treated by cholecystectomy

2

1

ii. Medically treated

2

1

iii. Current

2

1

b. Asymptomatic

2

1

History of cholestasis

a. Pregnancy-related

1

1

b. Past COC-related

2

1

Comment: Concern exists that history of COC-related cholestasis might predict subsequent cholestasis with LNG use. Whether risk exists with use of LNG-IUD is unclear.

Viral hepatitis

a. Acute or flare

1

1

b. Carrier

1

1

c. Chronic

1

1

Cirrhosis

a. Mild (compensated)

1

1

b. Severe§ (decompensated)

3

1

Liver tumors

a. Benign

2

1

i. Focal nodular hyperplasia

ii. Hepatocellular adenoma§

3

1

Comment: No evidence is available about hormonal contraceptive use in women with hepatocellular adenoma. COC use in healthy women is associated with development and growth of hepatocellular adenoma; whether other hormonal contraceptives have similar effects is not known.

b. Malignant§ (hepatoma)

3

1

Anemias

Thalassemia

1

2

Comment: Concern exists about an increased risk for blood loss with Cu-IUDs.

Sickle cell disease§

1

2

Comment: Concern exists about an increased risk for blood loss with Cu-IUDs.

Iron deficiency anemia

1

2

Comment: Concern exists about an increased risk for blood loss with Cu-IUDs.

Solid Organ Transplantation

Solid organ transplantation§

Initiation

Continuation

Initiation

Continuation

Evidence: No comparative studies have examined IUD use among transplant patients. Four case reports of transplant patients using IUDs provided inconsistent results, including beneficial effects and contraceptive failures (135--138).

a. Complicated: graft failure (acute or chronic), rejection, cardiac allograft vasculopathy

3

2

3

2

b. Uncomplicated

2

2

2

2

TABLE. (Continued) Classifications for intrauterine devices,*† including the LNG-IUD and the Cu-IUD

Condition

Category

Clarifications/Evidence/Comments

LNG-IUD

Cu-IUD

Drug Interactions

Antiretroviral (ARV) therapy

Initiation

Continuation

Initiation

Continuation

Clarification: No known interaction exists between ARV therapy and IUD use. However, AIDS as a condition is classified as Category 3 for insertion and Category 2 for continuation unless the woman is clinically well on ARV therapy, in which case, both insertion and continuation are classified as Category 2 (see AIDS condition).

a. Nucleoside reverse transcriptase inhibitors (NRTIs)

2/3

2

2/3

2

b. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

2/3

2

2/3

2

c. Ritonavir-boosted protease inhibitors

2/3

2

2/3

2

Anticonvulsant therapy

a. Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)

1

1

Evidence: Limited evidence suggests use of certain anticonvulsants does not interfere with the contraceptive effectiveness of the LNG-IUD (139).

b Lamotrigine

1

1

Evidence: No drug interactions have been reported among epileptic women taking lamotrigine and using the LNG-IUD (140).

Antimicrobial therapy

a. Broad-spectrum antibiotics

1

1

b. Antifungals

1

1

c. Antiparasitics

1

1

d. Rifampicin or rifabutin therapy

1

1

Evidence: One cross-sectional survey found that rifabutin had no impact on the effectiveness of the LNG-IUD (139).

* Abbreviations: LNG-IUD = levonorgestrel-releasing intrauterine device; Cu-IUD = copper IUD; STI = sexually transmitted infection; HIV = human immunodeficiency virus; BMI = body mass index; DVT = deep venous thrombosis; PE = pulmonary embolism; POC = progestin-only contraceptive; COC = combined oral contraceptive; SLE = systemic lupus erythematosus; MEC = Medical Eligibility Criteria; hCG = human chorionic gonadotropin; PID = pelvic inflammatory disease; AIDS = acquired immunodeficiency syndrome; ARV = antiretroviral; IBD = inflammatory bowel disease; NRTI = nucleoside reverse transcriptase inhibitor; NNRTI = non-nucleoside reverse transcriptase inhibitor.

† IUDs do not protect against STI/HIV. If risk exists for STI/HIV (including during pregnancy or postpartum), the correct and consistent use of condoms is recommended, either alone or with another contraceptive method. Consistent and correct use of the male latex condom reduces the risk for STIs and HIV transmission

§ Condition that exposes a woman to increased risk as a result of unintended pregnancy.

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