Contraception

BASIC INFORMATION

SYNONYMS
Birth control
Family planning
ICD-9CM CODES
V25.01Oral contraceptives
V25.02Other contraceptive measures
V25.09Family planning
V25.1IUD
V25.2Sterilization
ICD-10CM CODES
Z30.011Encounter for initial prescription of
contraceptive pills
Z30.018Encounter for initial prescription of
other contraceptives
Z30.09Encounter for other general
counseling and advice on
contraception
Z30.430Encounter for insertion of
intrauterine contraceptive device
Z30.2Encounter for sterilization

DIAGNOSIS
WORKUP
Thorough medical history
Thorough surgical history
Obstetric history (was fertility desired with
conception?)

Gynecologic history, including:

1. History of previous sexually transmitted
diseases
2. Number of partners
3. Previous difficulties with contraception
4. Frequency of intercourse
Family history

LABORATORY TESTS
Pap smear
Cultures, aerobic and Chlamydia
Pregnancy test if suspected pregnancy
Lipid profile if family history of premature
vascular event

TREATMENT
NONPHARMACOLOGIC THERAPY
Male condoms
1. 95% latex (rubber), 5% skin or natural
membrane
2. Proper use: place on an erect penis and
leave -inch empty space at the tip
of the condom; use with nonoil-based
lubricants
3. Effectiveness increased when used with
spermicides
Female condoms
1. Composed of polyurethane, with one end
open and one end closed
2. Proper use: place closed end over cervix,
open end hanging out of vagina to cover
penis and scrotum
3. Highly effective against HIV
Spermicides
1. Types: nonoxynol, octoxynol
2. Forms: jellies, creams, foams, suppositories, tablets, soluble films
3. 
Proper use: put in immediately before
intercourse; may be used with other barrier methods
Diaphragm and cervical cap
1. Must be fitted by practitioner, used with
contraceptive gels, and refitted with
weight gain or loss of 4.5 kg. Must also
be refit after pregnancy.
2. Diaphragm sizes: 50 to 105 mm; cervical
cap sizes 26, 28, and 30 mm
3. 
The correct fit allows the woman to
remain ambulatory without feeling the
device
4. Proper use of diaphragm: put in immediately before intercourse and keep in for 6
hr after intercourse; must not remain in
the vagina for longer than 24 hr
5. Proper use of cervical cap: fit over the
cervix exactly; must not remain in place
for longer than 48 hr
Lactation amenorrhea method
1. Depends on number of feedings per day;
effective as birth control for 6 mo if 15
or more feedings, lasting 10 min each,
are accomplished daily. If woman meets
criteria (e.g., breastfeeding only source of
infant feeding) 0.5%-2.0% failure rate in
the first 6 months after delivery.
2. Not a common practice in the U.S.
Withdrawal

Diseases
and Disorders

DEFINITION
Contraception refers to the various modalities
that a sexually active couple use to prevent pregnancy. These options can be either medical or
nonmedical and used by men or women or both.
An algorithm for helping couples select a contraceptive method is described in Fig. EC1-100.
Online Appendices A-F summarize U.S. medical eligibility criteria for contraceptive use. The
options are as follows:


No contraception (unprotected intercourse)
failure rate 85% both typical use and perfect
use
Abstinence
1. 12.4% of unmarried men
2. 13.2% of unmarried women
3. More frequently practiced before age 17
yr
4. 
No intercourse experienced by 13% of
women ages 30 to 34 yr
5. Failure rate 0%
Withdrawal
1. Used in only 2% of sexually active women
2. Failure rate with perfect use, 4%; with
typical use, 19%
Rhythm method (natural family planning)
1. Failure rate with perfect use, 1% to 9%;
with typical use, 20%
2. Symptothermal type: mucus method and
ovulation pain combined with basal body
temperature
3. 
Ovulation (Billings method): takes into
account mucus quality
4. 
Basal body temperature method: uses
biphasic temperature chart
5. Lactation amenorrhea method: effective
in fully breastfeeding women, especially
70 to 100 days after delivery; depends on
number of feedings per day
Barriers
1. Diaphragm and cervical cap: failure rate
5% to 9% in nulliparous women, 20% in
multiparous women
2. Female condom: failure rate with perfect
use, 5.1%; with typical use, 12.4%; FDA
labeling states 25% failure rate
3. 
Male condom: failure rate with perfect
use, 3%; with typical use, 12%
4. 
Spermicides (aerosols, foam, jellies,
creams, tabs): failure rate with perfect
use, 3%; with typical use, 21%
Oral contraceptives
1. Failure rate with perfect use, <1%; with
typical use, 3%
2. Come in combinations of estrogen/progestin or as progestin only
Hormonal implants and injectables
1. 
Implanon (etonogestrel) implant 2-yr
cumulative pregnancy rate 0.05%.
Nexplanon is essentially the same as
Implanon but with a barium sulfate core
for easier radiologic detection and a preloaded applicator to facilitate insertion.
2. Depo-Provera: failure rate 0.3% in first
year of use
3. Lunelle failure rate 0.2% in first year

4. 
Nestorone-releasing single implant: not
yet available
5. Jadelle implant: Successor to the Norplant
implant, which has been discontinued in
the U.S. The Jadelle implant is not available in the U.S.
Mini pill (progesterone only pill)
1. 
Failure rate with typical use, 1.1% to
13.2%
2. With perfect use, 5 pregnancies per 1000
women
Emergency postcoital contraception
1. Decreases pregnancy rate by 75% with
women treated immediately postcoitally
2. 
Involves dedicated hormonal (Plan B,
which contains levonorgestrel) use or
intrauterine device (IUD) insertion


IUD (available over the counter in some
states)
1. Progestasert: failure rate with perfect use,
2%; with typical use, 3%
2. Copper T (30-A): failure rate with perfect
use, 0.8%; with typical use, 3%
3. 
Levonorgestrel Intrauterine System
(Mirena)

