How To Use This Document

How to use this document

The recommendations in this report are intended to help health care providers address provision of contraceptive methods and management of side effects and issues related to contraceptive method use, such as how to help patients initiate use of a contraceptive method; which examinations and tests are needed before initiating use of a contraceptive method; what regular follow-up is needed; and how to address problems that often arise during use, including missed pills and side effects such as bleeding irregularities. Use of evidence-based recommendations by health care providers can remove unnecessary medical barriers and help patients access and successfully use contraceptive methods. Multiple medical barriers to initiating and continuing contraceptive methods might exist, such as unnecessary screening examinations and tests before starting the method (e.g., a pelvic examination before initiation of COCs), inability to receive the contraceptive on the same day as the visit (e.g., waiting for test results that might not be needed or waiting until the patient's next menstrual cycle to start use), and difficulty obtaining continued contraceptive supplies (e.g., restrictions on number of pill packs prescribed or dispensed at one time or requiring unnecessary follow-up procedures).^[20-24] Removing unnecessary steps can help patients access and successfully use contraception.

Each U.S. SPR recommendation addresses what a patient or health care provider can do in specific situations. Health care providers can also use the U.S. MEC to determine medical eligibility for use of specific contraceptive methods on the basis of a patient's characteristics and medical conditions.^[1] The full U.S. MEC recommendations and the evidence supporting those recommendations were updated in 2024 and are summarized (Appendix A).^[1]

The recommendations in this report are not intended to provide guidance on every aspect of provision and management of contraceptive method use. Instead, they incorporate the best available evidence to address specific issues regarding common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. Each contraceptive method section generally includes information about initiation of the method, regular follow-up, and management of problems with use (e.g., usage errors and side effects). Each section first provides the recommendation and then includes comments and a brief summary of the scientific evidence on which the recommendation is based. The level or certainty of evidence from the systematic reviews for each evidence summary is provided. For recommendations developed before 2024, the level of evidence was determined using the U.S. Preventive Services Task Force system, which includes ratings for study design (I: randomized controlled trials; II-1: controlled trials without randomization; II-2: observational studies; and II-3: multiple time series or descriptive studies), ratings for internal validity (good, fair, or poor), and categorization of the evidence as direct or indirect for the specific review question.^[25] For recommendations developed or revised in this updated publication, the certainty of evidence for each outcome was assessed as high, moderate, low, or very low using the GRADE approach.^[18],[19]

The information in this report is organized by contraceptive method. Recommendations are provided for permanent methods of contraception (tubal surgery and vasectomy) and for reversible methods of contraception, including the copper (380 mm²) IUD (Cu-IUD) and LNG (13.5 mg, 19.5 mg, or 52 mg) IUD; the etonogestrel (ENG) implant; progestin-only injectables (depot medroxyprogesterone acetate [DMPA]); progestin-only pills (POPs; norethindrone, norgestrel, and drospirenone); combined hormonal contraceptives (CHCs) that contain both estrogen and a progestin, including COCs, combined transdermal patches, and combined vaginal rings; and the standard days method (SDM). Recommendations also are provided for emergency use of the Cu-IUD and emergency contraceptive pills (ECPs).

For each contraceptive method, recommendations are provided on the timing for initiation of the method and indications for when and for how long additional contraception, or a back-up method, is needed. Many of these recommendations include guidance that a patient may start a contraceptive method at any time during their menstrual cycle, if it is reasonably certain that they are not pregnant. Guidance for health care providers also is provided on how to be reasonably certain that a patient is not pregnant, testosterone use and risk for pregnancy, and when contraceptive protection is no longer needed.

