Appendices for U.S. Selected Practice Recommendations for Contraceptive Use, 2024

Recommendations and Reports / August 8, 2024 / 73 (3);1–77

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Appendix A: Summary of Classifications for U.S. Medical Eligibility Criteria for Contraceptive Use, 2024

Health care providers can use the summary table as a quick reference guide to the classifications for hormonal contraceptive methods and intrauterine contraception to compare classifications across these methods (Box A1) (Table A1). For complete guidance, see U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (U.S. MEC) (1) for clarifications to the numeric categories, as well as for summaries of the evidence and additional comments. Hormonal contraceptives and intrauterine devices do not protect against sexually transmitted infections (STIs), including HIV infection, and persons using these methods 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).

Return to your place in the textBOX A1. Categories for classifying hormonal contraceptives and intrauterine devices

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 A1. Summary of classifications for hormonal contraceptive methods and intrauterine devices
Condition Cu-IUD LNG-IUD Implant DMPA POP CHC
Personal Characteristics and Reproductive History
Pregnancy 4* 4* NA* NA* NA* NA*
Age Menarche to
<20 years: 2		 Menarche to
<20 years: 2		 Menarche to
<18 years: 1		 Menarche to
<18 years: 2		 Menarche to
<18 years: 1		 Menarche to
<40 years: 1
≥20 years: 1 ≥20 years: 1 18–45 years: 1 18–45 years: 1 18–45 years: 1 ≥40 years: 2
>45 years: 1 >45 years: 2 >45 years: 1
Parity
a. Nulliparous 2 2 1 1 1 1
b. Parous 1 1 1 1 1 1
Breastfeeding
a. <21 days postpartum — — 2* 2* 2* 4*
b. 21 to <30 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) — — 2* 2* 2* 3*
  ii. Without other risk factors for VTE — — 2* 2* 2* 3*
c. 30–42 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* 3*
  ii. Without other risk factors for VTE — — 1* 1* 1* 2*
d. >42 days postpartum — — 1* 1* 1* 2*
Postpartum (nonbreastfeeding)
a. <21 days postpartum — — 1 2 1 4
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 3*
  ii. Without other risk factors for VTE — — 1 1 1 2
c. >42 days postpartum — — 1 1 1 1
Postpartum (including cesarean delivery, breastfeeding,
or nonbreastfeeding)
a. <10 minutes after delivery of the placenta 2* 2* — — — —
b. 10 minutes after delivery of the placenta to <4 weeks 2* 2* — — — —
c. ≥4 weeks 1* 1* — — — —
d. Postpartum sepsis 4 4 — — — —
Postabortion (spontaneous or induced)
a. First trimester abortion
  i. Procedural (surgical) 1* 1* 1* 1* 1* 1*
  ii. Medication 1* 1* 1* 1/2* 1* 1*
  iii. Spontaneous abortion with no intervention 1* 1* 1* 1* 1* 1*
b. Second trimester abortion
  i. Procedural (surgical) 2* 2* 1* 1* 1* 1*
  ii. Medication 2* 2* 1* 1* 1* 1*
  iii. Spontaneous abortion with no intervention 2* 2* 1* 1* 1* 1*
c. Immediate postseptic abortion 4 4 1* 1* 1* 1*
Past ectopic pregnancy 1 1 1 1 2 1
History of pelvic surgery (see recommendations for Postpartum [including cesarean delivery]) 1 1 1 1 1 1
Smoking
a. Age <35 years 1 1 1 1 1 2
b. Age ≥35 years
  i. <15 cigarettes per day 1 1 1 1 1 3
  ii. ≥15 cigarettes per day 1 1 1 1 1 4
Obesity
a. BMI ≥30 kg/m2 1 1 1 1 1 2*
b. Menarche to <18 years and BMI ≥30 kg/m2 1 1 1 2 1 2*
History of bariatric surgery
This condition is associated with increased risk for
adverse health events as a result of pregnancy.
a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy) 1 1 1 1 1 1
b. Malabsorptive procedures: decrease absorption of nutrients and calories by shortening the functional length of the small intestine (Roux-en-Y gastric bypass or biliopancreatic diversion) 1 1 1 1 3 COCs: 3
Patch and ring: 1
Surgery
a. Minor surgery without immobilization 1 1 1 1 1 1
b. Major surgery
  i. Without prolonged immobilization 1 1 1 1 1 2
  ii. With prolonged immobilization 1 1 1 2 1 4
Cardiovascular Disease
Multiple risk factors for atherosclerotic cardiovascular disease (e.g., older age, smoking, diabetes, hypertension, low HDL, high LDL, or high triglyceride levels) 1 2 2* 3* 2* 3/4*
