Using the recommendations

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Medical Eligibility Criteria for Contraceptive Use. 5th edition. Geneva: World Health Organization; 2015.

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Medical Eligibility Criteria for Contraceptive Use. 5th edition.

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IIUsing the recommendations

2.1. Background

The Medical eligibility criteria for contraceptive use (MEC) provides guidance regarding which clients can use contraceptive methods safely. The goal of the document is to improve access to, and quality of, family planning services by providing policy-makers, decision-makers and the scientific community with recommendations that can be used for developing or revising national guidelines on the medical eligibility criteria for the use of specific contraceptive methods. Methods covered by this guidance include all hormonal contraceptives, intrauterine devices, barrier methods, fertility awareness-based methods, coitus interruptus, lactational amenorrhoea method, male and female sterilization, and emergency contraception. These evidence-based recommendations do not indicate a “best” method that should be used in a particular medical context; rather, review of the recommendations allows for consideration of multiple methods that could be used safely by people with certain health conditions (e.g. hypertension) or relevant characteristics (e.g. age).

2.1.1. Reproductive and sexual health care as a human right

The Programme of Action of the International Conference on Population and Development (ICPD) defines reproductive health as: “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes”¹. The Programme of Action also states that the purpose of sexual health “is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases”. Recognizing the importance of agreements made at the ICPD and other international conferences and summits, the Beijing Declaration and Platform for Action defines reproductive rights in the following way:

Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other relevant consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number and spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.²

Among the Millennium Development Goals (MDGs) agreed by states in 2001, target 5b calls for universal access to reproductive health by 2015. Reproductive and sexual health care, including family planning services and information, is recognized not only as a key intervention for improving the health of men, women and children but also as a human right. International and regional human rights treaties, national constitutions and laws provide guarantees specifically relating to access to contraceptive information and services. These include the guarantee that states should ensure timely and affordable access to good quality sexual and reproductive health information and services, including contraception, which should be delivered in a way that ensures fully informed decision-making, respects dignity, autonomy, privacy and confidentiality, and is sensitive to individuals' needs and perspectives in a client–provider partnership.³ A rights-based approach to the provision of contraceptives assumes a holistic view of clients, which includes taking into account clients' sexual and reproductive health care needs and considering all appropriate eligibility criteria when helping clients choose and use a family planning method safely.

Evidence shows that the respect, protection and fulfilment of human rights contribute to positive health outcomes. The provision of contraceptive information and services that respect individual privacy, confidentiality and informed choice, along with a wide range of safe contraceptive methods, increase people's satisfaction and continued use of contraception.⁴ ⁵ ⁶ ⁷

Delivery of care in accordance with the client's human and reproductive rights is fundamental to quality of care. The development of international norms for medical eligibility criteria and practice recommendations for contraceptive use is only one aspect of improving the quality of reproductive health care. Many family planning programmes have included screening, treatment and follow-up procedures that reflect high standards of public health and clinical practice, but these should not be seen as eligibility requirements for specific contraceptive methods. These procedures include the screening and treatment of cervical cancer, anaemia and sexually transmitted infections (STIs), and the promotion of breastfeeding and cessation of smoking. Such procedures should be strongly encouraged if the human and material resources are available to carry them out, but they should not be seen as prerequisites for the acceptance and use of family planning methods since they are not necessary to establish eligibility for the use or continuation of a particular method.

2.1.2. Contraceptive choice

While this document primarily addresses medical eligibility criteria for contraceptive use, considerations of social, behavioural and other non-medical criteria – particularly client preference – must also be taken into account. To provide contraceptive choices to clients in a way that respects and fulfils their human rights necessitates enabling clients to make informed choices for themselves. Women's choices, however, are often taken away from them or limited by direct or indirect social, economic and cultural factors. From a woman's point of view, her choices are made at a particular time, in a particular societal and cultural context; choices are complex, multifactorial and subject to change. Decision-making regarding contraceptive methods usually requires the need to make trade-offs among the advantages and disadvantages of different methods, and these vary according to individual circumstances, perceptions and interpretations. Factors to consider when choosing a particular contraceptive method include the characteristics of the potential user, the baseline risk of disease, the adverse effects profile of different products, cost, availability and patient preferences.

This document does not provide recommendations about which specific product or brand to use after selecting a particular type of contraceptive method. Instead, it provides guidance for whether women with specific medical conditions or medically relevant physiological or personal characteristics are eligible to use various contraceptive methods. Decisions about what methods to use should also take into account clinical judgment and user preferences.

Issues of service quality and access that affect method use and choice

The following service-delivery criteria are universally relevant to the initiation and follow-up of all contraceptive method use:

Clients should be given adequate information to help them make an informed, voluntary choice of a contraceptive method. This information should at least include:
–
the relative effectiveness of the method;
–
correct usage of the method;
–
how it works;
–
common side-effects;
–
health risks and benefits of the method;
–
signs and symptoms that would necessitate a return to the clinic;
–
information on return to fertility after discontinuing method use; and
–
information on STI protection.
Information should be presented using language and formats that can be easily understood and accessed by the client.
In order to offer methods that require surgical approaches, insertion, fitting and/or removal by a trained health-care provider (i.e. sterilization, implants, IUDs, diaphragms, cervical caps), appropriately trained personnel in adequately equipped and accessible facilities must be available, and appropriate infection-prevention procedures must be followed.
Adequate and appropriate equipment and supplies need to be maintained and held in stock (e.g. contraceptive commodities, and supplies for infection-prevention procedures).
Service providers should be provided with guidelines, client cards or other screening tools.

2.1.3. Effectiveness of method

Contraceptive choice is in part dependent on the effectiveness of the contraceptive method in preventing unplanned pregnancy, which, in turn, is dependent for some methods not only on the protection afforded by the method itself, but also on how consistently and correctly it is used. Table 2.1 compares the percentage of women experiencing an unintended pregnancy during the first year of contraceptive method use when the method is used perfectly (consistently and correctly) and when it is used typically (assuming occasional non-use and/or incorrect use). Consistent and correct usage can both vary greatly with client characteristics such as age, income, desire to prevent or delay pregnancy, and culture. Methods that depend on consistent and correct usage by clients (e.g condoms and pills) have a wide range of effectiveness. Most men and women tend to be more effective users as they become more experienced with a method. However, programmatic aspects also have a profound effect on how effectively (consistently and correctly) the method will be used.

Table 2.1

Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year, United States.

2.1.4. Conditions that expose a woman to increased risk as a result of unintended pregnancy

Women with conditions that may make unintended pregnancy an unacceptable health risk should be advised that, because of their relatively higher typical-use failure rates, sole use of barrier methods for contraception and behaviour-based methods of contraception may not be the most appropriate choice for them. These conditions are noted in Box 2.1.

Box 2.1

Conditions that expose a woman to increased health risk as a result of unintended pregnancy. Breast cancer Complicated valvular heart disease

2.1.5. Return to fertility

Among contraceptive methods, only male and female sterilization are regarded as irreversible (or permanent). All other methods are reversible, usually with prompt return to fertility upon method discontinuation, with the exception of depot medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN). The median delay in return to fertility with these methods is 10 and 6 months, respectively, from the date of the last injection, regardless of the duration of their use. Male and female sterilization should be regarded as permanent methods (no possibility of future childbearing), and all individuals and couples considering these methods should be counselled accordingly. No other methods result in permanent infertility.

