US Medical Eligibility Criteria for Contraceptive Use, 2010
W E N D Y G R U B E , P H D , C R N P
U N I V E R S I T Y O F P E N N S Y L V A N I A
S C H O O L O F N U R S I N G


Half of pregnancies are unintended

Half of unintended pregnancies result from inconsistent or incorrect contraceptive use

Risk of method vs. risk of pregnancy
 What is the most
important issue for the clinician prescribing contraception?

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Breast Cancer
Complicated valvular heart disease
IDDM with complications
Endometrial/ovarian cancer
Epilepsy
Hypertension (systolic >160, diastolic >100)
Bariatric surgery in past 2 years
HIV/AIDS
Ischemic HD
Malignant gestational trophoblastic disease
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Hepatic malignancies
Peripartum cardiomyopathy
Schistosomiasis with liver fibrosis
Severe cirrhosis
Sickle cell disease
Solid organ transplant in past
2 years
Stroke
SLE
Thrombogenic mutations
Tuberculosis
CDC, MMWR, May 28, 2010

BASED ON THE CURRENT SCIENTIFIC EVIDENCE
 Category 1:

No restrictions for use


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Category 2:

Advantages of method outweigh the theoretical or proven risks: careful follow-up may be required
Category 3:
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Theoretical or proven risks outweigh the advantage of a method: generally not recommended
Category 4:

Unacceptable health risk if method used

Modifications
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VTE
Valvular heart disease
Ovarian cancer
Uterine fibroids
Postpartum
Breastfeeding
CDC, MMWR, May 28, 2010
Additions
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RA
Bariatric surgery
Peripartum cardiomyopathy
Endometrial hyperplasia
IBD
Solid organ transplant

P I L L S , P A T C H E S , A N D R I N G S

Menarche to <40 years
 Category 1
> 40 years old
 Category 2
Smoking
 <35 and smoke: 2


>35 and smoke <15/day: 3
>35 and smoke > 15/day: 4

< 1 month postpartum
 Category 3
1-6 months postpartum
 Category 2
6 months postpartum
 Category 2

Postpartum:
< 21 days
 Category 3
21 days
 Category 1
Postabortion
Immediately post abortion
1 st or 2 nd trimester
 Category 1

BMI > 30
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Category 2
Possible increased risk of
VTE, MI, stoke
Inconsistent evidence about body wt and efficacy
NOT more likely to gain

Restrictive procedures: gastric band or sleeve
 Category 1
Malabsorptive procedures
 COCs: Category 3
 P/R: Category 1

Adequately controlled:
 Category 3
Elevated BP levels:
S 140-159 OR D 90-99
 Category 3
S > 160 OR D > 100
 Category 4
Vascular disease
 Category 4
Hypertension during pregnancy
 Category 2

•
•
•
•
•
Hx of DVT/PE NOT on anticoagulant
•
Higher risk of recurrence
Estrogen associated
Pregnancy associated
Idiopathic
Thrombophilia
Cancer
Hx recurrence
Category 4
Lower risk for recurrence
Category 3

Acute DVT/PE
 Category 4
DVT/PE on anticoagulant for at least 3 months
•
•
Higher risk of recurrence
Thrombophilia
Cancer
• Recurrence
Category 4
Lower risk of recurrence
 No risk factors
Category 3

Family History: 1 st degree
 Category 2
Major surgery
 Prolonged immobilization


Category 4
No prolonged immobilization

Category 2
Minor surgery: no immobilization
 Category 1
Known thrombotic mutations
 Category 4
 COC users had a 2-20 fold high risk for thrombosis
Superficial venous thrombosis


Varicose veins

Category 1
Superficial thrombophlebitis

Category 2

Ischemic heart disease: current or history

Category 4
Stroke
 Category 4
Known hyperlipidemias


Category 2/3
Depends on type, severity, other risk factors
Valvular heart disease
 Uncomplicated


Category 2
Complicated
Peripartum cardiomyopathy: mild
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
< 6 months

Category 4
> 6 months
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
Category 3
Moderate or severe

Category 4

SLE
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Positive or unknown APL antibodies: C4
Thrombocytopenia: C2
Immunosuppression: C2
None of above: C2
RA
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Immunosuppression: C2
Non-suppressed: C2

Headaches
Not migraines:
Initiate: C1 Continue: C2
Migraines: No aura
<35 years old
Initiate: C2 Continue: C3
> 35 years old
Initiate: C3 Continue: C4
Migraines: with aura, and age
Initiate or continue: C4
Epilepsy
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
Category 1
Watch drug interactions
Depressive disorders
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
Category 1
No data on bipolar or postpartum disorders

