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US Selected Practice Recommendations for Contraceptive Use, 2016

Appendix A: Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, 2016

Health-care providers can use the summary table as a quick reference guide to the classifications for hormonal contraceptive methods and intrauterine contraception to compare classifications across these methods (Box A1) (Table A1). For complete guidance, see the 2016 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) (Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65[No. RR-3]) for clarifications to the numeric categories, as well as for summaries of the evidence and additional comments. Hormonal contraceptives and intrauterine devices 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 A1. 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 A1. Summary of classifications for hormonal contraceptive methods and intrauterine devices

Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs
Personal Characteristics And Reproductive History
Pregnancy 4* 4* NA* NA* NA* NA*
Age Menarche to <20 years: 2 Menarche to <20 years: 2 Menarche to <18 years: 1 Menarche to <18 years: 2 Menarche to <18 years: 1 Menarche to <40 years: 1
≥20 years: 1 ≥20 years: 1 18–45 years: 1 18–45 years: 1 18–45 years: 1 ≥40 years: 2
>45 years: 1 >45 years: 2 >45 years: 1
Parity
a. Nulliparous 2 2 1 1 1 1
b. Parous 1 1 1 1 1 1
Breastfeeding
a. <21 days postpartum 2* 2* 2* 4*
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*
ii. Without other risk factors for VTE 2* 2* 2* 3*
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*
ii. Without other risk factors for VTE 1* 1* 1* 2*
d. >42 days postpartum 1* 1* 1* 2*
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*
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
i. Breastfeeding 1* 2*
ii. Nonbreastfeeding 1* 1*
b. 10 minutes after delivery of the placenta to <4 weeks (breastfeeding or nonbreastfeeding) 2* 2*
c. ≥4 weeks (breastfeeding or nonbreastfeeding) 1* 1*
d. Postpartum sepsis 4 4
Postabortion
a. First trimester 1* 1* 1* 1* 1* 1*
b. Second trimester 2* 2* 1* 1* 1* 1*
c. Immediate postseptic abortion 4 4 1* 1* 1* 1*
Past ectopic pregnancy 1 1 1 1 2 1
History of pelvic surgery (see Postpartum [Including Cesarean Delivery] section) 1 1 1 1 1 1
Smoking
a. Age <35 years 1 1 1 1 1 2
b. Age ≥35 years
i. <15 cigarettes/day 1 1 1 1 1 3
ii. ≥15 cigarettes/day 1 1 1 1 1 4
Obesity
a. BMI ≥30 kg/m2 1 1 1 1 1 2
b. Menarche to <18 years and BMI ≥30 kg/m2 1 1 1 2 1 2
History of bariatric surgery
This condition is associated with increased risk for adverse health events as a result of pregnancy.
a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, or 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 or biliopancreatic diversion) 1 1 1 1 3 COCs: 3
Patch and ring: 1
Cardiovascular Disease
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*
Hypertension
Systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg are associated with increased risk for adverse health events as a result of pregnancy.
a. Adequately controlled hypertension 1* 1* 1* 2* 1* 3*
b. Elevated blood pressure levels
(properly taken measurements)
i. Systolic 140–159 mm Hg or diastolic 90–99 mm Hg 1* 1* 1* 2* 1* 3*
ii. Systolic ≥160 mm Hg or diastolic ≥100 mm Hg 1* 2* 2* 3* 2* 4*
c. Vascular disease 1* 2* 2* 3* 2* 4*
History of high blood pressure during pregnancy (when current blood pressure is measurable and normal) 1 1 1 1 1 2
Deep venous thrombosis/
Pulmonary embolism
a. History of DVT/PE, not receiving anticoagulant therapy
i. Higher risk for recurrent DVT/PE (one or more risk factors) 1 2 2 2 2 4

• History of estrogen-associated DVT/PE

• Pregnancy-associated DVT/PE

• Idiopathic DVT/PE

• Known thrombophilia, including antiphospholipid syndrome

• Active cancer (metastatic, receiving therapy, or within 6 months after clinical remission), excluding nonmelanoma skin cancer

