U.S. Medical Eligibility Criteria for Contraceptive Use, 2016

Recommendations and Reports / Vol. 65 / No. 3 July 29, 2016

U.S. Medical Eligibility Criteria

for Contraceptive Use, 2016

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

Morbidity and Mortality Weekly Report

Please note: An update has been published for this report. To view the update, please click here

Recommendations and Reports

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David W. Fleming, MD

William E. Halperin, MD, DrPH, MPH

King K. Holmes, MD, PhD

Robin Ikeda, MD, MPH

Rima F. Khabbaz, MD

Phyllis Meadows, PhD, MSN, RN

Jewel Mullen, MD, MPH, MPA

Jeff Niederdeppe, PhD

Patricia Quinlisk, MD, MPH

Patrick L. Remington, MD, MPH

Carlos Roig, MS, MA

William L. Roper, MD, MPH

William Schaffner, MD

CONTENTS

Introduction ............................................................................................................1

Methods

....................................................................................................................2

How to Use This Document

...............................................................................3

Keeping Guidance Up to Date

.......................................................................... 5

References

................................................................................................................8

Abbreviations and Acronyms

............................................................................9

Appendix A: Summary of Changes from U.S. Medical Eligibility Criteria

for Contraceptive Use, 2010

...........................................................................10

Appendix B: Classifications for Intrauterine Devices

............................. 18

Appendix C: Classifications for Progestin-Only Contraceptives

........ 35

Appendix D: Classifications for Combined Hormonal Contraceptives

.... 55

Appendix E: Classifications for Barrier Methods

..................................... 81

Appendix F: Classifications for Fertility Awareness–Based Methods

..... 88

Appendix G: Lactational Amenorrhea Method

....................................... 90

Appendix H: Coitus Interruptus (Withdrawal)

......................................... 91

Appendix I: Female and Male Sterilization

................................................ 92

Appendix J: Classifications for Emergency Contraception

.................. 93

Appendix K: Summary of Classifications for Hormonal Contraceptive

Methods and Intrauterine Devices

............................................................ 96

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US Department of Health and Human Services/Centers for Disease Control and Prevention

Introduction

Approximately 45% of all pregnancies that occur in the

United States are unintended (1), with associated increased

risks for adverse maternal and infant health outcomes (2) and

increased health care costs (3). Women, men, and couples

have increasing numbers of safe and effective choices for

contraceptive methods, including long-acting reversible

contraception methods such as intrauterine devices (IUDs)

and implants, to reduce the risk for an unintended pregnancy.

However, with these expanded options comes the need for

evidence-based guidance to help health care providers offer

quality family planning care to their patients, including

choosing the most appropriate contraceptive method for

individual circumstances and using that method correctly,

consistently, and continuously to maximize effectiveness.

In 2010, CDC published the first U.S. Medical Eligibility

Criteria for Contraceptive Use (U.S. MEC), which provided

recommendations on safe use of contraceptive methods

for women with various medical conditions and other

characteristics (and was adapted from global guidance

developed by the World Health Organization [WHO MEC])

(4,5). U.S. MEC is a companion document to the U.S. Selected

Practice Recommendations for Contraceptive Use (U.S. SPR),

which provides guidance on how to use contraceptive methods

safely and effectively once they are deemed to be medically

appropriate (6). WHO intended for the global guidance to

be used by local or national policy makers, family planning

program managers, and the scientific community as a reference

when they develop family planning guidance at the country

or program level. During 2008–2010, CDC participated in a

formal process to adapt the global guidance for appropriateness

Corresponding author: Kathryn M. Curtis, PhD, Division of

Reproductive Health, National Center for Chronic Disease Prevention

and Health Promotion, CDC. Telephone: 770-488-5200; E-mail:

[email protected].

U.S. Medical Eligibility Criteria for Contraceptive Use, 2016

Kathryn M. Curtis, PhD

Naomi K. Tepper, MD

Tara C. Jatlaoui, MD

Erin Berry-Bibee, MD

1,2

Leah G. Horton, MSPH

Lauren B. Zapata, PhD

Katharine B. Simmons, MD

1,2

H. Pamela Pagano, MPH

Denise J. Jamieson, MD

Maura K. Whiteman, PhD

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia

Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina

Summary

The 2016 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of

specific contraceptive methods by women and men who have certain characteristics or medical conditions. These recommendations

for health care providers were updated by CDC after review of the scientific evidence and consultation with national experts who

met in Atlanta, Georgia, during August 26–28, 2015. The information in this report updates the 2010 U.S. MEC (CDC. U.S.

medical eligibility criteria for contraceptive use, 2010. MMWR 2010:59 [No. RR-4]). Notable updates include the addition

of recommendations for women with cystic fibrosis, women with multiple sclerosis, and women receiving certain psychotropic drugs

or St. John’s wort; revisions to the recommendations for emergency contraception, including the addition of ulipristal acetate; and

revisions to the recommendations for postpartum women; women who are breastfeeding; women with known dyslipidemias, migraine

headaches, superficial venous disease, gestational trophoblastic disease, sexually transmitted diseases, and human immunodeficiency

virus; and women who are receiving antiretroviral therapy. The recommendations in this report 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. This report is not intended to be a substitute for professional medical advice for

individual patients. Persons should seek advice from their health care providers when considering family planning options.

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for use in the United States, which included rigorous

identification and critical appraisal of the scientific evidence

through systematic reviews, and input from national experts

on how to translate that evidence into recommendations for

U.S. health care providers (5). At that time, CDC committed

to keeping this guidance up to date and based on the best

available evidence, with full review every few years (5).

This document updates CDC’s U.S. MEC 2010 (5), based

on new evidence and input from experts. A summary of

changes from U.S. MEC 2010 is provided (Appendix A).

Notable updates include the following:

• addition of recommendations for women with cystic

fibrosis, women with multiple sclerosis, and women

receiving certain psychotropic drugs or St. John’s wort

• revisions to the recommendations for emergency

contraception, including the addition of ulipristal acetate

• revisions to the recommendations for postpartum women;

women who are breastfeeding; women with known

dyslipidemias, migraine headaches, superficial venous

disease, gestational trophoblastic disease, sexually transmitted

diseases (STDs), and human immunodeficiency virus

(HIV); and women who are receiving antiretroviral therapy

The goal of these recommendations is to remove unnecessary

medical barriers to accessing and using contraception, thereby

decreasing the number of unintended pregnancies. These

recommendations are meant to serve as a source of clinical

guidance for health care providers; health care providers should

always consider the individual clinical circumstances of each

person seeking family planning services. This report is not

intended to be a substitute for professional medical advice for

individual patients, who should seek advice from their health

care providers when considering family planning options.

Methods

Since publication of U.S. MEC 2010, CDC has monitored

the literature for new evidence relevant to the recommendations

through the WHO/CDC continuous identification of research

evidence (CIRE) system. This system identifies new evidence

as it is published and allows WHO and CDC to update

systematic reviews and facilitate updates to recommendations

as new evidence warrants. Automated searches are run in

PubMed weekly, and the results are reviewed. Abstracts that

meet specific criteria are added to the web-based CIRE system,

which facilitates coordination and peer review of systematic

reviews for both WHO and CDC (7). In 2014, CDC reviewed

all of the existing recommendations in U.S. MEC 2010 for

new evidence identified by CIRE that had the potential to

lead to a changed recommendation. During August 27–28,

2014, CDC held a meeting in Atlanta, Georgia, of 11

family planning experts and representatives from partner

organizations to solicit their input on the scope of and process

for updating both U.S. MEC 2010 and U.S. SPR 2013. The

participants were experts in family planning and represented

various types of health care providers, as well as health care

provider organizations. A list of participants is provided

at the end of this report. Meeting participants discussed

topics to be addressed in the update of U.S. MEC based on

new evidence published since 2010 (identified through the

CIRE system), topics addressed at a 2014 WHO meeting to

update global guidance, and suggestions CDC received from

health care providers for the addition of recommendations

for women with medical conditions not yet included in

U.S. MEC (e.g., from provider feedback through e-mail,

public inquiry, and questions received at conferences). CDC

identified several topics to consider when updating the

guidance, including revision of existing recommendations for

certain medical conditions or characteristics (breastfeeding,

postpartum, HIV, receiving antiretroviral therapy, obesity,

dyslipidemia, increased risk for STDs, superficial venous

thrombosis, gestational trophoblastic disease, and migraine

headaches), addition of recommendations for new medical

conditions (cystic fibrosis, multiple sclerosis, use of certain

psychotropic drugs, and St. John’s wort), and addition of

recommendations for new contraceptive methods (ulipristal

acetate for emergency contraception). CDC determined that

all other recommendations in U.S. MEC 2010 were up to

date and consistent with the existing body of evidence for

that recommendation.

