Appendix C: Classifications for Progestin-Only Contraceptives

At a glance

This page includes recommendations for health care providers for the use of progestin-only contraceptives 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 progestin-only contraceptives (POCs) include those for progestin-only implants (68 mg etonogestrel), progestin-only injectables (depot medroxyprogesterone acetate [DMPA], 150 mg intramuscular [DMPA-IM] or 104 mg subcutaneous [DMPA-SC]), and progestin-only pills (POPs) (containing norethindrone, norgestrel, or drospirenone [DRSP]) (Box C1) (Table C1). DMPA-SC can be administered by a health care provider or through self-administration. Recommendations in this report and U.S. Selected Practice Recommendations for Contraceptive Use, 2024[1] for provider-administered DMPA (IM or SC) also apply to self-administered DMPA-SC. POCs do not protect against sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection, and patients using POCs should be counseled that consistent and correct use of external (male) latex condoms reduces the risk for STIs, including HIV infection.[2] Use of internal (female) condoms can provide protection from transmission of STIs, although data are limited.[2] Patients also should be counseled that pre-exposure prophylaxis, when taken as prescribed, is highly effective for preventing HIV infection.[3]

Box C1. Categories for classifying progestin-only contraceptives

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 C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills

TABLE C1 CONDITIONS

Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Personal Characteristics and Reproductive History
Pregnancy NA NA NA Clarification: Use of POCs is not required. No known harm to the patient, the course of pregnancy, or the fetus occurs if POCs are inadvertently used during pregnancy. However, the relation between DMPA use during pregnancy and its effects on the fetus remains unclear.
Age Evidence: Most studies have found that women lose BMD during DMPA use but recover BMD after discontinuation.[4] Limited evidence demonstrates a weak association with fracture. However, one large study suggests that women who choose DMPA might be at higher risk for fracture before initiation.[5] It is unclear whether adult women with long durations of DMPA use can regain BMD to baseline levels before entering menopause and whether adolescents can reach peak bone mass after discontinuation of DMPA. The relation between these changes in BMD during the reproductive years and future fracture risk is unknown. Studies generally find no effect of POCs other than DMPA on BMD.[4–52]
a. Menarche to <18 years 1 2 1
b. 18–45 years 1 1 1
c. >45 years 1 2 1
Parity
a. Nulliparous 1 1 1 —
b. Parous 1 1 1 —
Breastfeeding
a. <21 days postpartum 2 2 2 Clarification (breastfeeding): Breastfeeding provides important health benefits for breastfeeding parent and infant. The U.S. Dietary Guidelines for Americans and American Academy of Pediatrics recommend that infants be exclusively breastfed for about the first 6 months with continued breastfeeding while introducing appropriate complementary foods for 1 year or longer[53] or up to age 2 years or longer.[54]
Evidence (breastfeeding): Two small, RCTs found no adverse impact on breastfeeding with initiation of etonogestrel implants within 48 hours postpartum. Other studies found that initiation of POPs, injectables, and implants at ≤6 weeks postpartum compared with nonhormonal use had no detrimental effect on breastfeeding outcomes or infant health, growth, and development in the first year postpartum. In general, these studies are of poor quality, lack standard definitions of breastfeeding or outcome measures, and have not included premature or ill infants.[55],[56]
Evidence: Limited evidence suggests that DMPA use might further elevate risk for VTE among postpartum women compared with non-use (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Comment: Risk factors for breastfeeding difficulties include previous breastfeeding difficulties, certain medical conditions, certain perinatal complications, and preterm birth. For all breastfeeding persons, with or without breastfeeding difficulties, discussions about contraception should include information about risks, benefits, and alternatives.
b. 21 to <30 days postpartum Clarification (breastfeeding): Breastfeeding provides important health benefits for breastfeeding parent and infant. The U.S. Dietary Guidelines for Americans and American Academy of Pediatrics recommend that infants be exclusively breastfed for about the first 6 months with continued breastfeeding while introducing appropriate complementary foods for 1 year or longer[53] or up to age 2 years or longer.[54]
Evidence (breastfeeding): Two small, RCTs found no adverse impact on breastfeeding with initiation of etonogestrel implants within 48 hours postpartum. Other studies found that initiation of POPs, injectables, and implants at ≤6 weeks postpartum compared with nonhormonal use had no detrimental effect on breastfeeding outcomes or infant health, growth, and development in the first year postpartum. In general, these studies are of poor quality, lack standard definitions of breastfeeding or outcome measures, and have not included premature or ill infants.[55],[56]
Evidence: Limited evidence suggests that DMPA use might further elevate risk for VTE among postpartum women compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Comment: Risk factors for breastfeeding difficulties include previous breastfeeding difficulties, certain medical conditions, certain perinatal complications, and preterm birth. For all breastfeeding persons, with or without difficulties, discussions about contraception should include information about risks, benefits, and alternatives.
  i. With other risk factors for VTE (e.g., age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ≥30 kg/m2, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking) 2 2 2
  ii. Without other risk factors for VTE 2 2 2
c. 30–42 days postpartum Clarification (breastfeeding): Breastfeeding provides important health benefits for breastfeeding parent and infant. The U.S. Dietary Guidelines for Americans and American Academy of Pediatrics recommend that infants be exclusively breastfed for about the first 6 months with continued breastfeeding while introducing appropriate complementary foods for 1 year or longer[53] or up to age 2 years or longer.[54]
Evidence (breastfeeding): Two small, RCTs found no adverse impact on breastfeeding with initiation of etonogestrel implants within 48 hours postpartum. Other studies found that initiation of POPs, injectables, and implants at ≤6 weeks postpartum compared with nonhormonal use had no detrimental effect on breastfeeding outcomes or infant health, growth, and development in the first year postpartum. In general, these studies are of poor quality, lack standard definitions of breastfeeding or outcome measures, and have not included premature or ill infants.[55],[56]