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.
a. Adequately controlled hypertension 1* 1* 1* 2* 1* 3*
b. Elevated blood pressure levels (properly taken
measurements)
  i. Systolic 140–159 mm Hg or diastolic 90–99 mm Hg 1* 1* 1* 2* 1* 3*
  ii. Systolic ≥160 mm Hg or diastolic ≥100 mm Hg 1* 2* 2* 3* 2* 4*
c. Vascular disease 1* 2* 2* 3* 2* 4*
History of high blood pressure during pregnancy (when current blood pressure is measurable and normal) 1 1 1 1 1 2
Deep venous thrombosis/Pulmonary embolism
This condition is associated with increased risk
for adverse health events as a result of
pregnancy.
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* 2* 2* 3*
b. History of DVT/PE, receiving anticoagulant therapy
(prophylactic dose)
  i. Higher risk for recurrent DVT/PE (one or more risk factors) 2* 2* 2* 3* 2* 4*
• 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* 2* 2* 3*
c. History of DVT/PE, not receiving anticoagulant therapy
  i. Higher risk for recurrent DVT/PE (one or more risk factors 1 2 2 3 2 4
• 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) 1 2 2 2 2 3
d. Family history (first-degree relatives) 1 1 1 1 1 2
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.		 1* 2* 2* 3* 2* 4*
Superficial venous disorders
a. Varicose veins 1 1 1 1 1 1
b. Superficial venous thrombosis (acute or history) 1 1 1 2 1 3*
Current and history of ischemic heart disease
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 1 Initiation Continuation Initiation Continuation 3 Initiation Continuation 4
2 3 2 3 2 3
Stroke (history of cerebrovascular accident)
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 1 2 Initiation Continuation 3 Initiation Continuation 4
2 3 2 3
Valvular heart disease
Complicated valvular heart disease is associated with
increased risk for adverse health events as a result of
pregnancy.
a. Uncomplicated 1 1 1 1 1 2
b. Complicated (pulmonary hypertension, risk for atrial fibrillation, or history of subacute bacterial endocarditis) 1 1 1 2 1 4
Peripartum cardiomyopathy
This condition is associated with increased risk for
adverse health events as a result of pregnancy.
a. Normal or mildly impaired cardiac function (New
York Heart Association Functional Class I or II: no
limitation of activities or slight, mild limitation
of activity) (3)
  i. <6 months 2 2 1 2 1 4
   ii. ≥6 months 2 2 1 2 1 3
b. Moderately or severely impaired cardiac function (New York Heart Association Functional Class III or IV: marked limitation of activity or should be at complete rest) (3) 2 2 2 3 2 4
Renal Disease
Chronic kidney disease
This condition is associated with increased risk
for adverse health events as a result of pregnancy.		 Initiation Continuation Initiation Continuation —
a. Current nephrotic syndrome 1 1 2 2 2 3 2*
DRSP POP with known hyperkalemia: 4*		 4
b. Hemodialysis 1 1 2 2 2 3 2*
DRSP POP with known hyperkalemia: 4*		 4
c. Peritoneal dialysis 2 1 2 2 2 3 2*
DRSP POP with known hyperkalemia: 4*		 4
Rheumatic Diseases
Systemic lupus erythematosus
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 Initiation Continuation — Initiation Continuation —
a. Positive (or unknown) antiphospholipid antibodies 1* 1* 2* 2* 3* 3* 2* 4*
b. Severe thrombocytopenia 3* 2* 2* 2* 3* 2* 2* 2*
c. Immunosuppressive therapy 2* 1* 2* 2* 2* 2* 2* 2*
d. None of the above 1* 1* 2* 2* 2* 2* 2* 2*
Rheumatoid arthritis Initiation Continuation Initiation Continuation —
a. Not receiving immunosuppressive therapy 1 1 1 1 1 2 1 2
b. Receiving immunosuppressive therapy 2 1 2 1 1 2/3* 1 2
Neurologic Conditions
Headaches
a. Nonmigraine (mild or severe) 1 1 1 1 1 1*
b. Migraine
  i. Without aura (includes menstrual migraine) 1 1 1 1 1 2*
  ii. With aura 1 1 1 1 1 4*
Epilepsy
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 1 1 1* 1* 1* 1*
Multiple sclerosis
a. Without prolonged immobility 1 1 1 2 1 1
b. With prolonged immobility 1 1 1 2 1 3
Depressive Disorders
Depressive disorders 1* 1* 1* 1* 1* 1*
Reproductive Tract Infections and Disorders
Vaginal bleeding patterns Initiation Continuation —
a. Irregular pattern without heavy bleeding 1 1 1 2 2 2 1
