Note from the Centers for Disease Control and Prevention (CDC) and the National Guideline Clearinghouse (NGC): This guidance will be updated as new evidence becomes available. Please check the CDC's Division of Reproductive Health Web site for any changes that have been made to the recommendations since this guideline was published.
How to Use This Document
These recommendations are intended to help health care providers determine the safe use of contraceptive methods among women and men with various characteristics and medical conditions. Providers also can use the synthesis of information in these recommendations when consulting with women, men, and couples about their selection of contraceptive methods. The tables in this document include recommendations for the use of contraceptive methods by women and men with particular characteristics or medical conditions. Each condition was defined as representing either an individual's characteristics (e.g., age, history of pregnancy) or a known preexisting medical/pathologic condition (e.g., diabetes and hypertension). The recommendations refer to contraceptive methods being used for contraceptive purposes; the recommendations do not consider the use of contraceptive methods for treatment of medical conditions because the eligibility criteria in these cases may differ. The conditions affecting eligibility for the use of each contraceptive method were classified under one of four categories (Box 1).
Box 1. Categories of Medical Eligibility Criteria (MEC) for Contraceptive Use
|1 = A condition for which there is no restriction for the use of the contraceptive method.
|2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks.
|3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
|4 = A condition that represents an unacceptable health risk if the contraceptive method is used.
Using the Categories in Practice
Health care providers can use these categories when assessing the safety of contraceptive method use for women and men with specific medical conditions or characteristics. Category 1 comprises conditions for which no restrictions exist for use of the contraceptive method. Classification of a method/condition as Category 2 indicates the method generally can be used, but careful follow-up may be required. For a method/condition classified as Category 3, use of that method usually is not recommended unless other more appropriate methods are not available or acceptable. The severity of the condition and the availability, practicality, and acceptability of alternative methods should be taken into account, and careful follow-up will be required. Hence, provision of a method to a woman with a condition classified as Category 3 requires careful clinical judgment and access to clinical services. Category 4 comprises conditions that represent an unacceptable health risk if the method is used. For example, a smoker aged <35 years generally can use combined oral contraceptives (COCs) (Category 2). However, for a woman aged ≥35 years who smokes <15 cigarettes per day, the use of COCs usually is not recommended unless other methods are not available or acceptable to her (Category 3). A woman aged ≥35 years who smokes ≥15 cigarettes per day should not use COCs because of unacceptable health risks, primarily the risk for myocardial infarction and stroke (Category 4). The programmatic implications of these categories may depend on the circumstances of particular professional or service organizations (e.g., in some settings, a Category 3 may mean that special consultation is warranted).
The recommendations address medical eligibility criteria for the initiation and continued use of all methods evaluated. The issue of continuation criteria is clinically relevant whenever a woman develops the condition while she is using the method.
When the categories differ for initiation and continuation, these differences are noted in the columns Initiation and Continuation. Where Initiation and Continuation are not denoted, the category is the same for initiation and continuation of use.
On the basis of this classification system, the eligibility criteria for initiating and continuing use of a specific contraceptive method are presented in tables (Appendices A–M in the original guideline document). In these tables, the first column indicates the condition. Several conditions were divided into subconditions to differentiate between varying types or severity of the condition. The second column classifies the condition for initiation and/or continuation into Category 1, 2, 3, or 4. For some conditions, the numeric classification does not adequately capture the recommendation; in this case, the third column clarifies the numeric category. These clarifications were determined during the discussions of the scientific evidence and the numeric classification and are considered a necessary element of the recommendation. The third column also summarizes the evidence for the recommendation, where evidence exists. The recommendations for which no evidence is cited are based on expert opinion from either the World Health Organization (WHO) or U.S. expert working group meetings and may be based on evidence from sources other than systematic reviews and presented at those meetings. For selected recommendations, additional comments appear in the third column and generally come from WHO or the U.S. expert working group participants.