1-yr failure rate, 1%


5-yr cumulative failure rate, 0.71 per
100 women


Female sterilization (tubal ligation): failure
rate with perfect use, 0.2%; with typical use,
3%
Male sterilization (vasectomy): failure rate of
0.1% in first year
Vaginal ring (Nuva ring): failure rate pearl
index 0.77
Contraceptive patch (Ortho Evra): failure rate
0.4% to 0.7%

365

366

Contraception
1. Withdrawal of the penis from the vagina
before ejaculation
2. Depends on self-control, but even with
withdrawal high typical use failure rate.
Rhythm method
1. Depends on awareness of physiology of
male and female reproductive tracts
2. Sperm viable in vagina for 2 to 7 days
3. Ovum life span 24 hr
Sterilization
1. Male:


Vasectomy to interrupt vas deferens
and block passage of sperm to seminal
ejaculate


Scalpel and nonscalpel techniques
available


More easily performed procedure
than female sterilization and does not
require general anesthesia
2. Female:


Leading method of birth control in U.S.
in women older than 30 yr


Interrupts fallopian tubes, blocking
passage of ovum proximally and sperm
distally through tube


Several types; modified Pomeroy done
during cesarean section or interval
laparoscopic using clips (Filshie, Hulka)
or banding


Essure-tubal occlusion through hysteroscopic placement of micro-inserts
into the fallopian tubes.

ACUTE GENERAL Rx
Combination oral contraceptives
1. Taken daily for 21 days, pill-free interval
of 7 days
2. 
Less than 50 mcg ethinyl estradiol in
most common combination oral contraceptives; progestins most commonly used
in combination pills are norethindrone,
levonorgestrel, norgestrel, norethindrone
acetate, ethynodiol diacetate, norgestimate, or desogestrel; triphasic combination oral contraceptives (give varying doses
of progestin and estrogens throughout
cycle); monophasic oral contraceptives:
offer same dose of progestin and estrogen
throughout cycle, taken daily at same
time; estrophasic pill (constant progesterone with variation of estrogen throughout
the cycle)
3. 
If pill taken with antibiotics, efficacy
affected by inadequate gastrointestinal
absorption in most cases; only rifampin
truly reduces pills effectiveness
4. Increased body weight decreases effectiveness
5. 
Table EC1-49 describes oral contraceptive formulations available in the United
States. Guidelines for use of combination estrogen-progestin contraceptives in
women 35 years of age and older are
described in Table EC1-50
Mini pill
1. Progestin only; taken without a break
2. Causes much irregular bleeding because
of the lack of estrogen effect on the lining
of the uterus

3. 
Table EC1-51 provides a summary and
recommendations for progestin-only oral
contraceptive use
Hormonal implants and injectables
1. Implanon/Nexplanon


Single etonogestrel-secreting device
that is inserted underneath the skin


Among the most effective contraceptive available

Approved by FDA in 2006 and effective
over 3-yr period
2. Depo-Provera


Medroxyprogesterone acetate given
every 3 mo in IM injection form

Major side effect: irregular bleeding

Fertility return possibly delayed up to 1
year or longer after last injection


Table EC1-52 provides a summary and
recommendations for depot medroxyprogesterone acetate (DMPA) use
3. Lunelle: monthly injectable administered
intramuscularly. Contains 0.5 ml aqueous, 5 mg estradiol cypionate, and 25 mg
medroxyprogesterone acetate
Postcoital contraception
1. Done on emergency basis, usually as a
result of noncompliance with birth control
or failure of birth control (e.g., condom
breakage) at the time of ovulation
2. Methods:

Hormonal methods:


Levonorgestrel is available either
as two 0.75 mg tablets taken 12 hr
apart (next choice) or as a 1.5 mg
tablet taken once (Plan B, one step).
It is indicated for emergency contraception to be used within 72 hr after
unexpected intercourse. It can be
obtained OTC by women >15 yr of
age and by prescription by younger
patients

Ulipristal (ELLA) is a progesteronereceptor agonist/antagonist available
by prescription only. It is a 30-mg,
single-dose tablet and can be taken
up to 5 days after unexpected intercourse

Copper IUD insertion within 5 days
of coitus
IUD
1. 
Device inserted into uterus to prevent
sperm and ovum from uniting in fallopian
tube
2. Types available in the U.S.:


ParaGard (Copper T/30-A): a polyethylene T wrapped with a fine copper wire
effective for 10 yr


Mirena Levonorgestrel Intrauterine
System: a T-shaped system with a
chamber that contains levonorgestrel.
Releases 20 mcg/day; is effective for 5 yr
Vaginal ring (NuvaRing)
1. Provides daily dose of 120 mcg of etonogestrel and 15 mcg ethinyl estradiol
2. Stays in vagina 3 wk and is removed the
fourth for a contraceptive-free interval
analogous to the placebo pills in oral
contraceptive pills

3. Increased body weight decreases effectiveness

Contraceptive patch (Ortho-Evra)
1. Provides low daily dose of steroids
2. Releases a progestin and estrogen (ethinyl estradiol)
3. Patch size 20 cm2
4. Each patch contains 6 mg norelgestromin
and delivers an estimated continuous
systemic dose of 150 mcg norelgestromin
and 20 mcg of ethinyl estradiol; common
dose 250 mcg/day progestin and 25 mcg/
day estrogen
5. Worn 3 out of 4 wk
6. Increased body weight decreases effectiveness
7. Concern for increased risk of thromboembolic events

CHRONIC Rx
With all the previously mentioned types of
birth control, patient is followed up at least
yearly, or as necessary, if problems arise.
Full history, physical examination, and Pap
smear, including cultures when needed, are
performed yearly.
Patients with medical problems are followed
up approximately every 6 mo when taking
hormonal therapy.
DISPOSITION
Follow yearly or more frequently according to
patients side effects.
Tailor birth control to patient according to
different needs or side effects present at
different times in life. Effective counseling
also requires an understanding of a womans
preference and medical risks, benefits, side
effects, and contraindications of each contraceptive method.
COMMENTS
With hormonal contraception, if neurologic or
cardiac symptoms arise, stop method immediately, evaluate, and refer to internist when
appropriate.
The effectiveness of long-acting reversible
contraception (IUDs and implants) is superior
to that of contraceptive pills, patch, or ring
and is not altered in adolescents and young
women.

