Appendix for Summary of Changes from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

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TABLE A1Summary of changes in classifications from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*,ƒ?

Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs Clarification
Breastfeeding Breastfeeding provides important health benefits for mother and infant. The U.S. Department of Health and Human Services recommends increasing the proportion of infants initially breastfed, exclusively breastfed through 6 months of life, and continuing breastfeeding through at least 1 year of life as key public health goals (1).
  1. <21 days postpartum
 2 2 2 4
  1. 21 to <30 days postpartum
  1. With other risk factors for VTE (such as age ƒ%�35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ƒ%�30, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking)
 2 2 2 3 (CHCs): For women with other risk factors for VTE, these risk factors might increase the classification to a ƒ?o4ƒ??.
  1. Without other risk factors for VTE
 2 2 2 3
  1. 30-42 days postpartum
  1. With other risk factors for VTE (such as age ƒ%�35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ƒ%�30, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking)
 1 1 1 3 (CHCs): For women with other risk factors for VTE, these risk factors might increase the classification to a ƒ?o4ƒ??.
  1. Without other risk factors for VTE
 1 1 1 2
  1. >42 days postpartum
 1 1 1 2
Postpartum (nonbreastfeeding women)
  1. <21 days postpartum
 1 1 1 4
  1. 21-42 days postpartum
  1. With other risk factors for VTE (such as age ƒ%�35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI ƒ%�30, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking)
 1 1 1 3 (CHCs): For women with other risk factors for VTE, these risk factors might increase the classification to a ƒ?o4ƒ??.
  1. Without other risk factors for VTE
 1 1 1 2
  1. >42 days postpartum
 1 1 1 1
Postpartum (including postcesarean delivery) Insertion of IUDs among postpartum women is safe and does not appear to increase health risks associated with IUD use such as infection. Higher rates of expulsion during the postpartum period should be considered as they relate to effectiveness, along with patient access to interval placement (i.e. not related to pregnancy) when expulsion rates are lower.
(Breastfeeding): Breastfeeding provides important health benefits for mother and infant. The U.S. Department of Health and Human Services recommends increasing the proportion of infants initially breastfed, exclusively breastfed through 6 months of life, and continuing breastfeeding through at least 1 year of life as key public health goals (1).
  1. <10 minutes after delivery of the placenta
  1. Breastfeeding
 1 2
  1. Nonbreastfeeding
 1 1
  1. 10 minutes after delivery of the placenta to <4 wks (breastfeeding or nonbreastfeeding)
 2 2
  1. ƒ%�4 wks (breastfeeding or nonbreastfeeding)
 1 1
  1. Postpartum sepsis
 4 4
Multiple risk factors for atherosclerotic cardiovascular disease (such as older age, smoking, diabetes, hypertension, low HDL, high LDL, or high triglycerides) 1 2 2 3 2 3/4 (Implants, DMPA, POP): When multiple major risk factors exist, risk for cardiovascular disease might increase substantially. Some 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.
(CHCs): When a woman has multiple major risk factors, any of which alone would substantially increase her risk for cardiovascular disease, use of CHCs might increase her risk to an unacceptable level. However, a simple addition of categories for multiple risk factors is not intended; for example, a combination of two risk factors assigned a category 2 might not necessarily warrant a higher category.
(Implants, DMPA, POP, CHCs): The recommendations apply to known preexisting medical conditions or characteristics. Few if any screening tests are needed before initiation of contraception. See the U.S. Selected Practice Recommendations for Contraceptive Use (available at
http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usspr.htm)
Superficial venous disorders
  1. Varicose veins
 1 1 1 1 1 1
  1. Superficial venous thrombosis (acute or history)
 1 1 1 1 1 3 (CHCs): Superficial venous thrombosis may be associated with an increased risk of VTE. If a woman has risk factors for concurrent DVT (such as known thrombophilia or cancer) or has current or history of DVT, refer to recommendations for deep venous thrombosis (DVT)/pulmonary embolism (PE). Superficial venous thrombosis associated with a peripheral intravenous catheter is less likely to be associated with additional thrombosis and use of CHCs may be considered.
Headaches (CHCs): Classification depends on accurate diagnosis of those severe headaches that are migrainous and those headaches that are not, as well as diagnosis of ever experiencing aura. Aura is a specific focal neurologic symptom. For more information about headache classification see: The International Headache Society Classification (Available at http://ihs-classification.org/en/). Any new headaches or marked changes in headaches should be evaluated.