Evidence: Limited evidence suggests that DMPA use might further elevate risk for VTE among postpartum women compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Comment: Risk factors for breastfeeding difficulties include previous breastfeeding difficulties, certain medical conditions, certain perinatal complications, and preterm birth. For all breastfeeding persons, with or without breastfeeding difficulties, discussions about contraception should include information about risks, benefits, and alternatives.
  i. With other risk factors for VTE (e.g., age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ≥30 kg/m2, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking) 1 2 1
  ii. Without other risk factors for VTE 1 1 1
d. >42 days postpartum 1 1 1 Clarification (breastfeeding): Breastfeeding provides important health benefits for breastfeeding parent and infant. The U.S. Dietary Guidelines for Americans and American Academy of Pediatrics recommend that infants be exclusively breastfed for about the first 6 months with continued breastfeeding while introducing appropriate complementary foods for 1 year or longer[53] or up to age 2 years or longer.[54]
Evidence: Overall, studies found that initiation of POPs, injectables, and implants at >6 weeks postpartum compared with nonhormonal use had no detrimental effect on breastfeeding outcomes or infant health, growth, and development in the first year postpartum. In general, these studies are of poor quality, lack standard definitions of breastfeeding or outcome measures, and have not included premature or ill infants.[56]
Comment: Risk factors for breastfeeding difficulties include previous breastfeeding difficulties, certain medical conditions, certain perinatal complications, and preterm birth. For all breastfeeding persons, with or without breastfeeding difficulties, discussions about contraception should include information about risks, benefits, and alternatives.
Postpartum
(nonbreastfeeding)
a. <21 days postpartum 1 2 1 Evidence: Limited evidence suggests that DMPA use might further elevate risk for VTE among postpartum women compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
b. 21–42 days postpartum
  i. With other risk factors for VTE (e.g., age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ≥30 kg/m2, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking) 1 2 1 Evidence: Limited evidence suggests that DMPA use might further elevate risk for VTE among postpartum women compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
  ii. Without other risk factors for VTE 1 1 1 —
c. >42 days postpartum 1 1 1 —
Postabortion
(spontaneous or
induced)
a. First trimester abortion Clarification: POCs may be started immediately after abortion completion or at time of medication abortion initiation.
Clarification (DMPA): After a first trimester medication abortion that did not include mifepristone, there is no restriction for the use of DMPA (category 1). After a first trimester medication abortion that included mifepristone, there is no restriction for use of DMPA after abortion completion (category 1) and benefits generally outweigh risks with DMPA use immediately at time of medication abortion initiation (category 2). Concurrent administration of DMPA with mifepristone might slightly decrease medication abortion effectiveness and increase risk for ongoing pregnancy. Risk for ongoing pregnancy with concurrent administration of DMPA with mifepristone should be considered along with personal preference and access to follow-up abortion and contraceptive care.
Evidence: Limited evidence suggests decreased first trimester medication abortion effectiveness with concurrent administration of DMPA with mifepristone (immediate) versus DMPA administration after abortion completion (delayed). In one study, the risk for ongoing pregnancy, while overall low, was higher with immediate (3.6%) versus delayed (0.9%) DMPA administration (difference 2.7%; 90% CI = 0.4–5.6%).[57] This difference was not seen with other progestin-only methods.[58] Evidence suggests that there is no increased risk for adverse events when POCs are initiated after first trimester procedural or medication abortion (immediately or delayed)[58] (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
  i. Procedural (surgical) 1 1 1
  ii. Medication 1 1/2 1
  iii. Spontaneous abortion with no intervention 1 1 1
b. Second trimester abortion Clarification: POCs may be started immediately after abortion completion or at time of medication abortion initiation.
  i. Procedural (surgical) 1 1 1
  ii. Medication 1 1 1
  iii. Spontaneous abortion with no intervention 1 1 1
c. Immediate postseptic abortion 1 1 1 Clarification: POCs may be started immediately after abortion completion or at time of medication abortion initiation.
Past ectopic pregnancy 1 1 2 Comment: POP users have a higher absolute rate of ectopic pregnancy than do users of other POCs but still lower than those using no method.
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 2 1 Evidence: Among adult women, generally no association has been found between baseline weight and weight gain among DMPA users compared with nonusers. Evidence is mixed for adolescent DMPA users, with certain studies observing greater weight gain among users with obesity compared with those without obesity but other studies demonstrating no association; methodologic differences across studies might account for the differences in findings. Data on other POC methods and other adverse outcomes including weight gain are limited.[59–76]
History of bariatric
surgery
This condition is associated
with increased risk for
adverse health events as a
result of pregnancy (Box 3).
a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy) 1 1 1 Evidence: Limited evidence demonstrated no substantial decrease in effectiveness of oral contraceptives among women who underwent laparoscopic placement of an adjustable gastric band.[77]
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 3 Evidence: Limited evidence demonstrated no substantial decrease in effectiveness of oral contraceptives among women who underwent a biliopancreatic diversion; however, evidence from pharmacokinetic studies suggested conflicting results regarding oral contraceptive effectiveness among women who underwent a jejunoileal bypass.[77]
Comment: Bariatric surgical procedures involving a malabsorptive component have the potential to decrease oral contraceptive effectiveness, perhaps further decreased by postoperative complications such as long-term diarrhea, vomiting, or both.
Surgery
a. Minor surgery without immobilization 1 1 1 —
b. Major surgery
  i. Without prolonged immobilization 1 1 1 —
  ii. With prolonged immobilization 1 2 1 Evidence: No direct evidence was identified on risk for thrombosis with POC use among those undergoing major surgery. Use of DMPA, which has been associated with a higher risk for venous thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among persons with prolonged immobilization after major surgery.