In preparation for a subsequent expert meeting held during

August 26–28, 2015, to review the scientific evidence for

potential recommendations, CDC staff members and other

invited authors listed at the end of this report conducted

independent systematic reviews for each of the topics being

considered. The purpose of these systematic reviews was to

identify direct evidence about the safety of contraceptive

method use by women with selected conditions (e.g., risk for

disease progression or other adverse health effects in women with

multiple sclerosis who use combined hormonal contraceptives

[CHCs]). Preferred Reporting Items for Systematic Reviews

and Meta-Analyses (PRISMA) guidelines were followed for

reporting systematic reviews (8,9), and strength and quality

of the evidence were assigned using the system of the U.S.

Preventive Services Task Force (10). When direct evidence

was limited or not available, indirect evidence (e.g., evidence

on surrogate outcomes or among healthy women) and

theoretical issues were considered and either added to direct

evidence within a systematic review or separately compiled for

presentation to the meeting participants. Completed systematic

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reviews were peer reviewed by two or three experts and then

provided to participants before the expert meeting. Reviews

are referenced and cited throughout this document; the full

reviews appear in the published literature and contain the

details of each review, including the systematic review question,

literature search protocol, inclusion and exclusion criteria,

evidence tables, and quality assessments. CDC staff continued

to monitor new evidence identified through the CIRE system

during the preparation for the August 2015 meeting.

During August 26–28, 2015, in Atlanta, Georgia, CDC

held a meeting with 44 participants who were invited to

provide their individual perspectives on the scientific evidence

presented and potential recommendations. Twenty-nine of the

participants represented a wide range of expertise in family

planning provision and research, and included obstetricians/

gynecologists, pediatricians, family physicians, nurse

practitioners, epidemiologists, and others with research and

clinical practice expertise in contraceptive safety, effectiveness,

and management; these individuals participated in the entire

meeting. Fifteen participants with expertise relevant to

specific topics on the meeting agenda provided information

and participated in the discussion (e.g., an expert in cystic

fibrosis was asked to provide general information about the

condition and to assist in interpreting the evidence and any

theoretical concerns on the use of contraceptive methods in

women with the condition); these participants provided input

only during the session for which their topics were discussed.

Lists of participants and any potential conflicts of interest

are provided at the end of this report. During the meeting,

the evidence from the systematic review for each topic was

presented, including direct evidence and any indirect evidence

or theoretical concerns. Participants provided their perspectives

on using the evidence to develop recommendations that would

meet the needs of U.S. health care providers. After the meeting,

CDC determined the recommendations in this report, taking

into consideration the perspectives provided by the meeting

participants. Feedback also was received from three external

reviewers, composed of health care providers and researchers

who had not participated in the update meetings. These

reviewers were asked to provide comments on the accuracy,

feasibility, and clarity of the recommendations. Areas of

research that need additional investigation also were considered

during the meeting (11).

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 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 is defined

as representing either an individual’s characteristics (e.g., age

or history of pregnancy) or a known preexisting medical or

pathologic condition (e.g., diabetes or 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

situations might differ. The conditions affecting eligibility for

the use of each contraceptive method are classified into one of

four categories (Box 1).

Using the Categories in Practice

Health care providers can use the eligibility 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, although careful follow-up might 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 considered,

and careful follow-up is required. Hence, provision of a

contraceptive 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

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.

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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 might depend

on the circumstances of particular professional or service

organizations. For example, in some settings, a category 3

might mean that a 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 medical condition develops or worsens during use of a

contraceptive method. When the categories differ for initiation

and continuation, these differences are noted in the Initiation

and Continuation columns. When initiation and continuation

are not indicated, 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–K). In these

tables, the first column indicates the condition. Several

conditions are divided into subconditions to differentiate

between varying types or severity of the condition. The second

column classifies the condition for initiation or continuation

(or both) into category 1, 2, 3, or 4. For certain conditions,

the numeric classification does not adequately capture the

recommendation; in these cases, the third column clarifies the

numeric category. These clarifications were determined during

the discussions of the scientific evidence and are considered a

necessary element of the recommendation. The third column

also summarizes the evidence for the recommendation if

evidence exists. The recommendations for which no evidence

is cited are based on expert opinion from either the WHO or

U.S. expert meeting in which these recommendations were

developed, and might be based on evidence from sources

other than systematic reviews. For certain recommendations,

additional comments appear in the third column and generally

come from the WHO meeting or the U.S. meeting.

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 intrauterine contraception, including

the copper-containing IUD and levonorgestrel-releasing IUDs

(Appendix B); progestin-only contraceptives (POCs), including

etonogestrel implants, depot medroxyprogesterone acetate

injections, and progestin-only pills (Appendix C); CHCs,

including low-dose (containing ≤35 µg ethinyl estradiol)

COCs, combined hormonal patch, and combined vaginal

ring (Appendix D); barrier contraceptive methods, including

male and female condoms, spermicides, diaphragm with

spermicide, and cervical cap (Appendix E); fertility awareness–

based methods (Appendix F); lactational amenorrhea method

(Appendix G); coitus interruptus (Appendix H); female and

male sterilization (Appendix I); and emergency contraception,

including emergency use of the copper-containing IUD and

emergency contraceptive pills (Appendix J). A table at the end

of this report summarizes the classifications for the hormonal

and intrauterine methods (Appendix K).

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

report 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, might

play an important role in determining the most appropriate

choice. Voluntary informed choice of contraceptive methods

is an essential guiding principle, and contraceptive counseling,

when applicable, might be an important contributor to the

successful use of contraceptive methods.

In choosing a method of contraception, dual protection from

the simultaneous risk for HIV and other STDs also should be

considered. Although hormonal contraceptives and IUDs are

highly effective at preventing pregnancy, they do not protect

against STDs, including HIV. Consistent and correct use of the

male latex condom reduces the risk for HIV infection and other

STDs, including chlamydial infection, gonococcal infection,

and trichomoniasis (12). Although evidence is limited, use

of female condoms can provide protection from acquisition

and transmission of STDs (12). All patients, regardless of

contraceptive choice, should be counseled about the use of

condoms and the risk for STDs, including HIV infection (12).

Additional information about prevention and treatment of

STDs is available from the CDC Sexually Transmitted Diseases

Treatment Guidelines (http://www.cdc.gov/std/treatment) (12).

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Contraceptive Method Effectiveness

Contraceptive method effectiveness is critical for minimizing

the risk for an 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 (Figure). Methods

that depend on consistent and correct use have a wide range of

effectiveness. IUDs and implants are considered long-acting,

reversible contraception (LARC); these methods are highly

effective because they do not depend on regular compliance

from the user. LARC methods are appropriate for most women,

including adolescents and nulliparous women. All women

should be counseled about the full range and effectiveness of

contraceptive options for which they are medically eligible so

that they can identify the optimal method.

Unintended Pregnancy and Increased

Health Risk

For women with conditions that might make pregnancy

an unacceptable health risk, long-acting, highly effective

contraceptive methods might be the best choice to avoid

unintended pregnancy (Figure). Women with these conditions

should be advised that sole use of barrier methods for

contraception and behavior-based methods of contraception

might not be the most appropriate choice because of their

relatively higher typical-use rates of failure (Figure). Conditions

included in U.S. MEC that are associated with increased

risk for adverse health events as a result of pregnancy are

identified throughout the document (Box 2). Some of the

medical conditions included in U.S. MEC recommendations

are treated with teratogenic drugs. While the woman’s

medical condition may not affect her eligibility to use certain

contraceptive methods, women using teratogenic drugs are

at increased risk for poor pregnancy outcomes; long-acting,

highly effective contraceptive methods might be the best

option to avoid unintended pregnancy or delay pregnancy

until teratogenic drugs are no longer needed.

Keeping Guidance Up to Date

Updating the evidence-based recommendations as new

scientific evidence becomes available is a challenge. CDC

will continue to work with WHO to identify and assess new

relevant evidence as it becomes available and to determine

whether changes in the recommendations are warranted (7).

In most cases, U.S. MEC follows the WHO guidance updates,

which typically occur every 5 years (or sooner if warranted

by new data). However, CDC will review all 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 U.S. MEC every 5 years

as well. Updates to the guidance will appear on the CDC

U.S. MEC website (http://www.cdc.gov/reproductivehealth/

UnintendedPregnancy/USMEC.htm).

Acknowledgments

This report is based, in part, on the work of the Promoting Family

Planning Team, Department of Reproductive Health and Research,

World Health Organization, and its development of Medical

Eligibility Criteria for Contraceptive Use, 5th edition.

