At a glance
This page includes recommendations for health care providers for the use of barrier methods for persons who have certain characteristics or medical conditions. This information comes from the 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC).
Overview
Classifications for barrier contraceptive methods include those for condoms, which include external (male) condoms (latex or synthetic) and internal (female) condoms, spermicide and vaginal pH modulator, and diaphragm with spermicide and cervical cap with spermicide (Box E1) (Table E1).
Patients should be counseled that consistent and correct use of external (male) latex condoms reduces the risk for sexually transmitted infections (STIs), including HIV infection.[1] Use of internal (female) condoms can provide protection from transmission of STIs, although data are limited.[1] Patients also should be counseled that pre-exposure prophylaxis, when taken as prescribed, is highly effective for preventing HIV infection.[2]
Box E1. Categories for classifying barrier methods
U.S. MEC 1
A condition for which there is no restriction for the use of the contraceptive method
U.S. MEC 2
A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
U.S. MEC 3
A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
U.S. MEC 4
A condition that represents an unacceptable health risk if the contraceptive method is used
Abbreviation: U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use.
Table E1. Classifications for barrier methods, including condoms, spermicide and vaginal pH modulator, and diaphragm with spermicide and cervical cap with spermicide
- Personal characteristics and reproductive history
- Cardiovascular disease
- Renal disease
- Rheumatic diseases
- Neurologic conditions
- Depressive disorders
- Reproductive tract infections and disorders
- HIV
- Other infections
- Endocrine conditions
- Gastrointestinal conditions
- Respiratory conditions
- Hematologic conditions
- Solid organ transplantation
- Drug interactions
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Personal Characteristics and Reproductive History | ||||
| Pregnancy | NA | NA | NA | Clarification: None of these methods are relevant for contraception during known pregnancy. However, for persons who remain at risk for STIs or HIV infection during pregnancy, the correct and consistent use of condoms is recommended. |
| Age | ||||
| a. Menarche to <40 years | 1 | 1 | 1 | — |
| b. ≥40 years | 1 | 1 | 1 | — |
| Parity | ||||
| a. Nulliparous | 1 | 1 | 1 | — |
| b. Parous | 1 | 1 | 2 | Clarification: Risk for cervical cap failure is higher in parous persons than in nulliparous persons. |
| Postpartum (breastfeeding and nonbreastfeeding) |
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| a. <6 weeks postpartum | 1 | 1 | NA | Clarification: Diaphragm and cap are unsuitable until uterine involution is complete. |
| b. ≥6 weeks postpartum | 1 | 1 | 1 | — |
| Postabortion (spontaneous or induced) |
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| a. First trimester abortion | 1 | 1 | 1 | — |
| b. Second trimester abortion | 1 | 1 | 1 | Clarification: Diaphragm and cap are unsuitable until 6 weeks after second trimester abortion. |
| c. Immediate postseptic abortion | 1 | 1 | 1 | — |
| Past ectopic pregnancy | 1 | 1 | 1 | — |
| History of pelvic surgery | 1 | 1 | 1 | — |
| Smoking | ||||
| a. Age <35 years | 1 | 1 | 1 | — |
| b. Age ≥35 years | ||||
| i. <15 cigarettes per day | 1 | 1 | 1 | — |
| ii. ≥15 cigarettes per day | 1 | 1 | 1 | — |
| Obesity | ||||
| a. BMI ≥30 kg/m2 | 1 | 1 | 1 | — |
| b. Menarche to <18 years and BMI ≥30 kg/m2 | 1 | 1 | 1 | — |
| History of bariatric surgery This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy) | 1 | 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 or biliopancreatic diversion) | 1 | 1 | 1 | — |
| Surgery | ||||
| a. Minor surgery without immobilization | 1 | 1 | 1 | — |
| b. Major surgery | ||||
| i. Without prolonged immobilization | 1 | 1 | 1 | — |
| ii. With prolonged immobilization | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Cardiovascular Disease | ||||
| Multiple risk factors for atherosclerotic cardiovascular disease (e.g., older age, smoking, diabetes, hypertension, low HDL, high LDL, or high triglyceride levels) | 1 | 1 | 1 | — |
| Hypertension Systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg are associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Adequately controlled hypertension | 1 | 1 | 1 | — |