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Cardiovascular Disease
Multiple risk factors for atherosclerotic cardiovascular disease (e.g., older age, smoking, diabetes, hypertension, low HDL, high LDL, or high triglyceride levels) 2 3 2 Clarification: When multiple major risk factors exist, risk for cardiovascular disease might increase substantially. Certain POCs might increase the risk for thrombosis, although this increase is substantially less than with COCs. The effects of DMPA might persist for some time after discontinuation.
Clarification: The recommendations apply to known pre-existing medical conditions or characteristics. Few if any screening tests are needed before initiation of contraception. See U.S. SPR (https://www.cdc.gov/contraception/hcp/usspr).[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).
a. Adequately controlled hypertension 1 2 1 Clarification: For all categories of hypertension, classifications are based on the assumption that no other risk factors exist for cardiovascular disease. 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 person as hypertensive.
Clarification: Persons adequately treated for hypertension are at lower risk for acute myocardial infarction and stroke than are untreated persons. Although no data exist, POC users with adequately controlled and monitored hypertension should be at lower risk for acute myocardial infarction and stroke than are untreated hypertensive POC users.
b. Elevated blood pressure
levels (properly taken
measurements)		 Clarification: For all categories of hypertension, classifications are based on the assumption that no other risk factors exist for cardiovascular disease. 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 person as hypertensive.
Evidence: Limited evidence suggests that among women with hypertension, those who used POPs or progestin-only injectables had a small increased risk for cardiovascular events compared with women who did not use these methods.[78]
  i. Systolic 140–159 mm Hg or diastolic 90–99 mm Hg 1 2 1
  ii. Systolic ≥160 mm Hg or diastolic ≥100 mm Hg 2 3 2
c. Vascular disease 2 3 2 Clarification: For all categories of hypertension, classifications are based on the assumption that no other risk factors exist for cardiovascular disease. 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 person as hypertensive.
Comment: Concern exists about hypoestrogenic effects and reduced HDL levels, particularly among users of DMPA. However, little concern exists about these effects with regard to POPs. The effects of DMPA might persist for some time after discontinuation.
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).
a. Current or history of DVT/PE, receiving anticoagulant therapy (therapeutic dose) (e.g., acute DVT/PE or long-term therapeutic dose) 2 2 2 Clarification: Persons using anticoagulant therapy are at risk for gynecologic complications of therapy, such as heavy or prolonged bleeding and hemorrhagic ovarian cysts. POCs can be of benefit in preventing or treating these complications; benefits might vary by POC dose and formulation. When a contraceptive method is used as a therapy, rather than solely to prevent pregnancy, the risk/benefit ratio might differ and should be considered on a case-by-case basis.
Evidence: Limited evidence was identified on use of POCs among women with acute DVT/PE receiving anticoagulant therapy (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). In one study among women with a history of acute VTE currently receiving therapeutic anticoagulant therapy (i.e., rivaroxaban or enoxaparin/vitamin K antagonist [warfarin or acenocoumarol]), the incidence of recurrent VTE was similar among estrogen users (CHC or estrogen-only pills), POC users, and women not on hormonal therapy.[79]
Limited evidence suggests that intramuscular injections of DMPA in women receiving chronic anticoagulation therapy do not pose a significant risk for hematoma at the injection site or increase the risk for heavy or irregular vaginal bleeding.[80]
b. History of DVT/PE,
receiving anticoagulant
therapy (prophylactic dose)		 Clarification: Persons using anticoagulant therapy are at risk for gynecologic complications of therapy, such as heavy or prolonged bleeding and hemorrhagic ovarian cysts. POCs can be of benefit in preventing or treating these complications; benefits might vary by POC dose and formulation. When a contraceptive method is used as a therapy, rather than solely to prevent pregnancy, the risk/benefit ratio might differ and should be considered on a case-by-case basis.
Evidence: Limited evidence was identified on use of POCs among women with acute DVT/PE receiving anticoagulant therapy (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Use of DMPA, which has been associated with a higher risk for venous thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among persons with a history of DVT/PE and at higher risk for recurrent DVT/PE.
Limited evidence suggests that intramuscular injections of DMPA in women receiving chronic anticoagulation therapy do not pose a significant risk for hematoma at the injection site or increase the risk for heavy or irregular vaginal bleeding.[80]
  i. Higher risk for recurrent DVT/PE (one or more risk factors) 2 3 2
• 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
  ii. Lower risk for recurrent DVT/PE (no risk factors) 2 2 2
c. History of DVT/PE, not
receiving anticoagulant
therapy
  i. Higher risk for recurrent DVT/PE (one or more risk factors) 2 3 2 Evidence: Use of DMPA, which has been associated with a higher risk for venous thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among persons with a history of DVT/PE and at higher risk for recurrent DVT/PE.
• 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
  ii. Lower risk for recurrent DVT/PE (no risk factors) 2 2 2 —
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).		 2 3 2 Clarification: Routine screening in the general population before contraceptive initiation is not recommended.
Clarification: If a person has current or history of DVT/PE, see recommendations for DVT/PE.
Clarification: Classification of antiphospholipid syndrome includes presence of a clinical feature (e.g., thrombosis or obstetric morbidity) and persistently abnormal antiphospholipid antibody test on two or more occasions at least 12 weeks apart.[81]
Evidence: Among women with factor V Leiden mutation, one study found that women using POCs had an increased risk for venous thrombosis compared with non-users without the mutation, with the highest relative risk for DMPA users.[82] Women with prothrombin gene mutation using POCs did not have an increased risk for venous thrombosis compared with nonusers without the mutation.[82] No evidence was identified on POC use among persons with protein S deficiency, protein C deficiency, antithrombin deficiency, or antiphospholipid syndrome (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Superficial venous
disorders
a. Varicose veins 1 1 1 —
b. Superficial venous thrombosis (acute or history) 1 2 1 Evidence: No direct evidence was identified on risk for thrombosis with POC use among persons with superficial venous thrombosis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Persons with superficial venous thrombosis are at higher risk for venous thrombosis than the general population.[83] Use of DMPA, which has been associated with a higher risk for venous thrombosis compared with non-use (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among persons with acute or history of superficial venous thrombosis.
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).		 Initiation Continuation Initiation Continuation Comment: Concern exists about hypoestrogenic effects and reduced HDL levels, particularly among users of DMPA. However, little concern exists about these effects with regard to POPs. The effects of DMPA might persist for some time after discontinuation.
2 3 3 2 3
Stroke (history of cerebrovascular accident)
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 Initiation Continuation Initiation Continuation Comment: Concern exists about hypoestrogenic effects and reduced HDL levels, particularly among users of DMPA. However, little concern exists about these effects with regard to POPs. The effects of DMPA might persist for some time after discontinuation.
2 3 3 2 3
Valvular heart disease
Complicated valvular heart
disease is associated with
increased risk for adverse
health events as a result of
pregnancy (Box 3).
a. Uncomplicated 1 1 1 —
b. Complicated (pulmonary hypertension, risk for atrial fibrillation, or history of subacute bacterial endocarditis) 1 2 1 Evidence: No direct evidence was identified on risk for thrombosis with POC use among persons with valvular heart disease (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Use of DMPA, which has been associated with a higher risk for venous thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among persons with complicated valvular heart disease.
Peripartum
cardiomyopathy
This condition is associated
with increased risk for
adverse health events as a
result of pregnancy (Box 3).		 Evidence: No direct evidence was identified on the safety of POC use among persons with peripartum cardiomyopathy (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Limited indirect evidence from noncomparative studies of women with cardiac disease demonstrated few cases of hypertension, thromboembolism, and heart failure in women with cardiac disease using POPs and DMPA.[84] Use of DMPA, which has been associated with a higher risk for venous thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among persons with peripartum cardiomyopathy.
Comment: Progestin-only implants might induce cardiac arrhythmias in healthy persons; persons with peripartum cardiomyopathy have a high incidence of cardiac arrhythmias.
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)[85]
  i. <6 months 1 2 1
  ii. ≥6 months 1 2 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)[85] 2 3 2

