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
In 1996, the World Health Organization (WHO) published the first edition of the Medical Eligibility Criteria for Contraceptive Use (MEC), which gave evidence-based guidance on the safety of contraceptive method use for women and men worldwide who had specific characteristics and medical conditions. Since that time, WHO has regularly updated its guidance on the basis of new evidence, and the WHO MEC is now in its fourth edition (1).
CDC, through close collaboration with WHO, has contributed substantially during the last 15 years to creation of WHO's global family planning guidance, which includes four documents: the medical eligibility criteria for contraceptive use, the selected practice recommendations for contraceptive use, a decision-making tool for clients and providers, and a global family planning handbook. This WHO guidance has been based on the best available scientific evidence, and CDC has served as the lead for establishing that evidence base and presenting the evidence to WHO for use during its expert working group meetings to create and update the guidance. WHO has always intended for its global guidance to be used by local or regional policy makers, managers of family planning programs, and the scientific community as a reference when they develop family planning guidance at the country or program level. The United Kingdom is one example of a country that has adapted the WHO MEC for its own use (2).
CDC undertook a formal process to adapt the WHO MEC at this time because the fourth edition of the WHO guidance is unlikely to undergo major revisions in the near future. Although the WHO guidance is already available in the United States through inclusion in textbooks, use by professional organizations, and incorporation into training programs, the adaptation of the guidance ensures its appropriateness for use in the United States and allows for further dissemination and implementation among U.S. health-care providers. Most of the U.S. guidance does not differ from the WHO guidance and covers approximately 60 characteristics or medical conditions. However, several changes have been made, including adaptations of selected WHO recommendations, addition of recommendations for new medical conditions, and removal of recommendations for contraceptive methods not currently available in the United States (Appendix A).
This document contains recommendations for health-care providers for the safe use of contraceptive methods by women and men with various characteristics and medical conditions. It is intended to assist health-care providers when they counsel women, men, and couples about contraceptive method choice. These recommendations are meant to be a source of clinical guidance; health-care providers should always consider the individual clinical circumstances of each person seeking family planning services.

# U S. Medical Eligibility Criteria for Contraceptive Use, 2010
Adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition May 28, 2010

# Methods
The process for adapting the WHO MEC for the United States comprised four major steps: 1) determination of the scope of and process for the adaptation, including a small meeting; 2) preparation and peer review of systematic reviews of the evidence to be used for the adaptation; 3) organization of a larger meeting to examine the evidence and provide input on the recommendations; and 4) finalization of the recommendations by CDC.
In June 2008, CDC held a 2-day meeting of eight key partners and U.S. family planning experts to determine the scope of and process for a U.S. adaptation of the WHO MEC. Participants were family planning providers, who also had expertise in conducting research on contraceptive safety and translating research evidence into guidance. WHO guidance is used widely around the world, including in the United States, and contains approximately 1,800 separate recommendations. In most cases, the evidence base would be the same for the U.S. and the WHO recommendation, and-because of the extensive collaboration between WHO and CDC in creating the international guidance-the process for determining the recommendations also would be the same. Therefore, CDC determined that the global guidance also should be the U.S. guidance, except when a compelling reason existed for adaptation, and that CDC would accept the majority of WHO guidance for use in the United States.
During the June 2008 meeting, CDC identified specific WHO recommendations for which a compelling reason existed to consider modification for the United States because of the availability of new scientific evidence or the context in which family planning services are provided in the United States. CDC also identified areas in which WHO guidance was inconsistent with current U.S. practice by contacting numerous professional and service organizations and individual providers. In addition, CDC assessed the need for adding recommendations for medical conditions not currently included in the WHO MEC. Through this process, a list was developed of existing WHO recommendations to consider adapting and new medical conditions to consider adding to the guidance. A systematic review of the scientific evidence was conducted for each of the WHO recommendations considered for adaptation and for each of the medical conditions considered for addition to the guidance. The purpose of these systematic reviews was to identify direct evidence about the safety of contraceptive method use by women (or men) with selected conditions (e.g., risk for disease progression or other adverse health effects in women with rheumatoid arthritis who use combined oral contraceptives). Information about indirect evidence (e.g., evidence from healthy women or animal studies) or theoretical considerations was obtained when direct evidence was not available. CDC conducted systematic reviews following standard guidelines (3,4), included thorough searches of PubMed and other databases of the scientific literature, and used the U.S. Preventive Services Task Force system to grade the strength and quality of the evidence (5). Each systematic review was peer-reviewed by two or three experts before being used in the adaptation process. These systematic reviews have been submitted for publication in peer-reviewed journals.
For most recommendations in this document, a limited number of studies address the use of a specific contraceptive method by women with a specific condition. Therefore, within the WHO guidance, as well as with this U.S. adaptation of the guidance, most of the decisions about medical eligibility criteria were often necessarily based on 1) extrapolations from studies that primarily included healthy women, 2) theoretical considerations about risks and benefits, and 3) expert opinion. Evidence was particularly limited for newer contraceptive methods. The total body of evidence for each recommendation included evidence based on direct studies or observations of the contraceptive method used by women (or men) with the condition and may have included 1) evidence derived from effects of the contraceptive method used by women (or men) without the condition and 2) indirect evidence or theoretical concerns based on studies of suitable animal models, human laboratory studies, or analogous clinical situations.
In February 2009, CDC held a meeting of 31 experts who were invited to provide their individual perspective on the scientific evidence presented and the discussions on potential recommendations that followed. This group included obstetricians/gynecologists, pediatricians, family physicians, nurse-midwives, nurse practitioners, epidemiologists, and others with expertise in contraceptive safety and provision. For each topic discussed, the evidence from the systematic review was presented; for most of the topics, an expert in the BOX 1. Categories of medical eligibility criteria for contraceptive use 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.
specific medical condition (e.g., rheumatoid arthritis) also gave a brief presentation on the condition and specific issues about contraceptive safety. CDC gathered input from the experts during the meeting and finalized the recommendations in this document. CDC plans to develop a research agenda to address topics identified during the meeting that need further investigation.