  1. Non-migrainous (mild or severe)
 1 1 1 1 1 1
  1. Migraine
  1. Without aura (this category of migraines includes menstrual migraine)
 1 1 1 1 1 2 (CHCs): Classification is for women without any other risk factors for stroke such as age, hypertension, and smoking.
  1. With aura
 1 1 1 1 1 4
Multiple sclerosis
  1. With prolonged immobility
 1 1 1 2 1 3
  1. Without prolonged immobility
 1 1 1 2 1 1
Gestational trophoblastic disease
This condition is associated with increased risk for adverse health events as a result of pregnancy; see .		 For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that women are under close medical supervision due to the need for monitoring of I&yacut;e-hCG levels for appropriate disease surveillance.
  1. Suspected gestational trophoblastic disease (immediate post-evacuation)
  1. Uterine size first trimester
 1 1 1 1 1 1
  1. Uterine size second trimester
 2 2 1 1 1 1
  1. Confirmed gestational trophoblastic disease (after initial evacuation and during monitoring)
  • I
  • C
  • I
  • C
  1. Undetectable/non-pregnant I&yacut;e-hCG levels
 1 1 1 1 1 1 1 1
  1. Decreasing I&yacut;e-hCG levels
 2 1 2 1 1 1 1 1 (IUD): For women with decreasing I&yacut;eƒ?hCG levels, the benefits of effective contraception must be weighed with individual circumstances, including risk for disease progression.
  1. Persistently elevated I&yacut;e-hCG levels or malignant disease, with no evidence or suspicion of intrauterine disease
 2 1 2 1 1 1 1 1
  1. Persistently elevated I&yacut;e-hCG levels or malignant disease, with evidence or suspicion of intrauterine disease
 4 2 4 2 1 1 1 1
STDs I C I C
  1. Current purulent cervicitis or chlamydial infection or gonorrhea
 4 2 4 2 1 1 1 1 (IUD continuation): Treat the STD using appropriate antibiotics. The IUD usually does not need to be removed if the woman wishes to continue using it. Continued use of an IUD depends on the womanƒ?(tm)s informed choice and her current risk factors for STDs and PID.
  1. Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)
 2 2 2 2 1 1 1 1
  1. Other factors related to STDs
 2 2 2 2 1 1 1 1 (IUD initiation): Most women do not require additional STD screening at the time of IUD insertion. If a woman with risk factors for STDs has not been screened for gonorrhea and chlamydia according to CDC STD Treatment guidelines (2), screening can be performed at the time of IUD insertion and insertion should not be delayed.
HIV
For women with HIV infection who are not clinically well or not on ARV therapy, this condition is associated with increased risk for adverse health events as a result of pregnancy; see .		 I C I C
  1. High risk for HIV
 2 2 2 2 1 1 1 1 (DMPA): Some studies suggest that women using progestin-only injectable contraception might be at increased risk for HIV acquisition; other studies do not show this association. CDC reviewed all available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk for HIV acquisition, women using progestin-only injectable contraception should be strongly advised to also always use condoms (male or female) and take other HIV preventive measures. Expansion of contraceptive method mix and further research on the relationship between hormonal contraception and HIV infection are essential. These recommendations will be continually reviewed in light of new evidence.
  1. HIV infection
 1 1 1 1 (Implants, DMPA, POP, CHCs): Drug interactions might exist between hormonal contraceptives and ARV drugs; refer to the section on drug interactions.
  1. Clinically well on ARV therapy
 1 1 1 1
  1. Not clinically well or not on ARV therapy
 2 1 2 1
Cystic fibrosis
This condition is associated with increased risk for adverse health events as a result of pregnancy; see .		 1 1 1 2 1 1 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 the U.S. MEC should be the same for women with cystic fibrosis who present with 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.
(Implants, DMPA, POP, CHCs): Certain drugs to treat cystic fibrosis (e.g. lumacaftor) may reduce effectiveness of hormonal contraceptives, including oral, injectable, transdermal, and implantable contraceptives.
Antiretroviral (ARV) therapy I C I C (IUD): No known interaction exists between ARV therapy and IUD use. However, IUD insertion is classified as Category 2 if the woman is not clinically well or not on ARV therapy. Otherwise, both insertion and continuation are classified as Category 1 (see HIV infection condition).