BOX 2. Conditions associated with increased risk for adverse health

events as a result of pregnancy*

Breast cancer

Complicated valvular heart disease

Cystic fibrosis

Diabetes: insulin dependent; with nephropathy,

retinopathy, or neuropathy or other vascular disease;

or of >20 years’ duration

Endometrial or ovarian cancer

Epilepsy

Hypertension (systolic ≥160 mm Hg or diastolic

≥100 mm Hg)

History of bariatric surgery within the past 2 years

HIV: not clinically well or not receiving antiretroviral therapy

Ischemic heart disease

Gestational trophoblastic disease

Hepatocellular adenoma and malignant liver

tumors (hepatoma)

Peripartum cardiomyopathy

Schistosomiasis with fibrosis of the liver

Severe (decompensated) cirrhosis

Sickle cell disease

Solid organ transplantation within the past 2 years

Stroke

Systemic lupus erythematosus

Thrombogenic mutations

Tuberculosis

* Long-acting, highly effective contraceptive methods might be the best

choice for women with conditions that are associated with increased risk

for adverse health events as a result of pregnancy. These women should

be advised that sole use of barrier methods for contraception and behavior-

based methods of contraception might not be the most appropriate choice

because of their relatively higher typical-use rates of failure.

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US Department of Health and Human Services/Centers for Disease Control and Prevention

FIGURE. Effectiveness of family planning methods*

SUN MON TUES WED THUR FRI SAT

2 3

4 5 6 7

9 10

12 13

16 17

19 20

25 26

2 3

JANUARY

Spermicide

Reversible Permanent

Male Sterilization Female Sterilization

Implant

Intrauterine Device

Injectable

Pill Patch Ring

Diaphragm

Male Condom Female Condom Withdrawal

Sponge

Fertility-Awareness

Based Methods

Spermicide

How to make your method

most eective

Vasectomy and

hysteroscopic sterilization:

After procedure, little or

nothing to do or remember.

Use another method for

rst 3 months.

Injectable: Get repeat

injections on time.

Pills: Take a pill each day.

Patch, Ring: Keep in place,

change on time.

Diaphragm: Use correctly

every time you have sex.

Condoms, sponge,

withdrawal, spermicides:

Use correctly every time

you have sex.

Fertility awareness-based

methods: Abstain or

use condoms on fertile

days. Newest methods

(Standard Days Method

and TwoDay Method)

may be the easiest to use

and consequently more

eective.

0.05 % LNG - 0.2 % Copper T - 0.8 % 0.15 % 0.5 %

(IUD)

(Vasectomy) (Abdominal, Laparoscopic, Hysteroscopic)

6 %

9 %

12 %

18 % 21 % 22 %

24 % 28 %

24 % parous women

12 % nulliparous women

Least

Eective

Most

Eective

Less than 1 pregnancy

6-12 pregnancies per

100 women in a year

per 100 women in a year

18 or more pregnancies

per 100 women in a year

CONDOMS SHOULD ALWAYS BE USED TO REDUCE THE RISK OF SEXUALLY TRANSMITTED INFECTIONS.

Other Methods of Contraception

Lactational Amenorrhea Method: LAM is a highly eective, temporary method of contraception.

Emergency Contraception: Emergency contraceptive pills or a copper IUD after unprotected intercourse substantially reduces risk of pregnancy.

[

]

Sources: Adapted from World Health Organization (WHO) Department of Reproductive Health and Research, Johns Hopkins Bloomberg School of Public Health/

Center for Communication Programs (CCP). Knowledge for health project. Family planning: a global handbook for providers (2011 update). Baltimore, MD; Geneva,

Switzerland: CCP and WHO; 2011; and Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397–404.

* The percentages indicate the number out of every 100 women who experienced an unintended pregnancy within the first year of typical use of each contraceptive method.

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U.S. Medical Eligibility Criteria for

Contraceptive Use Participants

CDC Guideline Development Group for U.S. Medical Eligibility

Criteria for Contraceptive Use and U.S. Selected Practice

Recommendations for Contraceptive Use

Kathryn M. Curtis, PhD (Chair), Erin Berry-Bibee, MD,

Suzanne G. Folger, PhD, Leah G. Horton, MSPH, Denise J.

Jamieson, MD, Tara C. Jatlaoui, MD, Polly A. Marchbanks, PhD, H.

Pamela Pagano, MPH, Halley E.M. Riley, MPH, Mirelys Rodriguez,

Katharine B. Simmons, MD, Naomi K. Tepper, MD, Maura K.

Whiteman, PhD, Lauren B. Zapata, PhD, CDC, Atlanta, Georgia.

Invited Meeting Participants, August 27–28, 2014, Atlanta, Georgia

Herbert Peterson, MD, University of North Carolina, Chapel

Hill, North Carolina (Chair); Gale Burstein, MD, Erie County

Department of Health, Buffalo, New York; Alison Edelman, MD,

Oregon Health and Science University, Portland, Oregon; Eve Espey,

MD, University of New Mexico, Albuquerque, New Mexico; Emily

Godfrey, MD, University of Washington, Seattle, Washington;

Andrew Kaunitz, MD, University of Florida, Jacksonville, Florida;

Susan Moskosky, MS, U.S. Department of Health and Human

Services, Rockville, Maryland; Kavita Nanda, MD, FHI360 and

American College of Obstetricians and Gynecologists, Durham,

North Carolina; Deborah Nucatola, MD, Planned Parenthood

Federation of America, New York, New York; Michael Policar, MD,

University of California, San Francisco, California; Carolyn Westhoff,

MD, Columbia University, New York, New York.

Systematic Review Presenters and Authors, Meeting, August 26–28,

2015, Atlanta, Georgia

Erin Berry-Bibee, MD, Kathryn M. Curtis, PhD, Leah G. Horton,

MSPH, Denise J. Jamieson, MD, Tara C. Jatlaoui, MD, Polly A.

Marchbanks PhD, Titilope Oduyebo, MD, Pamela Pagano, MPH,

Halley E.M. Riley, MPH, Katharine B. Simmons, MD, Naomi K.

Tepper, MD, Maura K. Whiteman, PhD, Lauren B. Zapata, PhD,

CDC, Atlanta, Georgia; Monica Dragoman, MD, Mary E. Gaffield,

PhD, Sharon J. Phillips, MD, Marleen Temmerman, MD, World Health

Organization, Geneva, Switzerland; Andra James, MD, Duke University

Medical Center, Durham, North Carolina; Nathalie Kapp, MD, HRA

Pharma, Paris, France; Kavita Nanda, MD, FHI360, Durham, North

Carolina; Seth Walker, MD, Emory University, Atlanta, Georgia.

Invited Meeting Participants, August 26–28, 2015, Atlanta, Georgia

Herbert Peterson, MD, University of North Carolina, Chapel

Hill, North Carolina (Chair); Rebecca Allen, MD, American Society

for Reproductive Medicine and Women and Infants Hospital,

Providence, Rhode Island; Jean Anderson, MD, Johns Hopkins

University, Baltimore, Maryland; Abbey Berenson, MD, University

of Texas Medical Branch, Galveston, Texas; Amanda Black, MD,

University of Ottawa, Ontario, Canada; Cora Collette Breuner, MD,

American Academy of Pediatrics and Seattle Children’s Hospital,

Seattle, Washington; Gale Burstein MD, Erie County Department

of Health, Buffalo, New York; Anne Calhoun, MD, University of

North Carolina, Chapel Hill, North Carolina; Nahida Chakhtoura,

MD, National Institutes of Health, Rockville, Maryland; Alicia

Christy, MD, National Institutes of Health, Rockville, Maryland;

Mitchell D. Creinin, MD, University of California, Davis, California;

Linda Dominguez, Southwest Women’s Health, Albuquerque,

New Mexico; Alison Edelman, MD, Oregon Health and Science

University, Portland, Oregon; Eve Espey, MD, University of

New Mexico, Albuquerque, New Mexico; Emily Godfrey, MD,

University of Washington, Seattle, Washington; Marji Gold, MD,

Albert Einstein College of Medicine, Bronx, New York; Donald

Goldstein, MD, Harvard Medical School, Boston, Massachusetts;

Robert Hatcher, MD, Emory University, Atlanta, Georgia; Mark

Hathaway, MD, JHPIEGO and Unity Healthcare, Washington,

DC; Stephen Heartwell, MD, Susan Thompson Buffett Foundation,

Omaha, Nebraska; Paula Hillard, MD, Stanford University, Palo

Alto, California; Maria Houtchens, MD, Harvard Medical School,

Boston, Massachusetts; Andra James, MD, Duke University Medical

Center, Durham, North Carolina; Andrew Kaunitz, MD, University

of Florida, Jacksonville, Florida; Myong-Jin Kim, Pharm-D, Food

and Drug Administration, Rockville, Maryland; Barbara Konkle,

MD, Bloodworks Northwest, Seattle, Washington; Tobias Kurth,

MD, INSERM, Bordeaux, France; Miriam Labbok, MD, Academy

of Breastfeeding Medicine and University of North Carolina, Chapel

Hill, North Carolina; Reagan McDonald-Mosley, MD, Planned

Parenthood Federation of America, New York, New York; Joan

Meek, MD, American Academy of Pediatrics and Florida State

University College of Medicine, Orlando, Florida; Mark Mirochnick,

MD, Boston University, Boston, Massachusetts; Susan Moskosky,

MS, U.S. Department of Health and Human Services, Rockville,

Maryland; Kavita Nanda, MD, FHI360, Durham, North Carolina;

