Morbidity and Mortality Weekly Report www.cdc.gov/mmwr Early Release May 28, 2010 / Vol. 59 U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 Adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition department of health and human services Centers for Disease Control and Prevention Early Release CONTENTS The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Introduction .............................................................................. 1 Disease Control and Prevention (CDC), U.S. Department of Health Methods ................................................................................... 2 and Human Services, Atlanta, GA 30333. How to Use This Document ......................................................... 3 Suggested Citation: Centers for Disease Control and Prevention. [Title]. MMWR Early Release 2010;59[Date]:[inclusive page numbers]. Using the Categories in Practice ............................................... 3 Recommendations for Use of Contraceptive Methods ................. 4 Centers for Disease Control and Prevention Contraceptive Method Choice .................................................. 4 Thomas R. Frieden, MD, MPH Director Contraceptive Method Effectiveness .......................................... 4 Peter A. Briss, MD, MPH Unintended Pregnancy and Increased Health Risk ..................... 4 Acting Associate Director for Science Keeping Guidance Up to Date .................................................... 4 James W. Stephens, PhD Office of the Associate Director for Science Appendices Stephen B. Thacker, MD, MSc A. Summary of Changes from WHO MEC to U.S. MEC ............ 7 Deputy Director for Surveillance, Epidemiology, and Laboratory Services B. Combined Hormonal Contraceptives .................................. 11 C. Progestin-Only Contraceptives ........................................... 34 Editorial and Production Staff Frederic E. Shaw, MD, JD D. Emergency Contraceptive Pills ........................................... 50 Editor, MMWR Series E. Intrauterine Devices ........................................................... 52 Christine G. Casey, MD Deputy Editor, MMWR Series F. Copper IUDs for Emergency Contraception.......................... 64 Teresa F. Rutledge G. Barrier Methods ............................................................... 65 Managing Editor, MMWR Series H. Fertility Awareness–Based Methods ................................... 71 David C. Johnson Lead Technical Writer-Editor I. Lactational Amenorrhea Method ......................................... 73 Karen L. Foster, MA J. Coitus Interruptus (Withdrawal) .......................................... 74 Project Editor K. Sterilization ...................................................................... 75 Martha F. Boyd Lead Visual Information Specialist L. Summary of Hormonal Contraceptives and IUDs.................. 76 Malbea A. LaPete M. Potential Drug Interactions: Hormonal Contraceptives Stephen R. Spriggs Terraye M. Starr and Antiretroviral Drugs ..................................................... 82 Visual Information Specialists Abbreviations and Acronyms ................................................... 85 Quang M. Doan, MBA Phyllis H. King Participants ............................................................................. 86 Information Technology Specialists Editorial Board William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA David W. Fleming, MD, Seattle, WA William E. Halperin, MD, DrPH, MPH, Newark, NJ King K. Holmes, MD, PhD, Seattle, WA Deborah Holtzman, PhD, Atlanta, GA John K. Iglehart, Bethesda, MD Dennis G. Maki, MD, Madison, WI Patricia Quinlisk, MD, MPH, Des Moines, IA Patrick L. Remington, MD, MPH, Madison, WI Barbara K. Rimer, DrPH, Chapel Hill, NC John V. Rullan, MD, MPH, San Juan, PR William Schaffner, MD, Nashville, TN Anne Schuchat, MD, Atlanta, GA Dixie E. Snider, MD, MPH, Atlanta, GA John W. Ward, MD, Atlanta, GA Vol. 59 Early Release 1 U S. Medical Eligibility Criteria for Contraceptive Use, 2010 Adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition Prepared by Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion Summary CDC created U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, from guidance developed by the World Health Organization (WHO) and finalized the recommendations after consultation with a group of health professionals who met in Atlanta, Georgia, during February 2009. This guidance comprises recommendations for the use of specific contraceptive methods by women and men who have certain characteristics or medical conditions. The majority of the U.S. guidance does not differ from the WHO guidance and covers >60 characteristics or medical conditions. However, some WHO recommendations were modified for use in the United States, including recommendations about contraceptive use for women with venous thromboembolism, valvular heart disease, ovarian cancer, and uterine fibroids and for postpartum and breastfeeding women. Recommendations were added to the U.S. guidance for women with rheumatoid arthritis, history of bariatric surgery, peripartum cardiomyopathy, endometrial hyperplasia, inflammatory bowel disease, and solid organ transplantation. The recommendations in this document are intended to assist health-care providers when they counsel women, men, and couples about contraceptive method choice. Although these recommendations are meant to serve as a source of clinical guidance, health-care providers should always consider the individual clinical circumstances of each person seeking family planning services. Introduction programs, and the scientific community as a reference when they develop family planning guidance at the country or pro- In 1996, the World Health Organization (WHO) pub- gram level. The United Kingdom is one example of a country lished the first edition of the Medical Eligibility Criteria for that has adapted the WHO MEC for its own use (2). Contraceptive Use (MEC), which gave evidence-based guidance CDC undertook a formal process to adapt the WHO MEC on the safety of contraceptive method use for women and at this time because the fourth edition of the WHO guidance is men worldwide who had specific characteristics and medical unlikely to undergo major revisions in the near future. Although conditions. Since that time, WHO has regularly updated its the WHO guidance is already available in the United States guidance on the basis of new evidence, and the WHO MEC through inclusion in textbooks, use by professional organizations, is now in its fourth edition (1). and incorporation into training programs, the adaptation of the CDC, through close collaboration with WHO, has con- guidance ensures its appropriateness for use in the United States tributed substantially during the last 15 years to creation of and allows for further dissemination and implementation among WHO’s global family planning guidance, which includes four U.S. health-care providers. Most of the U.S. guidance does not documents: the medical eligibility criteria for contraceptive differ from the WHO guidance and covers approximately 60 char- use, the selected practice recommendations for contraceptive acteristics or medical conditions. However, several changes have use, a decision-making tool for clients and providers, and a been made, including adaptations of selected WHO recommenda- global family planning handbook. This WHO guidance has tions, addition of recommendations for new medical conditions, been based on the best available scientific evidence, and CDC and removal of recommendations for contraceptive methods not has served as the lead for establishing that evidence base and currently available in the United States (Appendix A). presenting the evidence to WHO for use during its expert This document contains recommendations for health-care working group meetings to create and update the guidance. providers for the safe use of contraceptive methods by women WHO has always intended for its global guidance to be used and men with various characteristics and medical conditions. It is by local or regional policy makers, managers of family planning intended to assist health-care providers when they counsel women, men, and couples about contraceptive method choice. These Corresponding preparer: Kathryn M. Curtis, PhD, Division of recommendations are meant to be a source of clinical guidance; Reproductive Health, CDC, MS K-34, 4770 Buford Highway NE, Atlanta, GA 30341; Telephone 770-488-6397; Fax: 770-488-6391; health-care providers should always consider the individual E-mail [email protected] clinical circumstances of each person seeking family planning services. 2 Early Release May 28, 2010 Methods or theoretical considerations was obtained when direct evidence was not available. CDC conducted systematic reviews follow- The process for adapting the WHO MEC for the United ing standard guidelines (3,4), included thorough searches of States comprised four major steps: 1) determination of the PubMed and other databases of the scientific literature, and scope of and process for the adaptation, including a small used the U.S. Preventive Services Task Force system to grade meeting; 2) preparation and peer review of systematic reviews the strength