• History of recurrent DVT/PE

ii. Lower risk for recurrent DVT/PE (no risk factors) 1 2 2 2 2 3
b. Acute DVT/PE 2 2 2 2 2 4
c. DVT/PE and established anticoagulant therapy for at least 3 months
i. Higher risk for recurrent DVT/PE (one or more risk factors) 2 2 2 2 2 4*

• Known thrombophilia, including antiphospholipid syndrome

• Active cancer (metastatic, receiving therapy, or within 6 months after clinical remission), excluding nonmelanoma skin cancer

• History of recurrent DVT/PE

ii. Lower risk for recurrent DVT/PE (no risk factors) 2 2 2 2 2 3*
d. Family history (first-degree relatives) 1 1 1 1 1 2
e. Major surgery
i. With prolonged immobilization 1 2 2 2 2 4
ii. Without prolonged immobilization 1 1 1 1 1 2
f. Minor surgery without immobilization 1 1 1 1 1 1
Known thrombogenic mutations (e.g., factor V Leiden; prothrombin mutation; and protein S, protein C, and antithrombin deficiencies)
This condition is associated with increased risk for adverse health events as a result of pregnancy.
1* 2* 2* 2* 2* 4*
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*
Current and history of ischemic heart disease
This condition is associated with increased risk for adverse health events as a result of pregnancy.
Initiation Continuation Initiation Continuation Initiation Continuation
1 2 3 2 3 3 2 3 4
Stroke (history of cerebrovascular accident)
This condition is associated with increased risk for adverse health events as a result of pregnancy.
Initiation Continuation Initiation Continuation
1 2 2 3 3 2 3 4
Valvular heart disease
Complicated valvular heart disease is associated with increased risk for adverse health events as a result of pregnancy.
a. Uncomplicated 1 1 1 1 1 2
b. Complicated (pulmonary hypertension, risk for atrial fibrillation, or history of subacute bacterial endocarditis) 1 1 1 1 1 4
Peripartum cardiomyopathy
This condition is associated with increased risk for adverse health events as a result of pregnancy.
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 months 2 2 1 1 1 4
ii. ≥6 months 2 2 1 1 1 3
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). 2 2 2 2 2 4
Rheumatic Diseases
Systemic lupus erythematosus
This condition is associated with increased risk for adverse health events as a result of pregnancy.
Initiation Continuation Initiation Continuation
a. Positive (or unknown) antiphospholipid antibodies 1* 1* 3* 3* 3* 3* 3* 4*
b. Severe thrombocytopenia 3* 2* 2* 2* 3* 2* 2* 2*
c. Immunosuppressive therapy 2* 1* 2* 2* 2* 2* 2* 2*
d. None of the above 1* 1* 2* 2* 2* 2* 2* 2*
Rheumatoid arthritis Initiation Continuation Initiation Continuation
a. Receiving immunosuppressive therapy 2 1 2 1 1 2/3* 1 2
b. Not receiving immunosuppressive therapy 1 1 1 2 1 2
Neurologic Conditions
Headaches
a. Nonmigraine (mild or severe) 1 1 1 1 1 1*
b. Migraine
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*
Epilepsy
This condition is associated with increased risk for adverse health events as a result of pregnancy.
1 1 1* 1* 1* 1*
Multiple sclerosis
a. With prolonged immobility 1 1 1 2 1 3
b. Without prolonged immobility 1 1 1 2 1 1
Depressive Disorders
Depressive disorders 1* 1* 1* 1* 1* 1*
Reproductive Tract Infections and Disorders
Vaginal bleeding patterns Initiation Continuation
a. Irregular pattern without heavy bleeding 1 1 1 2 2 2 1
b. Heavy or prolonged bleeding (includes regular and irregular patterns) 2* 1* 2* 2* 2* 2* 1*
Unexplained vaginal bleeding
(suspicious for serious condition) before evaluation
Initiation Continuation Initiation Continuation
4* 2* 4* 2* 3* 3* 2* 2*
Endometriosis 2 1 1 1 1 1
Benign ovarian tumors (including cysts) 1 1 1 1 1 1
