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) Age<35
b) Age>35
(i) <15 cigarettes/day
(ii) >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 depression desires
long-term reversible contraception and is
thinking about the levonorgestrel-releasing
IUD. Is this method safe for her?
Answer:
A. Yes (Category 1)
Cinical scenario #3
21 year old female, history of multiple sexual
partners, living in an area of high HIV prevalence,
and is at high risk of contracting HIV. In addition to
strong and supportive counseling about risk
reduction and condom use, she also needs a highly
effective contraceptive method. What options are
available to her?
A. Progestin-only implants
B. Progestin-only injectables
C. Combined hormonal methods (pill, patch, ring)
WHO and US Recommendations prior to Feb 2012
Condition Combined
methods
Progestin-only
pills
Progestin-only
injectables
Progestin-
only implants
a) High risk
for HIV
1 1 1 1
b) HIV
infection
1* 1* 1* 1*
c) AIDS 1* 1* 1* 1*
*Drug interactions might exist between hormonal contraceptives and ARV
drugs; refer to the section on drug interactions.
WHO Consultation, Jan 31-Feb 1, 2012
Triggered by new data, including publication by
Heffron et al, Oct 2011
Concerns about hormonal contraception and HIV
Increased risk of HIV acquisition among non-infected women?
Increased risk of HIV disease progression among HIV-infected
women?
Increased risk of HIV transmission from infected women to non-
infected male partners?
Interactions between hormonal contraception and antiretrovirals?
WHO Consultation, Jan 31-Feb 1, 2012
75 global experts met in Geneva
Reviewed, biologic evidence, epidemiologic
evidence, programmatic issues, competing risks
Determined that numeric recommendations should
not change, but that a strong clarification should be
added to the recommendation for women at high risk
for HIV and use of progestin-only injectables
http://www.who.int/reproductivehealth/topics/family_
planning/hc_hiv/en/index.html
WHO Recommendations Feb 2012
Condition Combined
methods
Progestin-only
pills
Progestin-only
injectables
Progestin-
only implants
a) High risk
for HIV
1 1 1** 1
b) HIV
infection
1* 1* 1* 1*
c) AIDS 1* 1* 1* 1*
* *Some studies suggest that women using progestin-only injectable contraception
may be at increased risk of HIV acquisition, other studies do not report this
association. A WHO expert group reviewed all the 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 of HIV acquisition, women using progestin-only injectable
contraception should be strongly advised to also always use condoms, male
or female, and other HIV preventive measures. Expansion of contraceptive
method mix and further research on the relationship between hormonal
contraception and HIV infection is essential. These recommendations will be
continually reviewed in the light of new evidence.
Next Steps for US MEC
Review evidence and WHO recommendation
Determine whether any changes need to be made for
US recommendations
Any changes will be published as an update to the
US MEC
Scenario 3 21 year old female, history of multiple sexual
partners, living in an area of high HIV prevalence,
and is at high risk of contracting HIV. In addition to
strong and supportive counseling about risk
reduction and condom use, she also needs a highly
effective contraceptive method. What options are
available to her?
A. Progestin-only implants
B. Progestin-only injectables
C. Combined hormonal methods (pill, patch, ring)
D. All of the above
Dual protection
Next Steps
• Work with partners: dissemination, implementation, evaluation – Color-coded chart – PDA – Wheel – CME in MMWR
• Keeping guidance up to date
• Research gaps
• US adaptation of the WHO Selected Practice Recommendations for Contraceptive Use
Resources
• US MEC published in CDC’s Morbidity
and Mortality Weekly Report (MMWR): http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1
.htm?s_cid=rr5904a1_w
• CDC evidence-based family planning
guidance documents: http://www.cdc.gov/reproductivehealth/UnintendedPre
gnancy/USMEC.htm
The findings and conclusions in this
presentation have not been formally
disseminated by the Centers for
Disease Control and Prevention
and should not be construed to
represent any agency determination
or policy.
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