EVIDENCE
Available at www.expertconsult.com

SUGGESTED READINGS
Available at www.expertconsult.com
RELATED CONTENT
Contraception (Patient Information)
Emergency Contraception (Related Key Topic)
AUTHOR: RUBEN ALVERO, M.D.

Contraception
EVIDENCE
Abstract[1]
Objective:
To compare the risk of non-fatal venous thromboembolism in women receiving oral contraceptives containing drospirenone with that in women
receiving oral contraceptives containing levonorgestrel.
Design:
Nested case-control and cohort study.
Setting:
The study was based on information from PharMetrics, a United States
based company that collects information on claims paid by managed
care plans.
Participants:
The study encompassed all women aged 15 to 44 years who received
an oral contraceptive containing either drospirenone or levonorgestrel
after 1 January 2002. Cases were women with current use of a study
oral contraceptive and a diagnosis of venous thromboembolism in the
absence of identifiable clinical risk factors (idiopathic venous thromboembolism). Up to four controls were matched to each case by age and
calendar time.
Main Outcome Measures:
Odds ratios comparing the risk of non-fatal venous thromboembolism in users of the two contraceptives; incidence rates and rate ratios of nonfatal venous thromboembolism for users of each of the study
contraceptives.
Results:
186 newly diagnosed, idiopathic cases of venous thromboembolism
were identified in the study population and matched with 681 controls. In
the case-control analysis, the conditional odds ratio for venous thromboembolism comparing use of oral contraceptives containing drospirenone
with use of those containing levonorgestrel was 2.3 (95% confidence
interval 1.6 to 3.2). The incidence rates for venous thromboembolism in
the study population were 30.8 (95% confidence interval 25.6 to 36.8)
per 100 000 woman years among users of oral contraceptives containing
drospirenone and 12.5 (9.61 to 15.9) per 100,000 woman years among
users of oral contraceptives containing levonorgestrel. The age-adjusted
incidence rate ratio for venous thromboembolism for current use of oral
contraceptives containing drospirenone compared with those containing
levonorgestrel was 2.8 (2.1 to 3.8).
Conclusions:
The risk of non-fatal venous thromboembolism among users of oral contraceptives containing drospirenone seems to be around twice that of
users of oral contraceptives containing levonorgestrel, after the effects
of potential confounders and prescribing biases have been taken into
account.
Abstract[2]
Context:
Combinations of testosterone (T) and nestorone (NES; a nonandrogenic
progestin) transdermal gels may suppress spermatogenesis and prove
appealing to men for contraception.

366.e1

Objective:
The objective of the study was to determine the effectiveness of T gel
alone or combined with NES gel in suppressing spermatogenesis.
Design and Setting:
This was a randomized, double-blind, comparator clinical trial conducted
at two academic medical centers.
Participants:
Ninety-nine healthy male volunteers participated in the study.
Interventions:
Volunteers were randomized to one of three treatment groups applying
daily transdermal gels (group 1: T gel 10 g + NES 0 mg/placebo gel;
group 2: T gel 10 g + NES gel 8 mg; group 3: T gel 10 g + NES gel 12 mg).
Main Outcome Variable:
The main outcome variable of the study was the percentage of men
whose sperm concentration was suppressed to 1 million/ml or less by
20-24 wk of treatment.
Results:
Efficacy data analyses were performed on 56 subjects who adhered to
the protocol and completed at least 20 wk of treatment. The percentage of men whose sperm concentration was 1 million/ml or less was
significantly higher for T + NES 8 mg (89%, P <0.0001) and T + NES
12 mg (88%, P = 0.0002) compared with T + NES 0 mg group (23%).
The median serum total and free T concentrations in all groups were
maintained within the adult male range throughout the treatment period.
Adverse effects were minimal in all groups.
Conclusion:
A combination of daily NES + T gels suppressed sperm concentration to
1 million/ml or less in 88.5% of men, with minimal adverse effects, and
may be further studied as a male transdermal hormonal contraceptive.

Evidence-Based Reference
Jick SS etal.: Risk of non-fatal venous thromboembolism in women using oral
contraceptives containing drospirenone compared with women using oral contraceptives containing levonorgestrel: case-control study using United States
claims data, BMJ 340:d2151, 2011.
Ilani N, Roth MY, Amory JK, etal.: A new combination of testosterone and nestorone transdermal gels for male hormonal contraception, J Clin Endocrinol
Metab 97:34763486, 2012.

SUGGESTED READINGS
Bosworth MC etal.: An update on emergency contraception, Am Fam Phys
89(7):545550, 2014.
Spencer A etal.: Helping women choose appropriate hormonal contraception:
update on risks, benefits, and indications, Am J Med 122:497506, 2009.
Steinbrook R: Science, politics, and over-the-counter emergency contraception,
JAMA 307:365, 2012.
Winner B etal.: Effectiveness of long-acting reversible contraception, N Engl J
Med 366:19982007, 2012.

Contraception

366.e2

Assess patient wishes

Religious views

General choices

Permanent

Vasectomy

Tubal
sterilization

Natural family planning

Long term

Short term

Parity

STD risk

Normal

Relevant medical history

Elevated
Nulliparous

IUCD not
recommended

Rape, unprotected
intercourse, broken
condom, etc.