# How to Use this Document
These recommendations are intended to help health-care providers determine the safe use of contraceptive methods among women and men with various characteristics and medical conditions. Providers also can use the synthesis of information in these recommendations when consulting with women, men, and couples about their selection of contraceptive methods. The tables in this document include recommendations for the use of contraceptive methods by women and men with particular characteristics or medical conditions. Each condition was defined as representing either an individual's characteristics (e.g., age, history of pregnancy) or a known preexisting medical/pathologic condition (e.g., diabetes and hypertension). The recommendations refer to contraceptive methods being used for contraceptive purposes; the recommendations do not consider the use of contraceptive methods for treatment of medical conditions because the eligibility criteria in these cases may differ. The conditions affecting eligibility for the use of each contraceptive method were classified under one of four categories (Box 1).

# Using the Categories in Practice
Health-care providers can use these categories when assessing the safety of contraceptive method use for women and men with specific medical conditions or characteristics. Category 1 comprises conditions for which no restrictions exist for use of the contraceptive method. Classification of a method/ condition as Category 2 indicates the method generally can be used, but careful follow-up may be required. For a method/ condition classified as Category 3, use of that method usually is not recommended unless other more appropriate methods are not available or acceptable. The severity of the condition and the availability, practicality, and acceptability of alternative methods should be taken into account, and careful follow-up will be required. Hence, provision of a method to a woman with a condition classified as Category 3 requires careful clinical judgement and access to clinical services. Category 4 comprises conditions that represent an unacceptable health risk if the method is used. For example, a smoker aged <35 years generally can use combined oral contraceptives (COCs) (Category 2). However, for a woman aged 35 years who smokes <15 cigarettes per day, the use of COCs usually is not recommended unless other methods are not available or acceptable to her (Category 3). A woman aged 35 years who smokes 15 cigarettes per day should not use COCs because of unacceptable health risks, primarily the risk for myocardial infarction and stroke (Category 4). The programmatic implications of these categories may depend on the circumstances of particular professional or service organizations (e.g., in some settings, a Category 3 may mean that special consultation is warranted).
The recommendations address medical eligibility criteria for the initiation and continued use of all methods evaluated. The issue of continuation criteria is clinically relevant whenever a woman develops the condition while she is using the method. When the categories differ for initiation and continuation, these differences are noted in the columns Initiation and Continuation. Where Initiation and Continuation are not denoted, the category is the same for initiation and continuation of use.
On the basis of this classification system, the eligibility criteria for initiating and continuing use of a specific contraceptive method are presented in tables (Appendices A-M). In these tables, the first column indicates the condition. Several conditions were divided into subconditions to differentiate between varying types or severity of the condition. The second column classifies the condition for initiation and/or continuation into Category 1, 2, 3, or 4. For some conditions, the numeric classification does not adequately capture the recommendation; in this case, the third column clarifies the numeric category. These clarifications were determined during the discussions of the scientific evidence and the numeric classification and are considered a necessary element of the recommendation. The third column also summarizes the evidence for the recommendation, where evidence exists. The recommendations for which no evidence is cited are based on expert opinion from either the WHO or U.S. expert working group meetings and may be based on evidence from sources other than systematic reviews and presented at those meetings. For selected recommendations, additional comments appear in the third column and generally come from the WHO or the U.S. expert working group participants.

# Recommendations for Use of Contraceptive Methods
The classifications for whether women with certain medical conditions or characteristics can use specific contraceptive methods are provided for combined hormonal contraceptive methods, including low-dose (containing 35 g ethinyl estradiol) combined oral contraceptive pills, combined hormonal patch, and combined vaginal ring (Appendix B); progestin-only contraceptive methods, including progestinonly pills, depot medroxyprogesterone acetate injections, and etonogestrel implants (Appendix C); emergency contraceptive pills (Appendix D); intrauterine contraception, including the copper intrauterine device (IUD) and the levonorgestrel IUD (Appendix E); use of copper IUDs for emergency contraception (Appendix F); barrier contraceptive methods, including male and female condoms, spermicides, diaphragm with spermicide, and cervical cap (Appendix G); fertility awarenessbased methods (Appendix H); lactational amenorrhea method (Appendix I); coitus interruptus (Appendix J); and female and male sterilization (Appendix K). Tables at the end of the document summarize the classifications for the hormonal and intrauterine methods (Appendix L) and the evidence about potential drug interactions between hormonal contraceptives and antiretroviral therapies (Appendix M).