  1. Nucleoside reverse transcriptase inhibitors (NRTIs)
  1. Abacavir (ABC)
 1/2 1 1/2 1 1 1 1 1
  1. Tenofovir (TDF)
 1/2 1 1/2 1 1 1 1 1
  1. Zidovudine (AZT)
 1/2 1 1/2 1 1 1 1 1
  1. Lamivudine (3TC)
 1/2 1 1/2 1 1 1 1 1
  1. Didanosine (DDI)
 1/2 1 1/2 1 1 1 1 1
  1. Emtricitabine (FTC)
 1/2 1 1/2 1 1 1 1 1
  1. Stavudine (D4T)
 1/2 1 1/2 1 1 1 1 1
  1. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
  1. Efavirenz (EFV)
 1/2 1 1/2 1 2 1 2 2 (Implants, DMPA, POP, CHCs): Evidence suggests drug interactions between efavirenz and some hormonal contraceptives. These interactions may reduce the effectiveness of the hormonal contraceptive.
  1. Etravirine (ETR)
 1/2 1 1/2 1 1 1 1 1
  1. Nevirapine (NVP)
 1/2 1 1/2 1 1 1 1 1
  1. Rilpivirine (RPV)
 1/2 1 1/2 1 1 1 1 1
  1. Ritonavir-boosted protease inhibitors (PIs)
  1. Ritonavir-boosted atazanavir (ATV/r)
 1/2 1 1/2 1 2 1 2 2 (Implants, DMPA, POP): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs, due to the higher dose of DMPA.
(CHCs): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive.
  1. Ritonavir-boosted darunavir (DRV/r)
 1/2 1 1/2 1 2 1 2 2 (Implants, DMPA, POP): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs, due to the higher dose of DMPA.
(CHCs): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive.
  1. Ritonavir-boosted fosamprenavir (FPV/r)
 1/2 1 1/2 1 2 1 2 2 (Implants, DMPA, POP): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs, due to the higher dose of DMPA.
(CHCs): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive.
  1. Ritonavir-boosted lopinavir (LPV/r)
 1/2 1 1/2 1 1 1 1 1
  1. Ritonavir-boosted saquinavir (SQV/r)
 1/2 1 1/2 1 2 1 2 2 (Implants, DMPA, POP): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs, due to the higher dose of DMPA.
(CHCs): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive.
  1. Ritonavir-boosted tipranavir (TPV/r)
 1/2 1 1/2 1 2 1 2 2 (Implants, DMPA, POP): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs, due to the higher dose of DMPA.
(CHCs): There is theoretical concern for drug interactions between some ritonavir-boosted PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive.
  1. Protease inhibitors without ritonavir
  1. Atazanavir (ATV)
 1/2 1 1/2 1 1 1 1 2 (CHCs) Theoretically, increased levels of ethinyl estradiol due to interactions with ATV might increase the risk of adverse events.
  • ii.Fosamprenavir (FPV)
 1/2 1 1/2 1 2 2 2 3 (Implants, DMPA, POP): There is theoretical concern that interactions between FPV and hormonal contraceptives leading to decreased levels of FPV may diminish effectiveness of the antiretroviral. The drug interaction likely involves CYP3A4 pathways; progestin-only contraceptives have less effect on CYP3A4 enzymes than combined hormonal contraceptives.
(CHCs): There is concern that interactions between FPV and hormonal contraceptives leading to decreased levels of FPV may diminish effectiveness of the antiretroviral.
  1. Indinavir (IDV)
 1/2 1 1/2 1 1 1 1 1
  1. Nelfinavir (NFV)
 1/2 1 1/2 1 2 1 2 2 (Implants, DMPA, POP): There is theoretical concern for drug interactions between some PIs and some hormonal contraceptives that may reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs, due to the higher dose of DMPA. There is concern that interactions between NFV and progestin-only contraceptives may decrease NFV levels.
(CHCs): Evidence suggests drug interactions between some PIs and some hormonal contraceptives. These interactions may reduce the effectiveness of the hormonal contraceptive.
  1. CCR5 co-receptor antagonists
  1. Maraviroc (MVC)
 1/2 1 1/2 1 1 1 1 1
  1. HIV integrase strand transfer inhibitors
  1. Raltegravir (RAL)
 1/2 1 1/2 1 1 1 1 1
  1. Dolutegravir (DTG)
 1/2 1 1/2 1 1 1 1 1
  1. Elvitegravir (EVG)
 1/2 1 1/2 1 1 1 1 1
  1. Fusion inhibitors
  1. Enfuvirtide
 1/2 1 1/2 1 1 1 1 1
Psychotropic medications
  1. Selective serotonin reuptake inhibitors (SSRIs)
 1 1 1 1 1 1
St. Johnƒ?(tm)s wort 1 1 2 1 2 2

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