How to Use This Document

Overview

The recommendations in this report are intended to help health care providers determine the safe use of contraceptive methods among persons with certain characteristics and medical conditions. Providers can use the information in these recommendations during contraceptive counseling with patients. The tables include recommendations for the use of contraceptive methods by persons with certain characteristics or medical conditions. Each condition is defined as representing either a person's characteristics (e.g., age or postpartum status) or a known medical 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).

Box 1. Categories of medical eligibility criteria for contraceptive use

Contraceptive decision-making

CDC acknowledges the paramount importance of personal autonomy in contraceptive decision-making. This is critically important because of the context of historical and ongoing contraceptive coercion and reproductive mistreatment in the United States, especially among communities that have been marginalized, including human rights violations such as forced sterilization and enrollment in contraceptive trials without informed consent.^[10–12] Coercive practices in the health care system can include provider bias for certain contraceptive methods over a patient's reproductive goals and preferences, lack of person-centered counseling and support, and policies or incentives for uptake of certain contraceptive methods.^[11] For health care providers and the settings in which they work, it is important to acknowledge the structural systems that drive inequities (e.g., discrimination because of race, ethnicity, disability, sex, gender, and sexual orientation), work to mitigate harmful impacts, and recognize that provider bias (unconscious or explicit) might affect contraceptive counseling and provision of services.^[12] All persons seeking contraceptive care need access to appropriate counseling and services that support the person's values, goals, and reproductive autonomy. Health care providers can support the contraceptive needs of all persons by using a person-centered framework and recognizing the many factors that influence individual decision-making about contraception.^{[10],[12],[14]}

The U.S. MEC and U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) recommendations can be used to support a person's contraceptive decision-making (Box 2). Persons should have equitable access to the full range of contraceptive methods and be given the information they need for contraceptive decision-making in a noncoercive manner. Patient-centeredness has been defined by the Institute of Medicine as "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions".^[23] Shared decision-making and person-centered approaches to providing health care recognize the expertise of both the medical provider and the patient.^{[10],[12],[23]}

Health care providers should always consider the individual clinical and social factors of each person seeking contraceptive services and discuss reproductive desires, expectations, preferences, and priorities regarding contraception. A person might consider and prioritize many elements when choosing an acceptable contraceptive method, such as safety, effectiveness,^[24] availability (including accessibility and affordability), side effects, user control, reversibility, and ease of removal or discontinuation. In addition, a person's health risks associated with pregnancy and access to comprehensive health care services should be considered in these discussions. A person-centered approach to contraceptive decision-making prioritizes a person's preferences and reproductive autonomy rather than a singular focus on pregnancy prevention and respects the person as the main decision-maker in contraceptive decisions, including the decision not to use contraception or to discontinue contraceptive method use.^[12],[25] Voluntary informed choice of contraceptive methods is an essential guiding principle, and contraceptive counseling, where applicable, might be an important contributor to the successful use of contraceptive methods. Key resources provide additional information on person-centered contraceptive counseling and care.^{[7],[10],[12],[26]}

Box 2. Using the U.S. MEC and U.S. SPR recommendations to support contraceptive decision-making

• CDC acknowledges the paramount importance of personal autonomy in contraceptive decision-making.
• Persons should have equitable access to the full range of contraceptive methods.
• Contraceptive services should be offered in a noncoercive manner that honors a person’s values, goals, and reproductive autonomy.
• Shared decision-making and person-centered approaches recognize the expertise of both the health care provider and the person.
• A person-centered approach to contraceptive decision-making
  • prioritizes a person’s preferences and reproductive autonomy rather than a singular focus on pregnancy prevention,
  • respects the person as the main decision-maker in contraceptive decisions, and
  • includes respecting the decision not to use contraception or to discontinue contraceptive method use.
• U.S. MEC and U.S. SPR recommendations can be used by health care providers to support persons in contraceptive decision-making.
• U.S. MEC and U.S. SPR recommendations can be used by health care providers to remove unnecessary medical barriers to accessing and using contraception.

Abbreviations: U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use; U.S. SPR = U.S. Selected Practice Recommendations for Contraceptive Use.

Using U.S. MEC categories in practice

Health care providers can use the eligibility categories when assessing the safety of contraceptive method use for persons with certain characteristics or medical conditions. Category 1 comprises conditions for which no restrictions exist for use of the contraceptive method. However, category 1 does not imply that the method is the most appropriate choice for a person, who might be prioritizing other factors when considering contraception. Classification of a method or condition as category 2 indicates the method generally can be used, with additional discussion about risks and benefits, and careful follow-up might be required. For a method or 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 person with a condition classified as category 3 requires careful clinical judgment and might warrant additional counseling, consultation, or follow-up. Category 4 comprises conditions that represent an unacceptable health risk if the method is used. For example, a person who smokes and is aged <35 years generally can use combined oral contraceptives (COCs) (category 2). However, for a person 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 (category 3). A person 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 implementation of this clinical guidance might vary within different health systems, clinics, or settings. For example, in certain settings, category 3 might mean that a special consultation is warranted. Health departments and medical societies or organizations can provide information on implementation through additional guidance or clinical protocols.