b. Heavy or prolonged bleeding (includes regular and irregular patterns) 2* 1* 2* 2* 2* 2* 1*
Unexplained vaginal bleeding
(suspicious for serious condition) before evaluation		 Initiation Continuation Initiation Continuation —
4* 2* 4* 2* 3* 3* 2* 2*
Endometriosis 2 1 1 1 1 1
Benign ovarian tumors (including cysts) 1 1 1 1 1 1
Severe dysmenorrhea 2 1 1 1 1 1
Gestational trophoblastic disease
This condition is associated with increased risk for
adverse health events as a result of pregnancy.
a. Suspected gestational trophoblastic disease
(immediate postevacuation)
  i. Uterine size first trimester 1* 1* 1* 1* 1* 1*
  ii. Uterine size second trimester 2* 2* 1* 1* 1* 1*
b. Confirmed gestational trophoblastic disease (after initial evacuation and during monitoring) Initiation Continuation Initiation Continuation —
  i. Undetectable or nonpregnant β-hCG levels 1* 1* 1* 1* 1* 1* 1* 1*
  ii. Decreasing β-hCG levels 2* 1* 2* 1* 1* 1* 1* 1*
  iii. Persistently elevated β-hCG levels or malignant disease, with no evidence or suspicion of intrauterine disease 2* 1* 2* 1* 1* 1* 1* 1*
  iv. Persistently elevated β-hCG levels or malignant disease, with evidence or suspicion of intrauterine disease 4* 2* 4* 2* 1* 1* 1* 1*
Cervical ectropion 1 1 1 1 1 1
Cervical intraepithelial neoplasia 1 2 2 2 1 2
Cervical cancer (awaiting treatment) Initiation Continuation Initiation Continuation —
4 2 4 2 2 2 1 2
Breast disease
Breast cancer is associated with increased risk for
adverse health events as a result of pregnancy.
a. Undiagnosed mass 1 2* 2* 2* 2* 2*
b. Benign breast disease 1 1 1 1 1 1
c. Family history of cancer 1 1 1 1 1 1
d. Breast cancer
  i. Current 1 4 4 4 4 4
  ii. Past and no evidence of current disease for 5 years 1 3 3 3 3 3
Endometrial hyperplasia 1 1 1 1 1 1
Endometrial cancer
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 Initiation Continuation Initiation Continuation —
4 2 4 2 1 1 1 1
Ovarian cancer
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 1 1 1 1 1 1
Uterine fibroids 2 2 1 1 1 1
Anatomical abnormalities
a. Distorted uterine cavity (any congenital or acquired uterine abnormality distorting the uterine cavity in a manner that is incompatible with IUD placement) 4 4 —
b. Other abnormalities (including cervical stenosis or cervical lacerations) not distorting the uterine cavity or interfering with IUD placement 2 2
Pelvic inflammatory disease Initiation Continuation Initiation Continuation —
a. Current PID 4 2* 4 2* 1 1 1 1
b. Past PID
  i. With subsequent pregnancy 1 1 1 1 1 1 1 1
  ii. Without subsequent pregnancy 2 2 2 2 1 1 1 1
Sexually transmitted infections Initiation Continuation Initiation Continuation —
a. Current purulent cervicitis or chlamydial infection or gonococcal infection 4 2* 4 2* 1 1 1 1
b. Vaginitis (including Trichomonas vaginalis and bacterial vaginosis) 2 2 2 2 1 1 1 1
c. Other factors related to STIs 2* 2 2* 2 1 1 1 1
HIV
High risk for HIV infection Initiation Continuation Initiation Continuation —
1* 1* 1* 1* 1 1 1 1
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.		 — — — — 1* 1* 1* 1*
a. Clinically well receiving ARV therapy 1 1 1 1 — — — —
b. Not clinically well or not receiving ARV therapy 2 1 2 1 — — — —
Other Infections
Schistosomiasis
Schistosomiasis with fibrosis of the liver is associated
with increased risk for adverse health events
as a result of pregnancy.
a. Uncomplicated 1 1 1 1 1 1
b. Fibrosis of the liver (if severe, see recommendations for Cirrhosis) 1 1 1 1 1 1
Tuberculosis
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 Initiation Continuation Initiation Continuation —
a. Nonpelvic 1 1 1 1 1* 1* 1* 1*
b. Pelvic 4 3 4 3 1* 1* 1* 1*
Malaria 1 1 1 1 1 1
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.
a. History of gestational disease 1 1 1 1 1 1
b. Nonvascular disease
  i. Non-insulin dependent 1 2 2 2 2 2
  ii. Insulin dependent 1 2 2 2 2 2
c. Nephropathy, retinopathy, or neuropathy 1 2 2 3 2 3/4*
d. Other vascular disease or diabetes of >20 years’ duration 1 2 2 3 2 3/4*
Thyroid disorders
a. Simple goiter 1 1 1 1 1 1
b. Hyperthyroid 1 1 1 1 1 1
c. Hypothyroid 1 1 1 1 1 1
Gastrointestinal Conditions