# Contraceptive Method Choice
Many elements need to be considered by women, men, or couples at any given point in their lifetimes when choosing the most appropriate contraceptive method. These elements include safety, effectiveness, availability (including accessibility and affordability), and acceptability. The guidance in this document focuses primarily on the safety of a given contraceptive method for a person with a particular characteristic or medical condition. Therefore, the classification of Category 1 means that the method can be used in that circumstance with no restrictions with regard to safety but does not necessarily imply that the method is the best choice for that person; other factors, such as effectiveness, availability, and acceptability, may play a key role in determining the most appropriate choice. Voluntary informed choice of contraceptive methods is an essential guiding principle, and contraceptive counseling, where applicable, may be an important contributor to the successful use of contraceptive methods.
In choosing a method of contraception, the risk for sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), also must be considered. Although hormonal contraceptives and IUDs are highly effective at preventing pregnancy, they do not protect against STIs. Consistent and correct use of the male latex condom reduces the risk for STIs (6). When a male condom cannot be used properly for infection prevention, a female condom should be considered (7). Women who use contraceptive methods other than condoms should be counseled about the use of condoms and the risk for STIs (7). Additional information about prevention and treatment of STIs is available from CDC's Sexually Transmitted Diseases Treatment Guidelines () (7).

# Contraceptive Method Effectiveness
Contraceptive method effectiveness is critically important in minimizing the risk for unintended pregnancy, particularly among women for whom an unintended pregnancy would pose additional health risks. The effectiveness of contraceptive methods depends both on the inherent effectiveness of the method itself and on how consistently and correctly it is used (Table 1). Methods that depend on consistent and correct use have a wide range of effectiveness.

# Unintended Pregnancy and Increased Health Risk
For women with conditions that may make unintended pregnancy an unacceptable health risk, long-acting, highly effective contraceptive methods may be the best choice (Table 1). Women with these conditions should be advised that sole use of barrier methods for contraception and behavior-based methods of contraception may not be the most appropriate choice because of their relatively higher typical-use rates of failure (Table 1). Conditions included in the U.S. MEC for which unintended pregnancy presents an unacceptable health risk are identified throughout the document (Box 2).

# Keeping Guidance Up to Date
As with any evidence-based guidance document, a key challenge is keeping the recommendations up to date as new scientific evidence becomes available. CDC will continue to work with WHO to identify and assess all new relevant evidence and to determine whether changes to the recommendations are warranted (4). In most cases, the U.S. MEC will follow any updates in the WHO guidance, which typically occur every 3-4 years (or sooner if warranted by new data). However, CDC will review any WHO updates for their application in the United States. CDC also will identify and assess any new literature for the recommendations and medical conditions that are not included in the WHO guidance. CDC will completely review the U.S. MEC every 3-4 years as well. Updates to the guidance will appear on the CDC U.S. MEC website: http:// www.cdc.gov/reproductivehealth/UnintendedPregnancy/ USMEC.htm. The classification additions, deletions, and modifications from the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use, 4th Edition, are summarized below (Tables 1-3). For conditions for which

# BOX. 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. classification changed for 1 methods or the condition description underwent a major modification, WHO conditions and recommendations appear in curly brackets. May 28, 2010   Other deleted items Guidance for combined injectables, levonorgestrel implants, and norethisterone enanthate has been removed because these methods are not currently available in the United States.
Guidance for "blood pressure measurement unavailable" and "history of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy)" has been removed.

# Unintended pregnancy and increased health risk
The following conditions have been added to the WHO list of conditions that expose a woman to increased risk as a result of unintended pregnancy: history of bariatric surgery within the past 2 years, peripartum cardiomyopathy, and receiving a solid organ transplant within 2 years.
Combined hormonal contraceptives (CHCs) include lowdose (containing 35 g ethinyl estradiol ) combined oral contraceptives (COCs), the combined hormonal patch, and the combined vaginal ring. The combined hormonal patch and vaginal ring are relatively new contraceptive methods. Limited information is available about the safety of these methods among women with specific medical conditions. Moreover, epidemiologic data on the long-term effects of the combined hormonal patch and the vaginal ring were not available for review. Evidence indicates that the combined hormonal patch and the combined vaginal ring provide comparable safety and pharmacokinetic profiles to COCs with similar hormone formulations . Pending further studies, the evidence available for recommendations about COCs applies to the recommendations for the combined hormonal patch and vaginal ring. Therefore, the patch and ring should have the same categories (Box) as COCs, except where noted. The assigned categories should, therefore, be considered a preliminary, best judgement, which will be reevaluated as new data become available. CHCs do not protect against sexually transmitted infections (STIs) or human immunodeficiency virus (HIV).

# Appendix B Classifications for Combined Hormonal Contraceptives

# BOX. Categories for Classifying Combined Hormonal Contraceptives
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.  (34)(35)(36)(37)(38)(39)(40)(41). In premenopausal adult women, COC use has little to no effect on bone health while appearing to preserve bone mass in perimenopausal women (26,.
Postmenopausal women who have ever used COCs have similar BMD to postmenopausal women who have never used COCs (54,58,68,81,(91)(92)(93)(94)(95)(96)(97)(98)(99)(100)(101)(102)(103)(104)(105)(106)(107)(108)(109)(110). BMD in adolescent or premenopausal women may not accurately predict postmenopausal fracture risk (109,(111)(112)(113)(114)(115)(116)(117)(118)(119)(120)(121)(122).