| b. Elevated blood pressure levels (properly taken measurements) |
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| i. Systolic 140–159 mm Hg or diastolic 90–99 mm Hg | 1 | 1 | 1 | — |
| ii. Systolic ≥160 mm Hg or diastolic ≥100 mm Hg | 1 | 1 | 1 | — |
| c. Vascular disease | 1 | 1 | 1 | — |
| History of high blood pressure during pregnancy (when current blood pressure is measurable and normal) | 1 | 1 | 1 | — |
| Deep venous thrombosis/ Pulmonary embolism This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Current or history of DVT/PE, receiving anticoagulant therapy (therapeutic dose) (e.g., acute DVT/PE or long-term therapeutic dose) | 1 | 1 | 1 | — |
| b. History of DVT/PE, receiving anticoagulant therapy (prophylactic dose) |
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| i. Higher risk for recurrent DVT/PE (one or more risk factors) | 1 | 1 | 1 | — |
| • Thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; or antiphospholipid syndrome) • Active cancer (metastatic, receiving therapy, or within 6 months after clinical remission), excluding nonmelanoma skin cancer • History of recurrent DVT/PE |
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| ii. Lower risk for recurrent DVT/PE (no risk factors) | 1 | 1 | 1 | — |
| c. History of DVT/PE, not receiving anticoagulant therapy |
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| i. Higher risk for recurrent DVT/PE (one or more risk factors) | 1 | 1 | 1 | — |
| • History of estrogen-associated DVT/PE • Pregnancy-associated DVT/PE • Idiopathic DVT/PE • Thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; or antiphospholipid syndrome) • Active cancer (metastatic, receiving therapy, or within 6 months after clinical remission), excluding nonmelanoma skin cancer • History of recurrent DVT/PE |
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| ii. Lower risk for recurrent DVT/PE (no risk factors) | 1 | 1 | 1 | — |
| d. Family history (first-degree relatives) | 1 | 1 | 1 | — |
| Thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; or antiphospholipid syndrome) This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 1 | 1 | Clarification: Routine screening in the general population before contraceptive initiation is not recommended. |
| Superficial venous disorders | ||||
| a. Varicose veins | 1 | 1 | 1 | — |
| b. Superficial venous thrombosis (acute or history) | 1 | 1 | 1 | — |
| Current and history of ischemic heart disease This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 1 | 1 | — |
| Stroke (history of cerebrovascular accident) This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 1 | 1 | — |
| Valvular heart disease Complicated valvular heart disease is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Uncomplicated | 1 | 1 | 1 | — |
| b. Complicated (pulmonary hypertension, risk for atrial fibrillation, or history of subacute bacterial endocarditis) | 1 | 1 | 2 | — |
| Peripartum cardiomyopathy This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Normal or mildly impaired cardiac function (New York Heart Association Functional Class I or II: no limitation of activities or slight, mild limitation of activity) [3] |
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| i. <6 months | 1 | 1 | 1 | — |
| ii. ≥6 months | 1 | 1 | 1 | — |
| b. Moderately or severely impaired cardiac function (New York Heart Association Functional Class III or IV: marked limitation of activity or should be at complete rest) [3] | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Renal Disease | ||||
| Chronic kidney disease This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Current nephrotic syndrome | 1 | 1 | 1 | — |
| b. Hemodialysis | 1 | 1 | 1 | — |
| c. Peritoneal dialysis | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Rheumatic Diseases | ||||
| Systemic lupus erythematosus This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Positive (or unknown) antiphospholipid antibodies | 1 | 1 | 1 | — |
| b. Severe thrombocytopenia | 1 | 1 | 1 | — |
| c. Immunosuppressive therapy | 1 | 1 | 1 | — |
| d. None of the above | 1 | 1 | 1 | — |
| Rheumatoid arthritis | ||||
| a. Not receiving immunosuppressive therapy | 1 | 1 | 1 | — |
| b. Receiving immunosuppressive therapy | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Neurologic Conditions | ||||
| Headaches | ||||
| a. Nonmigraine (mild or severe) | 1 | 1 | 1 | — |
| b. Migraine | ||||