Inflammatory bowel disease (ulcerative colitis or Crohn’s disease) 1 1 1 2 2 2/3*
Gallbladder disease
a. Asymptomatic 1 2 2 2 2 2
b. Symptomatic
  i. Current 1 2 2 2 2 3
  ii. Treated by cholecystectomy 1 2 2 2 2 2
  iii. Medically treated 1 2 2 2 2 3
History of cholestasis
a. Pregnancy related 1 1 1 1 1 2
b. Past COC related 1 2 2 2 2 3
Viral hepatitis Initiation Continuation
a. Acute or flare 1 1 1 1 1 3/4* 2
b. Chronic 1 1 1 1 1 1 1
Cirrhosis
Decompensated cirrhosis is associated with increased
risk for adverse health events as a result of
pregnancy.
a. Compensated (normal liver function) 1 1 1 1 1 1
b. Decompensated (impaired liver function) 1 2 2 3 2 4
Liver tumors
Hepatocellular adenoma and malignant liver tumors are
associated with increased risk for adverse health events
as a result of pregnancy.
a. Benign
  i. Focal nodular hyperplasia 1 2 2 2 2 2
  ii. Hepatocellular adenoma 1 2 2 3 2 4
b. Malignant (hepatocellular carcinoma) 1 3 3 3 3 4
Respiratory Conditions
Cystic fibrosis
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 1* 1* 1* 2* 1* 1*
Hematologic Conditions
Thalassemia 2 1 1 1 1 1
Sickle cell disease
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 2 1 1 2/3* 1 4
Iron-deficiency anemia 2 1 1 1 1 1
Solid Organ Transplantation
Solid organ transplantation
This condition is associated with increased risk for adverse health events as a result of pregnancy.		 Initiation Continuation Initiation Continuation —
a. No graft failure 1 1 1 1 2 2/3* 2 2*
b. Graft failure 2 1 2 1 2 2/3* 2 4
Drug Interactions
Antiretrovirals used for prevention (PrEP)
or treatment of HIV infection
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 (https://clinicalinfo.hiv.gov/en/guidelines/perinatal/prepregnancy-counseling-childbearing-age-overview?view=full#table-3) (5) 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) (6).
a. Nucleoside reverse transcriptase inhibitors (NRTIs) Initiation Continuation Initiation Continuation —
  i. Abacavir (ABC) 1/2* 1* 1/2* 1* 1 1 1 1
  ii. Tenofovir (TDF) 1/2* 1* 1/2* 1* 1 1 1 1
  iii. Zidovudine (AZT) 1/2* 1* 1/2* 1* 1 1 1 1
  iv. Lamivudine (3TC) 1/2* 1* 1/2* 1* 1 1 1 1
  v. Didanosine (DDI) 1/2* 1* 1/2* 1* 1 1 1 1
  vi. Emtricitabine (FTC) 1/2* 1* 1/2* 1* 1 1 1 1
  vii. Stavudine (D4T) 1/2* 1* 1/2* 1* 1 1 1 1
b. Nonnucleoside reverse transcriptase
inhibitors (NNRTIs)
  i. Efavirenz (EFV) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
  ii. Etravirine (ETR) 1/2* 1* 1/2* 1* 1 1 1 1
  iii. Nevirapine (NVP) 1/2* 1* 1/2* 1* 1 1 1 1
  iv. Rilpivirine (RPV) 1/2* 1* 1/2* 1* 1 1 1 1
c. Ritonavir-boosted protease inhibitors
  i. Ritonavir-boosted atazanavir (ATV/r) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
  ii. Ritonavir-boosted darunavir (DRV/r) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
  iii. Ritonavir-boosted fosamprenavir (FPV/r) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
  iv. Ritonavir-boosted lopinavir (LPV/r) 1/2* 1* 1/2* 1* 1 1 1 1
  v. Ritonavir-boosted saquinavir (SQV/r) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
  vi. Ritonavir-boosted tipranavir (TPV/r) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
d. Protease inhibitors without ritonavir
  i. Atazanavir (ATV) 1/2* 1* 1/2* 1* 1 1 1 2*
  ii. Fosamprenavir (FPV) 1/2* 1* 1/2* 1* 2* 2* 2* 3*
  iii. Indinavir (IDV) 1/2* 1* 1/2* 1* 1 1 1 1
  iv. Nelfinavir (NFV) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
e. CCR5 co-receptor antagonists
  i. Maraviroc (MVC) 1/2* 1* 1/2* 1* 1 1 1 1
f. HIV integrase strand transfer inhibitors
  i. Raltegravir (RAL) 1/2* 1* 1/2* 1* 1 1 1 1
  ii. Dolutegravir (DTG) 1/2* 1* 1/2* 1* 1 1 1 1
  iii. Elvitegravir (EVG) 1/2* 1* 1/2* 1* 1 1 1 1
g. Fusion inhibitors
  i. Enfuvirtide 1/2* 1* 1/2* 1* 1 1 1 1
Anticonvulsant therapy
a. Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine) 1 1 2* 1* 3* 3*
b. Lamotrigine 1 1 1 1 1 3*
Antimicrobial therapy
a. Broad-spectrum antibiotics 1 1 1 1 1 1
b. Antifungals 1 1 1 1 1 1
c. Antiparasitics 1 1 1 1 1 1
d. Rifampin or rifabutin therapy 1 1 2* 1* 3* 3*
Psychotropic medications
a. Selective serotonin reuptake inhibitors (SSRIs) 1 1 1 1 1 1
St. John’s wort 1 1 2 1 2 2