# Postabortion
Clarification: COCs, P, or R may be started immediately postabortion. a. First trimester 1 Evidence: Women who started taking COCs immediately after first trimester medical or surgical abortion did not experience more side effects or adverse vaginal bleeding outcomes or clinically significant changes in coagulation parameters than did women who used a placebo, an IUD, a nonhormonal contraceptive method, or delayed COC initiation (134)(135)(136)(137)(138)(139)(140). Limited evidence on women using the ring immediately after first trimester medical or surgical abortion found no serious adverse events and no infection related to use of the combined vaginal contraceptive ring during 3 cycles of follow-up postabortion (141).
b. Second trimester 1 c. Immediate postseptic abortion 1
Past ectopic pregnancy 1 Comment: The risk for future ectopic pregnancy is increased among women who have had an ectopic pregnancy in the past. CHCs protect against pregnancy in general, including ectopic gestation.  (147,(153)(154)(155)(156)(157)(158)(159). Limited evidence is inconsistent about whether COC effectiveness varies by body weight or BMI (160)(161)(162)(163)(164)(165). Limited evidence suggests obese women are no more likely to gain weight after 3 cycles of the vaginal ring or COC than overweight or normal weight women.
A similar weight gain during the 3 months was noted between the COC group and the vaginal ring group across all BMI categories (166). The effectiveness of the patch decreased among women who weighed >90 kg; however, no association was found between pregnancy risk and BMI (18).  Evidence: Among women with hypertension, COC users were at higher risk than nonusers for stroke, acute myocardial infarction, and peripheral arterial disease (142,144,(151)(152)(153)155,(171)(172)(173)(174)(175)(176)(177)(178)(179)(180)(181)(182)(183)(184)(185)(186). Discontinuation of COCs in women with hypertension might improve blood pressure control (187). ii. Systolic 160 mm Hg or diastolic 100 mm Hg  4 c. Vascular disease 4
History of high blood pressure during pregnancy (where current blood pressure is measurable and normal)
2 Evidence: Women with a history of high blood pressure in pregnancy, who also used COCs, had a higher risk for myocardial infarction and VTE than did COC users who did not have a history of high blood pressure during pregnancy. The absolute risks for acute myocardial infarction and VTE in this population remained small (153,172,(184)(185)(186)(188)(189)(190)(191)(192)(193). ii. Lower risk for recurrent DVT/PE (no risk factors)
Deep
3 Clarification: Women on anticoagulant therapy are at risk for gynecologic complications of therapy, such as hemorrhagic ovarian cysts and severe menorrhagia. Hormonal contraceptive methods can be of benefit in preventing or treating these complications. When a contraceptive method is used as a therapy, rather than solely to prevent pregnancy, the risk/benefit ratio may differ and should be considered on a case-bycase basis. d. Family history (first-degree relatives) 2 Comment: Some conditions that increase the risk for DVT/PE are heritable. e. Major surgery i. With prolonged immobilization 4 ii. Without prolonged immobilization 2 f. Minor surgery without immobilization 1
Known thrombogenic mutations  (e.g., factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)
Clarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening.
Evidence: Among women with thrombogenic mutations, COC users had a 2-fold to 20-fold higher risk for thrombosis than did nonusers (159,.   (218).

# Superficial venous thrombosis
Comment: COCs might increase fluid retention in healthy women; fluid retention may worsen heart failure in women with peripartum cardiomyopathy. COCs might induce cardiac arrhythmias in healthy women; women with peripartum cardiomyopathy have a high incidence of cardiac arrhythmias. Evidence: Among women with migraine, women who also had aura had a higher risk for stroke than did those without aura (248-250). Women with a history of migraine who use COCs are about 2-4 times as likely to have an ischemic stroke as nonusers with a history of migraine (142,157,179,180,(249)(250)(251)(252)(253)(254). Evidence: A Cochrane Collaboration Review identified 1 randomized controlled trial evaluating the effectiveness of COC use compared with naproxen and danazol in treating menorrhagic women. Women with menorrhagia did not report worsening of the condition or any adverse events related to COC use (265).

# Rheumatic Diseases

# Unexplained vaginal bleeding (suspicious for serious condition)
Before evaluation 2 Clarification: If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation.

# Comment:
No conditions that cause vaginal bleeding will be worsened in the short term by use of CHCs.

# Endometriosis 1
Evidence: A Cochrane Collaboration Review identified 1 randomized controlled trial evaluating the effectiveness of COC use compared with a gonadotropin-releasing hormone analogue in treating the symptoms of endometriosis. Women with endometriosis did not report worsening of the condition or any adverse events related to COC use (266).

# Benign ovarian tumors (including cysts) 1
Severe dysmenorrhea 1 Evidence: Risk for side effects with COC use was not higher among women with dysmenorrhea than among women not using COCs. Some COC users had a reduction in pain and bleeding (267,268).
Gestational trophoblastic disease a. Decreasing or undetectable -hCG levels 1 Evidence: After molar pregnancy evacuation, the balance of evidence found COC use did not increase the risk for postmolar trophoblastic disease, and -hCG levels regressed more rapidly in some COC users than in nonusers (269-275). Limited evidence suggests that use of COCs during chemotherapy does not significantly affect the regression or treatment of postmolar trophoblastic disease compared with women who used a nonhormonal contraceptive method or DMPA during chemotherapy (276).
b. Persistently elevated -hCG levels or malignant disease  1 Cervical ectropion 1 Comment: Cervical ectropion is not a risk factor for cervical cancer, and restriction of CHC use is unnecessary.

# Cervical intraepithelial neoplasia 2
Evidence: Among women with persistent HPV infection, long-term COC use (5 years) might increase the risk for carcinoma in situ and invasive carcinoma (21,277). Limited evidence on women with low-grade squamous intraepithelial lesions found use of the vaginal ring did not worsen the condition (21).

# Cervical cancer (awaiting treatment) 2
Comment: Theoretical concern exists that CHC use might affect prognosis of the existing disease. While awaiting treatment, women may use CHCs. In general, treatment of this condition can render a woman sterile.