Estrogen OK

Barriers Spermicides P-only OC Barriers COC

DMPA
Implant

Special Circumstances

Estrogen not OK

Parous

Copper
IUCD

Likely pregnant now

Positive pregnancy test

Emergency contraception
Options counseling

Abortion Adoption

Parenthood

Contraception

FIGURE EC1-100 Helping couples select a contraceptive method. DMPA, Depot medroxyprogesterone
acetate; IUCD, intrauterine contraceptive device; OC, combination estrogen-progestin oral contraceptive; P-only
OC, progestin-only oral contraceptive; STD, sexually transmitted disease. (From Copeland LJ: Textbook of gynecology, ed 2, Philadelphia, 2000, Saunders.)

Contraception

366.e3

TABLE EC1-49 Oral Contraceptive Formulations Available in the United States

EE, 50 g monophasic

EE, 35 g monophasic

EE, 35 g biphasic
EE, 35 g triphasic

EE, 30 g monophasic

EE, 30 g triphasic
Extended cycle (84 active
tablets)
Extended cycle (84 estrogen/
progestin tablets, 7 tablets
10 g EE)
EE, 25 g
EE, 20 g monophasic

21 Hormonally active tablets

(2 inert tablets, 5 tablets
10g EE)
24 Hormonally active tablets
Extended cycle (84 estrogen/
progestin tablets, 7 tablets
10 g EE)
28 Hormonally active tablets
Progestin-only

Name

Estrogen

Progestin

Progestin Dose (mg)

Ovcon 50*
Ortho-Novum 1/50*
Norinyl 1 + 50*
Femcon Fe
Modicon*
Brevicon*
Ovcon 35*
Ortho-Cyclen*
Demulen 1/35*
Ortho-Novum 1/35*
Norinyl 1 + 35*
Ortho-Novum 10/11*
Ortho-Novum 7/7/7*
Ortho Tri-Cyclen*,
Tri-Norinyl*
Estrostep*,
Loestrin 1.5/30*
Ortho-Cept*
Desogen*
Lo-Ovral*
Nordette*
Levlen*
Yasmin*
Triphasil*
Tri-Levlen*
Seasonale*

EE
Mestranol
Mestranol
EE
EE
EE
EE
EE
EE
EE
EE
EE
EE
EE
EE
EE (20/30/35)
EE
EE
EE
EE
EE
EE
EE
EE (30/40/30)
EE (30/40/30)
EE

Norethindrone
Norethindrone
Norethindrone
Norethindrone
Norethindrone
Norethindrone
Norethindrone
Norgestimate
Ethynodiol diacetate
Norethindrone
Norethindrone
Norethindrone
Norethindrone
Norgestimate
Norethindrone
Norethindrone acetate
Norethindrone acetate
Desogestrel
Desogestrel
Norgestrel
Levonorgestrel
Levonorgestrel
Drospirenone
Levonorgestrel
Levonorgestrel
Levonorgestrel

1.0
1.0
1.0
0.4
0.5
0.5
0.4
0.25
1.0
1.0
1.0
0.5/1.0
0.5/0.75/1.0
0.18/0.215/0.25
0.5/1.0/0.5
1.0
1.5
0.15
0.15
0.3
0.15
0.15
3.0
0.05/0.075/0.125
0.05/0.075/0.125
0.150

Seasonique

EE

Levonorgestrel

0.150

Cyclessa*
Ortho Tri-Cyclen Lo
Loestrin 1/20*
Levlite*
Alesse*
Mircette*

EE
EE
EE
EE
EE
EE

Desogestrel
Norgestimate
Norethindrone acetate
Levonorgestrel
Levonorgestrel
Desogestrel

0.10/0.125/0.150
0.18/0.215/0.25
1.0
0.1
0.1
0.15

Yaz,
Loestrin 24Fe
LoSeasonique

EE
EE
EE

Drosperinone
Norethindrone acetate
Levonorgestrel

3.0
1.0
0.1

Lybrel
Micronor*

EE

Levonorgestrel
Norethindrone

0.09
0.35

*Generic versions available.

Chewable tablets.
Indicated for the treatment of acne in women desiring to use oral contraception.
Indicated for the treatment of premenstrual dysphoric disorder in women desiring to use oral contraception.
EE, Ethinyl estradiol.
From Melmed S, Polonsky KS, Larsen PR, Kronenberg HM: Williams textbook of endocrinology, ed 12, Philadelphia, 2011, Saunders, Elsevier.

Contraception

366.e4

TABLE EC1-50 World Health Organization (WHO) and American College of Obstetrics and Gynecology (ACOG)
Guidelines Regarding Use of Combination Estrogen-Progestin Contraceptives (Oral Contraception, Ring, Patch) in
Women 35 Years of Age and Older
Variable

ACOG Guidelines

WHO Guidelines

Obesity
Smoker
Hypertension
Diabetes
Migraine
None of the above risk factors

Progestin-only or intrauterine contraception* may be safer

Progestin-only or intrauterine contraception* should be used
Progestin-only or intrauterine contraception* should be used
Progestin-only or intrauterine contraception* should be used
Progestin-only or intrauterine contraception* should be used
Healthy, nonsmoking women doing well on a combination
contraceptive can continue their method until age 50-55 yr,
after weighing the risks and benefits

Benefit usually outweighs risks

Risk unacceptable
Risk unacceptable
Risk unacceptable
Risk unacceptable
For women 40 yr, the risk of cardiovascular disease increases with age and may also increase
with use of combined hormonal contraceptives.
In the absence of other adverse clinical conditions, combined hormonal contraceptives may be
used until menopause.

*Includes progestin-only oral contraception, depot medroxyprogesterone acetate (DMPA), contraceptive implants, copper intrauterine devices (IUDs), and progestin-releasing IUDs.
Obesity in women age 35 and older not specifically addressed.
From Melmed S, Polonsky KS, Larsen PR, Kronenberg HM: Williams textbook of endocrinology, ed 12, Philadelphia, 2011, Saunders, Elsevier.