Severe dysmenorrhea 2 1 1 1 1 1
Gestational trophoblastic disease
This condition is associated with increased risk for adverse health events as a result of pregnancy.
a. Suspected gestational trophoblastic disease (immediate postevacuation)
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/non-pregnant β-hCG levels 1* 1* 1* 1* 1* 1* 1* 1*
ii. Decreasing β-hCG levels 2* 1* 2* 1* 1* 1* 1* 1*
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*
iv. Persistently elevated β-hCG levels or malignant disease, with evidence or suspicion of intrauterine disease 4* 2* 4* 2* 1* 1* 1* 1*
Cervical ectropion 1 1 1 1 1 1
Cervical intraepithelial neoplasia 1 2 2 2 1 2
Cervical cancer (awaiting treatment) Initiation Continuation Initiation Continuation
4 2 4 2 2 2 1 2
Breast disease
Breast cancer is associated with increased risk of adverse health events as a result of pregnancy.
a. Undiagnosed mass 1 2 2* 2* 2* 2*
b. Benign breast disease 1 1 1 1 1 1
c. Family history of cancer 1 1 1 1 1 1
d. Breast cancer
i. Current 1 4 4 4 4 4
ii. Past and no evidence of current disease for 5 years 1 3 3 3 3 3
Endometrial hyperplasia 1 1 1 1 1 1
Endometrial cancer
This condition is associated with increased risk for adverse health events as a result of pregnancy.
Initiation Continuation Initiation Continuation
4 2 4 2 1 1 1 1
Ovarian cancer
This condition is associated with increased risk for adverse health events as a result of pregnancy.
1 1 1 1 1 1
Uterine fibroids 2 2 1 1 1 1
Anatomical abnormalities
a. Distorted uterine cavity (any congenital or acquired uterine abnormality distorting the uterine cavity in a manner that is incompatible with IUD insertion) 4 4
b. Other abnormalities (including cervical stenosis or cervical lacerations) not distorting the uterine cavity or interfering with IUD insertion 2 2
Pelvic inflammatory disease
a. Past PID Initiation Continuation Initiation Continuation
i. With subsequent pregnancy 1 1 1 1 1 1 1 1
ii. Without subsequent pregnancy 2 2 2 2 1 1 1 1
b. Current PID 4 2* 4 2* 1 1 1 1
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
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
HIV
Initiation Continuation Initiation Continuation
High risk for HIV 2 2 2 2 1 2* 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. 1* 1* 1* 1*
a. Clinically well receiving ARV therapy 1 1 1 1
b. Not clinically well or not receiving ARV therapy 2 1 2 1
Other Infections
Schistosomiasis
Schistosomiasis with fibrosis of the liver is associated with increased risk for adverse health events as a result of pregnancy.
a. Uncomplicated 1 1 1 1 1 1
b. Fibrosis of the liver (if severe, see Cirrhosis) 1 1 1 1 1 1
Tuberculosis
This condition is associated with increased risk for adverse health events as a result of pregnancy.
Initiation Continuation Initiation Continuation
a. Nonpelvic 1 1 1 1 1* 1* 1* 1*
b. Pelvic 4 3 4 3 1* 1* 1* 1*
Malaria 1 1 1 1 1 1
Endocrine Conditions
Diabetes
Insulin-dependent diabetes; diabetes with nephropathy, retinopathy, or neuropathy; diabetes with other vascular disease; or diabetes of >20 years’ duration are associated with increased risk of adverse health events as a result of pregnancy.
a. History of gestational disease 1 1 1 1 1 1
b. Nonvascular disease
i. Non-insulin dependent 1 2 2 2 2 2
ii. Insulin dependent 1 2 2 2 2 2
c. Nephropathy/retinopathy/neuropathy 1 2 2 3 2 3/4*
d. Other vascular disease or diabetes of >20 years’ duration 1 2 2 3 2 3/4*
Thyroid disorders
a. Simple goiter 1 1 1 1 1 1
b. Hyperthyroid 1 1 1 1 1 1
c. Hypothyroid 1 1 1 1 1 1
Gastrointestinal Conditions
Inflammatory bowel disease (ulcerative colitis or Crohn’s disease) 1 1 1 2 2 2/3*