2.1.6. STIs and contraception: dual protection

In addition to the imperative of international norms for contraceptive provision to assure quality of care in services, the social, cultural and behavioural context of each client must also be considered. In this regard, the problems of exposure to STIs, including HIV, deserve special consideration because of the equal importance of preventing pregnancy and preventing transmission of infections among sexually active clients of reproductive age. When a risk of HIV and other STI transmission exists,⁸ it is important that health-care providers offer information on safer sexual practices to prevent transmission and strongly recommend dual protection to all persons at significant risk, either through the simultaneous use of condoms with other methods or through the consistent and correct use of condoms alone for prevention of both pregnancy and STIs, including HIV. Women and men seeking contraceptive advice must always be reminded of the importance of condom use for preventing the transmission of STI/HIV and such use should be encouraged and facilitated where appropriate. 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.

2.2. How to use this document

The present document is intended for use by policy-makers, family planning programme managers and the scientific community. It aims to provide guidance to national family planning and reproductive health programmes in the preparation of guidelines for delivery of contraceptive services. It is not meant to serve as the actual guidelines but rather as a reference.

The guidance in this document is intended for interpretation at country and programme levels in a manner that reflects the diversity of situations and settings in which contraceptives are provided. While it is unlikely that the classification of categories in this document would change during this process, it is very likely that the application of these categories at country level will vary. In particular, the level of clinical knowledge and experience of various types of providers and the resources available at the service-delivery point will have to be taken into consideration.

Recommendations are presented in tables according to the contraceptive methods included in the guidance with each condition. Each condition was defined as representing either a known pre-existing medical/pathological condition (e.g. diabetes, hypertension) or a medically relevant individual characteristic (e.g. age, history of pregnancy).

It is expected that national and institutional health-care and service-delivery environments will decide the most suitable means for screening for conditions according to their public health importance. Client history will often be the most appropriate approach. A family planning provider may want to consult an expert in the underlying condition.

Initiation and continuation

The medical eligibility criteria for the initiation and continuation of all contraceptive methods are used in the evaluation of eligibility. The assessment of continuation criteria is clinically relevant whenever a woman develops the condition while she is using the method. Where medical eligibility for initiation and continuation of a contraceptive method differ, these differences are noted in the columns of the tables for each contraceptive method (I = initiation; C = continuation). Where I and C are not denoted, the category is the same for initiation and continuation of use.

As shown in Table 2.2 in a simplified template of the tables for each contraceptive (provided in section 2.7), the first column indicates the conditions (each in a separate row). Several conditions are subdivided to differentiate between varying degrees of the condition. The second column classifies the condition for initiation and/or continuation into one of the four MEC categories, as described in section 2.3. The third column provides space for any necessary clarifications or presentation of evidence regarding the classification

Table 2.2

Template of contraceptive method tables.

2.3. Using the categories in practice

Categories 1 and 4 are self-explanatory. Classification of a method/condition as Category 2 indicates the method can generally be used, but careful follow-up may be required. However, provision of a method to a woman with a condition classified as Category 3 requires careful clinical judgement and access to clinical services; for such a woman, the severity of the condition and the availability, practicality and acceptability of alternative methods should be taken into account. For a method/condition classified as Category 3, use of that method is not usually recommended unless other more appropriate methods are not available or acceptable. Careful follow-up will be required.

Where resources for clinical judgment are limited, such as in community-based services, the four-category classification framework can be simplified into two categories. With this simplification, a classification of Category 1 or 2 indicate that a woman can use a method, and a classification of Category 3 or 4 indicate that a woman is not medically eligible to use the method (see Table 2.3).

Table 2.3

Interpretation and application of the categories in practice.

Medical eligibility criteria (MEC) categories for contraceptive use

Category 1	A condition for which there is no restriction for the use of the contraceptive method
Category 2	A condition where the advantages of using the method generally outweigh the theoretical or proven risks
Category 3	A condition where the theoretical or proven risks usually outweigh the advantages of using the method
Category 4	A condition which represents an unacceptable health risk if the contraceptive method is used

2.4. Programmatic implications

The following issues need to be addressed when applying the medical eligibility criteria in this document to programmes:

informed choice
elements of quality of care
essential screening procedures for administering the methods
provider training and skills
referral and follow-up for contraceptive use as appropriate.

Service-delivery practices that are essential for the safe use of the particular contraceptive method should be distinguished from practices that may be appropriate for good health care but are not related to use of the method. The promotion of good health-care practices unrelated to safe contraception should be considered neither as a prerequisite nor as an obstacle to the provision of a contraceptive method, but as complementary to it.

As a next step, the recommendations on medical eligibility criteria need to be considered in light of the country context, so as to be applicable to providers at all levels of the service-delivery system. It is expected that national and institutional health-care and service-delivery environments will decide the most suitable means for screening for conditions according to their public health importance. Client history will often be the most appropriate approach. A family planning provider may want to consult an expert in the underlying condition. Countries will need to determine how far and by what means it may be possible to extend their services to the more peripheral levels of the health system. This may involve upgrading both staff and facilities where feasible and affordable, or it may require or a modest addition of equipment and supplies, and redeployment of space. It will also be necessary to address misperceptions sometimes held by providers and users about the risks and side-effects of particular methods, and to look closely at the needs and perspectives of women and men in the context of informed choice.

Adaptation is not always an easy task and is best done by those well acquainted with prevailing health conditions, behaviours and cultures. These improvements must be made within the context of users' informed choices and medical safety.

2.5. Clients with special needs

2.5.1. People with disabilities

According to United Nations Convention on the Rights of Persons with Disabilities (CRPD), people with disabilities must have access, on an equal basis with others, to all forms of sexual and reproductive health care (Article 25) as part of the general right to marry, found a family and retain their fertility (Article 23)⁹. Health-care professionals often fail to offer sexual and reproductive health services to people with disabilities, based on the common misconception that they are not sexually active.¹⁰ Provision of contraceptive services to people with disabilities may, however, require decisions regarding appropriate contraception considering the preferences of the individual, the nature of the disability and the specifics of different conceptive methods.

For example, some barrier methods may be difficult to use for those with limited manual dexterity; COCs may not be an appropriate method for women with impaired circulation or immobile extremities, even in the absence of known thrombogenic mutations, because of concerns about an increased risk of DVT; and other methods will be preferable for individuals with intellectual or mental health disabilities who have difficulty remembering to take daily medications. For women who have difficulty with menstrual hygiene, the impact of the contraceptive method on menstrual cycles should also be considered.

In all instances, medical decisions must be based upon informed choice, based on adequate sexual and reproductive health education. When the nature of the disability makes it more challenging to discern the will and preferences of the individual, contraceptives should only be provided in a manner consistent with Article 12 of the CRPD. Specifically, in such cases a process of supported decision-making should be instituted in which individuals who are trusted by the individual with disabilities, personal ombudsman and other support persons jointly participate with the individual in reaching a decision that is, to the greatest extent possible, consistent with the will and preference of that individual. Given the history of involuntary sterilization of persons with disabilities, often as a technique for menstrual management in institutions,¹¹ it is especially important to ensure that decisions about sterilization are only made with the full, uncoerced and informed consent of the individual, either alone or with support.