TABLE EC1-51 Summary and Recommendations for Progestin-Only Oral Contraceptive Use
1 . Progestin-only contraception is an option for women in whom an estrogen-containing contraceptive is either contraindicated or causes additional health concerns.
2. Ovulation is not consistently suppressed; the main contraceptive actions of progestin-only oral contraception are effects on cervical mucus and the endometrium.
3. The typical user failure rate with progestin-only oral contraception is estimated to be >8%. Women choosing progestin-only oral contraception are often subfertile
as a result of breast-feeding or older reproductive age, so the failure rate in these populations may be lower than in more fertile populations.
4. It is essential that the pill be taken at the same time each day to maximize contraceptive efficacy.
5. Menstrual irregularities are common in users of progestin-only oral contraception and represent the most frequent cause for contraceptive discontinuation.
From Melmed S, Polonsky KS, Larsen PR, Kronenberg HM: Williams textbook of endocrinology, ed 12, Philadelphia, 2011, Saunders, Elsevier.

TABLE EC1-52 Summary and Recommendations for Depot Medroxyprogesterone Acetate (DMPA) Use

1. DMPA is an excellent method of contraception for women who desire a long-term, reversible contraceptive method.
2. DMPA primarily acts by inhibiting follicular maturation and ovulation through inhibition of gonadotropin secretion. It also affects cervical mucus.
3. DMPA is available in two formulations: 150 mg/1 ml for IM injection and 104 mg/0.65 ml for SC injection.
4. The ideal time to initiate DMPA is within 5 days of the onset of menses to ensure absence of pregnancy. The dose is repeated every 3 months, with a 2-week
grace period.
5. Although DMPA does not permanently affect endocrine function, return of fertility may be delayed.
6. Thorough, candid counseling about side effects is important. Women who are well informed when they choose this method of contraception are much more likely
to become highly satisfied users with high continuation rates.
7. Menstrual changes occur in all women using DMPA and are the most frequent cause for discontinuation.
8. Because DMPA induces amenorrhea, it can be used for managing a variety of gynecologic and nongynecologic disorders, such as menorrhagia, dysmenorrhea,
and iron deficiency anemia.
9. There is no high-quality evidence that use of DMPA increases the risk of developing cancer, cardiovascular disease, or sexually transmitted infection. DMPA use
significantly reduces the risk of developing endometrial cancer.
10. There is an association between current DMPA use and decreased bone mineral density; losses in bone mineral density are temporary, reverse after discontinuation of DMPA, and have not been linked to postmenopausal osteoporosis or fractures.
From Melmed S, Polonsky KS, Larsen PR, Kronenberg HM: Williams textbook of endocrinology, ed 12, Philadelphia, 2011, Saunders, Elsevier.

Contraception

366.e5
Recommendations and Reports

Appendix A
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, 2010
Key:
1. No restriction (method can be used)
2. Advantages generally outweigh theoretical or proven
risks
3. Theoretical or proven risks usually outweigh the
advantages
4. Unacceptable health risk (method not to be used)

Condition

Sub-condition

Combined
pill, patch,
ring

I
Age

Anatomic
abnormalities

Updated June 2012. This summary sheet only contains

a subset of the recommendations from the US MEC.
For complete guidance, see: http://www.cdc.gov/
reproductivehealth/unintendedpregnancy/USMEC.htm.
Most contraceptive methods do not protect against sexually
transmitted infections (STIs). Consistent and correct use of
the male latex condom reduces the risk of STIs and HIV.

Progestinonly pill

Injection

Implant

LNG-IUD Copper-IUD

Menarche to
<40=1

Menarche to
<18=1

Menarche to
<18=2

Menarche to
<18=1

Menarche to
<20=2

Menarche to
<20=2

>40=2

18-45=1

18-45=1

18-45=1

>20=1

>20=1

>45=1

>45=2

>45=1

a) Distorted uterine
cavity

b) Other
abnormalities

Anemias
b) Sickle cell disease
anemia

Benign ovarian tumors

(including cysts)

Breast disease

a) Undiagnosed mass

2*

2*

2*

2*

b) Benign breast
disease

c) Family history of
cancer

d) Breast cancer
i) current

a) < 1 month
postpartum

3*

2*

2*

2*

b) 1 month or more
postpartum

2*

1*

1*

1*

ii) past and no

evidence of
current disease for
5 years
Breastfeeding
(see also Postpartum)

Cervical cancer

Awaiting treatment

Cervical ectropion

Cervical
intraepithelial
neoplasia

Contraception

366.e6
Recommendations and Reports

Appendix A (Continued)
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

Condition

Sub-condition

Combined
pill, patch,
ring

I
Cirrhosis

DVT/PE

Progestinonly pill

Injection

Implant

LNG-IUD Copper-IUD

a) Mild
(compensated)

b) Severe
(decompensated)

i) higher risk for

recurrent DVT/PE

ii) lower risk for

recurrent DVT/PE

i) higher risk for

recurrent DVT/PE

4*

ii) lower risk for

recurrent DVT/PE

3*

(i) with prolonged

immobilization

(ii) without
prolonged
immobilization

1*

1*

1*

1*

1*

1*

a) History of
DVT/PE, not
on anticoagulant
therapy

b) Acute DVT/PE
c) DVT/PE and
established on
anticoagulant
therapy for at least 3
months

d) Family history
e) Major surgery

f ) Minor
surgery without
immobilization
Depressive disorders

Contraception

366.e7
Recommendations and Reports

Appendix A (Continued)
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

Condition

Sub-condition

Combined
pill, patch,
ring

I
Diabetes mellitus

a) History of
gestational diabetes
mellitus only

Progestinonly pill

Injection

Implant

LNG-IUD Copper-IUD

(i) non-insulin
dependent

(ii) insulin
dependent

c) Nephropathy/
retinopathy/
neuropathy

3/4*

d) Other vascular
disease or diabetes of
>20 years duration

3/4*

b) Non-vascular
disease

Endometrial cancer

Endometrial
hyperplasia

Endometriosis

1*

1*

1*

1*

(i) treated by
cholecystectomy

(ii) medically
treated

Epilepsy

(see also Drug

Interactions)

