NEW! 2024 MEC & SPR (Free from the CDC)

The new 2024 US Medical Eligibility Criteria for Contraceptive Use (MEC) and the US Selected Practice Guidelines (SPR) were both just released by the Centers for Disease Control and Prevention. Each brings new recommendations and updates to previous recommendations.

The new MEC brings in new contraceptive methods, new doses or formulations of the contraceptive stand-by’s of pills, patches, rings, IUDs. Key revisions include recommendations for chronic kidney disease, breastfeeding, postpartum, postabortion, obesity, major surgery, deep venous thromboses and pulmonary embolism, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, treatment with HIV antivirals. 

Most people with chronic medical conditions can safely use a variety of methods of contraception, write Jennifer Villavicencio, MD, MPP, and Rebecca Allen, MD, MPH, in the new edition of Contraceptive Technology. (1) Health care providers caring for individuals with medical conditions may be concerned about the effects of contraceptives on the medical condition, and therefore may avoid providing contraceptives or addressing family planning needs. However, adverse outcomes and disease progression are often greater during pregnancy than during contraceptive use. Pregnancy itself can pose serious health risks to patients who have common medical conditions. (2) Given that the increase in maternal morbidity and mortality in the United States is due in part to chronic maternal conditions, providing appropriate contraceptive care is critical. (3) 

The US MEC will have the greatest benefit for patients if it is used by health care providers in everyday practice in order to decrease unnecessary barriers to contraceptive access. The US MEC app can be downloaded for free from the CDC for use in a smartphone. If a provider does not have access to a smartphone in their clinical setting, the guidelines can be downloaded to a desktop, or laminated charts can be used (apps, guidelines, and charts are available for free from US MEC.

Categories 1 and 2.

Using category 1 and 2 contraceptive methods freely can eliminate barriers to contraceptive use that may be based on misperception of risk rather than actual evidence of risk. Use of category 1 and 2 contraceptives may be more easily incorporated into your clinical practice, more easily taught to trainees who may have limited family planning experience, or may provide assurance that additional referral before contraceptive initiation is not needed. Similarly, medical conditions for which all contraceptive methods are category 1 and 2 should be considered as conditions for which there are no significant contraceptive safety concerns due to the condition itself

Category 3.

Category 3 indicates that the risks of using the contraceptive method outweigh the benefits, although the method may be used if nothing else is available or acceptable to the patient. This category most closely approximates the health care provider asking, “Are the risks from pregnancy greater than the risks from this contraceptive method?” If yes, then clinical judgment guides us to use the contraceptive method. Health care providers may understandably require more family planning experience before they are comfortable prescribing category 3 methods to their patients. 

Within a group practice or clinic, category 3 methods may signal when referral to a more experienced health care provider is needed. Prescribing a category 3 contraceptive method typically requires more time within a clinical visit to explain to patients the risks and benefits of the method, as well as alternative methods. Follow-up may be needed to assure that continued use is safe.

Category 4.

Category 4 conveys that an unacceptable risk is associated with use of that contraceptive in patients with that condition. Category 4 methods should be used only in rare circumstances and when there is no alternative method that is safe to use; for example, a patient with breast cancer using tamoxifen may benefit from protection of the endometrium conferred by the LNG IUD (the decision is best made in consultation with the medical oncologist).

Advocating for the highest-quality care for our patients requires conversations with the other health care providers involved in their care. In these circumstances, the expertise of other health care providers should be respected. However, subspecialty providers rarely if ever ask patients about their reproductive desires and might not have expertise in contraception and therefore may be uncomfortable due to their lack of knowledge or misinformation they have heard.

US Selected Practice Recommendations

The US SPR reviews the use of contraceptive methods, including screening tests that are needed before initiation of contraception. For example, blood pressure measurement before initiation of CHCs contributes to the safety of their use, say Villavicencio and Cwiak. COC users with unmeasured blood pressure were more likely to have complications after contraceptive initiation than users with measured blood pressure. (4) Documenting users’ weight and body mass index (BMI) at initiation of all contraceptive methods may contribute to the effectiveness of follow-up and future counseling as significant weight gain caused by contraceptive use is a concern for many patients.

While patients require a pelvic examination before IUD placement in order to rule out anatomic changes that preclude correct placement and decrease the risk of complications related to placement due to unrecognized infection, pregnancy, or cancer, a pelvic examination is not required prior to initiating other contraceptive methods. (5) Screening for anemia, hyperlipidemia, or diabetes does not contribute to the safety of contraceptive use, so it is not required before initiating or continuing contraceptive use. Screening the general population for thrombogenic mutations before CHC use is not cost-effective, but it may be indicated in patients with a strong family history of thromboembolism. The performance of tests for sexually transmitted infections, human papillomavirus testing, pap testing, and mammograms do not increase the safety of contraceptive use and should not be required before the provision of contraception unless an individual’s history indicates the need for the test. (6)

The 2024 SPR updates recommendations for medications for IUD placement and for bleeding irregularities during implant use, and it makes new recommendations for testosterone use and risk for pregnancy and for self-administration of injectable contraceptives. Check it out: US SPR

References

1. Villavicencio J, Allen RH. Contraception for people with medical conditions. In: Cason P, Cwiak C, Edelman A, et al. Contraceptive Technology. 22nd edition. Burlington, MA: Jones-Bartlett Learning, 2023.
2. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep. 2016;65:1-104.
3. Creanga AA, Berg CJ, Syverson C, et al. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125:5-12.
4. Tepper NK, Curtis KM, Steenland MW, et al. Blood pressure measurement prior to initiating hormonal contraception: a systematic review. Contraception. 2013;87:631-8.
5. Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA. 2001;285:2232-9.
6. Vandenbroucke JP, van der Meer FJ, Helmerhorst FM, et al. Factor V Leiden: should we screen oral contraceptive users and pregnant women? BMJ. 1996;313:1127-30.