Jeffrey Peipert, MD, Washington University, St. Louis, Missouri;

Michael Policar, MD, University of California, San Francisco,

California; Sarah Prager, MD, University of Washington, Seattle

Washington; David Soper, MD, Medical University of South

Carolina, Charleston, South Carolina; Lisa Soule, MD, Food and

Drug Administration, Rockville, Maryland; Alison Stuebe, MD,

American College of Obstetricians and Gynecologist and University

of North Carolina, Chapel Hill, North Carolina; James Trussell,

PhD, Princeton University, Princeton, New Jersey; Seth Walker, MD,

Emory University, Atlanta, Georgia; Nanette Wenger, MD, Emory

University, Atlanta, Georgia; Carolyn Westhoff, MD, Columbia

University, New York, New York; Christopher Zahn, MD, American

College of Obstetricians and Gynecologists, Washington, DC.

CDC Attendees

Wanda D. Barfield, MD, Peter Briss, MD, W. Craig Hooper, PhD,

Jill Huppert, MD, Caroline King, PhD, Michele Mandel, Titilope

Oduyebo, MD, Cria Perrine, MD, Sam Posner, PhD.

External Reviewers

Abigail R.A. Aiken, PhD, Princeton University, Princeton, New

Jersey; Linda Burdette, PA-C, Premier Women’s Health of Yakima,

Yakima, Washington; Mimi Zieman, MD, Planned Parenthood

Southeast, Atlanta, Georgia.

Recommendations and Reports

8 MMWR / July 29, 2016 / Vol. 65 / No. 3

US Department of Health and Human Services/Centers for Disease Control and Prevention

Conflicts of Interest for Invited Meeting Participants,

August 26–28, 2015, Atlanta, Georgia

Rebecca Allen, Nexplanon trainer for Merck and Liletta trainer for

Actavis, consultant, advisory board and education grant from Bayer;

Mitchell D. Creinin, Nexplanon trainer for Merck, litigation consultant

for Bayer, advisory board for Merck and Teva Pharmaceutical Industries,

Ltd., consultant for Lemonaid – PolkaDoc app, research support

to University of California, Davis from Medicines360, Contramed,

Merck, Eunice Kennedy Shriver National Institute of Child Health

and Human Development, and Society of Family Planning; Linda

Dominguez, speaker for Bayer, Merck, and Actavis; Alison Edelman,

royalties from Up to Date, Inc., consultant for Genzyme, grant support

from the National Institutes of Health and the Gates Foundation,

travel funds from the World Health Organization, grant support and

honorarium from Society of Family Planning, honorarium and travel

funds from Contemporary Forum, trainer for Merck, consultant

for Gynuity Health Projects, honorarium from CDC, Projects In

Knowledge, and American Congress of Obstetricians and Gynecologists,

advisory board for Agile Therapeutics; Eve Espey, travel funds from

the American Congress of Obstetricians and Gynecologists, Society

for Family Planning, and U.S. Food and Drug Administration,

Reproductive and Drug Advisory Committee for U.S. Food and Drug

Administration, travel funds and honoraria from Wayne State University,

Telluride Conference, New Mexico Department of Health Clinician

Conference, Planned Parenthood National Medical Conference and

Society of Family Planning, British Columbia Contraception Access

Research Team Conference, and American Congress of Obstetricians

and Gynecologists annual meeting; Emily Godfrey, research funding

from Bayer Women’s Health, Prima-Temp, and Teva Pharmaceutical

Industries, Ltd., trainer for Merck and Upstream USA, grant reviewer

for Fellowship of Family Planning and Society of Family Planning

Research Fund; Mark Hathaway, Liletta trainer and speaker for Actavis

and Medicines360, Nexplanon trainer for Merck, advisory board for

Contramed and Afaxys Pharmaceuticals; Paula Hillard, consultant for

American Civil Liberties Union, Advanced Health Media, CMEology,

National Sleep Foundation, and Planned Parenthood Federation of

America, honoraria from National Sleep Foundation, Dignity Health,

CMEology, Advance Health Media, and Medscape, editorial board for

Advanstar–Contemporary OB/GYN, board examiner for the American

Board of Obstetrics and Gynecology, contract reviewer for the U.S.

Department of Health and Human Services, editorial board for EBSCO–

PEMSoft, Nexplanon trainer for Merck, scientific advisor to Proctor and

Gamble, publication royalties from Wiley Blackwell Publishing; Andrew

Kaunitz, advisory board participant of Allergan, Bayer, Merck, and Pfizer,

clinical trial funding to University of Florida from Agile Therapeutics,

Bayer, Merck; Mark Mirochnick, data and safety monitoring board for

Merck and ViiV Healthcare, advisory board for Merck; Jeffrey Peipert,

research funding from Bayer and Teva Pharmaceutical Industries, Ltd.,

advisory board for Perrigo; Michael Policar, litigation consultant for

Bayer; James Trussell, advisory board for Merck and Teva Pharmaceutical

Industries, Ltd., consultant for Bayer; Nanette Wenger, research grants

from Alnylam Pharmaceuticals, Gilead Sciences, National Heart, Lung,

and Blood Institute, Pfizer, and Society for Women’s Health Research,

consultant for Amgen, AstraZeneca, Gilead Sciences and Merck;

Carolyn Westhoff, data and safety monitoring board for Merck and

Bayer, advisory board for Agile Therapeutics, MicroChips Biotech, and

Actavis, research support to Columbia University from Medicines360,

León Farma, and ContraMed.

Handling Conflicts of Interest

To promote transparency, all participants were asked to disclose any

potential conflicts of interest to CDC prior to the expert meeting and

to report any potential conflicts of interest during the introductory

portion of the expert meeting. All potential conflicts of interest are

listed above. No participants were excluded from discussion based

on potential conflicts of interest. CDC staff who ultimately decided

and developed these recommendations have no financial interests or

other relationships with the manufacturers of commercial products,

suppliers of commercial services, or commercial supporters relevant

to these recommendations.

References

1. Finer LB, Zolna MR. Declines in unintended pregnancy in the United

States, 2008–2011. N Engl J Med 2016;374:843–52.http://dx.doi.

org/10.1056/NEJMsa1506575

2. Gipson JD, Koenig MA, Hindin MJ. The effects of unintended pregnancy

on infant, child, and parental health: a review of the literature. Stud Fam Plann

2008;39:18–38. http://dx.doi.org/10.1111/j.1728-4465.2008.00148.x

3. Sonfield A, Kost K. Public costs from unintended pregnancies and the role

of public insurance programs in paying for pregnancy-related care: national

and state estimates for 2010. New York: Guttmacher Institute; 2015.

4. World Health Organization. Medical eligibility criteria for contraceptive

use. 4th ed. Geneva, Switzerland: World Health Organization; 2009.

5. CDC. U.S. medical eligibility criteria for contraceptive use, 2010.

MMWR Recomm Rep 2010;59(No. RR-4).

6. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. selected practice

recommendations for contraceptive use, 2016. MMWR Recomm Rep

2016;65(No. RR-4).

7. Mohllajee AP, Curtis KM, Flanagan RG, Rinehart W, Gaffield ML,

Peterson HB. Keeping up with evidence a new system for WHO’s

evidence-based family planning guidance. Am J Prev Med 2005;28:483–

90.http://dx.doi.org/10.1016/j.amepre.2005.02.008

8. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for

reporting systematic reviews and meta-analyses of studies that evaluate

health care interventions: explanation and elaboration. J Clin Epidemiol

2009;62:e1–34. http://dx.doi.org/10.1016/j.jclinepi.2009.06.006

9. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred

reporting items for systematic reviews and meta-analyses: the PRISMA

statement. Int J Surg 2010;8:336–41. http://dx.doi.org/10.1016/j.

ijsu.2010.02.007

10. Harris RP, Helfand M, Woolf SH, et al; Methods Work Group, Third US

Preventive Services Task Force. Current methods of the US Preventive Services

Task Force: a review of the process. Am J Prev Med 2001;20(Suppl):21–35.

http://dx.doi.org/10.1016/S0749-3797(01)00261-6

11. Horton L, Folger SG, Berry-Bibee E, Jatlaoui TC, Tepper NK, Curtis KM.

Research gaps from evidence-based contraception guidance: the U.S. Medical

Eligibility Criteria for Contraceptive Use, 2016, and the U.S. Selected Practice

Recommendations for Contraceptive Use, 2016. Contraception. In press 2016.