Gallbladder disease

a) Symptomatic

Gestational
trophoblastic disease

Headaches

(iii) current

b) Asymptomatic

a) Decreasing or
undetectable -hCG
levels

b) Persistently
elevated -hCG
levels or malignant
disease

a) Non-migrainous

1*

2*

1*

1*

1*

1*

1*

1*

1*

1*

1*

i) without aura,
age <35

2*

3*

1*

2*

2*

2*

2*

2*

2*

2*

1*

ii) without aura,

age >35

3*

4*

1*

2*

2*

2*

2*

2*

2*

2*

1*

iii) with aura, any

age

4*

4*

2*

3*

2*

3*

2*

3*

2*

3*

1*

b) Migraine

Contraception

366.e8
Recommendations and Reports

Appendix A (Continued)
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

Condition

Sub-condition

Combined
pill, patch,
ring

I
History of bariatric

surgery

a) Restrictive
procedures
b) Malabsorptive
procedures

History of cholestasis

Implant

LNG-IUD Copper-IUD

COCs: 3

P/R: 1
2

b) Past COC-related

History of pelvic surgery

High risk

1*

HIV infected
(see also Drug
Interactions)

1*

1*

1*

1*

AIDS (see also Drug

Interactions)

1*

1*

1*

1*

2*

2*

Clinically well on
therapy
Hyperlipidemias
Hypertension

Injection

a) Pregnancy-related

History of high blood pressure

during pregnancy

HIV

Progestinonly pill

If on treatment, see Drug Interactions

2/3*

2*

2*

2*

2*

1*

3*

1*

2*

1*

(i) systolic 140159 or diastolic

90-99

(ii) systolic 160

or diastolic 100

c) Vascular disease

(Ulcerative colitis,
Crohns disease)

2/3*

a) Adequately
controlled
hypertension
b) Elevated blood
pressure levels
(properly taken
measurements)

Ischemic heart
disease

Current and
history of

Liver tumors

a) Benign

i) Focal nodular
hyperplasia

ii) Hepatocellular
adenoma

b) Malignant
Malaria

Contraception

366.e9
Recommendations and Reports

Appendix A (Continued)
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

Condition

Sub-condition

Combined
pill, patch,
ring

I
Multiple risk factors for arterial

Progestinonly pill

cardiovascular disease

(such as older age,

smoking, diabetes
and hypertension)

Obesity

a) >30 kg/m2 BMI

b) Menarche to
<18 years and
>30 kg/m2 BMI

Ovarian cancer
Parity

3/4*

2*

Injection

Implant

C
3*

LNG-IUD Copper-IUD

2*

a) Nulliparous

b) Parous

(i) with
subsequent
pregnancy

(ii) without
subsequent
pregnancy

2*

2*

Past ectopic
pregnancy
a) Past, (assuming no
current risk factors
of STIs)

b) Current
Peripartum

cardiomyopathy

Postabortion

Postpartum
(see also Breastfeeding)

a) Normal or mildly
impaired cardiac
function
(i) <6 months

(ii) >6 months

b) Moderately or
severely impaired
cardiac function

a) First trimester

1*

1*

1*

1*

1*

1*

b) Second trimester

1*

1*

1*

1*

c) Immediately postseptic abortion

1*

1*

1*

1*

a) <21 days

3*

b) 21 days to
42 days
(i) with other risk
factors for VTE
(ii) without other
risk factors for
VTE
c) >42 days

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366.e10
Recommendations and Reports

Appendix A (Continued)
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

Condition

Sub-condition

Combined
pill, patch,
ring

I
Postpartum (in breastfeeding
or non-breastfeeding women,
including post-cesarean
section)

Schistosomiasis

Smoking

Solid organ
transplantation
Stroke

Implant

LNG-IUD Copper-IUD

b) 10 minutes after
delivery of the
placenta to
< 4 weeks

c) >4 weeks

d) Puerperal sepsis

NA*

NA*

NA*

NA*

a) On
immunosuppressive
therapy

2/3*

b) Not on
immunosuppressive
therapy

4*
2

4*
1

a) Uncomplicated

b) Fibrosis of the
liver

a) Current purulent
cervicitis or
chlamydial infection
or gonorrhea

2*

2*

b) Other STIs
(excluding HIV and
hepatitis)

c) Vaginitis
(including
trichomonas
vaginalis and
bacterial vaginosis)

d) Increased risk of
STIs

2/3*

2/3*

Severe dysmenorrhea
STIs

Injection

a) <10 minutes after

delivery of the
placenta

Pregnancy
Rheumatoid
arthritis

Progestinonly pill

a) Age <35

b) Age >35, <15

cigarettes/day

c) Age >35, >15

cigarettes/day

a) Complicated

b) Uncomplicated

2*

History of
cerebrovascular
accident

3
3

Contraception

366.e11
Recommendations and Reports

Appendix A (Continued)
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

Condition

Sub-condition

Combined
pill, patch,
ring

I
a) Varicose veins

erythematosus

Injection

Implant

LNG-IUD Copper-IUD

a) Positive (or
unknown)
antiphospholipid
antibodies

b) Severe
thrombocytopenia

2*

3*

2*

c)
Immunosuppressive
treatment

thrombophlebitis
Systemic lupus

Progestinonly pill

d) None of the above

4*

2*

2*

2*

2*

1*

mutations
Simple goiter/
hyperthyroid/
hypothyroid
Tuberculosis
(see also Drug
Interactions)
Unexplained vaginal bleeding