Abbreviations: ARV = antiretroviral; BMI = body mass index; CHC = combined hormonal contraceptive; COC = combined oral contraceptive; Cu-IUD = copper intrauterine device; DMPA = depot medroxyprogesterone acetate; DRSP = drospirenone; DVT = deep venous thrombosis; hCG = human chorionic gonadotropin; HDL = high-density lipoprotein; IUD = intrauterine device; LDL = low-density lipoprotein; LNG-IUD = levonorgestrel intrauterine device; NA = not applicable; PE = pulmonary embolism; PID = pelvic inflammatory disease; POP = progestin-only pill; PrEP = pre-exposure prophylaxis; STI = sexually transmitted infection; VTE = venous thromboembolism.
* Consult the respective appendix for each contraceptive method in U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (1) for clarifications to the numeric categories.

References

  1. Nguyen AT, Curtis KM, Tepper NK, et al. U.S. medical eligibility criteria for contraceptive use, 2024. 2024;73(No. RR-4):1–126.
  2. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. 2021;70(No. RR-4):1–187. https://doi.org/10.15585/mmwr.rr7004a1
  3. CDC. US Public Health Service preexposure prophylaxis for the prevention of HIV infection in the United States—2021 update: a clinical practice guideline. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf
  4. The Criteria Committee of the New York Heart Association. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Little, Brown and Co; 1994.
  5. Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Washington, DC: US Department of Health and Human Services; 2023. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/recommendations-arv-drugs-pregnancy-overview
  6. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Washington, DC: US Department of Health and Human Services; 2023. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf

Appendix B: When To Start Using Specific Contraceptive Methods

This appendix summarizes recommendations for when to start using specific contraceptive methods (Table B1).

