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Classifications for Fertility Awareness–Based Methods

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Fertility awareness-based (FAB) methods of family planning involve identifying the fertile days of the menstrual cycle, whether by observing fertility signs such as cervical secretions and basal body temperature or by monitoring cycle days (Box F1) (Table F1). FAB methods can be used in combination with abstinence or barrier methods during the fertile time. If barrier methods are used, see the Classifications for Barrier Methods.

No medical conditions worsen because of FAB methods. In general, FAB methods can be used without concern for health effects in persons who choose them. However, several conditions make their use more complex. The existence of these conditions suggests that 1) use of these methods should be delayed until the condition is corrected or resolved or 2) persons using FAB methods need special counseling, and a provider with particular training in use of these methods is generally necessary to ensure correct use.

Women with conditions that make pregnancy an unacceptable risk should be advised that FAB methods might not be appropriate for them because of the relatively higher typical-use failure rates of these methods. Symptoms-based and calendar-based methods do not protect against sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and women using these methods should be counseled that consistent and correct use of the male latex condom reduces the risk for transmission of HIV and other STDs. Use of female condoms can provide protection from transmission of STDs, although data are limited.

Box F1. Definitions for terms associated with fertility awareness-based methods
  • Symptoms-based methods: FAB methods based on observation of fertility signs (e.g., cervical secretions or basal body temperature) such as the cervical mucus method, the symptothermal method, and the TwoDay method.
  • Calendar-based methods: FAB methods based on calendar calculations such as the calendar rhythm method and the standard days method.
  • Acccept: No medical reason exists to deny the particular FAB method to a woman in this circumstance.
  • Caution: The method normally is provided in a routine setting but with extra preparation and precautions. For FAB methods, this usually means that special counselling might be needed to ensure correct use of the method by a woman in this circumstance.
  • Delay: Use of this method should be delayed until the condition is evaluated or corrected. Alternative temporary methods of contraception should be offered.

Abbreviation: FAB = fertility awareness–based.


TABLE F1. Fertility awareness-based methods, including symptoms-based and calendar-based methods
Condition Category Clarifications/Evidence/Comments
Symptoms-based method Calendar-based method
Personal Characteristics and Reproductive History
Pregnancy Not applicable Clarification: FAB methods are not relevant during pregnancy.
Life stage Comment: Menstrual irregularities are common in postmenarche and perimenopause and might complicate the use of FAB methods.
a. Postmenarche Caution Caution
b. Perimenopause Caution Caution
Breastfeeding Comment: Use of FAB methods when breastfeeding might be less effective than when not breastfeeding.
a. <6 weeks postpartum Delay Delay Comment: Women who are primarily breastfeeding and are amenorrheic are unlikely to have sufficient ovarian function to produce detectable fertility signs and hormonal changes during the first 6 months postpartum. However, the likelihood of resumption of fertility increases with time postpartum and with substitution of breast milk with other foods.
b. ≥6 weeks Caution Delay
c. After menses begin Caution Caution Clarification: When the woman notices fertility signs, particularly cervical secretions, she can use a symptoms-based method. First postpartum menstrual cycles in breastfeeding women vary significantly in length. Return to regularity takes several cycles. When she has had at least 3 postpartum menses and her cycles are regular again, she can use a calendar-based method. When she has had at least 4 postpartum menses and her most recent cycle lasted 26–32 days, she can use the standard days method. Before that time, a barrier method should be offered if the woman plans to use a FAB method later.
Postpartum (nonbreastfeeding women)
a. <4 weeks Delay Delay Clarification: Nonbreastfeeding women are not likely to have detectable fertility signs or hormonal changes before 4 weeks postpartum. Although the risk for pregnancy is low, ovulation before first menses is common; therefore, a method appropriate for the postpartum period should be offered.
b. ≥4 weeks Accept Delay Clarification: Nonbreastfeeding women are likely to have sufficient ovarian function to produce detectable fertility signs, hormonal changes, or both at this time; likelihood increases rapidly with time postpartum. Women can use calendar-based methods as soon as they have completed three postpartum menses. Methods appropriate for the postpartum period should be offered before that time.
Postabortion Caution Delay Clarification: After abortion, women are likely to have sufficient ovarian function to produce detectable fertility signs, hormonal changes, or both; likelihood increases with time postabortion. Women can start using calendar-based methods after they have had at least one postabortion menses (e.g., women who before this pregnancy primarily had cycles of 26–32 days can then use the standard days method). Methods appropriate for the postabortion period should be offered before that time.
Reproductive Tract Infections and Disorders
Irregular vaginal bleeding Delay Delay Clarification: Presence of this condition makes FAB methods unreliable. Therefore, barrier methods should be recommended until the bleeding pattern is compatible with proper method use. The condition should be evaluated and treated as necessary.
Vaginal discharge Delay Accept Clarification: Because vaginal discharge makes recognition of cervical secretions difficult, the condition should be evaluated and treated if needed before providing methods based on cervical secretions.
Use of drugs that affect cycle regularity, hormones, or fertility signs Caution /Delay Caution /Delay Clarification: Use of certain mood-altering drugs such as lithium, tricyclic antidepressants, and antianxiety therapies, as well as certain antibiotics and anti-inflammatory drugs, might alter cycle regularity or affect fertility signs. The condition should be carefully evaluated and a barrier method offered until the degree of effect has been determined or the drug is no longer being used.
Diseases that elevate body temperature
a. Chronic diseases Caution Accept Clarification: Elevated temperatures might make basal body temperature difficult to interpret but have no effect on cervical secretions. Thus, use of a method that relies on temperature should be delayed until the acute febrile disease abates. Temperature-based methods are not appropriate for women with chronically elevated temperatures. In addition, some chronic diseases interfere with cycle regularity, making calendar-based methods difficult to interpret.
b. Acute diseases Delay Accept

*Abbreviations: FAB = fertility awareness–based