[Table, Barrier methods (BARR)]. - Medical Eligibility Criteria for Contraceptive Use

BARRIER METHODS (BARR)
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY

PREGNANCY	NA	NA	NA	NA = not applicable Clarification: None of these methods are relevant for contraception during known pregnancy. However, for women who continue to be at risk of STI/HIV during pregnancy, the correct and consistent use of condoms is recommended.

AGE
a) Menarche to < 40 years	1	1	1
b) ≥ 40 years	1	1	1

PARITY
a) Nulliparous	1	1	1
b) Parous	1	1	2	Clarification: There is a higher risk of cervical cap failure in parous women than in nulliparous women.

POSTPARTUM
a) < 6 weeks postpartum	1	1	NA	Clarification: The diaphragm and cap are unsuitable until uterine involution is complete.
b) ≥ 6 weeks postpartum	1	1	1

POST-ABORTION
a) First trimester	1	1	1
b) Second trimester	1	1	1	Clarification: The diaphragm and cap are unsuitable until 6 weeks after second-trimester abortion.
c) Immediate post-septic abortion	1	1	1

PAST ECTOPIC PREGNANCY	1	1	1

HISTORY OF PELVIC SURGERY	1	1	1

SMOKING
a) Age < 35 years	1	1	1
b) Age > 35 years
i) < 15 cigarettes/day	1	1	1
ii) ≥ 15 cigarettes/day	1	1	1

OBESITY*
a) ≥ 30 kg/m² BMI	1	1	1
b) Menarche to < 18 years and ≥ 30 kg/m² BMI	1	1	1

BLOOD PRESSURE MEASUREMENT UNAVAILABLE	NA	NA	NA	Clarification: While a blood pressure measurement may be appropriate for good preventive health care, it is not required for safe and effective barrier method use. Women should not be denied the use of barrier methods simply because their blood pressure cannot be measured.

CARDIOVASCULAR DISEASE

MULTIPLE RISK FACTORS FOR ARTERIAL CARDIOVASCULAR DISEASE (such as older age, smoking, diabetes, hypertension and known dyslipidaemias)	1	1	1

HYPERTENSION
a) History of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy)	1	1	1
b) Adequately controlled hypertension, where blood pressure CAN be evaluated	1	1	1
c) Elevated blood pressure levels (properly taken measurements)
i) systolic 140–159 or diastolic 90–99 mm Hg	1	1	1
ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg	1	1	1
d) Vascular disease	1	1	1

HISTORY OF HIGH BLOOD PRESSURE DURING PREGNANCY (where current blood pressure is measurable and normal)	1	1	1

DEEP VEIN THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)
a) History of DVT/PE	1	1	1
b) Acute DVT/PE	1	1	1
c) DVT/PE and established on anticoagulant therapy	1	1	1
d) Family history (first-degree relatives)	1	1	1
e) Major surgery
i) with prolonged immobilization	1	1	1
ii) without prolonged immobilization	1	1	1
f) Minor surgery without immobilization	1	1	1

KNOWN THROMBOGENIC MUTATIONS (e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)	1	1	1	Clarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening.

SUPERFICIAL VENOUS DISORDERS
a) Varicose veins	1	1	1
b) Superficial venous thrombosis	1	1	1

CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE	1	1	1

STROKE (history of cerebrovascular accident)	1	1	1

KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORS	1	1	1	Clarification: Routine screening is not appropriate because of the rarity of the condition and the high cost of screening.

VALVULAR HEART DISEASE*
a) Uncomplicated	1	1	1
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)	1	1	2

RHEUMATIC DISEASES

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
a) Positive (or unknown) antiphospholipid antibodies	1	1	1
b) Severe thrombocytopenia	1	1	1
c) Immunosuppressive treatment	1	1	1
d) None of the above	1	1	1

NEUROLOGIC CONDITIONS

HEADACHES
a) Non-migrainous (mild or severe)	1	1	1
b) Migraine
i) without aura
age < 35 years	1	1	1
age ≥ 35 years	1	1	1
ii) with aura, at any age	1	1	1

EPILEPSY	1	1	1

DEPRESSIVE DISORDERS

DEPRESSIVE DISORDERS	1	1	1

REPRODUCTIVE TRACT INFECTIONS AND DISORDERS

UNEXPLAINED VAGINAL BLEEDING (suspicious for serious condition)
Before evaluation	1	1	1	Clarification: If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation.

ENDOMETRIOSIS	1	1	1

BENIGN OVARIAN TUMOURS (including cysts)	1	1	1

SEVERE DYSMENORRHOEA	1	1	1

GESTATIONAL TROPHOBLASTIC DISEASE
a) Decreasing or undetectable β-hCG levels	1	1	1
b) Persistently elevated β-hCG levels or malignant disease	1	1	1

CERVICAL ECTROPION	1	1	1

CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)	1	1	1	Clarification: The cap should not be used. There is no restriction for diaphragm use.