TABLE B1. When to start using specific contraceptive methods
Contraceptive method When to start (if the provider is reasonably certain that the patient is not pregnant)* Additional contraception (i.e., back-up) needed Examination or test needed before initiation†
Cu-IUD Anytime Not needed Bimanual examination and cervical inspection§
LNG-IUD Anytime If >7 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days Bimanual examination and cervical inspection§
Implant Anytime If >5 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days None
DMPA Anytime If >7 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days None
CHC Anytime If >5 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days Blood pressure measurement
Norethindrone or norgestrel POP Anytime If >5 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 2 days None
Drospirenone POP Anytime If >1 day after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days None

Abbreviations: BMI = body mass index; CHC = combined hormonal contraceptive; Cu-IUD = copper intrauterine device; DMPA = depot medroxyprogesterone acetate; IUD = intrauterine device; LNG-IUD = levonorgestrel intrauterine device; POP = progestin-only pill; STI = sexually transmitted infection; U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use.
* As appropriate, see recommendations for Emergency Contraception.
† Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. MEC 1) or generally can be used (U.S. MEC 2) among patients with obesity (BMI ≥30 kg/m2). However, measuring weight and calculating BMI (weight [kg]/height [m]2) at baseline might be helpful for discussing concerns about any changes in weight and whether changes might be related to use of the contraceptive method.
§ Most patients do not require additional STI screening at the time of IUD placement. If a patient with risk factors for STIs has not been screened for gonorrhea and chlamydia according to CDC’s Sexually Transmitted Infections Treatment Guidelines (https://www.cdc.gov/std/treatment-guidelines/default.htm), screening may be performed at the time of IUD placement, and placement should not be delayed. Patients with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD placement (U.S. MEC 4).
In situations in which the health care provider is uncertain whether the patient might be pregnant, the benefits of starting the implant, DMPA, CHC, and POP likely exceed any risk; therefore, starting the implant, DMPA, CHC, and POP should be considered at any time, with a follow-up pregnancy test in 2–4 weeks.

Appendix C: Examinations and Tests Needed Before Initiation of Contraceptive Methods

The examinations and tests noted apply to patients who are presumed to be healthy (Table C1). Those with known medical problems or other special conditions might need additional examinations and tests before being determined to be appropriate candidates for a particular method of contraception. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (U.S. MEC) might be useful in such circumstances (1). The following classification was considered useful in differentiating the applicability of the various examinations and tests (2):

  • Class A: Essential and mandatory in all circumstances for safe and effective use of the contraceptive method.
  • Class B: Contributes substantially to safe and effective use, but implementation may be considered within the public health context, service context, or both; risk of not performing an examination or test should be balanced against the benefits of making the contraceptive method available.
  • Class C: Does 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 good preventive health care or for diagnosing or assessing suspected medical conditions. 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.

No examinations or tests are needed before initiating condoms, spermicides, or vaginal pH modulators. A bimanual examination is necessary for diaphragm fitting. A bimanual examination and cervical inspection are needed for cervical cap fitting.

TABLE C1. Examinations and tests needed before initiation of contraceptive methods
Examination or test Contraceptive method and class
Cu-IUD and LNG-IUD Implant DMPA CHC POP Condom Spermicide and vaginal pH modulator Diaphragm/Cap (with spermicide)
Examination
Blood pressure C C C A* C C C C
Weight (BMI) (weight [kg]/height [m]2) —† —† —† —† —† C C C
Clinical breast examination C C C C C C C C
Bimanual examination and cervical inspection A C C C C C C A§
Laboratory test
Glucose C C C C C C C C
Lipids C C C C C C C C
Liver enzymes C C C C C C C C
Hemoglobin C C C C C C C C
Thrombophilia C C C C C C C C
Cervical cytology (Papanicolaou test) C C C C C C C C
STI screening with laboratory tests — C C C C C C C
HIV screening with laboratory tests C C C C C C C C