2.5.2. Adolescents

Adolescents in many countries lack adequate access to contraceptive information and services that are necessary to protect their sexual and reproductive health. There is an urgent need to implement programmes that both meet the contraceptive needs of adolescents and remove barriers to services. In general, adolescents are eligible to use all the same methods of contraception as adults, and must have access to a variety of contraceptive choices. Age alone does not constitute a medical reason for denying any method to adolescents. While some concerns have been expressed about the use of certain contraceptive methods by adolescents (e.g. the use of progestogen-only injectables by those below 18 years), these concerns must be balanced against the advantages of preventing unintended pregnancy. It is clear that many of the same eligibility criteria that apply to older clients also apply to young people. However, some conditions (e.g. cardiovascular disorders) that may limit the use of some methods in older women do not generally affect young people, since these conditions are rare in this age group.

Political and cultural factors may affect adolescents' ability to access contraceptive information and services. For example, where contraceptive services are available, adolescents (in particular unmarried ones) may not be able to obtain them because of restrictive laws and policies. Even if adolescents are able to obtain contraceptive services, they may not do so because of fear that their confidentiality will not be respected, or that health workers may be judgmental. All adolescents, regardless of marital status, have a right to privacy and confidentiality in health matters, including reproductive health care. Appropriate sexual and reproductive health services, including contraception, should be available and accessible to all adolescents without necessarily requiring parental or guardian authorization by law, policy or practice.

Social and behavioural issues should be key considerations in the choice of contraceptive methods by adolescents. For example, in some settings, adolescents are also at increased risk for STIs, including HIV. While adolescents may choose to use any one of the contraceptive methods available in their communities, in some cases, using methods that do not require a daily regimen may be more convenient. Adolescents, married or unmarried, have also been shown to be less tolerant of side-effects and therefore have high discontinuation rates. Method choice may also be influenced by factors such as sporadic patterns of intercourse and the need to conceal sexual activity and contraceptive use. For instance, sexually active adolescents who are unmarried have very different needs from those who are married and want to postpone, space or limit pregnancy. Expanding the number of method choices offered can lead to improved satisfaction, increased acceptance and increased prevalence of contraceptive use. Proper education and counselling – both before and at the time of method selection – can help adolescents address their particular needs and make informed and voluntary decisions. Every effort should be made to prevent the costs of services and/or methods from limiting the options available.

2.6. Summary of changes within the MEC fifth edition

The following tables highlight changes within the fifth edition of the MEC, compared with the fourth edition (see Tables 2.4–2.6). These changes include: changes to MEC categories between the earlier editions and the fifth edition; recommendations for new conditions issued in the fifth edition; changes to the labelling of certain conditions (in order to be consistent with current clinical practice); and details for the new contraceptive methods included in this fifth edition.

Table 2.4

Summary of changes from the fourth edition to the fifth edition of the MEC (changes are highlighted in bold).

Table 2.5

Emergency contraceptive pills (ECPs) (changes are highlighted in bold). Emergency contraceptive pills (ECPs) (changes are highlighted in bold)

Table 2.6

Progesterone-releasing vaginal ring (PVR) (changes are highlighted in bold).

2.7. Tables

2.7.1. Combined hormonal contraceptives (CHCs)

COMBINED ORAL CONTRACEPTIVES (COCs)

The recommendations in this guidance refer to low-dose COCs containing ≤ 35 mcg ethinyl estradiol combined with a progestogen.

Venous thrombosis is rare among women of reproductive age. All COCs are associated with an increased risk for venous thromboembolism (VTE) compared to non-use. A number of studies have found differences in risk for VTE associated with COCs containing different types of progestogens (1–19). Current evidence suggests that COCs containing levonorgestrel, norethisterone and norgestimate are associated with the lowest risk (20). The absolute differences, however, are very small.

Limited data do not suggest that the small absolute risk for arterial events associated with COC use varies according to the type of progestogen (5, 6, 20–34).

Recommendations in this guidance are the same for all COC formulations, irrespective of their progestogen content.

COMBINED INJECTABLE CONTRACEPTIVES (CICs)

Two CIC formulations, are considered here:

Cyclofem = medroxyprogesterone acetate 25 mg plus estradiol cypionate 5 mg
Mesigyna = norethisterone enanthate 50 mg plus estradiol valerate 5 mg

CICs contain the naturally occurring estrogen, estradiol plus a progestogen (35–39). Estradiol is less potent, has a shorter duration of effect and is more rapidly metabolized than the synthetic estrogens used in other contraceptive formulations such as COCs, the combined contraceptive patch (P) and the combined contraceptive vaginal ring (CVR). These differences imply that the type and magnitude of estrogen-related side-effects associated with CICs may be different from those experienced by COC/P/CVR users. In fact, short-term studies of CICs have shown little effect on blood pressure, haemostasis and coagulation, lipid metabolism and liver function in comparison with COCs (40–42). As CICs are administered by injection, the first-pass metabolism by the liver is avoided, thereby minimizing estradiol's effect on the liver.

However, CICs are a relatively new contraceptive method, and there are few epidemiological data on their long-term effects. There is also the concern that, while the effect of the hormonal exposure associated with use of COCs and progestogen-only pills (POPs) can be reduced immediately by discontinuing their use, this is not the case with injectables, for which the effect continues for some time after the last injection.

Pending further evidence, the Guideline Development Group (GDG) concluded that the evidence available for COCs applies to CICs in many but not all instances. Therefore, the GDG assigned categories for CICs somewhere between the categories for COCs and POPs. However, for severe pathologies (e.g. ischaemic heart disease), the classification of conditions was the same as for COCs. The assigned categories should, therefore, be considered a preliminary, best judgement, which will be re-evaluated as new data become available.

COMBINED CONTRACEPTIVE PATCH (P) AND COMBINED CONTRACEPTIVE VAGINAL RING (CVR)

The combined contraceptive patch (P) and combined vaginal ring (CVR) are relatively new contraceptive methods. Limited information is available on the safety of these methods among women with specific medical conditions. Moreover, epidemiological data on the long-term effects of P and CVR use were not available for the GDG to review. Most of the available studies received support from the manufacturers of these methods.

According to available evidence, the P provides a comparable safety and pharmacokinetic profile to COCs with similar hormone formulations (43–60). Reports of transient, short-term breast discomfort and skin-site reactions were greater among P users; however, less than 25% of users experienced these events (45, 49, 50, 56–58, 61). Limited evidence suggests the effectiveness of the P may decline for women weighing 90 kg or more (58, 60).

According to available evidence, the CVR provides a comparable safety and pharmacokinetic profile and has similar effects on ovarian function to COCs with similar hormone formulations in healthy women (61–75). Evidence from use in obese women (BMI ≥ 30 kg/m²) found that weight gain for women in this category was not different between CVR users and COC users (76). Limited evidence from use in women post medical and surgical abortion found no serious adverse events and no infection related to use during three cycles of follow-up post-abortion (77), and limited evidence on women with low-grade squamous intraepithelial lesions found that use of the vaginal ring did not worsen the condition (64).