Gallbladder disease
a. Symptomatic
i. Treated by cholecystectomy 1 2 2 2 2 2
ii. Medically treated 1 2 2 2 2 3
iii. Current 1 2 2 2 2 3
b. Asymptomatic 1 2 2 2 2 2
History of cholestasis
a. Pregnancy related 1 1 1 1 1 2
b. Past COC related 1 2 2 2 2 3
Viral hepatitis Initiation Continuation
a. Acute or flare 1 1 1 1 1 3/4* 2
b. Carrier 1 1 1 1 1 1 1
c. Chronic 1 1 1 1 1 1 1
Cirrhosis
Severe cirrhosis is associated with increased risk for adverse health events as a result of pregnancy.
a. Mild (compensated) 1 1 1 1 1 1
b. Severe (decompensated) 1 3 3 3 3 4
Liver tumors
Hepatocellular adenoma and malignant liver tumors are associated with increased risk for adverse health events as a result of pregnancy.
a. Benign
i. Focal nodular hyperplasia 1 2 2 2 2 2
ii. Hepatocellular adenoma 1 3 3 3 3 4
b. Malignant (hepatoma) 1 3 3 3 3 4
Respiratory Conditions
Cystic fibrosis
This condition is associated with increased risk for adverse health events as a result of pregnancy.
1* 1* 1* 2* 1* 1*
Anemias
Thalassemia 2 1 1 1 1 1
Sickle cell disease
This condition is associated with increased risk for adverse health events as a result of pregnancy.
2 1 1 1 1 2
Iron-deficiency anemia 2 1 1 1 1 1
Solid Organ Transplantation
Solid organ transplantation
This condition is associated with increased risk for adverse health events as a result of pregnancy.
Initiation Continuation Initiation Continuation
a. Complicated: graft failure (acute or chronic), rejection, or cardiac allograft vasculopathy 3 2 3 2 2 2 2 4
b. Uncomplicated 2 2 2 2 2 2*
Drug Interactions
Antiretroviral therapy Initiation Continuation Initiation Continuation
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*
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*
ii. Ritonavir-boosted darunavir (DRV/r) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
iii. Ritonavir-boosted fosemprenavir (FPV/r) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
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*
vi. Ritonavir-boosted tipranavir (TPV/r) 1/2* 1* 1/2* 1* 2* 1* 2* 2*
d. Protease inhibitors without ritonavir
i. Atazanavir (ATV) 1/2* 1* 1/2* 1* 1 1 1 2*
ii. Fosamprenavir (FPV) 1/2* 1* 1/2* 1* 2* 2* 2* 3*
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*
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
Anticonvulsant therapy
a. Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine) 1 1 2* 1* 3* 3*
b. Lamotrigine 1 1 1 1 1 3*
Antimicrobial therapy
a. Broad-spectrum antibiotics 1 1 1 1 1 1
b. Antifungals 1 1 1 1 1 1
c. Antiparasitics 1 1 1 1 1 1
d. Rifampin or rifabutin therapy 1 1 2* 1* 3* 3*
Psychotropic medications
a. SSRIs 1 1 1 1 1 1
St. John’s wort 1 1 2 1 2 2

Abbreviations: BMI = body mass index; COC = combined oral contraceptive; Cu-IUD = copper-containing IUD; DMPA = depot medroxyprogesterone acetate; DVT = deep venous thrombosis; hCG = human chorionic gonadotropin; HDL = high-density lipoprotein; HIV = human immunodeficiency virus.; IUD = intrauterine device; LDL = low-density lipoprotein; LNG-IUD = levonorgestrel-releasing IUD; NA = not applicable; PE = pulmonary embolism; PID = pelvic inflammatory disease; POP = progestin-only pill; SSRI = selective serotonin reuptake inhibitor; STD = sexually transmitted disease.

*Consult the respective appendix for each contraceptive method in the 2016 U.S. Medical Eligibility Criteria for Contraceptive Use (1) for clarifications to the numeric categories.

Reference

  1. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65(No. RR-3).
  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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