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Appendix A

Summary of Changes to the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th Edition, to Create the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010


The classification additions, deletions, and modifications from the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use, 4th Edition, are summarized below (Tables 1--3). For conditions for which classification changed for ≥1 methods or the condition description underwent a major modification, WHO conditions and recommendations appear in curly brackets.

BOX. Categories for Classifying Hormonal Contraceptives and Intrauterine Devices

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.


TABLE 1. Summary of changes in classifications from WHO Medical Eligibility Criteria for Contraceptive Use, 4th edition*

Condition

COC/P/R

POP

DMPA

Implants

LNG-IUD

Cu-IUD

Clarification

Breastfeeding

The US Department of Health and Human Services recommends that infants be exclusively breastfed during the first 4--6 months of life, preferably for a full 6 months. Ideally, breastfeeding should continue through the first year of life (1). {Not included in WHO MEC}

a. <1 mo postpartum {WHO: <6 wks postpartum}

3§ {4}

2§ {3}

2§ {3}

2§ {3}

b. 1 mo to <6 mos {WHO: ≥6 wks to <6 mos postpartum}

2§ {3}

Postpartum (in breastfeeding or nonbreastfeeding women), including post caesarean section

a. <10 min after delivery of the placenta {WHO: <48 hrs, including insertion immediately after delivery of the placenta}

2 {1 if not breastfeeding and 3 if breastfeeding}

b. 10 min after delivery of the placenta to <4 wks {WHO: ≥48 hrs to <4 wks}

2 {3}

2{3}

Deep venous thrombosis (DVT)/pulmonary embolism (PE)

a. History of DVT/PE, not on anticoagulant therapy

ii. Lower risk for recurrent DVT/PE (no risk factors)

3 {4}

b. Acute DVT/PE

2 {3}

2 {3}

2 {3}

2 {3}

2 {1}

c. DVT/PE and established on anticoagulant therapy for at least 3 mos


TABLE 1. (Continued) Summary of changes in classifications from WHO Medical Eligibility Criteria for Contraceptive Use, 4th edition*

Condition

COC/P/R

POP

DMPA

Implants

LNG-IUD

Cu-IUD

Clarification

i. Higher risk for recurrent DVT/PE (≥1 risk factors)

2 {1}

• Known thrombophilia, including antiphospholipid syndrome

• Active cancer (metastatic, on therapy, or within 6 mos after clinical remission), excluding non-melanoma skin cancer

• History of recurrent DVT/PE

ii. Lower risk for recurrent DVT/PE (no risk factors)

3§ {4}

2 {1}

Women on anticoagulant therapy are at risk for gynecologic complications of therapy such as hemorrhagic ovarian cysts and severe menorrhagia. Hormonal contraceptive methods can be of benefit in preventing or treating these complications. When a contraceptive method is used as a therapy, rather than solely to prevent pregnancy, the risk/benefit ratio may be different and should be considered on a case-by-case basis. {Not included in WHO MEC}

Valvular heart disease

b. Complicated(pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)

1 {2}

1 {2}

Ovarian cancer

1 {Initiation = 3, Continuation = 2}

1 {Initiation = 3, Continuation = 2}

Uterine fibroids

2 {1 if no uterine distortion and 4 if uterine distortion is present}

2 {1 if no uterine distortion and 4 if uterine distortion is present}

* For conditions for which classification changed for ≥1 methods or the condition description underwent a major modification, WHO conditions and recommendations appear in curly brackets.

Abbreviations: WHO = World Health Organization; COC = combined oral contraceptive; P = combined hormonal contraceptive patch; R = combined hormonal vaginal ring; POP = progestin-only pill; DMPA = depot medroxyprogesterone acetate; LNG-IUD = levonorgestrel-releasing intrauterine device; Cu-IUD = copper intrauterine device; DVT = deep venous thrombosis; PE = pulmonary embolism; VTE = venous thromboembolism.

§ Consult the clarification column for this classification.

Condition that exposes a women to increased risk as a result of unintended pregnancy.