CERVICAL CANCER* (AWAITING TREATMENT)	1	2	1	Clarification: The cap should not be used. There is no restriction for diaphragm use.

BREAST DISEASE
a) Undiagnosed mass	1	1	1
b) Benign breast disease	1	1	1
c) Family history of cancer	1	1	1
d) Breast cancer
i) current	1	1	1
ii) past and no evidence of current disease for 5 years	1	1	1

ENDOMETRIAL CANCER	1	1	1

OVARIAN CANCER	1	1	1

UTERINE FIBROIDS
a) Without distortion of the uterine cavity	1	1	1
b) With distortion of the uterine cavity	1	1	1

ANATOMICAL ABNORMALITIES	1	1	NA	NA = not applicable Clarification: The diaphragm cannot be used in certain cases of prolapse. Cap use is not appropriate for a client with a markedly distorted cervical anatomy.

PELVIC INFLAMMATORY DISEASE (PID)
a) Past PID (assuming no current risk factors for STIs)
i) with subsequent pregnancy	1	1	1
ii) without subsequent pregnancy	1	1	1
b) PID – current	1	1	1

STIS
a) Current purulent cervicitis or chlamydial infection or gonorrhoea	1	1	1
b) Other STIs (excluding HIV and hepatitis)	1	1	1
c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)	1	1	1
d) Increased risk of STIs	1	1	1

HIV/AIDS

HIGH RISK OF HIV*	1	4	4	Evidence: Repeated and high-dose use of the spermicide nonoxynol-9 was associated with increased risk of genital lesions, which may increase the risk of acquiring HIV (1).

ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE (WHO STAGE 1 OR 2)*	1	3	3

SEVERE OR ADVANCED HIV CLINICAL DISEASE (WHO STAGE 3 OR 4)*	1	3	3

OTHER INFECTIONS

SCHISTOSOMIASIS
a) Uncomplicated	1	1	1
b) Fibrosis of the liver	1	1	1

TUBERCULOSIS
a) Non-pelvic	1	1	1
a) Pelvic	1	1	1

MALARIA	1	1	1

HISTORY OF TOXIC SHOCK SYNDROME*	1	1	3

URINARY TRACT INFECTION*	1	1	2

ENDOCRINE CONDITIONS

DIABETES
a) History of gestational disease	1	1	1
b) Non-vascular disease
i) non-insulin-dependent	1	1	1
ii) insulin-dependent	1	1	1
c) Nephropathy/retinopathy/neuropathy	1	1	1
d) Other vascular disease or diabetes of > 20 years' duration	1	1	1

THYROID DISORDERS
a) Simple goitre	1	1	1
b) Hyperthyroid	1	1	1
c) Hypothyroid	1	1	1

GASTROINTESTINAL CONDITIONS

GALL BLADDER DISEASE
a) Symptomatic
i) treated by cholecystectomy	1	1	1
ii) medically treated	1	1	1
iii) current	1	1	1
b) Asymptomatic	1	1	1

HISTORY OF CHOLESTASIS
a) Pregnancy-related	1	1	1
b) Past-COC-related	1	1	1

VIRAL HEPATITIS
a) Acute or flare	1	1	1
b) Carrier	1	1	1
c) Chronic	1	1	1

CIRRHOSIS
a) Mild (compensated)	1	1	1
b) Severe (decompensated)	1	1	1

LIVER TUMOURS
a) Benign
i) focal nodular hyperplasia	1	1	1
ii) hepatocellular adenoma	1	1	1
b) Malignant (hepatoma)	1	1	1

ANAEMIAS

THALASSAEMIA	1	1	1

SICKLE CELL DISEASE	1	1	1

IRON-DEFICIENCY ANAEMIA	1	1	1

DRUG INTERACTIONS

ANTIRETROVIRAL THERAPY (ART)
a) Nucleoside reverse transcriptase inhibitors (NRTIs)				Clarification: There is no known drug interaction between ART and barrier method use. However, HIV clinical disease WHO stages 1 through 4 as conditions are classified as Category 3 for spermicides and diaphragms (see HIV conditions above).
Abacavir (ABC)	1	3	3
Tenofovir (TDF)	1	3	3
Zidovudine (AZT)	1	3	3
Lamivudine (3TC)	1	3	3
Didanosine (DDI)	1	3	3
Emtricitabine (FTC)	1	3	3
Stavudine (D4T)	1	3	3
b) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Efavirenz (EFV)	1	3	3
Etravirine (ETR)	1	3	3
Nevirapine (NVP)	1	3	3
Rilpivirine (RPV)	1	3	3
c) Protease inhibitors (PIs)
Ritonavir-boosted atazanavir (ATV/r)	1	3	3
Ritonavir-boosted lopinavir (LPV/r)	1	3	3
Ritonavir-boosted darunavir (DRV/r)	1	3	3
Ritonavir (RTV)	1	3	3
d) Integrase inhibitors
Raltegravir (RAL)	1	3	3

ANTICONVULSANT THERAPY
a) Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)	1	1	1
b) Lamotrigine	1	1	1

ANTIMICROBIAL THERAPY
a) Broad-spectrum antibiotics	1	1	1
b) Antifungals	1	1	1
c) Antiparasitics	1	1	1
d) Rifampicin or rifabutin therapy	1	1	1

ALLERGY TO LATEX	3	1	3	Clarification: This does not apply to plastic condoms/diaphragm.