Category 1
 Irregular, heavy, or prolonged bleeding
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Endometriosis
Benign ovarian tumors
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Severe dysmenorrhea
Gestational trophoblastic disease
Benign breast disease, or FHx of cancer
STIs/PID/HIV/AIDS
Endometrial hyperplasia
Endometrial or ovarian cancer
Fibroids
Category 2
 Unexplained vaginal bleeding
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Undiagnosed breast mass
CIN/cervical cancer awaiting treatment
Category 3
 Past breast cancer with no evidence of disease for 5 years
Category 4
 Current breast cancer

Diabetes
Gestational

Category 1
Nonvascular disease
 Category 2
Vascular disease

Categories 3/4
 Depends on severity
Thyroid disorders

Category 1
________________________
Liver tumors
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Benign

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Focal nodular hyperplasia: C2
Hepatocellular adenoma: C4
Malignant : C4
Inflammatory bowel disease
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Category 2/3
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Depends on risk for VTE
Gallbladder disease
 Asymptomatic: C2
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Symptomatic, surgery: C2
Medical treatment: C3
Cholestasis
 Pregnancy related: C2

COC related: C3
Cirrhosis
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Mild: C1
 Severe: C4
Viral Hepatitis
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Acute: C3/4 (with severity)
Chronic/carrier: C1

Anemias
Thalassemia
 Category 1
Iron deficiency
 Category 1
Sickle cell disease
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Category 2
Solid organ transplant
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Complicated (rejection, graft failure)
 Category 4
Uncomplicated

Category 2

Antiretroviral therapy
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NRTIs: Category 1
NNRTIs: Category 2
Ritonavir-boosted protease inhibitors: C3
Anticonvulsant therapy
 Decrease effectiveness
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Minimum 30μg EE use
Lamictil: possible increased seizures
Antimicrobial therapy
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Broad-spectrum antibiotics: Category 1
Antifungals: Category 1
Antiparasitics: Category 1
Rifampin: Category 3

P I L L S , I N J E C T I O N S , I M P L A N T S

Age: C1 POP, C2 DMPA <18 or >45
Breastfeeding
 < 1 month: Category 2
 > 1 month: Category 1
Postpartum: Category 1
Postabortion: Category 1
Past ectopic: C2 for POP only
Smoking: Category 1
Obesity: C1; C2 <18
Bariatric: C3 for malabsorptive procedures

Hypertension
Adequately controlled


POP, I: Category 1
DMPA: Category 2
Elevated BP levels
S 140-159/D 90-99
 POP, I: Category 1
 DMPA: Category 2
S > 160/D > 100
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POP/I: Category 2
DMPA: Category 3
HBP during pregnancy: C1
DVT/PE
History or acute
 Category 2
On or off anticoagulant
 Category 2
Major surgery/immobilized
 Category 2
Thrombotic mutations
 Category 2
Family History
 Category 1
Superficial thrombosis
 Category 1

Ischemic heart disease
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Initiation: POP, I: C2
 DMPA: C3
 Continuation: POP, I: C3
Stroke
Same as IHD
Valvular heart disease
 Category 1 for all
Peripartum cardiomyopathy
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Mild: Category 1
Moderate/severe: C2
Hyperlipidemia
 Category 3 for all

Rheumatic
SLE
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Positive or unknown APL antibodies: C3

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Severe thrombocytopenia:
C3
Immunosuppressed: C2
RA
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C1 for POP, I
C2 for DMPA
Neurologic
Headaches, non-migraine
 Category 1, all
Migraines
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No aura, C2 (C1 start OC)
Aura: C2 start, C3 continue
Epilepsy: C1
Depressive disorders: C1

Category 1:
 Endometriosis
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Benign ovarian tumors
Severe dysmenorrhea
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Gestational trophoblastic disease
Benign breast disease
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FHx breast cancer
Endometrial hyperplasia or cancer
Ovarian cancer
Uterine fibroids
STIs, PID
HIV/AIDS
Category 2:
 Irregular, heavy, or prolonged vaginal bleeding
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CIN/Cervical cancer (DMPA)
Undiagnosed breast mass
Category 3:
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Past breast cancer (>5 years)
Unexplained vaginal bleeding
Category 4:
Current breast cancer

Endocrine
Thyroid: Category 1
Diabetes
 Gestational: C1
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No vascular disease: C2
Vascular disease:

