Tables A1 and A2. Summary of Changes from US MEC, 2010
| Condition | Cu-IUD | LNG-IUD | Implants | DMPA | POP | CHCs | Clarification | |||
|---|---|---|---|---|---|---|---|---|---|---|
| Breastfeeding | ||||||||||
| a. <21 days postpartum | — | — | 2 | 2 | 2 | 4 | 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). | |||
| 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 | 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). | |||
| CHCs: For women with other risk factors for VTE, these risk factors might increase the classification to a category 4. | ||||||||||
| ii. Without other risk factors for VTE | — | — | 2 | 2 | 2 | 3 | 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). | |||
| 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 | 1 | 1 | 3 | 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). | |||
| CHCs: For women with other risk factors for VTE, these risk factors might increase the classification to a category 4. | ||||||||||
| ii. Without other risk factors for VTE | — | — | 1 | 1 | 1 | 2 | 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). | |||
| d. >42 days postpartum | — | — | 1 | 1 | 1 | 2 | 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). | |||
| Postpartum (nonbreastfeeding women) | ||||||||||
| a. <21 days postpartum | — | — | 1 | 1 | 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 | 1 | 1 | 3 | CHCs: For women with other risk factors for VTE, these risk factors might increase the classification to a category 4. | |||
| ii. Without other risk factors for VTE | — | — | 1 | 1 | 1 | 2 | — | |||
| c. >42 days postpartum | — | — | 1 | 1 | 1 | 1 | — | |||
| Postpartum (including cesarean delivery) | ||||||||||
| a. <10 minutes after delivery of the placenta | IUDs: 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). |
|||||||||
| i. Breastfeeding | 1 | 2 | — | — | — | — | ||||
| ii. Nonbreastfeeding | 1 | 1 | — | — | — | — | ||||
| b. 10 minutes after delivery of the placenta to <4 weeks (breastfeeding or nonbreastfeeding) | 2 | 2 | — | — | — | — | IUDs: 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). | ||||||||||
| c. ≥4 weeks (breastfeeding or nonbreastfeeding) | 1 | 1 | — | — | — | — | IUDs: 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). | ||||||||||
| d. Postpartum sepsis | 4 | 4 | — | — | — | — | — | |||
| 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 | Implants, DMPA, POP: When multiple major risk factors exist, risk for cardiovascular disease might increase substantially. Certain 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 category 2 risk factors 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. | ||||||||||
| Superficial venous disorders | ||||||||||
| a. Varicose veins | 1 | 1 | 1 | 1 | 1 | 1 | — | |||
| b. Superficial venous thrombosis (acute or history) | 1 | 1 | 1 | 1 | 1 | 3 | CHCs: Superficial venous thrombosis might be associated with an increased risk for VTE. If a woman has risk factors for concurrent DVT (e.g., known thrombophilia or cancer) or has current or history of DVT, see recommendations for DVT/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 | ||||||||||
| a. Nonmigraine (mild or severe) | 1 | 1 | 1 | 1 | 1 | 1 | CHCs: Classification depends on accurate diagnosis of those severe headaches that are migraines 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 Classification, 3rd edition (https://ichd-3.org/wp-content/uploads/2018/01/The-International-Classification-of-Headache-Disorders-3rd-Edition-2018.pdf). Any new headaches or marked changes in headaches should be evaluated. | |||
| b. Migraine | CHCs: Classification depends on accurate diagnosis of those severe headaches that are migraines 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, 3rd edition (https://ichd-3.org/wp-content/uploads/2018/01/The-International-Classification-of-Headache-Disorders-3rd-Edition-2018.pdf). Any new headaches or marked changes in headaches should be evaluated.CHCs: Classification is for women without any other risk factors for stroke (e.g., age, hypertension, and smoking). | |||||||||
| i. Without aura (This category of migraine includes menstrual migraine.) | 1 | 1 | 1 | 1 | 1 | 2 | ||||
| ii. With aura | 1 | 1 | 1 | 1 | 1 | 4 | ||||
| Multiple sclerosis | ||||||||||
| a. With prolonged immobility | 1 | 1 | 1 | 2 | 1 | 3 | — | |||
| b. 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 (Box 2). |
For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that women are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance. | |||||||||
| a. Suspected gestational trophoblastic disease (immediate postevacuation) | For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that women are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance. | |||||||||
| 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/nonpregnant β-hCG levels | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that women are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance. | |
| ii. Decreasing β-hCG levels | 2 | 1 | 2 | 1 | 1 | 1 | 1 | 1 | For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that women are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance. IUD: For women at higher risk for disease progression, the benefits of effective contraception must be weighed against the potential need for early IUD removal. |
|
| 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 | For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that women are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance. | |
| iv. Persistently elevated β-hCG levels or malignant disease, with evidence or suspicion of intrauterine disease | 4 | 2 | 4 | 2 | 1 | 1 | 1 | 1 | For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that women are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance. | |