Valvular heart
disease
Vaginal bleeding
patterns

a) Non-pelvic

1*

1*

1*

1*

b) Pelvic

1*

1*

1*

1*

(suspicious for
serious condition)
before evaluation

2*

2*

3*

3*

4*

2*

4*

2*

a) Uncomplicated

b) Complicated

a) Irregular pattern
without heavy
bleeding

b) Heavy or
prolonged bleeding

1*

2*

2*

2*

1*

2*

2*

Viral hepatitis
b) Carrier/Chronic

3/4*

Contraception

366.e12
Recommendations and Reports

Appendix A (Continued)
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

Condition

Sub-condition

Combined
pill, patch,
ring

Progestinonly pill

Injection

Implant

LNG-IUD Copper-IUD

Drug Interactions
Antiretroviral therapy

Anticonvulsant therapy

Antimicrobial therapy

a) Nucleoside
reverse transcriptase
inhibitors

1*

2/3*

2*

2/3*

2*

b) Non-nucleoside
reverse transcriptase
inhibitors

2*

2*

2*

2/3*

2*

2/3*

2*

c) Ritonavir-boosted
protease inhibitors

3*

3*

2*

2/3*

2*

2/3*

2*

a) Certain
anticonvulsants
(phenytoin,
carbamazepine,
barbiturates,
primidone,
topiramate,
oxcarbazepine)

3*

3*

2*

b) Lamotrigine

3*

a) Broad spectrum
antibiotics

b) Antifungals

c) Antiparasitics

d) Rifampicin or
rifabutin therapy

3*

3*

2*

Abbreviations: AIDS = acquired immunodeficiency syndrome; BMI = body mass index; C = continuation of contraceptive method; COC = combined oral
contraceptive; Cu-IUD = copper-containing intrauterine device; DVT = deep venous thrombosis; hCG = human chorionic gonadotropin; HIV = human
immunodeficiency virus; I = initiation of contraceptive method; LNG-IUD = levonorgestrel-releasing intrauterine device; NA = not applicable;
PE = pulmonary embolism; STI = sexually transmitted infection; VTE = venous thromboembolism.
Source: Modified from CDC. Summary chart of U.S. medical eligibility criteria for contraceptive use. Atlanta, GA: CDC; 2012. (Available at http://www
.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm.)
* Please see the complete guidance for a clarification to this classification: www.cdc.gov/reproductivehealth/unintendedpregnancy/USMEC.htm.
Condition that exposes a woman to increased risk as a result of unintended pregnancy.

Contraception

366.e13
Recommendations and Reports

Appendix B
When to Start Using Specific Contraceptive Methods

Contraceptive method

When to start (if the provider is

reasonably certain that the woman is
not pregnant)

Copper-containing IUD

Anytime

Not needed

Levonorgestrel-releasing IUD

Anytime

If >7 days after menses started, use

Bimanual examination and cervical
back-up method or abstain for 7 days. inspection

Implant

Anytime

If >5 days after menses started, use

None
back-up method or abstain for 7 days.

Injectable

Anytime

If >7 days after menses started, use

None
back-up method or abstain for 7 days.

Combined hormonal contraceptive

Anytime

If >5 days after menses started, use

Blood pressure measurement
back-up method or abstain for 7 days.

Progestin-only pill

Anytime

If >5 days after menses started, use

None
back-up method or abstain for 2 days.

Additional contraception
(i.e., back-up) needed

Examinations or tests needed

before initiation*
Bimanual examination and cervical
inspection

Abbreviations:
U.S. Medical
Eligibility Criteria for Contraceptive Use, 2010.
* Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. MEC 1) or generally
can be used (U.S. MEC 2) among obese women (Box 2). However, measuring weight and calculating BMI (weight [kg]/height [m]2) at baseline might be helpful for
monitoring any changes and counseling women who might be concerned about weight change perceived to be associated with their contraceptive method.
Most women do not require additional STD screening at the time of IUD insertion if they have already been screened according to CDCs STD Treatment Guidelines
(available at http://www.cdc.gov/std/treatment). If a woman has not been screened according to guidelines, screening can be performed at the time of IUD insertion,
and insertion should not be delayed. Women with purulent cervicitis or current chlamydial infection or gonorrhea should not undergo IUD insertion (U.S. MEC 4).
Women who have a very high individual likelihood of STD exposure (e.g., those with a currently infected partner) generally should not undergo IUD insertion
(U.S. MEC 3) (Box 2). For these women, IUD insertion should be delayed until appropriate testing and treatment occurs.

Contraception

366.e14
Recommendations and Reports

Appendix C
Examinations and Tests Needed Before Initiation of Contraceptive Methods
The examinations or tests noted apply to women who are
presumed to be healthy. Those with known medical problems
or other special conditions might need additional examinations
or tests before being determined to be appropriate candidates
for a particular method of contraception. The U.S. Medical
Eligibility Criteria for Contraceptive Use, 2010 (U.S. MEC),
might be useful in such circumstances (5). The following
classification was considered useful in differentiating the
applicability of the various examinations or tests:
Class A: essential and mandatory in all circumstances for
safe and effective use of the contraceptive method.
Class B: contributes substantially to safe and effective use,
but implementation may be considered within the public
health and/or service context; risk of not performing an
examination or test should be balanced against the benefits
of making the contraceptive method available.

Class C: does not contribute substantially to safe and

effective use of the contraceptive method.
These classifications focus on the relationship of the
examinations or tests to safe initiation of a contraceptive
method. They are not intended to address the appropriateness
of these examinations or tests in other circumstances. For
example, some of the examinations or tests that are not deemed
necessary for safe and effective contraceptive use might be
appropriate for good preventive health care or for diagnosing
or assessing suspected medical conditions.
No examinations or tests are needed before initiating
condoms or spermicides. A bimanual examination is necessary
for diaphragm fitting. A bimanual examination and cervical
inspection are needed for cervical cap fitting.