# Breast Disease a. Undiagnosed mass 2
Clarification: The woman should be evaluated as early as possible. b. Benign breast disease 1 c. Family history of cancer 1 Evidence: Women with breast cancer susceptibility genes (such as BRCA1 and BRCA2) have a higher baseline risk for breast cancer than do women without these genes. The baseline risk for breast cancer is also higher among women with a family history of breast cancer than among those who do not have such a history. However, current evidence does not suggest that the increased risk for breast cancer among women with either a family history of breast cancer or breast cancer susceptibility genes is modified by the use of COCs (278)(279)(280)(281)(282)(283)(284)(285)(286)(287)(288)(289)(290)(291)(292)(293)(294)(295). d. Breast cancer  Comment: Breast cancer is a hormonally sensitive tumor, and the prognosis for women with current or recent breast cancer might worsen with CHC use.
i. Current 4 ii. Past and no evidence of current disease for 5 yrs 3

# Endometrial hyperplasia 1
Endometrial cancer  1 Comment: COC use reduces the risk for endometrial cancer; whether P or R use reduces the risk for endometrial cancer is not known. While awaiting treatment, women may use COCs, P, or R. In general, treatment of this condition renders a woman sterile. May 28, 2010 1 Comment: COC use reduces the risk for ovarian cancer; whether P or R use reduces the risk for ovarian cancer is not known. While awaiting treatment, women may use COCs, P, or R. In general, treatment of this condition can render a woman sterile.
Uterine fibroids 1 Comment: COCs do not appear to cause growth of uterine fibroids, and P and R also are not expected to cause growth.

# Pelvic inflammatory disease (PID)
a. Past PID (assuming no current risk factors for STIs)
Comment: COCs might reduce the risk for PID among women with STIs but do not protect against HIV or lower genital tract STIs. Whether use of P or R reduces the risk for PID among women with STIs is unknown, but they do not protect against HIV or lower genital tract STIs. i. With subsequent pregnancy 1 ii.  .

# HIV/AIDS
High risk for HIV 1 Evidence: The balance of the evidence suggests no association between oral contraceptive use and HIV acquisition, although findings from studies conducted among higher risk populations have been inconsistent .

# HIV infection  1
Evidence: Most studies suggest no increased risk for HIV disease progression with hormonal contraceptive use, as measured by changes in CD4 cell count, viral load, or survival. Studies observing that women with HIV who use hormonal contraception have increased risks of acquiring STIs are generally consistent with reports among uninfected women. One direct study found no association between hormonal contraceptive use and an increased risk for HIV transmission to uninfected partners; several indirect studies reported mixed results about whether hormonal contraception is associated with increased risk for HIV-1 DNA or RNA shedding from the genital tract (377,(416)(417)(418)(419)(420)(421)(422)(423)(424)(425)(426)(427)(428)(429)(430)(431)(432).
AIDS

# Gastrointestinal Conditions
Inflammatory bowel disease (IBD) (ulcerative colitis, Crohn disease) 2/3 Clarification: For women with mild IBD and no other risk factor for VTE, the benefits of COC/P/R use generally outweigh the risks (Category 2). However, for women with IBD who are at increased risk for VTE (e.g., those with active or extensive disease, surgery, immobilization, corticosteroid use, vitamin deficiencies, or fluid depletion), the risks of COC/P/R use generally outweigh the benefits (Category 3).
Evidence: Risk for disease relapse was not significantly higher among women with IBD using oral contraceptives (most studies did not specify formulation) than among nonusers (461)(462)(463)(464)(465).
Absorption of COCs among women with mild ulcerative colitis and no or small ileal resections was similar to the absorption among healthy women (466,467). Findings might not apply to women with Crohn disease or more extensive bowel resections.
No data exist that evaluate the increased risk for VTE among women with IBD using COCs/P/R. However, women with IBD are at higher risk than unaffected women for VTE (468).
Gallbladder disease a. Symptomatic Comment: COCs, P, or R might cause a small increased risk for gallbladder disease. COCs, P, or R might worsen existing gallbladder disease. Evidence: Data suggest that in women with chronic hepatitis, COC use does not increase the rate or severity of cirrhotic fibrosis, nor does it increase the risk for hepatocellular carcinoma (469,470). For women who are carriers, COC use does not appear to trigger liver failure or severe dysfunction (471)(472)(473). Evidence is limited for COC use during active hepatitis (474). Anemias Thalassemia 1 Comment: Anecdotal evidence from countries where thalassemia is prevalent indicates that COC use does not worsen the condition.

# Sickle cell disease  2
Iron deficiency anemia 1 Comment: CHC use may decrease menstrual blood loss.

# Solid Organ Transplantation

# Anticonvulsant therapy
Clarification: Although the interaction of certain anticonvulsants with COCs, P, or R is not harmful to women, it is likely to reduce the effectiveness of COCs, P, or R. Use of other contraceptives should be encouraged for women who are long-term users of any of these drugs. When a COC is chosen, a preparation containing a minimum of 30 g EE should be used. d. Rifampicin or rifabutin therapy 3 Clarification: Although the interaction of rifampicin or rifabutin therapy with COCs, P, or R is not harmful to women, it is likely to reduce the effectiveness of COCs, P, or R. Use of other contraceptives should be encouraged for women who are long-term users of either of these drugs. When a COC is chosen, a preparation containing a minimum of 30 g EE should be used.