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Renal Disease
Chronic kidney disease
This condition is associated
with increased risk for
adverse health events as a
result of pregnancy (Box 3).
a. Current nephrotic syndrome 2 3 2
DRSP POP with known hyperkalemia: 4		 Clarification (DRSP POP): Persons with known hyperkalemia should not use DRSP POPs because of the risk for worsening hyperkalemia (category 4). For persons with CKD without known hyperkalemia (category 2), consider checking serum potassium level during first cycle of DRSP POPs.
Evidence: No direct evidence was identified on POC use among persons with CKD with current nephrotic syndrome (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Persons with severe CKD or nephrotic syndrome are at higher risk for thrombosis than the general population.[86–90] Use of DMPA, which has been associated with increased risk for thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among those with CKD with current nephrotic syndrome. Persons with severe CKD have a higher prevalence of fracture than the general population.[91–93] Use of DMPA, which has been associated with small changes in bone mineral density[4] might further elevate risk for fracture among persons with CKD with current nephrotic syndrome.
Comment: A person might have CKD without current nephrotic syndrome, but might have other conditions often associated with CKD (e.g., diabetes, hypertension, SLE). See recommendations for other conditions if they apply.
b. Hemodialysis 2 3 2
DRSP POP with known hyperkalemia: 4		 Clarification (DRSP POP): Persons with known hyperkalemia should not use DRSP POPs because of the risk for worsening hyperkalemia (category 4). For persons with CKD without known hyperkalemia (category 2), consider checking serum potassium level during first cycle of DRSP POPs.
Evidence: No direct evidence was identified on POC use among persons with CKD on hemodialysis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Persons with CKD on dialysis are at higher risk for thrombosis than the general population (94-96). Use of DMPA, which has been associated with increased risk for thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among those with CKD on dialysis. Persons with CKD on dialysis have a higher prevalence of fracture than the general population.[97–99] Use of DMPA, which has been associated with small changes in bone mineral density,[4] might further elevate risk for fracture among persons with CKD on dialysis.
Comment: A person might have CKD without hemodialysis, but might have other conditions often associated with CKD (e.g., diabetes, hypertension, SLE). See recommendations for other conditions if they apply.
c. Peritoneal dialysis 2 3 2
DRSP POP with known hyperkalemia: 4		 Clarification (DRSP POP): Persons with known hyperkalemia should not use DRSP POPs because of the risk for worsening hyperkalemia (category 4). For persons with CKD without known hyperkalemia (category 2), consider checking serum potassium level during first cycle of DRSP POPs.
Evidence: No direct evidence was identified on POC use among persons with CKD on peritoneal dialysis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Persons with CKD on dialysis are at higher risk for thrombosis than the general population.[94–96] Use of DMPA, which has been associated with increased risk for thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among those with CKD on dialysis. Persons with CKD on dialysis have a higher prevalence of fracture than the general population.[97–99] Use of DMPA, which has been associated with small changes in bone mineral density,[4] might further elevate risk for fracture among persons with CKD on dialysis.
Comment: A person might have CKD without peritoneal dialysis but might have other conditions often associated with CKD (e.g., diabetes, hypertension, and SLE). See recommendations for other conditions if they apply.

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Rheumatic Diseases
Systemic lupus
erythematosus
This condition is
associated with increased
risk for adverse health events
as a result of
pregnancy (Box 3).		 Initiation Continuation —
a. Positive (or unknown) antiphospholipid antibodies 2 3 3 2 Clarification: Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Categories assigned to such conditions in U.S. MEC should be the same for persons with SLE who have these conditions. For all subconditions 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.[100–118]
Evidence: No direct evidence was identified on POC use among persons with SLE with antiphospholipid antibodies[119] (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Persons with SLE with antiphospholipid antibodies are at higher risk for thrombosis than the general population.[120],[121] Use of DMPA, which has been associated with a higher risk for venous thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among persons with SLE with antiphospholipid antibodies.
b. Severe thrombocytopenia 2 3 2 2 Clarification: Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Categories assigned to such conditions in U.S. MEC should be the same for persons with SLE who have these conditions. For all subconditions 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.[100–118]
Comment: Severe thrombocytopenia increases the risk for bleeding. POCs might be useful in treating heavy or prolonged bleeding in persons with severe thrombocytopenia. However, given the increased or erratic bleeding that might be seen on initiation of DMPA and its irreversibility for 11–13 weeks after administration, initiation of this method in persons with severe thrombocytopenia should be done with caution.
c. Immunosuppressive therapy 2 2 2 2 Clarification: Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Categories assigned to such conditions in U.S. MEC should be the same for persons with SLE who have these conditions. For all subconditions 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.[100–118]
d. None of the above 2 2 2 2 Clarification: Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Categories assigned to such conditions in U.S. MEC should be the same for persons with SLE who have these conditions. For all subconditions 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.[100–118]
Rheumatoid arthritis
a. Not receiving immunosuppressive therapy 1 2 1 Evidence: Limited evidence demonstrates no consistent pattern of improvement or worsening of rheumatoid arthritis with use of oral contraceptives, progesterone, or estrogen.[122]
b. Receiving immunosuppressive therapy 1 2/3 1 Clarification (DMPA): DMPA use among persons receiving long-term corticosteroid therapy with a history of, or with risk factors for, nontraumatic fractures is classified as category 3. Otherwise, DMPA use for persons with rheumatoid arthritis is classified as category 2.
Evidence: Limited evidence demonstrates no consistent pattern of improvement or worsening of rheumatoid arthritis with use of oral contraceptives, progesterone, or estrogen.[122]