12. Workowski KA, Bolan GA. Sexually transmitted diseases treatment

guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3).

Recommendations and Reports

MMWR / July 29, 2016 / Vol. 65 / No. 3 9

US Department of Health and Human Services/Centers for Disease Control and Prevention

Abbreviations and Acronyms

ARV = antiretroviral [therapy]

BMD = bone mineral density

BMI = body mass index

CHC = combined hormonal contraceptive

COC = combined oral contraceptive

Cu-IUD = copper-containing intrauterine device

DMPA = depot medroxyprogesterone acetate

DVT = deep venous thrombosis

ECP = emergency contraceptive pills

FAB = fertility awareness–based [methods]

hCG = human chorionic gonadotropin

HDL = high-density lipoprotein

HIV = human immunodeficiency virus

IBD = inflammatory bowel disease

IUD = intrauterine device

LARC = long-acting reversible contraception

LDL = low-density lipoprotein

LNG = levonorgestrel

LNG-IUD = levonorgestrel-releasing intrauterine device

NET-EN = norethisterone enantate

NNRTI = nonnucleoside reverse transcriptase inhibitor

NRTI = nucleoside reverse transcriptase inhibitor

PE = pulmonary embolism

PID = pelvic inflammatory disease

POC = progestin-only contraceptive

POP = progestin-only pill

SLE = systemic lupus erythematosus

SSRI = selective serotonin reuptake inhibitors

STD = sexually transmitted disease

UPA = ulipristal acetate

U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use

U.S. SPR = U.S. Selected Practice Recommendations for Contraceptive Use

VTE = venous thromboembolism

Recommendations and Reports

10 MMWR / July 29, 2016 / Vol. 65 / No. 3

US Department of Health and Human Services/Centers for Disease Control and Prevention

Appendix A

Summary of Changes from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

BOX A1. Categories for classifying intrauterine devices and

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.

The classification additions, deletions, and modifications

from the 2010 U.S. Medical Eligibility Criteria for Contraceptive

Use (U.S. MEC) are summarized in the following tables

(Box A1) (Tables A1 and A2). For conditions for which

classifications changed for one or more contraceptive methods

or the condition description underwent a major modification,

the changes or modifications are in bold italics (Tables A1

and A2). Conditions that do not appear in this table remain

unchanged from the 2010 U.S. MEC.

TABLE A1. Summary of changes in classifications from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*

Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs Clarification

Breastfeeding

a. <21 days postpartum — — 2 2 2 4 Breastfeeding provides important health benets for

mother and infant. The U.S. Department of Health and

Human Services recommends increasing the proportion

of infants initially breastfed, exclusively breastfed through

6 months of life, and continuing breastfeeding through at

least 1 year of life as key public health goals (1).

b. 21 to <30 days postpartum

i. With other risk factors for

VTE (e.g., age ≥35 years,

previous VTE, thrombophilia,

immobility, transfusion at

delivery, peripartum

cardiomyopathy, BMI ≥30 kg/

, postpartum hemorrhage,

postcesarean delivery,

preeclampsia, or smoking)

— — 2 2 2 3 Breastfeeding provides important health benets for

mother and infant. The U.S. Department of Health and

Human Services recommends increasing the proportion

of infants initially breastfed, exclusively breastfed through

6 months of life, and continuing breastfeeding through at

least 1 year of life as key public health goals (1).

CHCs: For women with other risk factors for VTE, these risk

factors might increase the classication to a category 4.

ii. Without other risk factors

for VTE

— — 2 2 2 3 Breastfeeding provides important health benets for

mother and infant. The U.S. Department of Health and

Human Services recommends increasing the proportion

of infants initially breastfed, exclusively breastfed through

6 months of life, and continuing breastfeeding through at

least 1 year of life as key public health goals (1).

c. 30–42 days postpartum

i. With other risk factors for

VTE (e.g., age ≥35 years,

previous VTE, thrombophilia,

immobility, transfusion at

delivery, peripartum

cardiomyopathy, BMI ≥30 kg/

, postpartum hemorrhage,

postcesarean delivery,

preeclampsia, or smoking)

— — 1 1 1 3 Breastfeeding provides important health benets for

mother and infant. The U.S. Department of Health and

Human Services recommends increasing the proportion

of infants initially breastfed, exclusively breastfed through

6 months of life, and continuing breastfeeding through at

least 1 year of life as key public health goals (1).

CHCs: For women with other risk factors for VTE, these risk

factors might increase the classication to a category 4.

ii. Without other risk factors

for VTE

— — 1 1 1 2 Breastfeeding provides important health benets for

mother and infant. The U.S. Department of Health and

Human Services recommends increasing the proportion

of infants initially breastfed, exclusively breastfed through

6 months of life, and continuing breastfeeding through at

least 1 year of life as key public health goals (1).

d. >42 days postpartum — — 1 1 1 2 Breastfeeding provides important health benets for

mother and infant. The U.S. Department of Health and

Human Services recommends increasing the proportion

of infants initially breastfed, exclusively breastfed through

6 months of life, and continuing breastfeeding through at

least 1 year of life as key public health goals (1).

See table footnotes on page 16.

Recommendations and Reports

MMWR / July 29, 2016 / Vol. 65 / No. 3 11

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE A1. (Continued) Summary of changes in classifications from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*

Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs Clarification

Postpartum (nonbreastfeeding

women)

a. <21 days postpartum — — 1 1 1 4 —

b. 21–42 days postpartum

i. With other risk factors for

VTE (e.g., age ≥35 years,

previous VTE, thrombophilia,

immobility, transfusion at

delivery, peripartum

cardiomyopathy, BMI ≥30 kg/

, postpartum hemorrhage,

postcesarean delivery,

preeclampsia, or smoking)

— — 1 1 1 3 CHCs: For women with other risk factors for VTE, these risk

factors might increase the classication to a category 4.

ii. Without other risk factors

for VTE

— — 1 1 1 2 —

c. >42 days postpartum — — 1 1 1 1 —

Postpartum (including cesarean

delivery)

a. <10 minutes after delivery of

the placenta

IUDs: Insertion of IUDs among postpartum women is safe

and does not appear to increase health risks associated

with IUD use such as infection. Higher rates of expulsion

during the postpartum period should be considered as

they relate to eectiveness, along with patient access to

interval placement (i.e., not related to pregnancy) when

expulsion rates are lower.

Breastfeeding: Breastfeeding provides important health

benets for mother and infant. The U.S. Department of

Health and Human Services recommends increasing the

proportion of infants initially breastfed, exclusively

breastfed through 6 months of life, and continuing

breastfeeding through at least 1 year of life as key public

health goals (1).

i. Breastfeeding 1 2 — — — —

ii. Nonbreastfeeding 1 1 — — — —

b. 10 minutes after delivery of

the placenta to <4 weeks

(breastfeeding or

nonbreastfeeding)

2 2 — — — — IUDs: Insertion of IUDs among postpartum women is safe

and does not appear to increase health risks associated

with IUD use such as infection. Higher rates of expulsion

during the postpartum period should be considered as

they relate to eectiveness, along with patient access to

interval placement (i.e., not related to pregnancy) when

expulsion rates are lower.

Breastfeeding: Breastfeeding provides important health

benets for mother and infant. The U.S. Department of

Health and Human Services recommends increasing the

proportion of infants initially breastfed, exclusively

breastfed through 6 months of life, and continuing

breastfeeding through at least 1 year of life as key public

health goals (1).

c. ≥4 weeks (breastfeeding or

nonbreastfeeding)

1 1 — — — — IUDs: Insertion of IUDs among postpartum women is safe

and does not appear to increase health risks associated

with IUD use such as infection. Higher rates of expulsion

during the postpartum period should be considered as

they relate to eectiveness, along with patient access to

interval placement (i.e., not related to pregnancy) when

expulsion rates are lower.

Breastfeeding: Breastfeeding provides important health

benets for mother and infant. The U.S. Department of

Health and Human Services recommends increasing the

proportion of infants initially breastfed, exclusively

breastfed through 6 months of life, and continuing

breastfeeding through at least 1 year of life as key public

health goals (1).

d. Postpartum sepsis 4 4 — — — — —

See table footnotes on page 16.