TABLE. Examinations and tests needed before initiation of contraceptive methods

Contraceptive method and class
Examination or test
Examination
Blood pressure
Weight (BMI) (weight [kg]/
height [m]2)
Clinical breast examination
Bimanual examination and
cervical inspection
Laboratory test
Glucose
Lipids
Liver enzymes
Hemoglobin
Thrombogenic mutations
Cervical cytology
(Papanicolaou smear)
STD screening with laboratory
tests
HIV screening with laboratory
tests

Cu-IUD and
LNG-IUD

Implant

Injectable

CHC

POP

Condom

Diaphragm or
cervical cap

Spermicide

A*

C
C

C
C

C
C

C
A

C
C

C
C

C
C

C
C

C
C

C
A

C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

Abbreviations: BMI = body mass index; CHC = combined hormonal contraceptive; Cu-IUD = copper-containing intrauterine device; DMPA = depot medroxyprogesterone
acetate; HIV = human immunodeficiency virus; LNG-IUD = levonorgestrel-releasing intrauterine device; POP = progestin-only pill; STD = sexually transmitted disease;
U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use, 2010.
* In cases in which access to health care might be limited, the blood pressure measurement can be obtained by the woman in a nonclinical setting (e.g., pharmacy
or fire station) and self-reported to the provider.
Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. MEC 1) or generally
can be used (U.S. MEC 2) among obese women (Box 2). However, measuring weight and calculating BMI at baseline might be helpful for monitoring any changes
and counseling women who might be concerned about weight change perceived to be associated with their contraceptive method.
A bimanual examination (not cervical inspection) is needed for diaphragm fitting.
Most women do not require additional STD screening at the time of IUD inser tion if they have already been screened according to CDCs STD Treatment Guidelines
(available at http://www.cdc.gov/std/treatment). If a woman has not been screened according to guidelines, screening can be performed at the time of IUD insertion
and insertion should not be delayed. Women with purulent cervicitis or current chlamydial infection or gonorrhea should not undergo IUD insertion (U.S. MEC 4).
Women who have a very high individual likelihood of STD exposure (e.g., those with a currently infected partner) generally should not undergo IUD insertion
(U.S. MEC 3). For these women, IUD insertion should be delayed until appropriate testing and treatment occurs.

Contraception

366.e15
Recommendations and Reports

Appendix D
Routine Follow-Up After Contraceptive Initiation
These recommendations address when routine follow-up
is recommended for safe and effective continued use of
contraception for healthy women. The recommendations refer
to general situations and might vary for different users and

different situations. Specific populations that might benefit

from more frequent follow-up visits include adolescents, those
with certain medical conditions or characteristics, and those
with multiple medical conditions.

TABLE. Routine follow-up after contraceptive initiation

Contraceptive method
Action

Cu-IUD or LNG-IUD

Implant

Injectable

CHC

POP

Assess any changes in health status, including medications, that

would change the methods appropriateness for safe and
effective continued use based on U.S. MEC (i.e., category 3 and 4
conditions and characteristics) (Box 2).

Consider performing an examination to check for the presence of

IUD strings.

Consider assessing weight changes and counseling women who

are concerned about weight change perceived to be associated
with their contraceptive method.

Measure blood pressure.

General follow-up
Advise women to return at any time to discuss side effects or other
problems or if they want to change the method. Advise women
using IUDs, implants, or injectables when the IUD or implant
needs to be removed or when a reinjection is needed. No routine
follow-up visit is required.
Other routine visits
Assess the womans satisfaction with her current method and
whether she has any concerns about method use.

Abbreviations: CHC = combined hormonal contraceptive; Cu-IUD = copper-containing intrauterine device; HIV = human immunodeficiency virus; IUD = intrauterine
device; LNG-IUD = levonorgestrel-releasing intrauterine device; POP = progestin-only pill; U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use, 2010.

Contraception

366.e16
Recommendations and Reports

Appendix E
Management of Women with Bleeding Irregularities While Using Contraception

If bleeding persists, or if the woman requests it, medical treatment can be considered.*

Cu-IUD
users

LNG-IUD
users

For unscheduled
spotting or light
bleeding or for heavy
or prolonged bleeding:
NSAIDs (57 days
of treatment)

Implant
users

For unscheduled
spotting or light
bleeding or heavy/
prolonged bleeding:
NSAIDs (57 days
of treatment)
Hormonal treatment
(if medically eligible)
with COCs or
estrogen (1020 days
of treatment)

Injectable
(DMPA) users

For unscheduled
spotting or light
bleeding:
NSAIDs (57 days
of treatment)
For heavy or
prolonged bleeding:
NSAIDs (57 days of
treatment)
Hormonal treatment
(if medically eligible)
with COCs or estrogen
(1020 days of
treatment)

CHC users (extended or

continuous regimen)

Hormone-free interval
for 34 consecutive days

Not recommended during

extended or continuous
CHC use

Not recommended more

than once per month
because contraceptive
reduced

Abbreviations: CHC = combined hormonal contraceptive; COC = combined oral contraceptive; Cu-IUD = copper-containing intrauterine device; DMPA = depot
medroxyprogesterone acetate; LNG-IUD = levonorgestrel-releasing intrauterine device; NSAIDs = nonsteroidal antiinflammatory drugs.
* If clinically warranted, evaluate for underlying condition. Treat the condition or refer for care.
Heavy or prolonged bleeding, either unscheduled or menstrual, is uncommon.

Contraception

366.e17
Recommendations and Reports

Appendix F
Management of the IUD when a Cu-IUD or an LNG-IUD User Is Found to Have
Pelvic Inf lammatory Disease
Treat PID.*
Counsel about condom use.
IUD does not need to be removed.

Woman wants to continue IUD.

Woman wants to discontinue IUD.

Reassess in 2448 hours.

Remove IUD after beginning antibiotics.

Clinical improvement

No clinical improvement

Continue IUD.

Continue antibiotics.
Consider removal of IUD.

Offer another contraceptive method.

Offer emergency contraception.

Offer another contraceptive method.

Offer emergency contraception.

Abbreviations: Cu-IUD = copper-containing IUD; IUD = intrauterine device; LNG-IUD = levonorgestrel-releasing IUD; PID = pelvic inflammatory disease.
* Treat according to CDCs STD Treatment Guidelines (available at http://www.cdc.gov/std/treatment).