For each contraceptive method, recommendations include the examinations and tests needed before initiation of the method. These recommendations apply to patients who are presumed to be healthy. Most patients need no or very few examinations or tests before initiating a contraceptive method although examinations or tests might be needed to address other noncontraceptive health needs.^[6] Patients with known medical problems or other special conditions might need additional examinations or tests before being determined to be appropriate candidates for a particular method of contraception. U.S. MEC might be useful in such circumstances.^[1] Any additional screening needed for preventive health care can be performed at the time of contraception initiation, and initiation should not be delayed for test results. The following classification system was developed by WHO and adopted by CDC to categorize the applicability of the various examinations or tests before initiation of contraceptive methods:^[26]

Class A: These tests and examinations are essential and mandatory in all circumstances for safe and effective use of the contraceptive method.

Class B: These tests and examinations contribute substantially to safe and effective use, although implementation may be considered within the public health context, service context, or both. The risk of not performing an examination or test should be balanced against the benefits of making the contraceptive method available.

Class C: These tests and examinations do not contribute substantially to safe and effective use of the contraceptive method.

These classifications focus on the relation of the examinations or tests to safe initiation of a contraceptive method. They are not intended to address the appropriateness of these examinations or tests in other circumstances. For example, certain examinations or tests that are not deemed necessary for safe and effective contraceptive use might be appropriate for quality preventive health care or for diagnosing or assessing suspected medical conditions. Systematic reviews were conducted for multiple different types of examinations and tests to assess whether a screening test was associated with safe use of contraceptive methods. Because no single convention exists for screening panels for certain diseases (e.g., diabetes, lipid disorders, and liver diseases), the search strategies included broad terms for the tests and diseases of interest.

Summary charts and clinical algorithms that summarize the guidance for the various contraceptive methods have been developed for many of the recommendations, including when to start using specific contraceptive methods (Appendix B), examinations and tests needed before initiating the various contraceptive methods (Appendix C), routine follow-up after initiating contraception (Appendix D), management of bleeding irregularities among users of specific contraceptive methods (Appendix E), and management of IUDs when users are found to have pelvic inflammatory disease (PID) (Appendix F). Additional tools are available on the CDC website.

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],[11],[13]} 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.^[13] All persons seeking contraceptive care need access to appropriate counseling and services that support the person's values, goals, and reproductive autonomy.^[9-13] 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],[13]}

U.S. MEC and U.S. SPR recommendations can be used to support a person's contraceptive decision-making (Box 1). 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".^[27] Shared decision-making and person-centered approaches to providing health care recognize the expertise of both the medical provider and the patient.^{[10],[13],[27]}

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, availability (including accessibility and affordability), side effects, user control, reversibility, and ease of removal or discontinuation.^[28] Although most contraceptive methods are safe for use by most persons, U.S. MEC provides recommendations for the safety of specific contraceptive methods for persons with certain characteristics and medical conditions; a U.S. MEC summary (Appendix A) and the categories of medical eligibility criteria (U.S. MEC 1–4) for contraceptive use (Box 2) are provided.^[1],[2] 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.^[13],[29] 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.^{[6],[10],[13],[30]}

Box 1. Using the U.S. Medical Eligibility Criteria for Contraceptive Use and U.S. Selected Practice Recommendations for Contraceptive Use 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 supports 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.
  • 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.

Box 2. Categories of medical eligibility criteria for contraceptive use

Source: Nguyen AT, Curtis KM, Tepper NK, et al. U.S. medical eligibility criteria for contraceptive use, 2024. MMWR Recomm Rep 2024;73(No. RR-4):1–126.

Abbreviation: U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use.

Prevention of sexually transmitted infections

All patients, regardless of contraceptive choice, should be counseled about the use of condoms and the risk for STIs, including HIV infection.^[31] 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.^[31] Although evidence is limited, use of internal (female) condoms can provide protection from acquisition and transmission of STIs.^[31] Patients also should be counseled that pre-exposure prophylaxis (PrEP), when taken as prescribed, is highly effective for preventing HIV infection.^[32] Additional information about prevention and treatment of STIs is available from CDC’s Sexually Transmitted Infections Treatment Guidelines,^[31] 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.^[32]