Pending further evidence, the GDG concluded that the evidence available for COCs applies to the combined contraceptive P and CVR, and therefore the P and CVR should have the same categories as COCs. The assigned categories should, therefore, be considered a preliminary, best judgement, which will be re-evaluated as new data become available.

COMBINED HORMONAL CONTRACEPTIVES (CHCs)

CHCs do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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	CATEGORY I = initiation, C = continuation								CLARIFICATIONS/EVIDENCE

	COC		P		CVR		CIC

^† recommendations reviewed for the MEC 5^th edition, further details after this table * additional comments after this table	COC = combined oral contraceptive P = combined contraceptive patch CVR = combined contraceptive vaginal ring CIC = combined injectable contraceptive
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY

PREGNANCY	NA		NA		NA		NA		NA = not applicable Clarification: Use of COCs, P, CVR or CICs is not required. There is no known harm to the woman, the course of her pregnancy, or the fetus if COCs, P, CVR or CICs are accidentally used during pregnancy.

AGE^†*									Evidence: Evidence about whether CHC use affects fracture risk is inconsistent (78–89), although 3 recent studies show no effect (90–92). CHC use may decrease bone mineral density (BMD) in adolescents, especially in those choosing very low dose formulations (< 30 μg ethinyl estradiol-containing COCs) (91, 93–105). CHC use has little to no effect on BMD in premenopausal women (90, 93–102, 106–109), and may preserve bone mass in those who are perimenopausal (103, 104, 110–117). BMD is a surrogate marker for fracture risk that may not be valid for premenopausal women, and which, therefore, may not accurately predict current or future (postmenopausal) fracture risk (118–120).
a) Menarche to < 40 years	1		1		1		1
b) ≥ 40 years	2		2		2		2

PARITY
a) Nulliparous	1		1		1		1
b) Parous	1		1		1		1

BREASTFEEDING ^†									Evidence: Clinical studies demonstrate conflicting results regarding effects on breastfeeding continuation or exclusivity in women exposed to COCs during lactation. No consistent effects on infant growth or illness have been reported (121–126). Adverse health outcomes or manifestations of exogenous estrogen in infants exposed to combined contraceptives through breast-milk have not been demonstrated; however, studies have been inadequately designed to determine whether a risk of either serious or subtle long-term effects exists.
a) < 6 weeks postpartum	4		4		4		4
b) ≥ 6 weeks to < 6 months postpartum (primarily breastfeeding)	3		3		3		3
c) ≥ 6 months postpartum	2		2		2		2

POSTPARTUM (IN NON-BREASTFEEDING WOMEN) ^† Although the risk of venous thromboembolism (VTE) is the same in breastfeeding and non-breastfeeding women, use of CHCs is generally not recommended prior to 6 months postpartum in women who are breastfeeding.

a) < 21 days									Clarification: For women up to 6 weeks postpartum with other risk factors for VTE, such as immobility, transfusion at delivery, BMI > 30 kg/m², postpartum haemorrhage, immediately post-caesarean delivery, pre-eclampsia or smoking, use of CHCs may pose an additional increased risk for VTE. Evidence: VTE risk is elevated during pregnancy and the postpartum period; this risk is most pronounced in the first 3 weeks after delivery, declining to near baseline levels by 42 days postpartum (127–131). Use of CHCs, which increases the risk of VTE in healthy reproductive-age women, may pose an additional risk during this time (132). Risk of pregnancy during the first 21 days postpartum is very low, but increases after that time in non-breastfeeding women; ovulation before first menses is common (133).
i) without other risk factors for VTE	3		3		3		3
ii) with other risk factors for VTE	4		4		4		4
b) ≥ 21 days to 42 days
i) without other risk factors for VTE	2		2		2		2
ii) with other risk factors for VTE	3		3		3		3
c) > 42 days	1		1		1		1

POST-ABORTION									Clarification: COCs, P, CVR or CICs may be started immediately post-abortion. Evidence: Women who started taking COCs immediately after first-trimester medical or surgical abortion did not experience more side-effects or adverse vaginal bleeding outcomes or clinically significant changes in coagulation parameters compared with women who used a placebo, an IUD, a non-hormonal contraceptive method, or delayed COC initiation (134–141). Limited evidence on women using the CVR immediately after first-trimester medical or surgical abortion indicated no serious adverse events and no infection related to CVR use during 3 cycles of follow-up post-abortion (77).
a) First trimester	1		1		1		1
b) Second trimester	1		1		1		1
c) Immediate post-septic abortion	1		1		1		1

PAST ECTOPIC PREGNANCY*	1		1		1		1

HISTORY OF PELVIC SURGERY	1		1		1		1

SMOKING									Evidence: COC users who smoked were at increased risk of cardiovascular diseases, especially myocardial infarction (MI), compared with those who did not smoke. Studies also showed an increased risk of MI with increasing number of cigarettes smoked per day (30, 31, 142–151).
a) Age < 35 years	2		2		2		2
b) Age ≥ 35 years
i) < 15 cigarettes/day	3		3		3		2
ii) ≥ 15 cigarettes/day	4		4		4		3

OBESITY									Evidence: Obese women who use COCs are more likely to experience VTE than obese women who do not use COCs. The absolute risk of VTE in healthy women of reproductive age is small. Limited evidence suggests that obese women who use COCs do not have a higher risk of acute MI or stroke than obese non-users (146, 147, 151–156). Limited evidence suggests obese women are no more likely to gain weight after 3 cycles of using CVR or COCs than overweight or normal-weight women. A similar weight gain during 3 months was noted in both the COC group and the CVR group across all BMI categories (76). Overall, evidence suggests that contraceptive effectiveness is maintained among obese CHC users (157–172); however, among women with very high BMI using COC, evidence is inconsistent (161, 167, 171). No association was found between pregnancy risk and BMI among P users (161, 167, 171). The effectiveness of the patch decreased among women who weighed > 90 kg in 1 study (172).
a) ≥ 30 kg/m² BMI	2		2		2		2
b) Menarche to < 18 years and ≥ 30 kg/m² BMI	2		2		2		2

BLOOD PRESSURE MEASUREMENT UNAVAILABLE	NA		NA		NA		NA		NA = not applicable Clarification: It is desirable to have blood pressure measurements taken before initiation of COC, P, CVR or CIC use. However, in some settings, blood pressure measurements are unavailable. In many of these settings, pregnancy-related morbidity and mortality risks are high, and COCs, P, CVR or CICs may be among the few methods widely available. In such settings, women should not be denied use of COCs, P, CVR or CICs simply because their blood pressure cannot be measured.

CARDIOVASCULAR DISEASE

MULTIPLE RISK FACTORS FOR ARTERIAL CARDIOVASCULAR DISEASE (e.g. older age, smoking, diabetes, hypertension and known dyslipidaemias)	3/4		3/4		3/4		3/4		Clarification: When a woman has multiple major risk factors, any of which alone would substantially increase the risk of cardiovascular disease, use of COCs, P, CVR or CICs may 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 2 risk factors assigned a Category 2 may not necessarily warrant a higher category.