# Evidence:
The balance of the evidence suggests that rifampicin reduces the effectiveness of COCs (545)(546)(547)(548)(549)(550)(551)(552)(553)(554)(555)(556)(557)(558)(559)(560). Data on rifabutin are limited, but effects on metabolism of COCs are less than with rifampicin, and small studies have not shown evidence of ovulation (547,554).
- Abbreviations: STI = sexually transmitted infection; HIV = human immunodeficiency virus; COC = combined oral contraceptive; P = patch; R = ring; EE = ethinyl estradiol; BMD = bone mineral density; CHC = combined hormonal contraceptive; IUD = intrauterine device; VTE = venous thromboembolism; BMI = body mass index; DVT = deep venous thrombosis; PE = pulmonary embolism; SLE = systemic lupus erythematosus; MEC = Medical Eligibility Criteria; hCG = human chorionic gonadotropin; DMPA = depot medroxyprogesterone acetate; HPV = human papillomavirus; PID = pelvic inflammatory disease; AIDS = acquired immunodeficiency syndrome; ARV = antiretroviral; IBD = inflammatory bowel disease; NRTI = nucleoside reverse transcriptase inhibitor; NNRTI = non-nucleoside reverse transcriptase inhibitor.  COCs/P/R do not protect against STI/HIV. If risk for STI/HIV (including during pregnancy or postpartum) exists, the correct and consistent use of condoms is recommended, either alone or with another contraceptive method. Consistent and correct use of the male latex condom reduces the risk for STI/HIV transmission.  Condition that exposes a woman to increased risk as a result of unintended pregnancy.

# Classifications for Progestin-Only Contraceptives
Classifications for progestin-only contraceptives (POCs) include those for progestin-only pills, depot medroxyprogesterone acetate, and progestin-only implants (Box). POCs do BOX. Categories for Classifying Progestin-Only Contraceptives 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. not protect against sexually transmitted infections (STIs) or human immunodeficiency virus (HIV).    (115,116).
Comment: Progestin-only implants might induce cardiac arrhythmias in healthy women; women with peripartum cardiomyopathy have a high incidence of cardiac arrhythmias. May 28, 2010

# Unexplained vaginal bleeding (suspicious for serious condition)
Clarification: If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation.
Comment: POCs might cause irregular bleeding patterns, which might mask symptoms of underlying pathology. The effects of DMPA might persist for some time after discontinuation.
Before evaluation 2 3 3
Endometriosis 1 1 1
Benign ovarian tumors (including cysts)

# Gastrointestinal Conditions
Inflammatory bowel disease (IBD) (ulcerative colitis, Crohn disease) 2 2 1 Evidence: Risk for disease relapse among women with IBD using oral contraceptives (most studies did not specify formulation) did not increase significantly from that for nonusers (212)(213)(214)(215)(216).
Comment: Absorption of POPs among women with IBD might be reduced if the woman has substantial malabsorption caused by severe disease or small bowel surgery.
Women with IBD have a higher prevalence than the general population of osteoporosis and osteopenia. Use of DMPA, which has been associated with small changes in BMD, might be of concern. Early Release May 28, 2010   hCG = human chorionic gonadotropin; HPV = human papillomavirus; PID = pelvic inflammatory disease; AIDS = acquired immunodeficiency syndrome; IBD = inflammatory bowel disease; ARV = antiretroviral; LNG = levonorgestrel; NRTI = nucleoside reverse transcriptase inhibitor; NNRTI = non-nucleoside reverse transcriptase inhibitor; ETG = etonogestrel.  POCs do not protect against STI/HIV. If risk exists for STI/HIV (including during pregnancy or postpartum), the correct and consistent use of condoms is recommended, either alone or with another contraceptive method. Consistent and correct use of the male latex condom reduces the risk for STIs and HIV transmission.  Condition that exposes a woman to increased risk as a result of unintended pregnancy. - Abbreviations: STI = sexually transmitted infection; HIV = human immunodeficiency virus; ECP, emergency contraceptive pill; IUD = intrauterine device; COC = combined oral contraceptive; POP = progestin-only pill; CHC = combined hormonal contraceptive; POC = progestin-only contraceptive  ECPs do not protect against STI/HIV. If risk exists for STI/HIV (including during pregnancy or postpartum), the correct and consistent use of condoms is recommended, either alone or with another contraceptive method. Consistent and correct use of the male latex condom reduces the risk for STIs and HIV transmission.  Condition that exposes a woman to increased risk as a result of unintended pregnancy.