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Neurologic Conditions
Headaches
a. Nonmigraine (mild or severe) 1 1 1 —
b. Migraine Evidence: No studies directly examined the risk for stroke among women with migraine using POCs.[123] Limited evidence demonstrated that women using POPs, DMPA, or implants do not have an increased risk for ischemic stroke compared with nonusers.[124]
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).[125]
  i. Without aura (includes menstrual migraine) 1 1 1
  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 Clarification: If a person is taking anticonvulsants, see recommendations for Drug Interactions. Certain anticonvulsants lower POC effectiveness.
Multiple sclerosis Evidence: Limited evidence demonstrates that use of COCs or oral contraceptives (type not specified) among women with multiple sclerosis does not worsen the clinical course of disease.[126]
Comment: Persons with multiple sclerosis might have compromised bone health from disease-related disability, immobility, and use of corticosteroids. Use of DMPA, which has been associated with small changes in BMD, might be of concern.
a. Without prolonged immobility 1 2 1
b. With prolonged immobility 1 2 1

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Depressive disorders
Depressive disorders 1 1 1 Clarification: If a person is taking psychotropic medications or St. John’s wort, see recommendations for Drug Interactions.
Evidence: The frequency of psychiatric hospitalizations for women with bipolar disorder or depression did not significantly differ among women using DMPA, LNG-IUD, Cu-IUD, or sterilization.[127]

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Reproductive Tract Infections and Disorders
Vaginal bleeding patterns
a. Irregular pattern without heavy bleeding 2 2 2 Comment: Irregular menstrual bleeding patterns are common among healthy persons. POC use frequently induces an irregular bleeding pattern. Implant use might induce irregular bleeding patterns, especially during the first 3–6 months, although these patterns might persist longer.
b. Heavy or prolonged bleeding (includes regular and irregular patterns) 2 2 2 Clarification: Unusually heavy bleeding should raise the suspicion of a serious underlying condition.
Unexplained vaginal bleeding (suspicious for serious condition) before evaluation 3 3 2 Clarification: If pregnancy or an underlying pathological condition (e.g., pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation.
Comment: POCs might cause irregular bleeding patterns, which might mask symptoms of underlying pathologic conditions. The effects of DMPA might persist for some time after discontinuation.
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).		 Clarification: For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that persons are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance.
a. Suspected gestational
trophoblastic disease
(immediate
postevacuation)
  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)
  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 2 2 1 Evidence: Among women with persistent human papillomavirus infection, long-term DMPA use (≥5 years) might increase the risk for carcinoma in situ and invasive carcinoma.[128]
Cervical cancer (awaiting treatment) 2 2 1 Comment: Theoretical concern exists that POC use might affect prognosis of the existing disease. While awaiting treatment, POCs may be used. In general, treatment of this condition can render a person infertile.
Breast disease
Breast cancer is associated
with increased risk for
adverse health events as a
result of pregnancy
(Box 3).
a. Undiagnosed mass 2 2 2 Clarification: Evaluation of mass should be pursued as early as possible.
b. Benign breast disease 1 1 1 —
c. Family history of cancer 1 1 1 —
d. Breast cancer
  i. Current 4 4 4 Comment: Breast cancer is a hormonally sensitive tumor, and the prognosis for persons with current or recent breast cancer might worsen with POC use.
  ii. Past and no evidence of current disease for 5 years 3 3 3
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 Comment: While awaiting treatment, POCs may be used. In general, treatment of this condition renders a person infertile.
Ovarian cancer
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 1 1 1 Comment: While awaiting treatment, POCs may be used. In general, treatment of this condition renders a person infertile.
Uterine fibroids 1 1 1 Comment: POCs do not appear to cause growth of uterine fibroids.
Pelvic inflammatory disease Comment: Whether POCs, like COCs, reduce the risk for PID among persons with STIs is unknown; however, they do not protect against HIV infection or lower genital tract STIs.
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 —

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
HIV
High risk for HIV infection 1 1 1 Evidence: High-quality evidence from one RCT observed no statistically significant differences in HIV acquisition between DMPA-IM versus Cu-IUD, DMPA-IM versus LNG implant, and Cu-IUD versus LNG implant. Of the low-to-moderate-quality evidence from 14 observational studies, certain studies suggested a possible increased risk for HIV infection with progestin-only injectable use, which was most likely due to unmeasured confounding. Low-quality evidence from three observational studies did not suggest an increased HIV infection risk for implant users. No studies of sufficient quality were identified for POPs.[129–131]
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 1 1 Clarification: Drug interactions might exist between hormonal contraceptives and ARV drugs (see recommendations for Drug Interactions).
Evidence: Overall, evidence does not support an association between POC use and progression of HIV infection. Limited direct evidence on an association between POC use and transmission of HIV to noninfected partners, as well as studies measuring genital viral shedding as a proxy for infectivity, have had mixed results. Studies measuring whether hormonal contraceptive methods affect plasma HIV viral load generally have found no effect.[132–134]