| Sexually transmitted diseases | Initiation | Continuation | Initiation | Continuation | ||||||
| a. Current purulent cervicitis or chlamydial infection or gonococcal infection | 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 wants to continue using it. Continued use of an IUD depends on the woman’s informed choice and her current risk factors for STDs and PID. | |
| b. Vaginitis (including Trichomonas vaginalis and bacterial vaginosis) | 2 | 2 | 2 | 2 | 1 | 1 | 1 | 1 | — | |
| c. 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 may be performed at the time of IUD insertion and insertion should not be delayed. | |
| High risk for HIV | Initiation | Continuation | Initiation | Continuation | 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. | |||||
| 2 | 2 | 2 | 2 | 1 | 1 | 1 | 1 | |||
| HIV infection For women 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 (Box 2). |
— | — | — | — | 1 | 1 | 1 | 1 | Implants, DMPA, POP, CHCs: Drug interactions might exist between hormonal contraceptives and ARV drugs; see Drug Interactions section. | |
| a. Clinically well receiving ARV therapy | 1 | 1 | 1 | 1 | — | — | — | — | — | |
| b. Not clinically well or not receiving ARV therapy | 2 | 1 | 2 | 1 | — | — | — | — | — | |
| Cystic fibrosis This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 2). |
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 U.S. MEC should be the same for women with cystic fibrosis who have 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) might reduce effectiveness of hormonal contraceptives, including oral, injectable, transdermal, and implantable contraceptives. | ||||||||||
| Antiretroviral therapy | Initiation | Continuation | Initiation | Continuation | 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 receiving ARV therapy. Otherwise, both insertion and continuation are classified as category 1 (see HIV Infection section). | |||||
| a. Nucleoside reverse transcriptase inhibitors (NRTIs) | ||||||||||
| 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 | Implants, DMPA, POP, CHCs: Evidence suggests drug interactions between efavirenz and certain hormonal contraceptives. These interactions might reduce the effectiveness of the hormonal contraceptive. | |
| 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 |
Implants, DMPA, POP: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA. |
|
| CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. | ||||||||||
| ii. Ritonavir-boosted darunavir (DRV/r) | 1/2 | 1 | 1/2 | 1 | 2 | 1 | 2 | 2 | Implants, DMPA, POP: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA. | |
| CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. | ||||||||||
| iii. Ritonavir-boosted fosamprenavir (FPV/r) | 1/2 | 1 | 1/2 | 1 | 2 | 1 | 2 | 2 | Implants, DMPA, POP: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA. | |
| CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. | ||||||||||
| 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 | Implants, DMPA, POP: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA. | |
| CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. | ||||||||||
| vi. Ritonavir-boosted tipranavir (TPV/r) | 1/2 | 1 | 1/2 | 1 | 2 | 1 | 2 | 2 | Implants, DMPA, POP: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA. | |
| CHCs: Theoretically, drug interactions might occur between certain ritonavir-boosted protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. | ||||||||||
| d. Protease inhibitors without ritonavir | ||||||||||
| i. Atazanavir (ATV) | 1/2 | 1 | 1/2 | 1 | 1 | 1 | 1 | 2 | CHCs: Theoretical concern exists that increased levels of ethinyl estradiol because of interactions with ATV might increase the risk for adverse events. | |
| ii. Fosamprenavir (FPV) | 1/2 | 1 | 1/2 | 1 | 2 | 2 | 2 | 3 | Implants, DMPA, POP: Theoretical concern exists that interactions between FPV and hormonal contraceptives leading to decreased levels of FPV might diminish effectiveness of the antiretroviral drug. The drug interaction likely involves CYP3A4 pathways; POCs have less effect on CYP3A4 enzymes than CHCs. | |
| CHCs: Concern exists that interactions between FPV and hormonal contraceptives leading to decreased levels of FPV might diminish effectiveness of the antiretroviral drug. | ||||||||||
| 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 | Implants, DMPA, POP: Theoretically, drug interactions might occur between certain protease inhibitors and certain hormonal contraceptives that might reduce the effectiveness of the hormonal contraceptive. Any potential effect on contraceptive effectiveness is likely to be lower with DMPA than with other POCs because of the higher dose of DMPA. Concern exists that interactions between NFV and POCs might decrease NFV levels. | |
| CHCs: Evidence suggests drug interactions between certain protease inhibitors and certain hormonal contraceptives. These interactions might reduce the effectiveness of the hormonal contraceptive. | ||||||||||
| 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 | — | |
| Psychotropic medications | ||||||||||
| a. 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-containing intrauterine device; DMPA = depot medroxyprogesterone acetate; DVT = deep venous thrombosis; hCG = human chorionic gonadotropin; HDL = high-density lipoprotein; HIV = human immunodeficiency virus; LDL = low-density lipoprotein; LNG-IUD = levonorgestrel-releasing intrauterine device; PE = pulmonary embolism; PID = pelvic inflammatory disease; POC = progestin-only contraceptive; POP = progestin-only pill; SSRI = selective serotonin uptake inhibitor; STD = sexually transmitted disease; VTE = venous thromboembolism.