POP, I: C2

DMPA: C3
GI
Inflammatory bowel disease:
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
POP, DMPA: C2
Implants: C1
Gallbladder disease: C2
COC-related cholestasis
 Category 2
Viral hepatitis: C1
Severe cirrhosis: C3
Liver tumors: C2/3

Anemias
 Category 1
Solid organ transplant
 Category 2
Drug interactions:
 Anticonvulsants:



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Lamotrogine: C1
Others: DMPA: C1
Implant: C2
POPs: C3
Antiretroviral therapy
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DMPA: C1 for all
NRTIs: C1 for all methods
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NNRTIs: C2 POPs and I
Ritonavir-boosted PIs: C3 for POPs; C2 for I
Antimicrobials: all C1 except
 Rifampin: C1 DMPA

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C2 Implant
C3 POPs

Category 1
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Breastfeeding
Hx ectopic
Bariatric surgery
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RA
IBD
Solid organ transplant
Repeated use
Rape
Category 2
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Severe CVD
Angina
Migraine
Severe liver disease

C O P P E R A N D L E V O N O R G E S T R E L - R E L E A S I N G

Age
 Menarche to <20: C2
 > 20: Category 1
Nulliparous women: C2
Postpartum: Category 2
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Cu: C1 < 10 minutes PP
Puerperal sepsis: C4
Postabortion
 First trimester: C1
 Second trimester: C2
Past ectopic history
 Category 1
Smoking

Category 1
Obesity
 Category 1
Bariatric surgery
 Category 1

Hypertension


Category 1 except
S >160/D>100 & vascular disease: LNG C2
DVT/PE


Cu: Category 1
LNG: Category 2
Acute DVT/PE: C2 both
Known thrombogenic
 Category 2
Ischemic heart disease


Category 2: LNG
Category 1: Cu
Stroke, hyperlipidemia

Category 2: LNG
 Category 1: Cu
Valvular heart disease

Category 1

No antibiotic prophylaxis
Peripartum cardiomyopathy: C2 both

Rheumatic
SLE


Positive APL antibodies

LNG: C3 Cu: C1
Severe thrombocytopenia

LNG: C2 Cu: C3

RA
Immunosuppressed

Both: C2
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
Immunosuppressed: C2
Not suppressed: C1
Neurologic
Migraine
 With/without aura

LNG: C2 Cu: C1
Epilepsy
 Category 1 (both)
Depressive disorders
 Category 1 (both)

Irregular bleeding

Category 1 (both)
Heavy, prolonged
 LNG: C1 Cu: C2
Unexplained bleeding

Category 4 initiation
Endometriosis
 LNG: C1 Cu: C2
Benign ovarian tumors

Category 1 (both)
Severe dysmenorrhea

LNG: C1 Cu: C2
STIs: C2 CT/GC: C4 (initiation)
PID: Hx: C1 with subsequent pregnancy; C2 without

Current: C4
Gestational trophoblastic Dx

Category ¾
CIN
 LNG: C2 Cu: C1
Cervical cancer (await Rx)

Category 4: initiation
Breast mass, cancer
 LNG: C2/3/4 Cu: C1
Endometrial hyperplasia

Category 1 (both)
Endometrial cancer: C4
Ovarian cancer: C1
Uterine fibroids: C2
Anatomic abnormalities: C4
HIV: C2 AIDS: C3
Pelvic Tb: Category 4

Diabetes


Gestational: C1
Treatment: Cu: C1
LNG: C2
Thyroid
 Category 1
IBD: Category 1
Gallbladder disease
 Cu: C1 LNG: C2
Viral hepatitis: C1
Cirrhosis: Mild, C1
 Severe: LNG: C3 Cu: C1
Liver tumors: Cu: C1


FNH: LNG: C2
Adenoma, hepatoma:
LNG: C3

Anemias
 LNG: C1 Cu: C2
Solid organ transplant


Uncomplicated

Category 2 (both)
Complicated

Category 3 initiation
Drug interactions
 Antiretroviral therapy

Clinically well on ARV: initiation drops to C2

Anticonvulsants

Category 1

Antimicrobials

Category 1

C O N D O M S , S P E R M I C I D E S , D I A P H R A G M S

Cervical cap +/- diaphragm



Parous women: C2
Complicated valvular HD
High risk for HIV: C4




HIV/AIDS: C3
Toxic shock Hx: C3
UTI: C2
Allergy to latex: C3
Spermicides



Cervical cancer: C2
High risk for HIV: C4
HIV/AIDS: C3