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
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).
a. Uncomplicated 1 1 1 Evidence: Among women with uncomplicated schistosomiasis, limited evidence demonstrated that DMPA use had no adverse effects on liver function.[135]
b. Fibrosis of the liver (if severe, see recommendations for Cirrhosis) 1 1 1 —
Tuberculosis
This condition is
associated with increased
risk for adverse health
events as a result of
pregnancy (Box 3).		 Clarification: If a person is taking rifampin, see recommendations for Drug Interactions. Rifampin is likely to decrease the effectiveness of certain POCs.
a. Nonpelvic 1 1 1
b. Pelvic 1 1 1
Malaria 1 1 1 —

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
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).
a. History of gestational disease 1 1 1 Evidence: POCs had no adverse effects on serum lipid levels in women with a history of gestational diabetes in two small studies.[136],[137] Limited evidence is inconsistent about the development of noninsulin-dependent diabetes among users of POCs with a history of gestational diabetes.[138–141]
b. Nonvascular disease Evidence: Among women with insulin-dependent or noninsulin-dependent diabetes, limited evidence on use of POCs (POPs, DMPA, and LNG implant) 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.[142–145]
  i. Non-insulin dependent 2 2 2
  ii. Insulin dependent 2 2 2
c. Nephropathy, retinopathy or neuropathy 2 3 2 Comment: Concern exists about hypoestrogenic effects and reduced HDL levels, particularly among users of DMPA. The effects of DMPA might persist for some time after discontinuation. Certain POCs might increase the risk for thrombosis, although this increase is substantially less than with COCs.
d. Other vascular disease or diabetes of >20 years’ duration 2 3 2 Comment: Concern exists about hypoestrogenic effects and reduced HDL levels, particularly among users of DMPA. The effects of DMPA might persist for some time after discontinuation. Certain POCs might increase the risk for thrombosis, although this increase is substantially less than with COCs.
Thyroid disorders
a. Simple goiter 1 1 1 —
b. Hyperthyroid 1 1 1 —
c. Hypothyroid 1 1 1 —

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Gastrointestinal Condition
Inflammatory bowel disease (ulcerative colitis or Crohn’s disease) 1 2 2 Evidence: Risk for disease relapse among women with IBD using oral contraceptives (most studies did not specify formulation) did not increase significantly from that for nonusers.[146]
Comment: Absorption of POPs among persons with IBD might be reduced if the person has substantial malabsorption caused by severe disease or small bowel surgery.
Women with IBD have a higher prevalence of osteoporosis and osteopenia than the general population. Use of DMPA, which has been associated with small changes in BMD, might be of concern.
Gallbladder disease
a. Asymptomatic 2 2 2 —
b. Symptomatic
  i. Current 2 2 2 —
  ii. Treated by cholecystectomy 2 2 2 —
  iii. Medically treated 2 2 2 —
History of cholestasis
a. Pregnancy related 1 1 1
b. Past COC related 2 2 2 Comment: Theoretical concern exists that a history of COC-related cholestasis might predict subsequent cholestasis with POC use. However, this has not been documented.
Viral hepatitis
a. Acute or flare 1 1 1 Evidence: No direct evidence was identified on POC use among persons with viral hepatitis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
b. Chronic 1 1 1 Evidence: No evidence was identified on POC use among persons with viral hepatitis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Cirrhosis
Decompensated cirrhosis is
associated with increased risk
for adverse health events as a
result of pregnancy (Box 3).
a. Compensated (normal liver function) 1 1 1 Evidence: No direct evidence was identified on POC use among persons with cirrhosis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
b. Decompensated (impaired liver function) 2 3 2 Evidence: No direct evidence was identified on POC use among persons with cirrhosis. (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). DMPA use has been associated with a higher risk for venous thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Comment: Hepatic metabolism of exogenous hormones might be impaired in persons with liver dysfunction, which could lead to increased progestin levels in circulation and progestin-related side effects and adverse events (e.g., thrombosis), which might vary by dose and formulation. Any progestin-related hepatotoxicity might be less tolerated in persons with existing liver dysfunction.
Liver tumors
Hepatocellular adenoma
and malignant liver tumors
are associated with increased
risk for adverse health
events as a result
of pregnancy (Box 3).
a. Benign
  i. Focal nodular hyperplasia 2 2 2 Evidence: Limited evidence suggests that progestin use does not influence either progression or regression of focal nodular hyperplasia (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
  ii. Hepatocellular adenoma 2 3 2 Evidence: Limited evidence suggests that hepatocellular adenomas generally regress or remain stable during progestin use (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
b. Malignant (hepatocellular carcinoma) 3 3 3 Evidence: No direct evidence was identified on POC use among persons with hepatocellular carcinoma (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Respiratory Conditions
Cystic fibrosis
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 1 2 1 Clarification: Persons with cystic fibrosis are at increased risk for diabetes, liver disease, gallbladder disease, and VTE (particularly related to use of central venous catheters) and are frequently prescribed antibiotics. Categories assigned to such conditions in U.S. MEC should be the same for persons with cystic fibrosis who have these conditions. For cystic fibrosis, classifications are based on the assumption that no other conditions are present; these classifications must be modified in the presence of such conditions.
Clarification: Certain drugs to treat cystic fibrosis (e.g., lumacaftor) might reduce effectiveness of hormonal contraceptives, including oral, injectable, transdermal, and implantable contraceptives.
Evidence: Limited evidence suggests that use of COCs or oral contraceptives (type not specified) among women with cystic fibrosis is not associated with worsening of disease severity. Very limited evidence suggests that cystic fibrosis does not impair the effectiveness of hormonal contraception.[147]
Comment: Persons with cystic fibrosis have a higher prevalence of osteopenia, osteoporosis, and fragility fractures than the general population. Use of DMPA, which has been associated with small changes in BMD, might be of concern.