BARRIER METHODS (BARR)

If there is a risk of sexually transmitted infections (STIs), including HIV, then the correct and consistent use of condoms is recommended. When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.

CONDITION
* additional comments after this table

CATEGORY
I = initiation, C = continuation

CLARIFICATIONS/EVIDENCE

Condom

Diaphragm

Spermicide

Condoms = male latex condoms, male polyurethane condoms, female condoms
Diaphragm = diaphragm (with spermicide), cervical cap

Women with conditions that make pregnancy an unacceptable risk should be advised that barrier methods for pregnancy prevention may not be appropriate for those who cannot use them consistently and correctly because of their relatively higher typical-use failure rates.

PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY

PREGNANCY

NA = not applicable

Clarification: None of these methods are relevant for contraception during known pregnancy. However, for women who continue to be at risk of STI/HIV during pregnancy, the correct and consistent use of condoms is recommended.

AGE

a) Menarche to < 40 years

b) ≥ 40 years

PARITY

a) Nulliparous

b) Parous

Clarification: There is a higher risk of cervical cap failure in parous women than in nulliparous women.

POSTPARTUM

a) < 6 weeks postpartum

Clarification: The diaphragm and cap are unsuitable until uterine involution is complete.

b) ≥ 6 weeks postpartum

POST-ABORTION

a) First trimester

b) Second trimester

Clarification: The diaphragm and cap are unsuitable until 6 weeks after second-trimester abortion.

c) Immediate post-septic abortion

PAST ECTOPIC PREGNANCY

HISTORY OF PELVIC SURGERY

SMOKING

a) Age < 35 years

b) Age > 35 years

i) < 15 cigarettes/day

ii) ≥ 15 cigarettes/day

OBESITY*

a) ≥ 30 kg/m² BMI

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

BLOOD PRESSURE MEASUREMENT UNAVAILABLE

Clarification: While a blood pressure measurement may be appropriate for good preventive health care, it is not required for safe and effective barrier method use. Women should not be denied the use of barrier methods simply because their blood pressure cannot be measured.

CARDIOVASCULAR DISEASE

MULTIPLE RISK FACTORS FOR ARTERIAL CARDIOVASCULAR DISEASE
(such as older age, smoking, diabetes, hypertension and known dyslipidaemias)

HYPERTENSION

a) History of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy)

b) Adequately controlled hypertension, where blood pressure CAN be evaluated

c) Elevated blood pressure levels (properly taken measurements)

i) systolic 140–159 or diastolic 90–99 mm Hg

ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg

d) Vascular disease

HISTORY OF HIGH BLOOD PRESSURE DURING PREGNANCY
(where current blood pressure is measurable and normal)

DEEP VEIN THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)

a) History of DVT/PE

b) Acute DVT/PE

c) DVT/PE and established on anticoagulant therapy

d) Family history (first-degree relatives)

e) Major surgery

i) with prolonged immobilization

ii) without prolonged immobilization

f) Minor surgery without immobilization

KNOWN THROMBOGENIC MUTATIONS
(e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)

Clarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening.

SUPERFICIAL VENOUS DISORDERS

a) Varicose veins

b) Superficial venous thrombosis

CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE

STROKE
(history of cerebrovascular accident)

KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORS

Clarification: Routine screening is not appropriate because of the rarity of the condition and the high cost of screening.

VALVULAR HEART DISEASE*

a) Uncomplicated

b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)

RHEUMATIC DISEASES

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

a) Positive (or unknown) antiphospholipid antibodies

b) Severe thrombocytopenia

c) Immunosuppressive treatment

d) None of the above

NEUROLOGIC CONDITIONS

HEADACHES

a) Non-migrainous (mild or severe)

b) Migraine

i) without aura

age < 35 years

age ≥ 35 years

ii) with aura, at any age

EPILEPSY

DEPRESSIVE DISORDERS

REPRODUCTIVE TRACT INFECTIONS AND DISORDERS

UNEXPLAINED VAGINAL BLEEDING
(suspicious for serious condition)

Before evaluation

Clarification: If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation.