Recommendations and Reports

12 MMWR / July 29, 2016 / Vol. 65 / No. 3

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE A1. (Continued) Summary of changes in classifications from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*

Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs Clarification

Multiple risk factors for

atherosclerotic cardiovascular

disease (e.g., older age,

smoking, diabetes, hyperten-

sion, low HDL, high LDL, or

high triglyceride levels)

1 2 2 3 2 3/4 Implants, DMPA, POP: When multiple major risk factors

exist, risk for cardiovascular disease might increase

substantially. Certain POCs might increase the risk for

thrombosis, although this increase is substantially less

than with COCs. The eects of DMPA might persist for

some time after discontinuation.

CHCs: When a woman has multiple major risk factors, any

of which alone would substantially increase her risk for

cardiovascular disease, use of CHCs might increase her risk

to an unacceptable level. However, a simple addition of

categories for multiple risk factors is not intended; for

example, a combination of two category 2 risk factors

might not necessarily warrant a higher category.

Implants, DMPA, POP, CHCs: The recommendations

apply to known preexisting medical conditions or

characteristics. Few if any screening tests are needed

before initiation of contraception. See the U.S. Selected

Practice Recommendations for Contraceptive Use (http://

www.cdc.gov/reproductivehealth/unintendedpreg-

nancy/usspr.htm)

Supercial venous disorders

a. Varicose veins 1 1 1 1 1 1 —

b. Supercial venous

thrombosis (acute or history)

1 1 1 1 1 3 CHCs: Supercial venous thrombosis might be associated

with an increased risk for VTE. If a woman has risk factors

for concurrent DVT (e.g., known thrombophilia or cancer)

or has current or history of DVT, see recommendations

for DVT/PE. Supercial venous thrombosis associated

with a peripheral intravenous catheter is less likely to be

associated with additional thrombosis and use of CHCs

may be considered.

Headaches

a. Nonmigraine (mild or severe) 1 1 1 1 1 1 CHCs: Classication depends on accurate diagnosis of

those severe headaches that are migraines and those

headaches that are not, as well as diagnosis of ever

experiencing aura. Aura is a specic focal neurologic

symptom. For more information about headache

classication see The International Headache Classication,

3rd edition (http://www.ihs-classication.org/_downloads/

mixed/International-Headache-Classication-III-ICHD-III-

2013-Beta.pdf). Any new headaches or marked changes in

headaches should be evaluated.

b. Migraine CHCs: Classication depends on accurate diagnosis of those

severe headaches that are migraines and those headaches

that are not, as well as diagnosis of ever experiencing aura.

Aura is a specic focal neurologic symptom. For more

information about headache classication see The

International Headache Society Classication, 3rd edition

(http://www.ihs-classication.org/_downloads/mixed/

International-Headache-Classication-III-ICHD-III-2013-Beta.

pdf). Any new headaches or marked changes in headaches

should be evaluated.

CHCs: Classication is for women without any other risk

factors for stroke (e.g., age, hypertension, and smoking).

i. Without aura (This category

of migraine includes

menstrual migraine.)

1 1 1 1 1 2

ii. With aura 1 1

1 1 1 4

Multiple sclerosis

a. With prolonged immobility 1 1 1 2 1 3 —

b. Without prolonged

immobility

1 1 1 2 1 1 —

Gestational trophoblastic

disease

This condition is associated with

increased risk for adverse health

events as a result of pregnancy

(Box 2).

For all subconditions of gestational trophoblastic

disease, classications are based on the assumption that

women are under close medical supervision because of

the need for monitoring of β-hCG levels for appropriate

disease surveillance.

a. Suspected gestational

trophoblastic disease

(immediate postevacuation)

For all subconditions of gestational trophoblastic

disease, classications are based on the assumption that

women are under close medical supervision because of

the need for monitoring of β-hCG levels for appropriate

disease surveillance.

i. Uterine size rst trimester 1 1 1 1 1 1

ii. Uterine size second

trimester

2 2 1 1 1 1

See table footnotes on page 16.

Recommendations and Reports

MMWR / July 29, 2016 / Vol. 65 / No. 3 13

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE A1. (Continued) Summary of changes in classifications from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*

Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs Clarification

b. Conrmed gestational

trophoblastic disease (after

initial evacuation and during

monitoring)

Initiation Continuation Initiation Continuation

i. Undetectable/nonpregnant

β-hCG levels

1 1 1 1 1 1 1 1 For all subconditions of gestational trophoblastic

disease, classications are based on the assumption that

women are under close medical supervision because of

the need for monitoring of β-hCG levels for appropriate

disease surveillance.

ii. Decreasing β-hCG levels 2 1 2 1 1 1 1 1 For all subconditions of gestational trophoblastic

disease, classications are based on the assumption that

women are under close medical supervision because of

the need for monitoring of β-hCG levels for appropriate

disease surveillance.

IUD: For women at higher risk for disease progression, the

benets of eective contraception must be weighed against

the potential need for early IUD removal.

iii. Persistently elevated

β-hCG levels or malignant

disease, with no evidence or

suspicion of intrauterine

disease

2 1 2 1 1 1 1 1 For all subconditions of gestational trophoblastic

disease, classications are based on the assumption that

women are under close medical supervision because of

the need for monitoring of β-hCG levels for appropriate

disease surveillance.

iv. Persistently elevated

β-hCG levels or malignant

disease, with evidence or

suspicion of intrauterine

disease

4 2 4 2 1 1 1 1 For all subconditions of gestational trophoblastic

disease, classications are based on the assumption that

women are under close medical supervision because of

the need for monitoring of β-hCG levels for appropriate

disease surveillance.

Sexually transmitted diseases Initiation Continuation Initiation Continuation

a. Current purulent cervicitis or

chlamydial infection or

gonococcal infection

4 2 4 2 1 1 1 1 IUD continuation: Treat the STD using appropriate

antibiotics. The IUD usually does not need to be removed

if the woman wants to continue using it. Continued use of

an IUD depends on the woman’s informed choice and her

current risk factors for STDs and PID.

b. Vaginitis (including

Trichomonas vaginalis and

bacterial vaginosis)

2 2 2 2 1

1 1 1 —

c. Other factors related to STDs 2 2 2 2 1 1 1 1 IUD initiation: Most women do not require additional STD

screening at the time of IUD insertion. If a woman with risk

factors for STDs has not been screened for gonorrhea and

chlamydia according to CDC STD treatment guidelines (2),

screening may be performed at the time of IUD insertion

and insertion should not be delayed.

High risk for HIV Initiation Continuation Initiation Continuation DMPA: Some studies suggest that women using

progestin-only injectable contraception might be at

increased risk for HIV acquisition; other studies do not

show this association. CDC reviewed all available

evidence and agreed that the data were not suciently

conclusive to change current guidance. However,

because of the inconclusive nature of the body of

evidence on possible increased risk for HIV acquisition,

women using progestin-only injectable contraception

should be strongly advised to also always use condoms

(male or female) and take other HIV preventive

measures. Expansion of contraceptive method mix and

further research on the relationship between hormonal

contraception and HIV infection are essential. These

recommendations will be continually reviewed in light of

new evidence.

2 2 2 2 1 1 1 1

HIV infection

For women with HIV infection

who are not clinically well or not

receiving ARV therapy, this

condition is associated with

increased risk for adverse health

events as a result of pregnancy

(Box 2).

— — — — 1 1 1 1 Implants, DMPA, POP, CHCs: Drug interactions might

exist between hormonal contraceptives and ARV drugs;

see Drug Interactions section.

a. Clinically well receiving ARV

therapy

1 1 1 1 — — — — —

b. Not clinically well or not

receiving ARV therapy

2 1 2 1 — — — — —

See table footnotes on page 16.

Recommendations and Reports

14 MMWR / July 29, 2016 / Vol. 65 / No. 3

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE A1. (Continued) Summary of changes in classifications from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*

Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs Clarification

Cystic brosis

This condition is associated with

increased risk for adverse health

events as a result of pregnancy

(Box 2).

1 1 1 2 1 1 Persons with cystic brosis are at increased risk for

diabetes, liver disease, gallbladder disease, and VTE

(particularly related to use of central venous catheters)

and are frequently prescribed antibiotics. Categories

assigned to such conditions in U.S. MEC should be the

same for women with cystic brosis who have these

conditions. For cystic brosis, classications are based on

the assumption that no other conditions are present;

these classications must be modied in the presence of

such conditions.

Implants, DMPA, POP, CHCs: Certain drugs to treat cystic

brosis (e.g., lumacaftor) might reduce eectiveness of

hormonal contraceptives, including oral, injectable,

transdermal, and implantable contraceptives.

