US Medical Eligibility Criteria for

Contraceptive Use

Kathryn M. Curtis, PhD

Division of Reproductive Health

Centers for Disease Control and

Prevention

Objectives

• Describe the US Medical Eligibility Criteria

for Contraceptive Use

• Describe the current evidence-based

recommendations about the safety of

contraceptive methods for adolescents

• Be able to apply the US MEC

recommendations in certain situations

Unintended Pregnancy

 49% of pregnancies in the United States are

unintended

 Little change over time

 Unintended pregnancy associated with adverse

maternal and infant outcomes

 Rates of unintended pregnancy among women with

alcohol or drug dependency unknown

Finer, 2011

So why are unintended

pregnancy rates so high?

• 52% due to non-use of contraception

• 48% due to contraceptive failure

– Effectiveness of method

– Consistent and correct use

Finer, 2006

Long Acting Reversible Contraception

(LARC) • “Forgettable contraception”

• Not dependent on compliance/adherence

• Available in US: – IUDs: copper and hormonal

– Implant

• “expanding access to LARC for young women has been declared a national priority” (IOM)

• “Encourage implants and IUDs for all appropriate candidates, including nulliparous women and adolescents.” (ACOG 2009)

Typical Effectiveness of Family Planning Methods

Adapted from: WHO. Family Planning: A Global Handbook

Long acting reversible contraceptives (LARCs)

Tier 1

Tier 2

Tier 4

Tier 3

Contraceptive Use in US Current Method Use, 2006-2008, women ages 15-44 Percentage

Female sterilization 16.7

Male sterilization 6.1

Pill 17.3

Implant, Lunelle, Patch 0.7

DMPA 2.0

Ring 1.5

IUD 3.4

Condom 10.0

Other 4.0

No use, at risk 7.3

NSFG, http://www.cdc.gov/NCHS/data/series/sr_23/sr23_029.pdf

Contraceptive Use in US Current Method Use, 2006-2008, women ages 15-44 Percentage

Female sterilization 16.7

Male sterilization 6.1

Pill 17.3

Implant, Lunelle, Patch 0.7

DMPA 2.0

Ring 1.5

IUD 3.4

Condom 10.0

Other 4.0

No use, at risk 7.3

NSFG, http://www.cdc.gov/NCHS/data/series/sr_23/sr23_029.pdf

Contraceptive Use in US Current Method Use, 2006-2008, women ages 15-44 Percentage

Female sterilization 16.7

Male sterilization 6.1

Pill 17.3 (Tier 2)

Implant, Lunelle, Patch 0.7

DMPA 2.0

Ring 1.5

IUD 3.4

Condom 10.0 (Tier 3)

Other 4.0

No use, at risk 7.3

NSFG, http://www.cdc.gov/NCHS/data/series/sr_23/sr23_029.pdf

Contraceptive Use in US Current Method Use, 2006-2008, women ages 15-44 Percentage

Female sterilization 16.7

Male sterilization 6.1

Pill 17.3

Implant, Lunelle, Patch 0.7 (Tiers 1-2)

DMPA 2.0

Ring 1.5

IUD 3.4 (Tier 1)

Condom 10.0

Other 4.0

No use, at risk 7.3

NSFG, http://www.cdc.gov/NCHS/data/series/sr_23/sr23_029.pdf

U.S. Medical Eligibility Criteria

for Contraceptive Use (MEC)

Why is evidence-based

guidance needed?

• To base family planning practices on the best

available evidence

• To address misconceptions regarding who

can safely use contraception

• To reduce medical barriers

• To improve access and quality of care in

family planning

US MEC

 Evidence-based recommendations on the use of

contraceptive methods among women with medical

conditions or other characteristics

 Adapted from global guidance, World Health

Organization

 Purpose of recommendations:

 To assist health care providers in counseling about contraceptive

method choice

 To serve as source of clinical guidance

 Health care providers should always consider

individual clinical circumstances

MEC Categories 1. A condition for which there is no restriction for the

use of the contraceptive method.

2. A condition where the advantages of using the

method generally outweigh the theoretical or proven

risks.

3. A condition where the theoretical or proven risks

usually outweigh the advantages of using the

method.

4. A condition which represents an unacceptable health

risk if the contraceptive method is used.

Smoking and Contraceptive Use

SMOKING

a) Age35

(i) 15 cigarettes/day

Cu-IUD

1

1

1

1

1 1

POPCONDITION CHC LNG-IUDDMPA

1

1

IMP

11

1

1

1

2

3

4

1

1

US MEC

• Box 2: Conditions associated with

increased risk for adverse health events as

a result of unintended pregnancy.

– Long-acting, highly effective contraceptive

methods may be the best choice

– Sole use of barrier and behavior-based methods

may not be the most appropriate choice

because of their relatively higher typical-use

rates of failure

A 30 y.o. female is PPD#2, ready to be discharged from hospital and desires

contraception. She plans to breastfeed.

Which hormonal methods are safe for her

to use?

A. Combined methods only

B. Progestin-only methods only

C. Any hormonal method

Clinical scenario #1

Updated CDC guidance

CDC, MMWR, 2011; 60(878-883)

Risk of Venous Thromboembolism

 Risk of VTE high in postpartum period

 Range: 25-99 per 10,000 women

 22-84 times as high as non-pregnant, non-postpartum woman

 Decreases over time, especially in first 3 weeks

 Unclear when baseline risk is reached, probably around 42 days

 Risk of VTE with combined hormonal contraceptive

use

 ~3-7 times as high as non-CHC users

 Overall risk low: 1-10 per 10,000 women

Jackson, 2011

Breastfeeding

• Two considerations for contraception and

breastfeeding

– Potential effect on breastfeeding performance

(initiation, maintenance, duration of lactation

and need for supplementation)

– Potential effect on infant health and

development (infant weight, infant length,

physical findings, health problems, and

psychomotor development)

Breastfeeding- evidence

• Progestin-only methods

– 43 studies

– POPs, DMPA, implants, and LNG-IUD

– No adverse effect on breastfeeding

performance

– No adverse effect on infant growth,

health, or development through 6 years

of age

Kapp, 2010

Breastfeeding- evidence

• Combined hormonal methods

– 10 studies of COCs

– 4 studies reported decreased duration

and higher rates of supplemental feeding

– 1 study no difference in breastfeeding

performance

– No adverse effect on infant growth,

health, or development through 8 years

of age Kapp, 2010

Breastfeeding- gaps

• Most observational studies

• Methodologic concerns

• No consistent definitions of breastfeeding

• No consensus on outcome measures for

breastfeeding or infant health

• No inclusion of ill or premature infants

• Need longer follow up

CDC, MMWR, 2011; 60(878-883)

CDC, MMWR, 2011; 60(878-883)

A 30 y.o. female is PPD#2, ready to be

discharged from hospital and desires

contraception. She plans to breastfeed.

Which hormonal methods are safe for her

to use?

Answer:

B. Progestin-only methods only (Category 2)

Clinical scenario #1

Clinical scenario #2

A 25 y.o. female with depression desires

long-term reversible contraception and is

thinking about the levonorgestrel-releasing

IUD. Is this method safe for her?

A. Yes

B. No

Depression

CONDITION COC/P

/R

POP DMPA Implants LNG-

IUD

Cu-IUD

Depression 1* 1* 1* 1* 1* 1

*This classification is based on data for women with selected depressive

disorders. No data on bipolar disorder or postpartum deprresion were

available. A potential for drug interactions between certain antidepressant

medications and hormonal contraceptives.

Clinical scenario #2

A 25 y.o. female with depress