Abbreviations: BMI = body mass index; CHC = combined hormonal contraceptive; Cu-IUD = copper intrauterine device; DMPA = depot medroxyprogesterone acetate; IUD = intrauterine device; LNG-IUD = levonorgestrel intrauterine device; POP = progestin-only pill; STI = sexually transmitted infection; U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use.
* In instances in which blood pressure cannot be measured by a provider, blood pressure measured in other settings can be reported by the patient to their provider.
† Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. MEC 1) or generally can be used (U.S. MEC 2) among patients with obesity (BMI ≥30 kg/m2). However, measuring weight and calculating BMI at baseline might be helpful for discussing concerns about any changes in weight and whether changes might be related to use of the contraceptive method.
§ A bimanual examination (not cervical inspection) is needed for diaphragm fitting.
Most patients do not require additional STI screening at the time of IUD placement. If a patient with risk factors for STIs has not been screened for gonorrhea and chlamydia according to CDC’s Sexually Transmitted Infections Treatment Guidelines (https://www.cdc.gov/std/treatment-guidelines/default.htm), screening may be performed at the time of IUD placement, and placement should not be delayed. Patients with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD placement (U.S. MEC 4).

References

  1. Nguyen AT, Curtis KM, Tepper NK, et al. U.S. medical eligibility criteria for contraceptive use, 2024. 2024;73(No. RR-4):1–126.
  2. World Health Organization. Selected practice recommendations for contraceptive use, 2nd ed. Geneva, Switzerland: WHO Press; 2004.

Appendix D: Routine Follow-Up After Contraceptive Initiation

This appendix addresses when routine follow-up is recommended for safe and effective continued use of contraception for healthy patients (Table D1). The recommendations refer to general situations and might vary for different users and different situations. Specific populations who might benefit from more frequent follow-up visits include adolescents, those with certain medical conditions or characteristics, and those with multiple medical conditions.

TABLE D1. Routine follow-up actions after contraceptive initiation
Action Contraceptive method
Cu-IUD or LNG-IUD Implant DMPA CHC POP
General follow-up
Advise the patient that they may contact their provider at any time to discuss side effects or other problems or if they want to change the method. Advise patients using IUDs, implants, or DMPA when the IUD or implant needs to be removed or when a reinjection is needed. No routine follow-up visit is required. X* X* X* X* X*
Other routine visits
Assess the patient’s satisfaction with their current method and whether they have any concerns about method use. X* X* X* X* X*
Assess any changes in health status, including medications, that would change the method’s appropriateness for safe and effective continued use on the basis of U.S. MEC (i.e., category 3 and 4 conditions and characteristics) (Box 2). X* X* X* X* X*
Consider performing an examination to check for the presence of IUD strings. X* —† —† —† —†
Consider assessing weight changes and discussing concerns about any changes in weight and whether changes might be related to use of the contraceptive method. X* X* X* X* X*
Measure blood pressure. —† —† —† X* —†

Abbreviations: CHC = combined hormonal contraceptive; Cu-IUD = copper intrauterine device; DMPA = depot medroxyprogesterone acetate; IUD = intrauterine device; LNG-IUD = levonorgestrel intrauterine device; POP = progestin-only pill; U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use.
* The action is applicable to the contraceptive method.
† The action is not applicable to the contraceptive method.

Appendix E: Management of Bleeding Irregularities While Using Contraception

This appendix summarizes recommendations for management of bleeding irregularities while using contraception (Figure E1).

FIGURE E1. Management of bleeding irregularities while using contraception*

Figure describes management of bleeding irregularities while using contraception.

Abbreviations: CHC = combined hormonal contraceptive; COC = combined oral contraceptive; Cu-IUD = copper intrauterine device; DMPA = depot medroxyprogesterone acetate; EE = ethinyl estradiol; LNG-IUD = levonorgestrel intrauterine device; NSAID = nonsteroidal anti-inflammatory drug; SERM = selective estrogen receptor modulator.

* If clinically indicated, consider an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids). If an underlying health condition is found, treat the condition or refer for care.

Appendix F: Management of Intrauterine Devices When Users Are Found To Have Pelvic Inflammatory Disease

This appendix summarizes recommendations for management of intrauterine devices when users are found to have pelvic inflammatory disease (Figure F1).

FIGURE F1. Management of intrauterine devices when users of copper intrauterine devices or levonorgestrel intrauterine devices are found to have pelvic inflammatory disease*

Figure describes management of intrauterine devices when users of copper and levonorgestrel intrauterine devices are found to have pelvic inflammatory disease.

Abbreviations: IUD = intrauterine device; PID = pelvic inflammatory disease.

* Refer to CDC Sexually Transmitted Infections Treatment Guidelines (https://www.cdc.gov/std/treatment-guidelines/default.htm) for information on PID diagnostic considerations and treatment regimens.

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