HYPERTENSION For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, the risk of cardiovascular disease may increase substantially. A single reading of blood pressure level is not sufficient to classify a woman as hypertensive.

a) History of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy)	3		3		3		3		Clarification: Evaluation of cause and level of hypertension is recommended, as soon as feasible. Evidence: Women who did not have a blood pressure check before initiation of COC use had an increased risk of acute MI and stroke (26, 32, 33, 173, 174).

b) Adequately controlled hypertension, where blood pressure CAN be evaluated	3		3		3		3		Clarification: Women adequately treated for hypertension are at reduced risk of acute MI and stroke as compared with untreated women. Although there are no data, COC, P, CVR or CIC users with adequately controlled and monitored hypertension should be at reduced risk of acute MI and stroke compared with untreated hypertensive COC, P, CVR or CIC users. Evidence: Among women with hypertension, COC users were at increased risk of stroke, acute MI, and peripheral arterial disease compared with non-users (14, 26, 31, 33, 142, 144, 150, 151, 173–185). Discontinuation of COCs in women with hypertension may improve blood pressure control (186).
c) Elevated blood pressure levels (properly taken measurements)
i) systolic 140–159 or diastolic 90–99 mm Hg	3		3		3		3
ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg	4		4		4		4
d) Vascular disease	4		4		4		4

HISTORY OF HIGH BLOOD PRESSURE DURING PREGNANCY (where current blood pressure is measurable and normal)	2		2		2		2		Evidence: Women using COCs who had a history of high blood pressure in pregnancy had an increased risk of MI and VTE, compared with COC users who did not have a history of high blood pressure during pregnancy. The absolute risks of acute MI and VTE in this population remained small (32, 33, 151, 174, 176, 187–192).

DEEP VEIN THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)*
a) History of DVT/PE	4		4		4		4
b) Acute DVT/PE	4		4		4		4
c) DVT/PE and established on anticoagulant therapy	4		4		4		4
d) Family history (first-degree relatives)	2		2		2		2
e) Major surgery
i) with prolonged immobilization	4		4		4		4
ii) without prolonged immobilization	2		2		2		2
f) Minor surgery without immobilization	1		1		1		1

KNOWN THROMBOGENIC MUTATIONS (e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)	4		4		4		4		Clarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening. Evidence: Among women with thrombogenic mutations, COC users had a 2- to 20-fold higher risk of thrombosis than non-users (3, 155, 193–214).

SUPERFICIAL VENOUS DISORDERS ^†
a) Varicose veins	1		1		1		1		Evidence: One study suggested that among women with varicose veins, the rate of VTE and superficial venous thrombosis (SVT) was higher in oral contraceptive users compared with non-users; however, statistical significance was not reported and the number of events was small (215).
b) Superficial venous thrombosis (SVT)	2		2		2		2		Clarification: SVT may be associated with an increased risk of VTE. Evidence: One study demonstrated that among women with SVT, the risk of VTE was higher in oral contraceptive users compared with non-users (216).

CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE	4		4		4		4

STROKE (history of cerebrovascular accident)	4		4		4		4

KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORS ^†	2		2		2		2		Clarification: Routine screening is not appropriate because of the rarity of the condition and the high cost of screening. Increased levels of total cholesterol, low-density lipoprotein (LDL) and triglycerides, as well as a decreased level of high-density lipoprotein (HDL), are known risk factors for cardiovascular disease. Women with known severe genetic lipid disorders are at much higher lifetime risk for cardiovascular disease and may warrant further clinical consideration. Evidence: Limited evidence on use of CHCs among women with dyslipidaemia and risk of cardiovascular outcomes provided inconsistent results. One study suggested an increased risk for MI among COC users with hypercholesterolaemia compared to non-users without hypercholesterolaemia (217); 1 study suggested an increased risk for VTE and for stroke among COC users with dyslipidaemia compared to COC users without dyslipidaemia (22); and 1 study suggested no worsening of lipid abnormalities among CHC users with dyslipidaemia compared to non-users with dyslipidaemia (218). No evidence of risk for pancreatitis was identified.

VALVULAR HEART DISEASE*
a) Uncomplicated	2		2		2		2
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)	4		4		4		4

RHEUMATIC DISEASES

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) People with SLE are at increased risk of ischaemic heart disease, stroke and venous thromboembolism (VTE). Categories assigned to such conditions in the Medical eligibility criteria for contraceptive use should be the same for women with SLE who present with these conditions. For all categories of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors. Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives (219–236).

a) Positive (or unknown) antiphospholipid antibodies	4		4		4		4		Evidence: Antiphospholipid antibodies are associated with a higher risk for both arterial and venous thrombosis (237-239).
b) Severe thrombocytopenia	2		2		2		2
c) Immunosuppressive treatment	2		2		2		2
d) None of the above	2		2		2		2

NEUROLOGIC CONDITIONS

HEADACHES*	I	C	I	C	I	C	I	C	Clarification: Classification depends on accurate diagnosis of those severe headaches that are migrainous and those that are not. Any new headaches or marked changes in headaches should be evaluated. Classification is for women without any other risk factors for stroke. Risk of stroke increases with age, hypertension and smoking. Evidence: Among women with migraine, women who also had aura had a higher risk of stroke than those without aura (240–242). Women with a history of migraine who use COCs are about 2–4 times as likely to have an ischaemic stroke as non-users with a history of migraine (142, 154, 181, 182, 240–246).
HEADACHES*
a) Non-migrainous (mild or severe)	1	2	1	2	1	2	1	2
b) Migraine
i) without aura
age < 35 years	2	3	2	3	2	3	2	3
age ≥ 35 years	3	4	3	4	3	4	3	4
ii) with aura, at any age	4	4	4	4	4	4	4	4

EPILEPSY	1		1		1		1		Clarification: If a woman is taking anticonvulsants, refer to the last section of this table, on drug interactions. Certain anticonvulsants lower COC effectiveness. The extent to which P, CVR or CIC use is similar to COC use in this regard remains unclear.

DEPRESSIVE DISORDERS

DEPRESSIVE DISORDERS	1		1		1		1		Clarification: The classification is based on data for women with selected depressive disorders. No data on bipolar disorder or postpartum depression were available. There is a potential for drug interactions between certain antidepressant medications and hormonal contraceptives. Evidence: COC use did not increase depressive symptoms in women with depression compared to baseline or to non-users with depression (247–256).

REPRODUCTIVE TRACT INFECTIONS AND DISORDERS

VAGINAL BLEEDING PATTERNS*
a) Irregular pattern without heavy bleeding	1		1		1		1
b) Heavy or prolonged bleeding (includes regular and irregular patterns)	1		1		1		1		Clarification: Unusually heavy bleeding should raise the suspicion of a serious underlying condition. Evidence: A Cochrane Collaboration review identified 1 randomized controlled trial evaluating the effectiveness of COC use compared with naproxen and danazol in treating menorrhagic women. Women with menorrhagia did not report worsening of the condition or any adverse events related to COC use (257).

UNEXPLAINED VAGINAL BLEEDING* (suspicious for serious condition)
a) Before evaluation	2		2		2		2		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		1		Evidence: A Cochrane review identified 1 randomized controlled trial evaluating the effectiveness of COC use compared with a gonadotropin-releasing hormone (GnRH) analogue in treating the symptoms of endometriosis. Women with endometriosis did not report worsening of the condition or any adverse events related to COC use (258).