| i. Without aura (includes menstrual migraine) | 1 | 1 | 1 | Comment: Menstrual migraine is a subtype of migraine without aura. For more information see the International Headache Society’s International Classification of Headache Disorders, 3rd ed. (https://ichd-3.org).[4] |
| ii. With aura | 1 | 1 | 1 | — |
| Epilepsy This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 1 | 1 | — |
| Multiple sclerosis | ||||
| a. Without prolonged immobility | 1 | 1 | 1 | — |
| b. With prolonged immobility | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Reproductive Tract Infections and Disorders | ||||
| Unexplained vaginal bleeding (suspicious for serious condition) before evaluation |
1 | 1 | 1 | Clarification: If pregnancy or an underlying pathological condition (e.g., pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation. |
| Endometriosis | 1 | 1 | 1 | — |
| Benign ovarian tumors (including cysts) | 1 | 1 | 1 | — |
| Severe dysmenorrhea | 1 | 1 | 1 | — |
| Gestational trophoblastic disease This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Suspected gestational trophoblastic disease (immediate postevacuation) |
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| i. Uterine size first trimester | 1 | 1 | 1 | — |
| ii. Uterine size second trimester | 1 | 1 | 1 | — |
| b. Confirmed gestational trophoblastic disease (after initial evacuation and during monitoring) |
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| i. Undetectable or nonpregnant β–hCG levels | 1 | 1 | 1 | — |
| ii. Decreasing β–hCG levels | 1 | 1 | 1 | — |
| iii. Persistently elevated β-hCG levels or malignant disease, with no evidence or suspicion of intrauterine disease | 1 | 1 | 1 | — |
| iv. Persistently elevated β-hCG levels or malignant disease, with evidence or suspicion of intrauterine disease | 1 | 1 | 1 | — |
| Cervical ectropion | 1 | 1 | 1 | — |
| Cervical intraepithelial neoplasia | 1 | 1 | 1 | Clarification: The cap should not be used. Diaphragm use has no restrictions. |
| Cervical cancer (awaiting treatment) | 1 | Vaginal pH modulator: 1 Spermicide: 2 |
1 | Clarification: The cap should not be used. Diaphragm use has no restrictions. Comment: Repeated and high-dose use of the spermicide nonoxynol-9 can cause vaginal and cervical irritation or abrasions. |
| Breast disease Breast cancer is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Undiagnosed mass | 1 | 1 | 1 | — |
| b. Benign breast disease | 1 | 1 | 1 | — |
| c. Family history of cancer | 1 | 1 | 1 | — |
| d. Breast cancer | ||||
| i. Current | 1 | 1 | 1 | — |
| ii. Past and no evidence of current disease for 5 years | 1 | 1 | 1 | — |
| Endometrial hyperplasia | 1 | 1 | 1 | — |
| Endometrial cancer This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 1 | 1 | — |
| Ovarian cancer This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 1 | 1 | — |
| Uterine fibroids | 1 | 1 | 1 | — |
| Anatomical abnormalities | 1 | 1 | NA | Clarification: The diaphragm cannot be used in certain cases of prolapse. Cap use is not appropriate for a person with markedly distorted cervical anatomy. |
| Pelvic inflammatory disease | ||||
| a. Current PID | 1 | 1 | 1 | — |
| b. Past PID | ||||
| i. With subsequent pregnancy | 1 | 1 | 1 | — |
| ii. Without subsequent pregnancy | 1 | 1 | 1 | — |
| Sexually transmitted infections | ||||
| a. Current purulent cervicitis or chlamydial infection or gonococcal infection | 1 | 1 | 1 | — |
| b. Vaginitis (including Trichomonas vaginalis and bacterial vaginosis) | 1 | 1 | 1 | — |
| c. Other factors related to STIs | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| HIV | ||||
| High risk for HIV infection | 1 | Vaginal pH modulator: 1 Spermicide: 4 |
4 | Evidence: Repeated and high-dose use of the spermicide nonoxynol-9 was associated with increased risk for genital lesions, which might increase the risk for HIV infection.[5] Comment: Diaphragm and cap use is assigned category 4 because of concerns about the spermicide, not the diaphragm or cap. |
| HIV infection For persons with HIV infection who are not clinically well or not receiving ARV therapy, this condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | Vaginal pH modulator: 1 Spermicide: 3 |
3 | Comment: Use of spermicides, including with diaphragms and caps, can disrupt the cervical mucosa, which might increase viral shedding and HIV transmission to noninfected sex partners. |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Other Infections | ||||
| Schistosomiasis Schistosomiasis with fibrosis of the liver is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Uncomplicated | 1 | 1 | 1 | — |