# Gallbladder disease

# Classifications for Intrauterine Devices
Classifications for intrauterine devices (IUDs) are for the levonorgestrel-releasing (20 g/24 hours) IUD and the copperbearing IUD (Box). IUDs do not protect against sexually BOX. Categories for Classifying 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. Evidence: Risk for complications from immediate versus delayed insertion of an IUD after abortion did not differ. Expulsion was greater when an IUD was inserted after a second trimester abortion than when inserted after a first trimester abortion. Safety or expulsion for postabortion insertion of an LNG-IUD did not differ from that of a Cu-IUD (24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37). transmitted infections (STIs) or human immunodeficiency virus (HIV).   (38)(39)(40). c. DVT/PE and established on anticoagulant therapy for at least 3 mos Evidence: No direct evidence exists on the use of POCs among women with acute DVT/PE. Although findings on the risk for venous thrombosis with the use of POCs in otherwise healthy women are inconsistent, any small increased risk is substantially less than that with COCs (38)(39)(40).
Evidence: Limited evidence indicates that insertion of the LNG-IUD does not pose major bleeding risks in women on chronic anticoagulant therapy. (41)(42)(43)(44) Comment: The LNG-IUD might be a useful treatment for menorrhagia in women on long-term chronic anticoagulation therapy. i. Higher risk for recurrent DVT (77)(78)(79)(80)(81).
Benign ovarian tumors (including cysts) 1 1
Severe dysmenorrhea 1 2 Comment: Dysmenorrhea might intensify with Cu-IUD use. LNG-IUD use has been associated with reduction of dysmenorrhea. Gestational trophoblastic disease a. Decreasing or undetectable -hCG levels 3 3 Evidence: Limited evidence suggests that women using an IUD after uterine evacuation for a molar pregnancy are not at greater risk for postmolar trophoblastic disease than are women using other methods of contraception (82-84). b. Persistently elevated -hCG levels or malignant disease  4 4 Evidence: Limited evidence suggests that women using an IUD after uterine evacuation for a molar pregnancy are not at greater risk for postmolar trophoblastic disease than are women using other methods of contraception (82-84)

# Cervical ectropion 1 1
Cervical intraepithelial neoplasia 2 1 Comment: Theoretical concern exists that LNG-IUDs might enhance progression of cervical intraepithelial neoplasia.

# Cervical cancer (awaiting treatment)
Initiation Continuation Initiation Continuation Comment: Concern exists about the increased risk for infection and bleeding at insertion. The IUD most likely will need to be removed at the time of treatment, but until then, the woman is at risk for pregnancy. Evidence: Among women with endometrial hyperplasia, no adverse health events occurred with LNG-IUD use; most women experienced disease regression (85)(86)(87)(88)(89)(90)(91)(92)(93).

# Endometrial cancer 
Initiation Continuation Initiation Continuation Comment: Concern exists about the increased risk for infection, perforation, and bleeding at insertion. The IUD most likely will need to be removed at the time of treatment, but until then, the woman is at risk for pregnancy. Ovarian cancer  1 1 Comment: Women with ovarian cancer who undergo fertility sparing treatment and need contraception may use an IUD.

# Uterine fibroids 2 2
Evidence: Among women with uterine fibroids using an LNG-IUD, most experienced improvements in serum levels of hemoglobin, hematocrit, and ferritin (73,(94)(95)(96)(97)(98)(99)(100) and menstrual blood loss (73,75,(94)(95)(96)(97)(98)(99)(100)(101). Rates of LNG-IUD expulsion were higher in women with uterine fibroids (11%) than in women without fibroids (0%-3%); these findings were not statistically significant or significance testing was not conducted (75,101). Rates of expulsion from noncomparative studies ranged from 0%-20% (94,(96)(97)(98)(99)(100).
Comment: Women with heavy or prolonged bleeding should be assigned the category for that condition.

# 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)

# Appendix H Classifications for Fertility Awareness-Based Methods
Fertility awareness-based (FAB) methods of family planning involve identifying the fertile days of the menstrual cycle, whether by observing fertility signs such as cervical secretions and basal body temperature or by monitoring cycle days (Box). FAB methods can be used in combination with abstinence or barrier methods during the fertile time. If barrier methods are used, refer to Appendix G.
No medical conditions become worse because of use of FAB methods. In general, FAB methods can be used without concern for health effects to persons who choose them. However, a number of conditions make their use more complex. The existence of these conditions suggests that 1) use of these methods should be delayed until the condition is corrected or resolved or 2) persons using FAB methods will require special counseling, and a more highly trained provider is generally necessary to ensure correct use.
Women with conditions that make pregnancy an unacceptable risk should be advised that FAB methods might not be appropriate for them because of the relatively higher typical-use failure rates of these methods. FAB methods do not protect against sexually transmitted infections (STIs) or human immunodeficiency virus (HIV).

# Box. Definitions for terms associated with fertility awarenessbased methods

# Symptoms-based methods 
: FAB methods based on observation of fertility signs (e.g., cervical secretions, basal body temperature) such as the Cervical Mucus Method, the Symptothermal Method, and the TwoDay Method.

# Calendar-based methods 
: FAB methods based on calendar calculations such as the Calendar Rhythm Method and the Standard Days Method.

# Acccept (A) 
: There is no medical reason to deny the particular FAB method to a woman in this circumstance.

# Caution (C) 
: The method is normally provided in a routine setting but with extra preparation and precautions. For FAB methods, this usually means that special counselling might be needed to ensure correct use of the method by a woman in this circumstance.

# Delay (D) 
: Use of this method should be delayed until the condition is evaluated or corrected. Alternative temporary methods of contraception should be offered.

# Reproductive Tract Infections and Disorders
Irregular vaginal bleeding D D Comment: Presence of this condition makes FAB methods unreliable. Therefore, barrier methods should be recommended until the bleeding pattern is compatible with proper method use. The condition should be evaluated and treated as necessary.
Vaginal discharge D A Comment: Because vaginal discharge makes recognition of cervical secretions difficult, the condition should be evaluated and treated if needed before providing methods based on cervical secretions.