BENIGN OVARIAN TUMOURS (INCLUDING CYSTS)	1		1		1		1

SEVERE DYSMENORRHOEA	1		1		1		1		Evidence: There was no increased risk of side-effects with COC use among women with dysmenorrhoea compared with women not using COCs. Some COC users had a reduction in pain and bleeding (259, 260).

GESTATIONAL TROPHOBLASTIC DISEASE									Evidence: Following molar pregnancy evacuation, the balance of evidence found COC use did not increase the risk of post-molar trophoblastic disease, and some COC users experienced a more rapid regression in human chorionic gonadotropin (hCG) levels, compared with non-users (261–268). Limited evidence suggests that use of COCs during chemotherapeutic treatment does not significantly affect the regression or treatment of post-molar trophoblastic disease compared with women who used a non-hormonal contraceptive method or depot medroxyprogesterone acetate (DMPA) during chemotherapeutic treatment (269).
a) Decreasing or undetectable β-hCG levels	1		1		1		1
b) Persistently elevated β-hCG levels or malignant disease	1		1		1		1

CERVICAL ECTROPION*	1		1		1		1

CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)	2		2		2		2		Evidence: Among women with persistent human papillomavirus (HPV) infection, long-term COC use (≥ 5 years) may increase the risk of carcinoma in situ and invasive carcinoma (64, 270). Limited evidence on women with low-grade squamous intraepithelial lesions found use of the vaginal ring did not worsen the condition (64).

CERVICAL CANCER* (AWAITING TREATMENT)	2		2		2		2

BREAST DISEASE*
a) Undiagnosed mass	2		2		2		2		Clarification: Evaluation should be pursued as early as possible.
b) Benign breast disease	1		1		1		1
c) Family history of cancer	1		1		1		1		Evidence: Women with breast cancer susceptibility genes (such as BRCA1 and BRCA2) have a higher baseline risk of breast cancer than women without these genes. The baseline risk of breast cancer is also higher among women with a family history of breast cancer than among those who do not have such a history. Current evidence, however, does not suggest that the increased risk of breast cancer among women with either a family history of breast cancer or breast cancer susceptibility genes is modified by the use of combined oral contraceptives (175, 271–293).
d) Breast cancer
i) current	4		4		4		4
ii) past and no evidence of current disease for 5 years	3		3		3		3

ENDOMETRIAL CANCER*	1		1		1		1

OVARIAN CANCER*	1		1		1		1

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

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

STIs
a) Current purulent cervicitis or chlamydial infection or gonorrhoea	1		1		1		1
b) Other STIs (excluding HIV and hepatitis)	1		1		1		1
c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)	1		1		1		1
d) Increased risk of STIs	1		1		1		1		Evidence: Evidence suggests that there may be an increased risk of chlamydial cervicitis among COC users at high risk of STIs. For other STIs, there is either evidence of no association between COC use and STI acquisition or too limited evidence to draw any conclusions (289–369).

HIV/AIDS ^†

High risk of HIV	1		1		1		1		Evidence: Eight studies assessed the use of COCs and were considered to be “informative but with important limitations” (370). Seven of these studies found no statistically significant association between use of COCs and HIV acquisition (371–378), although 1 study among sex workers in Kenya did (379).

Asymptomatic or mild HIV clinical disease (WHO stage 1 or 2)	1		1		1		1		Clarification for asymptomatic or mild HIV disease (WHO stage 1 or 2) and severe or advanced HIV disease (WHO stage 3 or 4): Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to the last section of this table, on drug interactions. Evidence for asymptomatic or mild HIV disease (WHO stage 1 or 2) and severe or advanced HIV disease (WHO stage 3 or 4): Out of 8 available studies, 7 suggested no association between use of COCs and progression of HIV, as measured by CD4 count < 200 cells/mm3, initiation of antiretroviral therapy (ART), or mortality (380–386). One randomized controlled trial found an increased risk of a composite outcome of declining CD4 count or death among COC users when compared with users of copper-bearing IUDs (387, 388). Two prospective observational studies directly assessed the effects of different hormonal contraceptive methods on female-to-male HIV transmission by measuring seroconversions in male partners of women known to be using hormonal contraceptives. One of these studies reported an elevated, but not statistically significant, point estimate for COCs (378). The other study also did not find a statistically significant association for COCs (389). Studies indirectly assessing the effect of various hormonal contraceptive methods on female-to-male HIV transmission by measuring genital viral shedding as a proxy for infectivity have had mixed results. The majority of indirect studies measuring whether various hormonal contraceptive methods affect plasma HIV viral load have found no effect (381, 390–404).
Severe or advanced HIV clinical disease (WHO stage 3 or 4)	1		1		1		1

OTHER INFECTIONS

SCHISTOSOMIASIS
a) Uncomplicated	1		1		1		1		Evidence: Among women with uncomplicated schistosomiasis, COC use had no adverse effects on liver function (405–411).
b) Fibrosis of the liver (if severe, see cirrhosis)	1		1		1		1

TUBERCULOSIS
a) Non-pelvic	1		1		1		1		Clarification: If a woman is taking rifampicin, refer to the last section of this table, on drug interactions. Rifampicin is likely to decrease COC effectiveness. The extent to which P or CVR use is similar to COC use in this regard remains unclear.
b) Pelvic	1		1		1		1

MALARIA	1		1		1		1

ENDOCRINE CONDITIONS

DIABETES
a) History of gestational disease	1		1		1		1		Evidence: The development of non-insulin-dependent diabetes in women with a history of gestational diabetes is not increased by the use of COCs (412–419). Likewise, lipid levels appear to be unaffected by COC use (420–422).
b) Non-vascular disease									Evidence: Among women with insulin- or non-insulin-dependent diabetes, COC use had limited effect on daily insulin requirements and no effect on long-term diabetes control (e.g. haemoglobin A1c levels) or progression to retinopathy. Changes in lipid profile and haemostatic markers were limited, and most changes remained within normal values (419, 422–430).
i) non-insulin dependent	2		2		2		2
ii) insulin dependent	2		2		2		2
c) Nephropathy/retinopathy/neuropathy	3/4		3/4		3/4		3/4		Clarification: The category should be assessed according to the severity of the condition.
d) Other vascular disease or diabetes of > 20 years' duration	3/4		3/4		3/4		3/4		Clarification: The category should be assessed according to the severity of the condition.