| b. Fibrosis of the liver | 1 | 1 | 1 | — |
| Tuberculosis This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Nonpelvic | 1 | 1 | 1 | — |
| b. Pelvic | 1 | 1 | 1 | — |
| Malaria | 1 | 1 | 1 | — |
| History of toxic shock syndrome | 1 | 1 | 3 | Comment: Toxic shock syndrome has been reported in association with contraceptive sponge and diaphragm use. |
| Urinary tract infection | 1 | Vaginal pH modulator: 2 Spermicide: 1 |
2 | Comment: Use of diaphragms and spermicides might increase risk for urinary tract infection. |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Endocrine Conditions | ||||
| Diabetes Insulin-dependent diabetes; diabetes with nephropathy, retinopathy, or neuropathy; diabetes with other vascular disease; or diabetes of >20 years’ duration are associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. History of gestational disease | 1 | 1 | 1 | — |
| b. Nonvascular disease | ||||
| i. Non-insulin dependent | 1 | 1 | 1 | — |
| ii. Insulin dependent | 1 | 1 | 1 | — |
| c. Nephropathy, retinopathy, or neuropathy | 1 | 1 | 1 | — |
| d. Other vascular disease or diabetes of >20 years’ duration | 1 | 1 | 1 | — |
| Thyroid disorders | ||||
| a. Simple goiter | 1 | 1 | 1 | — |
| b. Hyperthyroid | 1 | 1 | 1 | — |
| c. Hypothyroid | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Gastrointestinal Conditions | ||||
| Inflammatory bowel disease (ulcerative colitis or Crohn’s disease) | 1 | 1 | 1 | — |
| Gallbladder disease | ||||
| a. Asymptomatic | 1 | 1 | 1 | — |
| b. Symptomatic | ||||
| i. Current | 1 | 1 | 1 | — |
| ii. Treated by cholecystectomy | 1 | 1 | 1 | — |
| iii. Medically treated | 1 | 1 | 1 | — |
| History of cholestasis | ||||
| a. Pregnancy related | 1 | 1 | 1 | — |
| b. Past COC related | 1 | 1 | 1 | — |
| Viral hepatitis | ||||
| a. Acute or flare | 1 | 1 | 1 | — |
| b. Chronic | 1 | 1 | 1 | — |
| Cirrhosis Decompensated cirrhosis is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Compensated (normal liver function) | 1 | 1 | 1 | — |
| b. Decompensated (impaired liver function) | 1 | 1 | 1 | — |
| Liver tumors Hepatocellular adenoma and malignant liver tumors are associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. Benign | ||||
| i. Focal nodular hyperplasia | 1 | 1 | 1 | — |
| ii. Hepatocellular adenoma | 1 | 1 | 1 | — |
| b. Malignant (hepatocellular carcinoma) | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Respiratory Conditions | ||||
| Cystic fibrosis This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Hematologic Conditions | ||||
| Thalassemia | 1 | 1 | 1 | — |
| Sickle cell disease This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 1 | 1 | — |
| Iron deficiency anemia | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | ||
|---|---|---|---|---|
| Condom | Spermicide/Vaginal pH modulator | Diaphragm/Cap (with spermicide) | ||
| Solid Organ Transplantation | ||||
| Solid organ transplantation This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
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| a. No graft failure | 1 | 1 | 1 | — |
| b. Graft failure | 1 | 1 | 1 | — |
Abbreviations: ARV = antiretroviral; BMI = body mass index; COC = combined oral contraceptive; DVT = deep venous thrombosis; hCG = human chorionic gonadotropin; HDL = high-density lipoprotein; LDL = low-density lipoprotein; NA = not applicable; PE = pulmonary embolism; PID = pelvic inflammatory disease; PrEP = pre-exposure prophylaxis; STI = sexually transmitted infection.
References
- Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. PMID:34292926 https://doi.org/10.15585/mmwr.rr7004a1
- CDC. US Public Health Service preexposure prophylaxis for the prevention of HIV infection in the United States—2021 update: a clinical practice guideline. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. /hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf
- The Criteria Committee of the New York Heart Association. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Little, Brown and Co; 1994.
- Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders. 3rd ed. Cephalalgia 2018;38:1–211. https://www.ichd-3.org/wp-content/uploads/2018/01/The-International-Classification-of-Headache-Disorders-3rd-Edition-2018.pdf
- Wilkinson D, Ramjee G, Tholandi M, Rutherford G. Nonoxynol-9 for preventing vaginal acquisition of HIV infection by women from men. Cochrane Database Syst Rev 2002;2002:CD003936. PMID:12519622 https://doi.org/10.1002/14651858.CD003936