Antiretroviral therapy Initiation Continuation Initiation Continuation IUD: No known interaction exists between ARV therapy

and IUD use. However, IUD insertion is classied as

category 2 if the woman is not clinically well or not

receiving ARV therapy. Otherwise, both insertion and

continuation are classied as category 1 (see HIV

Infection section).

a. Nucleoside reverse

transcriptase inhibitors (NRTIs)

i. Abacavir (ABC) 1/2 1 1/2 1 1 1 1 1 —

ii. Tenofovir (TDF) 1/2 1 1/2 1 1 1 1 1 —

iii. Zidovudine (AZT) 1/2 1 1/2 1 1 1 1 1 —

iv. Lamivudine (3TC) 1/2 1 1/2 1 1 1 1 1 —

v. Didanosine (DDI) 1/2 1 1/2 1 1 1 1 1 —

vi. Emtricitabine (FTC) 1/2 1 1/2 1 1 1 1 1 —

vii. Stavudine (D4T) 1/2 1 1/2 1 1 1 1 1 —

b. Nonnucleoside reverse

transcriptase inhibitors

(NNRTIs)

i. Efavirenz (EFV) 1/2 1 1/2 1 2 1

2 2 Implants, DMPA, POP, CHCs: Evidence suggests drug

interactions between efavirenz and certain hormonal

contraceptives. These interactions might reduce the

eectiveness of the hormonal contraceptive.

ii. Etravirine (ETR) 1/2 1 1/2 1 1 1 1 1 —

iii. Nevirapine (NVP) 1/2 1 1/2 1 1 1 1 1 —

iv. Rilpivirine (RPV) 1/2 1 1/2 1 1 1 1 1 —

c. Ritonavir-boosted protease

inhibitors

i. Ritonavir-boosted

atazanavir (ATV/r)

1/2 1 1/2 1 2 1 2 2 Implants, DMPA, POP: Theoretically, drug interactions

might occur between certain ritonavir-boosted protease

inhibitors and certain hormonal contraceptives that

might reduce the eectiveness of the hormonal

contraceptive. Any potential eect on contraceptive

eectiveness is likely to be lower with DMPA than with

other POCs because of the higher dose of DMPA.

CHCs: Theoretically, drug interactions might occur

between certain ritonavir-boosted protease inhibitors

and certain hormonal contraceptives that might reduce

the eectiveness of the hormonal contraceptive.

ii. Ritonavir-boosted

darunavir (DRV/r)

1/2 1 1/2 1 2 1 2 2 Implants, DMPA, POP: Theoretically, drug interactions

might occur between certain ritonavir-boosted protease

inhibitors and certain hormonal contraceptives that

might reduce the eectiveness of the hormonal

contraceptive. Any potential eect on contraceptive

eectiveness is likely to be lower with DMPA than with

other POCs because of the higher dose of DMPA.

CHCs: Theoretically, drug interactions might occur

between certain ritonavir-boosted protease inhibitors

and certain hormonal contraceptives that might reduce

the eectiveness of the hormonal contraceptive.

See table footnotes on page 16.

Recommendations and Reports

MMWR / July 29, 2016 / Vol. 65 / No. 3 15

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE A1. (Continued) Summary of changes in classifications from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*

Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs Clarification

iii. Ritonavir-boosted

fosamprenavir (FPV/r)

1/2 1 1/2 1 2 1 2 2 Implants, DMPA, POP: Theoretically, drug interactions

might occur between certain ritonavir-boosted protease

inhibitors and certain hormonal contraceptives that

might reduce the eectiveness of the hormonal

contraceptive. Any potential eect on contraceptive

eectiveness is likely to be lower with DMPA than with

other POCs because of the higher dose of DMPA.

CHCs: Theoretically, drug interactions might occur

between certain ritonavir-boosted protease inhibitors

and certain hormonal contraceptives that might reduce

the eectiveness of the hormonal contraceptive.

iv. Ritonavir-boosted

lopinavir (LPV/r)

1/2 1 1/2 1 1 1 1 1 —

v. Ritonavir-boosted

saquinavir (SQV/r)

1/2 1 1/2 1 2 1 2 2 Implants, DMPA, POP: Theoretically, drug interactions

might occur between certain ritonavir-boosted protease

inhibitors and certain hormonal contraceptives that

might reduce the eectiveness of the hormonal

contraceptive. Any potential eect on contraceptive

eectiveness is likely to be lower with DMPA than with

other POCs because of the higher dose of DMPA.

CHCs: Theoretically, drug interactions might occur

between certain ritonavir-boosted protease inhibitors

and certain hormonal contraceptives that might reduce

the eectiveness of the hormonal contraceptive.

vi. Ritonavir-boosted

tipranavir (TPV/r)

1/2 1 1/2 1 2 1 2 2 Implants, DMPA, POP: Theoretically, drug interactions

might occur between certain ritonavir-boosted protease

inhibitors and certain hormonal contraceptives that

might reduce the eectiveness of the hormonal

contraceptive. Any potential eect on contraceptive

eectiveness is likely to be lower with DMPA than with

other POCs because of the higher dose of DMPA.

CHCs: Theoretically, drug interactions might occur

between certain ritonavir-boosted protease inhibitors

and certain hormonal contraceptives that might reduce

the eectiveness of the hormonal contraceptive.

d. Protease inhibitors without

ritonavir

i. Atazanavir (ATV) 1/2 1 1/2 1 1 1 1 2 CHCs: Theoretical concern exists that increased levels of

ethinyl estradiol because of interactions with ATV might

increase the risk for adverse events.

ii. Fosamprenavir (FPV) 1/2 1 1/2 1 2 2 2 3 Implants, DMPA, POP: Theoretical concern exists that

interactions between FPV and hormonal contraceptives

leading to decreased levels of FPV might diminish

eectiveness of the antiretroviral drug. The drug

interaction likely involves CYP3A4 pathways; POCs have

less eect on CYP3A4 enzymes than CHCs.

CHCs: Concern exists that interactions between FPV and

hormonal contraceptives leading to decreased levels of FPV

might diminish eectiveness of the antiretroviral drug.

iii. Indinavir (IDV) 1/2 1 1/2 1 1 1 1 1 —

iv. Nelnavir (NFV) 1/2 1 1/2 1

2 1 2 2 Implants, DMPA, POP: Theoretically, drug interactions

might occur between certain protease inhibitors and

certain hormonal contraceptives that might reduce the

eectiveness of the hormonal contraceptive. Any

potential eect on contraceptive eectiveness is likely to

be lower with DMPA than with other POCs because of the

higher dose of DMPA. Concern exists that interactions

between NFV and POCs might decrease NFV levels.

CHCs: Evidence suggests drug interactions between

certain protease inhibitors and certain hormonal

contraceptives. These interactions might reduce the

eectiveness of the hormonal contraceptive.

See table footnotes on page 16.

Recommendations and Reports

16 MMWR / July 29, 2016 / Vol. 65 / No. 3

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE A1. (Continued) Summary of changes in classifications from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*

Condition Cu-IUD LNG-IUD Implants DMPA POP CHCs Clarification

e. CCR5 co-receptor

antagonists

i. Maraviroc (MVC) 1/2 1 1/2 1 1 1 1 1 —

f. HIV integrase strand transfer

inhibitors

i. Raltegravir (RAL) 1/2 1 1/2 1 1 1 1 1 —

ii. Dolutegravir (DTG) 1/2 1 1/2 1 1 1 1 1 —

iii. Elvitegravir (EVG) 1/2 1 1/2 1 1 1 1 1 —

g. Fusion inhibitors

i. Enfuvirtide 1/2 1 1/2 1 1 1 1 1 —

Psychotropic medications

a. SSRIs 1 1 1 1 1 1 —

St. John’s wort 1 1 2 1 2 2 —

Abbreviations: ARV=antiretroviral; BMI=body mass index; CHC=combined hormonal contraceptive; COC=combined oral contraceptive; Cu-IUD=copper-containing intrauterine device;

DMPA=depot medroxyprogesterone acetate; DVT=deep venous thrombosis; hCG=human chorionic gonadotropin; HDL=high-density lipoprotein; HIV = human immunodeficiency

virus; LDL=low-density lipoprotein; LNG-IUD=levonorgestrel-releasing intrauterine device; PE=pulmonary embolism; PID=pelvic inflammatory disease; POC = progestin-only contraceptive;

POP=progestin-only pill; SSRI = selective serotonin uptake inhibitor; STD=sexually transmitted disease; VTE=venous thromboembolism.

* For conditions for which classification changed for one or more contraceptive methods or the condition description underwent a major modification, the changes or modifications are in

bold italics.

TABLE A2. Summary of changes for emergency contraception from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*

Condition

Category

ClarificationCu-IUD UPA LNG COC

Pregnancy 4

NA NA NA

IUD: The IUD is not indicated during pregnancy and should not be used

because of the risk for serious pelvic infection and septic spontaneous

abortion.

ECPs: Although this method is not indicated for a woman with a known or

suspected pregnancy, no harm to the woman, the course of her pregnancy, or

the fetus if ECPs are inadvertently used is known to exist.