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

GASTROINTESTINAL CONDITIONS

GALL BLADDER DISEASE*
a) Symptomatic
i) treated by cholecystectomy	2		2		2		2
ii) medically treated	3		3		3		2
iii) current	3		3		3		2
b) Asymptomatic	2		2		2		2

HISTORY OF CHOLESTASIS*
a) Pregnancy related	2		2		2		2
b) Past-COC related	3		3		3		2

VIRAL HEPATITIS	I	C	I	C	I	C	I	C
VIRAL HEPATITIS
a) Acute or flare	3/4	2	3/4	2	3/4	2	3	2	Clarification: The category should be assessed according to the severity of the condition.
b) Carrier	1	1	1	1	1	1	1	1	Evidence: Data suggest that in women with chronic hepatitis, COC use does not increase the rate or severity of cirrhotic fibrosis, nor does it increase the risk of hepatocellular carcinoma (431, 432). For women who are carriers, COC use does not appear to trigger liver failure or severe dysfunction (408, 433, 434). Evidence is limited for COC use during active hepatitis (435, 436).
c) Chronic	1	1	1	1	1	1	1	1

CIRRHOSIS
a) Mild (compensated)	1		1		1		1
b) Severe (decompensated)	4		4		4		3

LIVER TUMOURS*
a) Benign
i) focal nodular hyperplasia	2		2		2		2		Evidence: There is limited, direct evidence that hormonal contraceptive use does not influence either progression or regression of liver lesions among women with focal nodular hyperplasia (437–439).
ii) hepatocellular adenoma	4		4		4		3
b) Malignant (hepatoma)	4		4		4		3/4

ANAEMIAS

THALASSAEMIA*	1		1		1		1

SICKLE CELL DISEASE	2		2		2		2

IRON-DEFICIENCY ANAEMIA*	1		1		1		1

DRUG INTERACTIONS

ANTIRETROVIRAL THERAPY (ART) ^†
a) Nucleoside reverse transcriptase inhibitors (NRTIs)									Evidence: NRTIs do not appear to have significant risk of interactions with hormonal contraceptive methods (440, 441).
Abacavir (ABC)	1		1		1		1
Tenofovir (TDF)	1		1		1		1
Zidovudine (AZT)	1		1		1		1
Lamivudine (3TC)	1		1		1		1
Didanosine (DDI)	1		1		1		1
Emtricitabine (FTC)	1		1		1		1
Stavudine (D4T)	1		1		1		1

b) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)									Clarification: Antiretroviral drugs have the potential to either decrease or increase the levels of steroid hormones in women using hormonal contraceptives. Pharmacokinetic data suggest potential drug interactions between some antiretroviral drugs (particularly some NNRTIs and ritonavir-boosted PIs) and some hormonal contraceptives. These interactions may reduce the effectiveness of the hormonal contraceptive. Evidence: Three clinical studies, including 1 large study, found use of nevirapine-containing ART did not increase ovulation or pregnancy rates in women taking COCs (442–445). For efavirenz-containing ART, a pharmacokinetic study showed consistent significant decreases in contraceptive hormone levels in women taking COCs, and a small clinical study showed higher ovulation rates in women taking efavirenz-containing ART and COCs (445–447). Etravirine and rilpivirine do not interact with COCs (448, 449).
Efavirenz (EFV)	2		2		2		2
Etravirine (ETR)	1		1		1		1
Nevirapine (NVP)	2		2		2		2
Rilpivirine (RPV)	1		1		1		1
c) Protease inhibitors (PIs)
Ritonavir-boosted atazanavir (ATV/r)	2		2		2		2
Ritonavir-boosted lopinavir (LPV/r)	2		2		2		2
Ritonavir-boosted darunavir (DRV/r)	2		2		2		2
Ritonavir (RTV)	2		2		2		2
d) Integrase inhibitors									Evidence: The integrase inhibitor raltegravir does not appear to interact with COCs (440, 441, 454, 455).
Raltegravir (RAL)	1		1		1		1

ANTICONVULSANT THERAPY
a) Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)	3		3		3		2		Clarification: Although the interaction of certain anticonvulsants with COCs, P or CVR is not harmful to women, it is likely to reduce the effectiveness of COCs, P or CVR. Use of other contraceptives should be encouraged for women who are long-term users of any of these drugs. When a COC is chosen, a preparation containing a minimum of 30 μg of ethinyl estradiol (EE) should be used. Evidence: Use of certain anticonvulsants may decrease the effectiveness of COCs (456-459).
b) Lamotrigine	3		3		3		3		Clarification: The recommendation for lamotrigine does not apply when lamotrigine is already being taken with other drugs that strongly inhibit (such as sodium valproate) or induce (such as carbamazepine) its metabolism, since, in these cases, the moderate effect of the combined contraceptive is unlikely to be apparent. Evidence: Pharmacokinetic studies show levels of lamotrigine decrease significantly during COC use and increase significantly during the pill-free interval (460-464). Some women who used both COCs and lamotrigine experienced increased seizure activity in 1 trial (464).

ANTIMICROBIAL THERAPY
a) Broad-spectrum antibiotics	1		1		1		1		Evidence: Most broad-spectrum antibiotics do not affect the contraceptive effectiveness of COCs (465–501), P (502), or CVR (503).
b) Antifungals	1		1		1		1		Evidence: Studies of antifungal agents have shown no clinically significant pharmacokinetic interactions with COCs (504–513) or CVR (514).
c) Antiparasitics	1		1		1		1		Evidence: Studies of antiparasitic agents have shown no clinically significant pharmacokinetic interactions with COCs (411, 515–519).
d) Rifampicin or rifabutin therapy	3		3		3		2		Clarification: Although the interaction of rifampicin or rifabutin therapy with COCs, P, CVR or CICs is not harmful to women, it is likely to reduce the effectiveness of COCs, P, CVR or CICs. Use of other contraceptives should be encouraged for women who are long-term users of either of these drugs. When a COC is chosen, a preparation containing a minimum of 30 μg EE should be used. Evidence: The balance of the evidence suggests that rifampicin reduces the effectiveness of COCs (520–535). Data on rifabutin are limited, but effects on metabolism of COCs are less than with rifampicin, and small studies have not shown evidence of ovulation (363, 522, 535).

RECOMMENDATIONS REVIEWED FOR FIFTH EDITION

These recommendations were reviewed according to WHO requirements for guideline development, as part of the preparation of the Medical eligibility criteria for contraceptive use, fifth edition. The Population, Intervention, Comparator, Outcome (PICO) questions developed by the Guideline Development Group (GDG) and the databases searched to retrieve the evidence, which guided the preparation of systematic reviews, are described in greater detail in Part I of this document. Additionally, GRADE evidence profiles, the overall GRADE assessment of the quality of the evidence, summaries of the evidence supporting the recommendation(s), and other supplementary remarks from the GDG regarding the recommendations, are available in Part I.

ADDITONAL COMMENTS

AGE

Age ≥ 40 years: The risk of cardiovascular disease increases with age and may also increase with combined hormonal contraceptive (CHC) use. In the absence of other adverse clinical conditions, CHCs can be used until menopause.

PAST ECTOPIC PREGNANCY

The risk of future ectopic pregnancy is increased in these women. CHCs provide protection against pregnancy in general, including ectopic gestation.

DEEP VEIN THROMBOSIS/PULMONARY EMBOLISM

Family history of DVT/PE (first-degree relatives): Some conditions which increase the risk of DVT/PE are heritable.

VALVULAR HEART DISEASE

Among women with valvular heart disease, CHC use may further increase the risk of arterial thrombosis; women with complicated valvular heart disease are at greatest risk.

HEADACHES

Aura is a specific focal neurologic symptom. For more information on this and other diagnostic criteria, see: Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edition. Cephalalgia. 2004;24(Suppl 1):1–150.¹²

VAGINAL BLEEDING PATTERNS

Irregular menstrual bleeding patterns are common among healthy women.

UNEXPLAINED VAGINAL BLEEDING

There are no conditions that cause vaginal bleeding that will be worsened in the short term by use of CHCs.

