Morbidity and Mortality Weekly Report Early Release / Vol. 62 June 14, 2013 U.S. Selected Practice Recommendations for Contraceptive Use, 2013 Adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, 2nd Edition Continuing Education Examination available at http://www.cdc.gov/mmwr/cme/conted.html. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Early Release CONTENTS CONTENTS (Continued) Introduction ............................................................................................................1 Appendix A: Summary Chart of U.S. Medical Eligibility Criteria for Methods ....................................................................................................................2 Contraceptive Use, 2010 .................................................................................. 47 How To Use This Document ...............................................................................3 Appendix B: When To Start Using Specific Contraceptive Summary of Changes from WHO SPR ............................................................4 Methods .............................................................................................................. 55 Contraceptive Method Choice .........................................................................4 Appendix C: Examinations and Tests Needed Before Initiation of Maintaining Updated Guidance ......................................................................4 Contraceptive Methods ................................................................................. 56 How To Be Reasonably Certain that a Woman Is Not Pregnant ............5 Appendix D: Routine Follow-Up After Contraceptive Initiation ........ 57 Intrauterine Contraception ................................................................................7 Appendix E: Management of Women with Bleeding Irregularities Implants ................................................................................................................. 14 While Using Contraception .......................................................................... 58 Injectables ............................................................................................................. 17 Appendix F: Management of the IUD when a Cu-IUD or an LNG-IUD Combined Hormonal Contraceptives ......................................................... 22 User Is Found To Have Pelvic Inflammatory Disease ........................... 59 Progestin-Only Pills ............................................................................................ 29 Standard Days Method ..................................................................................... 33 Emergency Contraception .............................................................................. 34 Female Sterilization ........................................................................................... 35 Disclosure of Relationship Male Sterilization ................................................................................................ 36 CDC, our planners, and our content experts wish to disclose they have no financial interests or other relationships with When Women Can Stop Using Contraceptives ....................................... 37 the manufacturers of commercial products, suppliers of com- Conclusion ............................................................................................................ 37 mercial services, or commercial supporters. Planners have Acknowledgment ............................................................................................... 38 reviewed content to ensure there is no bias. This document will not include any discussion of the unlabeled use of a product References ............................................................................................................. 38 or a product under investigational use, with the exception that some of the recommendations in this document might be inconsistent with package labeling. CDC does not accept commercial support. Front cover photos, left to right: intrauterine device, oral contraceptive pills, diaphragm, syringe for injectable contraceptives, male condom, transdermal contraceptive patch, etonogestrel implant, vaginal ring. The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Suggested Citation: Centers for Disease Control and Prevention. [Title]. MMWR 2013;62(No. RR-#):[inclusive page numbers]. Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director Harold W. Jaffe, MD, MA, Associate Director for Science James W. Stephens, PhD, Director, Office of Science Quality Denise M. Cardo, MD, Acting Deputy Director for Surveillance, Epidemiology, and Laboratory Services Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office MMWR Editorial and Production Staff Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series Martha F. Boyd, Lead Visual Information Specialist Christine G. Casey, MD, Deputy Editor, MMWR Series Maureen A. Leahy, Julia C. Martinroe, Teresa F. Rutledge, Managing Editor, MMWR Series Stephen R. Spriggs, Terraye M. Starr David C. Johnson, Lead Technical Writer-Editor Visual Information Specialists Catherine B. Lansdowne, MS, Project Editor Quang M. Doan, MBA, Phyllis H. King Information Technology Specialists MMWR Editorial Board William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Matthew L. Boulton, MD, MPH, Ann Arbor, MI Timothy F. Jones, MD, Nashville, TN Virginia A. Caine, MD, Indianapolis, IN Rima F. Khabbaz, MD, Atlanta, GA Barbara A. Ellis, PhD, MS, Atlanta, GA Dennis G. Maki, MD, Madison, WI Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Patricia Quinlisk, MD, MPH, Des Moines, IA David W. Fleming, MD, Seattle, WA Patrick L. Remington, MD, MPH, Madison, WI William E. Halperin, MD, DrPH, MPH, Newark, NJ John V. Rullan, MD, MPH, San Juan, PR King K. Holmes, MD, PhD, Seattle, WA William Schaffner, MD, Nashville, TN Early Release U.S. Selected Practice Recommendations for Contraceptive Use, 2013 Adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, 2nd Edition Prepared by Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion Summary The U. S. Selected Practice Recommendations for Contraceptive Use 2013 (U.S. SPR), comprises recommendations that address a select group of common, yet sometimes controversial or complex, issues regarding initiation and use of specific contraceptive methods. These recommendations are a companion document to the previously published CDC recommendations U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 (U.S. MEC). U.S. MEC describes who can use various methods of contraception, whereas this report describes how contraceptive methods can be used. CDC based these U.S. SPR guidelines on the global family planning guidance provided by the World Health Organization (WHO). Although many of the recommendations are the same as those provided by WHO, they have been adapted to be more specific to U.S. practices or have been modified because of new evidence. In addition, four new topics are addressed, including the effectiveness of female sterilization, extended use of combined hormonal methods and bleeding problems, starting regular contraception after use of emergency contraception, and determining when contraception is no longer needed. The recommendations in this report are intended to serve as a source of clinical guidance for health-care providers; health-care providers should always consider the individual clinical circumstances of each person seeking family planning services. This report is not intended to be a substitute for professional medical advice for individual patients. Persons should seek advice from their health-care providers when considering family planning options. Introduction about contraceptive method choice. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 (U.S. MEC), focuses on who Unintended pregnancy rates remain high in the United can safely use specific methods of contraception and provides States; approximately 50% of all pregnancies are unintended, recommendations for the safety of contraceptive methods for with higher proportions among adolescent and young women, women with various medical conditions (e.g., hypertension and women who are racial/ethnic minorities, and women with lower diabetes) and characteristics (e.g., age, parity, and smoking status) 1 levels of education and income ( ). Unintended pregnancies (Appendix A) (5). The recommendations in this new guide, U.S. 2 increase the risk for poor maternal and infant outcomes ( ) Selected Practice Recommendations for Contraceptive Use, 2013 and in 2002, resulted in $5 billion in direct medical costs in the (U.S. SPR), focuses on how contraceptive methods can be used 3 United States ( ). Approximately half of unintended pregnancies and provides recommendations on optimal use of contraceptive are among women who were not using contraception at the methods for persons of all ages, including adolescents. time they became pregnant; the other half are among women During the past 15 years, CDC has contributed to the who became pregnant despite reported use of contraception development and updating of the WHO global