The recommendations address medical eligibility criteria for the initiation and continued use of all contraceptive methods evaluated. The issue of medical eligibility criteria for continuation of a contraceptive method 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. When different initiation and continuation recommendations are not given, 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, B, C, D, E, and J). In these tables, the first column indicates the condition. Multiple conditions are divided into subconditions to differentiate between varying condition types or severity. The next columns provide classifications of the condition for initiation, continuation, or both into categories 1, 2, 3, or 4 for specific contraceptive methods. For certain conditions, the last column further clarifies the numeric category in cases where the numeric classification does not adequately capture the recommendation. These clarifications are considered a necessary element of the recommendation. The last column also summarizes the evidence for the recommendation if evidence exists. The recommendations for which no evidence is cited might be based on information from sources other than systematic reviews and might take into account individual perspectives from either the World Health Organization (WHO) or U.S. expert meetings in which these recommendations were developed. For certain recommendations, comments in the third column can provide additional rationale or other information about the recommendation. Information provided along with the numeric recommendation (i.e., clarifications, evidence, and comments) is additional detail that providers can use as part of their counseling and referrals, as needed.

U.S. MEC recommendations comprise one aspect of contraceptive counseling. All persons should be counseled about the full range of contraceptive options for which they are medically eligible. Voluntary informed choice of contraceptive methods is an essential guiding principle of these recommendations, and person-centered contraceptive counseling can help to ensure a person's contraceptive needs are met successfully.

Recommendations for use of contraceptive methods

The classifications for whether persons with certain characteristics or medical conditions can safely use specific contraceptive methods are provided for intrauterine devices (IUDs), including the copper IUD (Cu-IUD) and levonorgestrel IUD (LNG-IUD) (Appendix B); progestin-only contraceptives (POCs), including progestin-only implants, depot medroxyprogesterone acetate injections, and progestin-only pills (POPs) (Appendix C); combined hormonal contraceptives (CHCs), including COCs, combined transdermal patches, and combined vaginal rings (Appendix D); barrier contraceptive methods, including external (male) and internal (female) condoms, spermicides and vaginal pH modulator, and diaphragm with spermicide or cervical cap with spermicide (Appendix E); fertility awareness–based methods (Appendix F); lactational amenorrhea method (Appendix G); coitus interruptus (Appendix H); permanent contraception, including tubal surgery and vasectomy (Appendix I); and emergency contraception, including emergency use of the Cu-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).

Prevention of sexually transmitted infections

All patients, regardless of contraceptive choice, should be counseled about the use of condoms and the risk for sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection.^[27] Most contraceptive methods, such as hormonal methods, IUDs, and permanent contraception do not protect against STIs, including HIV infection. Consistent and correct use of external (male) latex condoms reduces the risk for STIs, including HIV infection.^[27] Although evidence is limited, use of internal (female) condoms can provide protection from acquisition and transmission of STIs.^[27] Patients also should be counseled that pre-exposure prophylaxis (PrEP), when taken as prescribed, is highly effective for preventing HIV infection.^[28] Additional information about prevention and treatment of STIs is available from CDC's Sexually Transmitted Infections Treatment Guidelines (https://www.cdc.gov/std/treatment-guidelines/default.htm),^[27] and information on PrEP for prevention of HIV infection is available from the U.S. Public Health Service's Preexposure Prophylaxis for the Prevention of HIV Infection in the United States — 2021 Update: A Clinical Practice Guideline (https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf).^[28]

Pregnancy and increased health risk

Discussion of health risks associated with pregnancy is an important aspect of contraceptive counseling. For persons with certain medical conditions, pregnancy poses increased health risks. 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 3). This is not a comprehensive list of all conditions that could lead to adverse events during pregnancy. Certain medical conditions included in U.S. MEC recommendations also are treated with teratogenic drugs, which could have adverse effects when used during pregnancy. When applying U.S. MEC classifications during person-centered counseling, health care providers should discuss the risks of a particular contraceptive method as well as the health risks associated with pregnancy. Even though permanent contraception and long-acting, reversible contraceptive methods are highly effective, persons should be provided with the full range of contraceptive options and supported in their autonomous decisions about pregnancy planning and contraceptive choices. Discussions about pregnancy should include reviewing access to comprehensive health care services and subspecialists for a high-risk pregnancy.^[29]

Box 3. Conditions included in U.S. Medical Eligibility Criteria for Contraceptive Use associated with increased risk for adverse health events as a result of pregnancy*

• Breast cancer
• Chronic kidney disease: with current nephrotic syndrome, receiving hemodialysis, or receiving peritoneal dialysis
• Complicated valvular heart disease
• Cystic fibrosis
• Decompensated cirrhosis
• Deep venous thrombosis/pulmonary embolism
• Diabetes: insulin dependent; with nephropathy, retinopathy, or neuropathy or other vascular disease; or of >20 years’ duration
• Endometrial cancer
• Epilepsy
• Gestational trophoblastic disease
• Hepatocellular adenoma and malignant liver tumors (hepatocellular carcinoma)
• History of bariatric surgery within the past 2 years
• HIV infection: not clinically well or not receiving antiretroviral therapy
• Hypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg)
• Ischemic heart disease
• Ovarian cancer
• Peripartum cardiomyopathy
• Schistosomiasis with fibrosis of the liver
• Sickle cell disease
• Solid organ transplantation within the past 2 years
• Stroke
• Systemic lupus erythematosus
• Thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; or antiphospholipid syndrome)
• Tuberculosis

* Even though permanent contraception and long-acting, reversible contraceptive methods are highly effective, persons should be provided with the full range of contraceptive options and supported in their autonomous decisions about pregnancy planning and contraceptive choices. Discussions about pregnancy should include reviewing access to comprehensive health care services and subspecialists for a high-risk pregnancy.

References