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
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 2/3 1 Clarification (DMPA): The category should be assessed according to the severity of the condition and risk for thrombosis.
Evidence: Limited evidence suggests that POC use does not increase risk for thrombosis among persons with sickle cell disease (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Persons with sickle cell disease are at higher risk for stroke and venous thrombosis than the general population.[148–151] Use of DMPA, which has been associated with a higher risk for venous thrombosis compared with nonuse (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516), might further elevate risk for thrombosis among persons with sickle cell disease. POC might be beneficial in reducing clinical symptoms (e.g., pain crises) (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Iron deficiency anemia 1 1 1 Comment: Changes in the menstrual pattern associated with POC use have little effect on hemoglobin levels.

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Solid Organ Transplantation
Solid organ
transplantation
This condition is
associated with increased
risk for adverse health
events as a result of
pregnancy (Box 3).
a. No graft failure 2 2/3 2 Clarification (DMPA): DMPA use among persons receiving long-term immunosuppressive therapy with a history of, or risk factors for, nontraumatic fractures is classified as category 3. Otherwise, DMPA use for persons with solid organ transplantation is classified as category 2.
Evidence: One study observed no differences in transplant-related adverse outcomes (e.g., infection, graft failure, and graft rejection) or occurrence of pregnancy between transplant recipients using the implant and those using no hormonal method (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). No direct evidence was identified on bone health or fracture with use of POCs, including DMPA, among persons with solid organ transplantation. Persons with solid organ transplantation have a higher prevalence of osteoporosis and fracture than the general population, especially in the early posttransplantation period.[152] Use of DMPA, which has been associated with small changes in bone mineral density compared with nonuse[4] might further elevate risk for fracture among persons with solid organ transplantation.
b. Graft failure 2 2/3 2