* For conditions for which classification changed for one or more contraceptive methods or the condition description underwent a major modification, the changes or modifications are in bold italics.
| Condition | Category | Clarification | |||
|---|---|---|---|---|---|
| Cu-IUD | UPA | LNG | COC | ||
| Pregnancy |
4 |
NA |
NA | NA | IUD: The IUD is not indicated during pregnancy and should not be used because of the risk for serious pelvic infection and septic spontaneous abortion. |
| ECPs: Although this method is not indicated for a woman with a known or suspected pregnancy, no harm to the woman, the course of her pregnancy, or the fetus if ECPs are inadvertently used is known to exist. | |||||
| Breastfeeding |
1 |
1 |
1 |
1 |
UPA: Breastfeeding is not recommended for 24 hours after taking UPA because it is excreted in breast milk with highest concentrations in the first 24 hours, and maximum maternal serum levels are reached 1-3 hours after administration. Mean UPA concentrations in breast milk decrease markedly from 0 to 24–48 hours and then slowly decrease over 5 days (3). Breast milk should be expressed and discarded for 24 hours after taking UPA. |
| Past ectopic pregnancy |
1 |
1 |
1 |
1 |
— |
| History of bariatric surgery This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 2). |
|||||
| a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy) |
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 |
— |
| History of severe cardiovascular disease (ischemic heart disease, cerebrovascular attack, or other thromboembolic conditions) This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 2). |
1 | 2 |
2 |
2 |
— |
| Rheumatoid arthritis | |||||
| a. Receiving immunosuppressive therapy |
2 |
1 |
1 |
1 |
— |
| b. Not receiving immunosuppressive therapy |
1 |
1 |
1 |
1 |
— |
| Migraine |
1 |
1 |
1 |
2 |
— |
| Inflammatory bowel disease (ulcerative colitis or Crohn’s disease) |
1 |
1 |
1 |
1 |
— |
| Severe liver disease (including jaundice) This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 2). |
1 |
2 |
2 |
2 |
— |
| Solid organ transplantation This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 2). |
|||||
| a. Complicated: graft failure (acute or chronic), rejection, or cardiac allograft vasculopathy |
3 |
1 |
1 |
1 |
— |
| b. Uncomplicated |
2 |
1 |
1 |
1 |
— |
| Repeated ECP use |
1 |
1 |
1 |
1 |
ECPs: Recurrent ECP use is an indication that the woman requires further counseling about other contraceptive options. Frequently repeated ECP use might be harmful for women with conditions classified as 2, 3, or 4 for CHC or POC use. |
| Sexual assault |
2 |
1 |
1 |
1 |
IUD: Women who have experienced sexual assault are at increased risk for STDs. According to CDC STD treatment guidelines, routine presumptive treatment of chlamydia, gonorrhea, and trichomonas is recommended after sexual assault (2). Women with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD insertion (category 4). |
| Obesity (BMI ≥30 kg/m2) |
1 |
2 |
2 |
2 |
ECPs: ECPs might be less effective among women with BMI ≥30 kg/m2 than among women with BMI <25 kg/m2. Despite this, no safety concerns exist. |
| CYP3A4 inducers (e.g., bosentan, carbamazepine, felbamate, griseofulvin, oxcarbazepine, phenytoin, rifampin, St. John’s wort, topiramate, efavirenz, and lumacaftor) |
1 |
2 |
2 |
2 |
ECPs: Strong CYP3A4 inducers might reduce the effectiveness of ECPs. |
Abbreviations: BMI = body mass index; CHC = combined hormonal contraceptive; COC = combined oral contraceptive; Cu-IUD = copper-containing intrauterine device; ECP = emergency contraceptive pill; IUD = intrauterine device; LNG = levonorgestrel; NA = not applicable; POC = progestin-only contraceptive; STD = sexually transmitted disease; UPA = ulipristal acetate.
* For conditions for which classification changed for one or more contraceptive methods or the condition description underwent a major modification, the changes or modifications are in bold italics.
References
- US Department of Health and Human Services. Healthy people 2020: maternal, infant, and child health objectives. Washington, DC: US Department of Health and Human Services; 2015. http://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives
- Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-03). PubMed
- Watson Pharmaceuticals. Ella [Prescribing information]. Morristown, NJ; 2010. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf
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