# Other
Use of drugs that affect cycle regularity, hormones, and/or fertility signs C/D C/D Comment: Use of certain mood-altering drugs such as lithium, tricyclic antidepressants, and antianxiety therapies, and certain antibiotics and anti-inflammatory drugs, might alter cycle regularity or affect fertility signs. The condition should be carefully evaluated and a barrier method offered until the degree of effect has been determined or the drug is no longer being used.
Diseases that elevate body temperature a. Chronic diseases C A Comment: Elevated temperature levels might make basal body temperature difficult to interpret but have no effect on cervical secretions. Thus, use of a method that relies on temperature should be delayed until the acute febrile disease abates.
Temperature-based methods are not appropriate for women with chronically elevated temperatures. In addition, some chronic diseases interfere with cycle regularity, making calendar-based methods difficult to interpret.
b. Acute diseases D A - Abbreviations: FAB = fertility awareness-based; A = accept; C = caution; D = delay; STI = sexually transmitted infection; HIV = human immunodeficiency infection.  Fertility awareness-based methods do not protect against STI/HIV. If risk exists for STI/HIV (including during pregnancy or postpartum), the correct and consistent use of condoms is recommended, either alone or with another contraceptive method. Consistent and correct use of the male latex condom reduces the risk for STIs and HIV transmission.
The Bellagio Consensus provided the scientific basis for defining the conditions under which breastfeeding can be used safely and effectively for birth-spacing purposes, and programmatic guidelines were developed for use of lactational amenorrhea in family planning (1,2). These guidelines include the following three criteria, all of which must be met to ensure adequate protection from an unplanned pregnancy: 1) amenorrhea; 2) fully or nearly fully breastfeeding, and 3) <6 months postpartum.
The main indications for breastfeeding are to provide an ideal food for the infant and protect against disease. No medical conditions exist for which use of the lactational amenorrhea method for contraception is restricted. However, breastfeeding might not be recommended for women or infants with certain conditions.
Women with conditions that make pregnancy an unacceptable risk should be advised that the lactational amenorrhea method might not be appropriate for them because of its relatively higher typical-use failure rates. The lactational amenorrhea method does not protect against sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). If risk exists for STI/HIV (including during pregnancy or postpartum), the correct and consistent use of condoms is recommended, either alone or with another contraceptive method. Consistent and correct use of the male latex condom reduces the risk for STIs and HIV transmission.

# HIV Infection
HIV can be transmitted from mother to infant through breastfeeding. Therefore, in the United States, where replace-ment feeding is affordable, feasible, acceptable, sustainable, and safe, breastfeeding for women with HIV is not recommended (3,4).

# Other Medical Conditions
The American Academy of Pediatrics also recommends against breastfeeding for women with active untreated tuberculosis disease, who are positive for human T-cell lymphotropic virus types I or II, or who have herpes simplex lesions on a breast (infant can feed from the other breast). In addition, infants with classic galactosemia should not breastfeed (4).

# Medication Used during Breastfeeding
To protect infant health, the American Academy of Pediatrics does not recommend breastfeeding for women receiving certain drugs, including diagnostic or therapeutic radioactive isotopes or exposure to radioactive materials, antimetabolites or chemotherapeutic agents, and current use of drugs of abuse (4). May 28, 2010
Coitus interruptus (CI), also known as withdrawal, is a traditional family planning method in which the man completely removes his penis from the vagina, and away from the external genitalia of the female partner, before he ejaculates. CI prevents sperm from entering the woman's vagina, thereby preventing contact between spermatozoa and the ovum.
This method might be appropriate for couples who are highly motivated and able to use this method - effectively; with religious or philosophical reasons for not using other - methods of contraception; who need contraception immediately and have entered - into a sexual act without alternative methods available; who need a temporary method while awaiting the start of - another method; or who have intercourse infrequently. - Some benefits of CI are that the method, if used correctly, does not affect breastfeeding and is always available for primary use or use as a back-up method. In addition, CI involves no economic cost or use of chemicals. CI has no directly associated health risks. CI does not protect against sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). If risk exists for STI/HIV (including during pregnancy or postpartum), the correct and consistent use of condoms is recommended, either alone or with another contraceptive method. Consistent and correct use of the male latex condom reduces the risk for STIs and HIV transmission.
CI is unforgiving of incorrect use, and its effectiveness depends on the willingness and ability of the couple to use withdrawal with every act of intercourse. Women with conditions that make pregnancy an unacceptable risk should be advised that CI might not be appropriate for them because of its relatively higher typical-use failure rates.

# Appendix J Coitus Interruptus (Withdrawal)
Tubal sterilization for women and vasectomy for men are permanent, safe, and highly effective methods of contraception. In general, no medical conditions would absolutely restrict a person's eligibility for sterilization (with the exception of known allergy or hypersensitivity to any materials used to complete the sterilization method). However, certain conditions place a woman at high surgical risk; in these cases, careful consideration should be given to the risks and benefits of other acceptable alternatives, including long-acting, highly effective, reversible methods and vasectomy. Female and male sterilization do not protect against sexually transmitted infections (STIs) or human immunodeficiency virus (HIV). If risk exists for STI/HIV (including during pregnancy or postpartum), the correct and consistent use of condoms is recommended, either alone or with another contraceptive method. Consistent and correct use of the male latex condom reduces the risk for STIs and HIV transmission.
Because these methods are intended to be irreversible, persons who choose sterilization should be certain that they want to prevent pregnancy permanently. Most persons who choose sterilization remain satisfied with their decision. However, a small proportion of women regret this decision (1%-26% from different studies, with higher rates of regret reported by women who were younger at sterilization) (1,2). Regret among men about vasectomy has been reported to be approximately 5% (3), similar to the proportion of women who report regretting their husbands' vasectomy (6%) (4). Therefore, all persons should be appropriately counseled about the permanency of sterilization and the availability of highly effective, reversible methods of contraception.