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Table C1. Classifications for progestin-only contraceptives, including implants, depot medroxyprogesterone acetate, and progestin-only pills
Condition Category Clarification/Evidence/Comment
Implant DMPA POP
Drug Interactions
Antiretrovirals used for
prevention (PrEP) or
treatment of HIV infection		 Comment: These recommendations generally are for ARV agents used alone. However, most persons receiving ARV are using multiple drugs in combination. In general, whether interactions between ARVs and hormonal contraceptives differ when ARVs are given alone or in combination is unknown.
See the following guidelines for the most up-to-date recommendations on drug-drug interactions between hormonal contraception and antiretrovirals: 1) Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States (https://clinicalinfo.hiv.gov/en/guidelines/perinatal/prepregnancy-counseling-childbearing-age-overview?view=full#table-3)[153] and 2) Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV (https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-overview?view=full).[154]
a. Nucleoside reverse
transcriptase inhibitors
(NRTIs)
  i. Abacavir (ABC) 1 1 1 Evidence: NRTIs do not appear to have significant risk for interactions with hormonal contraceptive methods.[155–160]
  ii. Tenofovir (TDF) 1 1 1
  iii. Zidovudine (AZT) 1 1 1
  iv. Lamivudine (3TC) 1 1 1
  v. Didanosine (DDI) 1 1 1
  vi. Emtricitabine (FTC) 1 1 1
  vii. Stavudine (D4T) 1 1 1
b. Nonnucleoside reverse
transcriptase inhibitors
(NNRTIs)
  i. Efavirenz (EFV) 2 1 2 Clarification: Evidence suggests drug interactions between EFV and certain hormonal contraceptives. These interactions might reduce the effectiveness of the hormonal contraceptive.
Evidence: One study found that women using etonogestrel implants with EFV had a higher pregnancy rate than women not using ARVs, although confidence intervals overlapped and absolute pregnancy rates were still lower than for other hormonal methods; another study found that etonogestrel levels were decreased and 5% of women had presumptive ovulation while using etonogestrel implants with EFV.[161],[162] Three studies of women using LNG implants demonstrated increased pregnancy rates for women using EFV-containing ARV therapy compared with no ARV use, although absolute pregnancy rates were still lower than for other hormonal methods in one study;[162–164] another study of LNG implant users found no difference in pregnancy rates with EFV compared with no EFV.[165] No significant effects were found on pregnancy rates, DMPA levels, EFV levels, or HIV disease progression in women using DMPA and EFV compared with DMPA alone.[162],[165–169] No significant effects were found on HIV disease progression in women using LNG implants and EFV compared with no ARVs.[164] No data have assessed effectiveness of contraceptive implants during later years of use when progestin concentrations are lower and risk for failure from drug interactions might be greater.
  ii. Etravirine (ETR) 1 1 1 —
  iii. Nevirapine (NVP) 1 1 1 Evidence: Five studies found no significant increase in pregnancy rates among women using implants and NVP compared with implants alone.[162–165],[170] Four studies found no significant increase in pregnancy rates among women using DMPA or other contraceptive injectables and NVP compared with DMPA or other contraceptive injectables alone.[162],[165],[168],[171] One study found no ovulations or changes in DMPA concentrations.[166] No effect was found on HIV disease progression with use of NVP and DMPA or LNG implants.[164],[166],[168–170],[172] No data have assessed effectiveness of contraceptive implants during later years of use when progestin concentrations are lower and risk for failure from drug interactions might be greater.
  iv. Rilpivirine (RPV) 1 1 1 —
c. Ritonavir-boosted
protease inhibitors
  i. Ritonavir-boosted atazanavir (ATV/r) 2 1 2 Clarification: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA.
Evidence: One pharmacokinetic study demonstrated increased progestin concentrations with use of POPs and ATV/r compared with POPs alone.[173]
  ii. Ritonavir-boosted darunavir (DRV/r) 2 1 2 Clarification: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA.
  iii. Ritonavir-boosted fosamprenavir (FPV/r) 2 1 2 Clarification: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA.
  iv. Ritonavir-boosted lopinavir (LPV/r) 1 1 1 Evidence: One study demonstrated no pregnancies, no ovulations, no change in LPV/r level, and no change in HIV disease progression in women using DMPA;[174] another study found a small increase in pregnancy rate in women using DMPA with LPV/r compared with no ARV therapy, however confidence intervals overlapped.[162] Two studies found no increased risk for pregnancy in women using implants.[162],[163] Two studies found contraceptive hormones increased in women using LPV/r with DMPA or etonogestrel implants.[161],[174]
  v. Ritonavir-boosted saquinavir (SQV/r) 2 1 2 Clarification: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA.
  vi. Ritonavir-boosted tipranavir (TPV/r) 2 1 2 Clarification: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA.
d. Protease inhibitors
without ritonavir
  i. Atazanavir (ATV) 1 1 1 Comment: When ATV is administered with cobicistat, theoretical concern exists for a drug interaction with hormonal contraceptives. Cobicistat is an inhibitor of CYP3A and CYP2D6 and could theoretically increase contraceptive hormone levels. However, its effects on CYP enzymes and drug levels might vary when combined with other ARVs.
  ii. Fosamprenavir (FPV) 2 2 2 Clarification: Theoretical concern exists that interactions between FPV and hormonal contraceptives leading to decreased levels of FPV might diminish effectiveness of the ARV drug. The drug interaction likely involves CYP3A4 pathways; POCs have less effect on CYP3A4 enzymes than CHCs.
  iii. Indinavir (IDV) 1 1 1 —
  iv. Nelfinavir (NFV) 2 1 2 Clarification: Theoretically, drug interactions might occur between certain protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA. Concern exists that interactions between NFV and POCs might decrease NFV levels.
Evidence: One study found no pregnancies, no ovulations, no change in DMPA concentrations and no change in HIV disease progression with use of DMPA and NFV compared with DMPA alone; NFV concentrations were decreased with concomitant DMPA use.[166],[168]
e. CCR5 co-receptor
antagonists
  i. Maraviroc (MVC) 1 1 1 —
f. HIV integrase strand transfer
inhibitors
  i. Raltegravir (RAL) 1 1 1 —
  ii. Dolutegravir (DTG) 1 1 1 —
  iii. Elvitegravir (EVG) 1 1 1 Comment: When EVG is administered with cobicistat, theoretical concern exists for a drug interaction with hormonal contraceptives. Cobicistat is an inhibitor of CYP3A and CYP2D6 and could theoretically increase contraceptive hormone levels. However, its effects on CYP enzymes and drug levels might vary when combined with other ARVs.
g. Fusion inhibitors
  i. Enfuvirtide 1 1 1 —
Anticonvulsant therapy
a. Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine) 2 1 3 Clarification: Although the interaction of certain anticonvulsants with POPs and etonogestrel implants is not harmful, it is likely to reduce the effectiveness of POPs and etonogestrel implants. Whether increasing the hormone dose of POPs alleviates this concern remains unclear. Use of other contraceptives should be encouraged for persons who are long-term users of any of these drugs. Use of DMPA is a category 1 because its effectiveness is not decreased by use of certain anticonvulsants.
Evidence: Use of certain anticonvulsants might decrease the effectiveness of POCs.[175–178]
b. Lamotrigine 1 1 1 Evidence: No drug interactions have been reported among women with epilepsy receiving lamotrigine and POCs.[178],[179]
Antimicrobial therapy
a. Broad-spectrum antibiotics 1 1 1 —
b. Antifungals 1 1 1 —
c. Antiparasitics 1 1 1 —
d. Rifampin or rifabutin therapy 2 1 3 Clarification: Although the interaction of rifampin or rifabutin with POPs and etonogestrel implants is not harmful, it is likely to reduce the effectiveness of POPs and etonogestrel implants. Use of other contraceptives should be encouraged for persons who are long-term users of any of these drugs. Use of DMPA is a category 1 because its effectiveness is not decreased by use of rifampin or rifabutin. Whether increasing the hormone dose of POPs alleviates this concern remains unclear.
Psychotropic medications Comment: For many common psychotropic agents, limited or no theoretical concern exits for clinically significant drug interactions when co-administered with hormonal contraceptives. However, either no or very limited data exist examining potential interactions for these classes of medications.
a. Selective serotonin reuptake inhibitors (SSRIs) 1 1 1 Evidence: No evidence specifically examined the use of POCs with SSRIs. Limited clinical and pharmacokinetic data do not demonstrate concern for SSRIs decreasing the effectiveness of oral contraceptives. Limited evidence suggests that for women taking SSRIs, the use of hormonal contraceptives was not associated with differences in effectiveness of the SSRI for treatment or in adverse events when compared with women not taking hormonal contraceptives.[180]
Comment: Drugs that are inhibitors of CYP3A4 or CYP2C9 theoretically have the potential to increase levels of contraceptive steroid, which might increase adverse events. Fluvoxamine is an SSRI known to be a moderate inhibitor of both 3A4 and 2C9; however, no clinical or pharmacokinetic studies were identified to explore potential drug-drug interactions.
St. John’s wort 2 1 2 Evidence: No evidence specifically examined the use of POCs with St. John’s wort. Although clinical data are limited, studies with pharmacokinetic and pharmacodynamics outcomes raise concern that St. John’s wort might decrease effectiveness of hormonal contraceptives, including increased risk for breakthrough bleeding and ovulation and increased metabolism of estrogen and progestin. Any interactions might be dependent on the dose of St. John’s wort, and the concentration of active ingredients across types of St. John’s wort preparations might vary.[181]
Comment: Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA.

Abbreviations: ARV = antiretroviral; BMD = bone mineral density; BMI = body mass index; CHC = combined hormonal contraceptive; CKD = chronic kidney disease; COC = combined oral contraceptive; Cu-IUD = copper intrauterine device; CYP = cytochrome P450; DMPA = depot medroxyprogesterone acetate; DRSP = drospirenone; DVT = deep venous thrombosis; hCG = human chorionic gonadotropin; HDL = high-density lipoprotein; IBD = inflammatory bowel disease; IM = intramuscular; LDL = low-density lipoprotein; LNG = levonorgestrel; LNG-IUD = levonorgestrel intrauterine device; NA = not applicable; PE = pulmonary embolism; PID = pelvic inflammatory disease; POC = progestin-only contraceptive; POP = progestin-only pill; PrEP = pre-exposure prophylaxis; RCT = randomized clinical trial; SLE = systemic lupus erythematosus; STI = sexually transmitted infection; 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.

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National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP); Division of Reproductive Health