ENDOMETRIOSIS

BENIGN OVARIAN TUMOURS
(including cysts)

SEVERE DYSMENORRHOEA

GESTATIONAL TROPHOBLASTIC DISEASE

a) Decreasing or undetectable β-hCG levels

b) Persistently elevated β-hCG levels or malignant disease

CERVICAL ECTROPION

CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)

Clarification: The cap should not be used. There is no restriction for diaphragm use.

CERVICAL CANCER* (AWAITING TREATMENT)

Clarification: The cap should not be used. There is no restriction for diaphragm use.

BREAST DISEASE

a) Undiagnosed mass

b) Benign breast disease

c) Family history of cancer

d) Breast cancer

i) current

ii) past and no evidence of current disease for 5 years

ENDOMETRIAL CANCER

OVARIAN CANCER

UTERINE FIBROIDS

a) Without distortion of the uterine cavity

b) With distortion of the uterine cavity

ANATOMICAL ABNORMALITIES

NA = not applicable

Clarification: The diaphragm cannot be used in certain cases of prolapse. Cap use is not appropriate for a client with a markedly distorted cervical anatomy.

PELVIC INFLAMMATORY DISEASE (PID)

a) Past PID (assuming no current risk factors for STIs)

i) with subsequent pregnancy

ii) without subsequent pregnancy

b) PID – current

STIS

a) Current purulent cervicitis or chlamydial infection or gonorrhoea

b) Other STIs (excluding HIV and hepatitis)

c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)

d) Increased risk of STIs

HIV/AIDS

HIGH RISK OF HIV*

Evidence: Repeated and high-dose use of the spermicide nonoxynol-9 was associated with increased risk of genital lesions, which may increase the risk of acquiring HIV (1).

ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE
(WHO STAGE 1 OR 2)*

SEVERE OR ADVANCED HIV CLINICAL DISEASE
(WHO STAGE 3 OR 4)*

OTHER INFECTIONS

SCHISTOSOMIASIS

a) Uncomplicated

b) Fibrosis of the liver

TUBERCULOSIS

a) Non-pelvic

a) Pelvic

MALARIA

HISTORY OF TOXIC SHOCK SYNDROME*

URINARY TRACT INFECTION*

ENDOCRINE CONDITIONS

DIABETES

a) History of gestational disease

b) Non-vascular disease

i) non-insulin-dependent

ii) insulin-dependent

c) Nephropathy/retinopathy/neuropathy

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

THYROID DISORDERS

a) Simple goitre

b) Hyperthyroid

c) Hypothyroid

GASTROINTESTINAL CONDITIONS

GALL BLADDER DISEASE

a) Symptomatic

i) treated by cholecystectomy

ii) medically treated

iii) current

b) Asymptomatic

HISTORY OF CHOLESTASIS

a) Pregnancy-related

b) Past-COC-related

VIRAL HEPATITIS

a) Acute or flare

b) Carrier

c) Chronic

CIRRHOSIS

a) Mild (compensated)

b) Severe (decompensated)

LIVER TUMOURS

a) Benign

i) focal nodular hyperplasia

ii) hepatocellular adenoma

b) Malignant (hepatoma)

ANAEMIAS

THALASSAEMIA

SICKLE CELL DISEASE

IRON-DEFICIENCY ANAEMIA

DRUG INTERACTIONS

ANTIRETROVIRAL THERAPY (ART)

a) Nucleoside reverse transcriptase inhibitors (NRTIs)

Clarification: There is no known drug interaction between ART and barrier method use. However, HIV clinical disease WHO stages 1 through 4 as conditions are classified as Category 3 for spermicides and diaphragms (see HIV conditions above).

Abacavir (ABC)

Tenofovir (TDF)

Zidovudine (AZT)

Lamivudine (3TC)

Didanosine (DDI)

Emtricitabine (FTC)

Stavudine (D4T)

b) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

Efavirenz (EFV)

Etravirine (ETR)

Nevirapine (NVP)

Rilpivirine (RPV)

c) Protease inhibitors (PIs)

Ritonavir-boosted atazanavir (ATV/r)

Ritonavir-boosted lopinavir (LPV/r)

Ritonavir-boosted darunavir (DRV/r)

Ritonavir (RTV)

d) Integrase inhibitors

Raltegravir (RAL)

ANTICONVULSANT THERAPY

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

b) Lamotrigine

ANTIMICROBIAL THERAPY

a) Broad-spectrum antibiotics

b) Antifungals

c) Antiparasitics

d) Rifampicin or rifabutin therapy

ALLERGY TO LATEX

Clarification: This does not apply to plastic condoms/diaphragm.

From: II, Using the recommendations

Cover of Medical Eligibility Criteria for Contraceptive Use

Medical Eligibility Criteria for Contraceptive Use. 5th edition.

Geneva: World Health Organization; 2015.

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