Breastfeeding 1

1 1 1

UPA: Breastfeeding is not recommended for 24 hours after taking UPA

because it is excreted in breast milk with highest concentrations in the first

24 hours, and maximum maternal serum levels are reached 1-3 hours after

administration. Mean UPA concentrations in breast milk decrease markedly

from 0 to 24–48 hours and then slowly decrease over 5 days (3). Breast milk

should be expressed and discarded for 24 hours after taking UPA.

Past ectopic pregnancy 1

1 1 1

—

History of bariatric surgery

This condition is associated with increased risk for adverse

health events as a result of pregnancy (Box 2).

a. Restrictive procedures: decrease storage capacity of

the stomach (vertical banded gastroplasty, laparoscopic

adjustable gastric band, or laparoscopic sleeve gastrectomy)

1 1 1

—

b. Malabsorptive procedures: decrease absorption of nutrients

and calories by shortening the functional length of the

small intestine (Roux-en-Y gastric bypass or biliopancreatic

diversion)

1 1 1

—

History of severe cardiovascular disease (ischemic heart disease,

cerebrovascular attack, or other thromboembolic conditions)

This condition is associated with increased risk for adverse

health events as a result of pregnancy (Box 2).

2 2 2

—

Rheumatoid arthritis

a. Receiving immunosuppressive therapy 2

1 1 1

—

b. Not receiving immunosuppressive therapy 1

1 1 1

—

Migraine 1

1 1 2

—

Inflammatory bowel disease (ulcerative colitis or Crohn’s disease) 1

1 1 1

—

Severe liver disease (including jaundice)

This condition is associated with increased risk for adverse

health events as a result of pregnancy (Box 2).

2 2 2

—

See table footnotes on page 17.

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MMWR / July 29, 2016 / Vol. 65 / No. 3 17

US Department of Health and Human Services/Centers for Disease Control and Prevention

References

1. US Department of Health and Human Services. Healthy people 2020:

maternal, infant, and child health objectives. Washington, DC: US

Department of Health and Human Services; 2015. http://www.

healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-

child-health/objectives

TABLE A2. (Continued) Summary of changes for emergency contraception from U.S. Medical Eligibility Criteria for Contraceptive Use, 2010*

Condition

Category

ClarificationCu-IUD UPA LNG COC

Solid organ transplantation

This condition is associated with increased risk for adverse

health events as a result of pregnancy (Box 2).

a. Complicated: graft failure (acute or chronic), rejection, or

cardiac allograft vasculopathy

1 1 1

—

b. Uncomplicated 2

1 1 1

—

Repeated ECP use 1

1 1 1

ECPs: Recurrent ECP use is an indication that the woman requires further

counseling about other contraceptive options. Frequently repeated ECP use

might be harmful for women with conditions classified as 2, 3, or 4 for CHC or

POC use.

Sexual assault 2

1 1 1

IUD: Women who have experienced sexual assault are at increased risk

for STDs. According to CDC STD treatment guidelines, routine presumptive

treatment of chlamydia, gonorrhea, and trichomonas is recommended after

sexual assault (2). Women with current purulent cervicitis or chlamydial

infection or gonococcal infection should not undergo IUD insertion (category 4).

Obesity (BMI ≥30 kg/m

) 1

2 2 2

ECPs: ECPs might be less effective among women with BMI ≥30 kg/m

than

among women with BMI <25 kg/m

. Despite this, no safety concerns exist.

CYP3A4 inducers (e.g., bosentan, carbamazepine, felbamate,

griseofulvin, oxcarbazepine, phenytoin, rifampin, St. John’s

wort, topiramate, efavirenz, and lumacaftor)

2 2 2

ECPs: Strong CYP3A4 inducers might reduce the effectiveness of ECPs.

Abbreviations: BMI=body mass index; CHC=combined hormonal contraceptive; COC=combined oral contraceptive; Cu-IUD=copper-containing intrauterine device; ECP=emergency

contraceptive pill; IUD=intrauterine device; LNG=levonorgestrel; NA=not applicable; POC=progestin-only contraceptive; STD=sexually transmitted disease; UPA=ulipristal acetate.

* For conditions for which classification changed for one or more contraceptive methods or the condition description underwent a major modification, the changes or modifications are in bold italics.

2. Workowski KA, Bolan GA. Sexually transmitted diseases treatment

guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-03).

3. Watson Pharmaceuticals. Ella [Prescribing information]. Morristown, NJ; 2010.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf

Recommendations and Reports

18 MMWR / July 29, 2016 / Vol. 65 / No. 3

US Department of Health and Human Services/Centers for Disease Control and Prevention

Appendix B

Classifications for Intrauterine Devices

Classifications for intrauterine devices (IUDs) are for

the copper-containing IUD and levonorgestrel-releasing

IUD (containing a total of either 13.5 mg or 52 mg

levonorgestrel) (Box B1) (Table B1). IUDs do not protect

against sexually transmitted diseases (STDs), including human

immunodeficiency virus (HIV), and women using these

methods should be counseled that consistent and correct use of

the male latex condom reduces the risk for transmission of HIV

and other STDs. Use of female condoms can provide protection

from transmission of STDs, although data are limited.

BOX B1. 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.

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US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE B1. Classifications for intrauterine devices, including the copper-containing intrauterine device and levonorgestrel-releasing

intrauterine device

Condition

Category

Clarifications/Evidence/CommentsCu-IUD LNG-IUD

Personal Characteristics and Reproductive History

Pregnancy 4 4 Clarification: The IUD is not indicated during pregnancy and should not be

used because of the risk for serious pelvic infection and septic spontaneous

abortion.

Age

a. Menarche to <20 years 2 2 Comment: Concern exists both about the risk for expulsion from nulliparity

and for STDs from sexual behavior in younger age groups.

b. ≥20 years 1 1 —

Parity

a. Nulliparous 2 2 Evidence: Data conflict about whether IUD use is associated with infertility

among nulliparous women, although well-conducted studies suggest no

increased risk (1–9).

b. Parous 1 1 —

Postpartum (including cesarean

delivery)

a. <10 minutes after delivery of the

placenta

Clarification: Insertion of IUDs among postpartum women is safe and does

not appear to increase health risks associated with IUD use such as infection.

Higher rates of expulsion during the postpartum period should be considered

as they relate to effectiveness, along with patient access to interval placement

(i.e., not related to pregnancy) when expulsion rates are lower.

Clarification (breastfeeding): Breastfeeding provides important health

benefits for mother and infant. The U.S. Department of Health and Human

Services recommends increasing the proportion of infants initially breastfed,

exclusively breastfed through 6 months of life, and continuing breastfeeding

through at least 1 year of life as key public health goals (10).

Evidence: Studies suggest that immediate postplacental (<10 minutes) and

early postpartum (10 minutes up until 72 hours) placement of Cu-IUDs and

LNG-IUDs is associated with increased risk for expulsion compared with

interval placement (i.e., not related to pregnancy). Early postpartum placement

has similar or increased risk for expulsion compared with immediate

postplacental placement. Although immediate postplacental placement at the

time of cesarean delivery might have increased risk for expulsion compared

with interval placement, risk appears lower than that for placement at the time

of vaginal delivery. Evidence for infection, perforation, and removals for pain or

bleeding are limited; however, these events are rare (11–62).

Evidence (breastfeeding): Two randomized controlled trials found

conflicting results on breastfeeding outcomes when LNG-IUDs were initiated

immediately postpartum compared with 6–8 weeks postpartum. Initiation

of LNG-IUDs immediately postpartum had no other harmful effect on infant

health, growth, or development (63,64). Breastfeeding women using IUDs do

not have an increased risk for certain IUD-related adverse events including

expulsion, infection, pain, or bleeding compared with nonbreastfeeding

women. The risk for perforation is increased independently among

breastfeeding women and among women ≤36 weeks postpartum,

compared with non-postpartum women; however, the absolute risk for

perforation remains low (11–62,65).

Comment (breastfeeding): Certain women might be at risk for breastfeeding

difficulties, such as women with previous breastfeeding difficulties, certain

medical conditions, or certain perinatal complications and those who

deliver preterm. For these women, as for all women, discussions about

contraception for breastfeeding women should include information about

risks, benefits, and alternatives.

i. Breastfeeding 1 2

ii. Nonbreastfeeding 1 1

See table footnotes on page 30.

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20 MMWR / July 29, 2016 / Vol. 65 / No. 3

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE B1. (Continued) Classifications for intrauterine devices, including the copper-containing intrauterine device and levonorgestrel-

releasing intrauterine device

Condition

Category

Clarifications/Evidence/CommentsCu-IUD LNG-IUD

b. 10 minutes after delivery of the

placenta to <4 weeks (breastfeeding

or nonbreastfeeding)

2 2 Clarification: Insertion of IUDs among postpartum women is safe and does