Recommendations for Use of Contraceptive Methods
The classifications for whether women with certain medical conditions or characteristics can use specific contraceptive methods are provided in several appendices in the original guideline document for the following contraceptive methods:
- Combined hormonal contraceptive methods, including lose-dose (containing ≤35 micrograms of ethinyl estradiol) combined oral contraceptive pills, combined hormonal patch, and combined vaginal ring (Appendix B)
- Progestin-only contraceptive methods, including progestin-only pills, depot medroxyprogesterone acetate injections, and etonogestrel implants (Appendix C)
- Emergency contraceptive pills (Appendix D)
- Intrauterine contraception, including the copper intrauterine device (IUD) and the levonorgestrel IUD (Appendix E)
- Use of copper IUDs for emergency contraception (Appendix F)
- Barrier contraceptive methods, including male and female condoms, spermicides, diaphragm with spermicide, and cervical cap (Appendix G)
- Fertility awareness-based methods (Appendix H)
- Lactational amenorrhea method (Appendix I)
- Coitus interruptus (withdrawal) (Appendix J)
- Female and male sterilization (Appendix K)
Tables at the end of the document summarize the classifications for the hormonal and intrauterine methods (Appendix L) and the evidence about potential drug interactions between hormonal contraceptives and antiretroviral therapies (Appendix M).
Contraceptive Method Choice
Many elements need to be considered by women, men, or couples at any given point in their lifetimes when choosing the most appropriate contraceptive method. These elements include safety, effectiveness, availability (including accessibility and affordability), and acceptability. The guidance in this document focuses primarily on the safety of a given contraceptive method for a person with a particular characteristic or medical condition. Therefore, the classification of Category 1 means that the method can be used in that circumstance with no restrictions with regard to safety but does not necessarily imply that the method is the best choice for that person; other factors, such as effectiveness, availability, and acceptability, may play a key role in determining the most appropriate choice. Voluntary informed choice of contraceptive methods is an essential guiding principle, and contraceptive counseling, where applicable, may be an important contributor to the successful use of contraceptive methods.
In choosing a method of contraception, the risk for sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), also must be considered. Although hormonal contraceptives and IUDs are highly effective at preventing pregnancy, they do not protect against STIs. Consistent and correct use of the male latex condom reduces the risk for STIs. When a male condom cannot be used properly for infection prevention, a female condom should be considered. Women who use contraceptive methods other than condoms should be counseled about the use of condoms and the risk for STIs. Additional information about prevention and treatment of STIs is available from CDC's Sexually Transmitted Diseases Treatment Guidelines (http://www.cdc.gov/std/treatment ).
Recently, CDC assessed evidence regarding the safety of combined hormonal contraceptive use during the postpartum period. This report summarizes that assessment and the resulting updated guidance. These updated recommendations state that postpartum women should not use combined hormonal contraceptives during the first 21 days after delivery because of the high risk for venous thromboembolism (VTE) during this period. During 21–42 days postpartum, women without risk factors for VTE generally can initiate combined hormonal contraceptives, but women with risk factors for VTE (e.g., previous VTE or recent cesarean delivery) generally should not use these methods. After 42 days postpartum, no restrictions on the use of combined hormonal contraceptives based on postpartum status apply.
See the text of the 2011 addendum for complete recommendations for use of combined hormonal contraceptives during the postpartum period and for use of other contraceptive methods during the postpartum period.
Recently, CDC assessed the evidence regarding hormonal contraceptive use and the risk for human immunodeficiency virus (HIV) acquisition, transmission, and disease progression. This report summarizes that assessment and the resulting updated guidance. These updated recommendations affirm the previous guidance, which stated that 1) the use of hormonal contraceptives, including combined hormonal contraceptives, progestin-only pills, depot medroxyprogesterone acetate (DMPA), and implants, is safe for women at high risk for HIV infection or infected with HIV (US MEC category 1), and 2) all women who use contraceptive methods other than condoms should be counseled regarding the use of condoms and the risk for sexually transmitted infections. However, a clarification is added to the recommendation for women at high risk for HIV infection who use progestin-only injectables to acknowledge the inconclusive nature of the body of evidence regarding the association between progestin-only injectable use and HIV acquisition. The clarification also notes the importance of condom use and other HIV preventive measures, expansion of the variety of contraceptive methods available (i.e., contraceptive method mix), and the need for further research on these issues.
See the text of the 2012 addendum for recommendations for contraceptive use by women who are at high risk for HIV infection, or who have HIV infection, or who have acquired immunodeficiency syndrome (AIDS).