TABLE 2. Summary of recommendations for medical conditions added to the U.S. Medical Eligibility Criteria for Contraceptive Use*

Condition

COC/P/R

POP

DMPA

Implants

LNG-IUD

Cu-IUD

Clarification

History of bariatric surgery

a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, 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, biliopancreatic diversion)

COCs: 3 P/R: 1

3

1

1

1

1

Peripartum cardiomyopathy

a. Normal or mildly impaired cardiac function (New York Heart Association Functional Class I or II: patients with no limitation of activities or patients with slight, mild limitation of activity) (2)

i <6 mos

4

1

1

1

2

2

ii ≥6 mos

3

1

1

1

2

2

b. Moderately or severely impaired cardiac function (New York Heart Association Functional Class III or IV: patients with marked limitation of activity or patients who should be at complete rest) (2)

4

2

2

2

2

2

Rheumatoid arthritis

Initiation

Continuation

Initiation

Continuation

a. On immunosuppressive therapy

2

1

2/3§

1

2

1

2

1

DMPA use among women on long-term corticosteroid therapy with a history of, or risk factors for, nontraumatic fractures is classified as Category 3. Otherwise, DMPA use for women with rheumatoid arthritis is classified as Category 2.

b. Not on immunosuppressive therapy

2

1

2

1

1

1

Endometrial hyperplasia

1

1

1

1

1

1

Inflammatory bowel disease (IBD)

(ulcerative colitis, Crohn disease)

2/3§

2

2

1

1

1

For women with mild IBD, with no other risk factors for VTE, the benefits of COC/P/R use generally outweigh the risks (Category 2). However, for women with IBD with increased risk for VTE (e.g., those with active or extensive disease, surgery, immobilization, corticosteroid use, vitamin deficiencies, fluid depletion), the risks for COC/P/R use generally outweigh the benefits (Category 3).

Solid organ transplantation

Initiation

Continuation

Initiation

Continuation

a. Complicated: graft failure (acute or chronic), rejection, cardiac allograft vasculopathy

4

2

2

2

3

2

3

2

b. Uncomplicated

2§

2

2

2

2

2

Women with Budd-Chiari syndrome should not use COC/P/R because of the increased risk for thrombosis.

* Abbreviations: COC = combined oral contraceptive; P = combined hormonal contraceptive patch; R = combined hormonal vaginal ring: POP = progestin-only pill; DMPA = depot medroxyprogesterone acetate; LNG-IUD = levonorgestrel-releasing intrauterine device; Cu-IUD = copper intrauterine device; IBD = inflammatory bowel disease; VTE = venous thromboembolism.

Condition that exposes a women to increased risk as a result of unintended pregnancy.

§ Consult the clarification column for this classification.


TABLE 3. Summary of additional changes to the U.S. Medical Eligibility Criteria for Contraceptive Use

Condition/Contraceptive method

Change

Emergency contraceptive pills

History of bariatric surgery, rheumatoid arthritis, inflammatory bowel disease, and solid organ transplantation were added to Appendix D and given a Category 1.

Barrier methods

For 6 conditions---history of bariatric surgery, peripartum cardiomyopathy, rheumatoid arthritis, endometrial hyperplasia, inflammatory bowel disease, and solid organ transplantation---the barrier methods are classified as Category 1.

Sterilization

In general, no medical conditions would absolutely restrict a person's eligibility for sterilization. Recommendations from the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use about specific settings and surgical procedures for sterilization are not included here. The guidance has been replaced with general text on sterilization.

Other deleted items

Guidance for combined injectables, levonorgestrel implants, and norethisterone enanthate has been removed because these methods are not currently available in the United States.

Guidance for "blood pressure measurement unavailable" and "history of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy)" has been removed.

Unintended pregnancy and increased health risk

The following conditions have been added to the WHO list of conditions that expose a woman to increased risk as a result of unintended pregnancy: history of bariatric surgery within the past 2 years, peripartum cardiomyopathy, and receiving a solid organ transplant within 2 years.

References

  1. Office on Women's Health, US Department of Health and Human Services. HHS blueprint for action on breastfeeding. Washington, DC: US Department of Health and Human Services, Office on Women's Health; 2000.
  2. 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 & Co; 1994.

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