CERVICAL ECTROPION

Cervical ectropion is not a risk factor for cervical cancer, and there is no need for restriction of CHC use.

CERVICAL CANCER (AWAITING TREATMENT)

There is some theoretical concern that CHC use may affect prognosis of the existing disease. While awaiting treatment, women may use CHCs. In general, treatment of this condition renders a woman sterile.

BREAST DISEASE

Breast cancer: Breast cancer is a hormonally sensitive tumour, and the prognosis of women with current or recent breast cancer may worsen with CHC use.

ENDOMETRIAL CANCER

COC use reduces the risk of developing endometrial cancer.

Awaiting treatment: Women may use COCs, CICs, P or CVR. In general, treatment of this condition renders a woman sterile.

OVARIAN CANCER

COC use reduces the risk of developing ovarian cancer.

Awaiting treatment: Women may use COCs, CICs, P or CVR. In general, treatment of this condition renders a woman sterile.

UTERINE FIBROIDS

COCs do not appear to cause growth of uterine fibroids, and CICs, P and CVR are not expected to either.

PELVIC INFLAMMATORY DISEASE (PID)

COCs may reduce the risk of PID among women with STIs, but do not protect against HIV or lower genital tract STIs. Whether CICs, P or CVR reduce the risk of PID among women with STIs is unknown but they do not protect against HIV or lower genital tract STIs.

GALL BLADDER DISEASE

COCs, CICs, P or CVR may cause a small increased risk of gall bladder disease.

There is also concern that COCs, CICs, P or CVR may worsen existing gall bladder disease.

Unlike COCs, CICs have been shown to have minimal effect on liver function in healthy women, and have no first-pass effect on the liver.

HISTORY OF CHOLESTASIS

Pregnancy-related: History of pregnancy-related cholestasis may predict an increased risk of developing COC-related cholestasis.

Past-COC-related: History of COC-related cholestasis predicts an increased risk with subsequent COC use.

LIVER TUMOURS

There is no evidence regarding hormonal contraceptive use among women with hepatocellular adenoma.

COC use in healthy women is associated with development and growth of hepatocellular adenoma.

THALASSAEMIA

There is anecdotal evidence from countries where thalassaemia is prevalent that COC use does not worsen the condition.

IRON-DEFICIENCY ANAEMIA

CHC use may decrease menstrual blood loss.

References

1.: Effect of different progestagens in low oestrogen oral contraceptives on venous thromboembolic disease. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet. 1995;346(8990):1582–8. [PubMed: 7500749]
2.: Bergendal A, Persson I, Odeberg J, Sundstrom A, Holmstrom M, Schulman S, et al. Association of venous thromboembolism with hormonal contraception and thrombophilic genotypes. Obstet Gynecol. 2014;124(3):600–9. [PubMed: 25162263]
3.: Bloemenkamp KW, Rosendaal FR, Helmerhorst FM, Buller HR, Vandenbroucke JP. Enhancement by factor V Leiden mutation of risk of deep-vein thrombosis associated with oral contraceptives containing a third-generation progestagen. Lancet. 1995;346(8990):1593–6. [PubMed: 7500751]
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498.: London BM, Lookingbill DP. Frequency of pregnancy in acne patients taking oral antibiotics and oral contraceptives. Arch Dermatol. 1994;130:392–3. [PubMed: 8129425]
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505.: Sinofsky FE, Pasquale SA. The effect of fluconazole on circulating ethinyl estradiol levels in women taking oral contraceptives. Am J Obstet Gynecol. 1998;178:300–4. [PubMed: 9500490]
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510.: Kovacs I, Somos P, Hamori M. Examination of the potential interaction between ketoconazole (Nizoral) and oral contraceptives with special regard to products of low hormone content (Rigevidon, anteovin). Therapia Hungarica (English edition). 1986;34:167–70. [PubMed: 3441880]
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516.: McGready R, Stepniewska K, Seaton E, Cho T, Cho D, Ginsberg A, et al. Pregnancy and use of oral contaceptives reduces the biotransformation of proguanil to cycloguanil. Eur J Clin Pharmacol. 2003;59:553–7. [PubMed: 12955370]
517.: Karbwang J, Looareesuwan S, Back DJ, Migasana S, Bunnag D. Effect of oral contraceptive steroids on the clinical course of malaria infection and on the pharmacokinetics of mefloquine in Thai women. Bull World Health Organ. 1988;66:763–7. [PMC free article: PMC2491144] [PubMed: 3266115]
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520.: Gupta KC, Ali MY. Failure of oral contraceptive with rifampicin. Med J Zambia. 1981;15:23. [PubMed: 7269801]
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522.: Barditch-Crovo P, Trapnell CB, Ette E, Zacur HA, Coresh J, Rocco LE, et al. The effects of rifampicin and rifabutin on the pharmacokinetics and pharmacodynamics of a combination oral contraceptive. Clin Pharmacol Ther. 1999;65:428–38. [PubMed: 10223781]
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2.7.2. Progestogen-only contraceptives (POCs)

PROGESTOGEN-ONLY PILLS (POPs)

POPs contain only a progestogen and no estrogen.

PROGESTOGEN-ONLY INJECTABLES (POIs)

These injectables include depot medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN).

There are three formulations considered here:

DMPA-IM = 150 mg of DMPA given intramuscularly
DMPA-SC = 104 mg of DMPA given subcutaneously
NET-EN = 200 mg of NET-EN given intramuscularly

Identified evidence for the conditions of age, obesity, endometriosis and HIV among DMPA-SC users appear consistent with existing recommendations for DMPA-IM (1–12). Further, DMPA-SC and DMPA-IM appear to be therapeutically equivalent, with similar safety profiles when used by healthy women (3, 5, 11). Pending further evidence, the Guideline Development Group (GDG) concluded that the evidence available for DMPA-IM applies to DMPA-SC and, therefore, DMPA-SC should have the same categories as DMPA-IM; the assigned recommendations should be considered a preliminary best judgement, which will be re-evaluated as new data become available.

PROGESTOGEN-ONLY IMPLANTS

Progestogen-only implants are a type of long-acting, reversible contraception. The various types of implants that are considered here are the following:

Levonorgestrel (LNG): The LNG-containing implants are Norplant®, Jadelle® and Sino-implant (II)®.
1. Norplant® is a 6-rod implant, each rod containing 36 mg of LNG (no longer in production).
2. Jadelle® is a 2-rod implant, each rod containing 75 mg of LNG
3. Sino-implant (II) ® is a 2-rod implant, each rod containing 75 mg of LNG
Etonogestrel (ETG): The ETG-containing implants are Implanon® and Nexplanon®. Both consist of a single-rod implant containing 68 mg of ETG.

No studies were identified that provided direct evidence on the use of the Sino-implant (II) among women with medical conditions in the MEC and included a comparison group. Evidence from three studies of healthy women demonstrate that Sino-implant (II) has a similar safety and pharmacokinetic profile to that of other LNG implants, with no significant differences in serious adverse events, such as ectopic pregnancy or discontinuation due to medical problems (13–15). Therefore, safety data from studies of other LNG implants among women with medical conditions were used due to the similarity of Sino-implant (II) and other LNG implants in hormone formulation, quality profile and daily release rates. The GDG assigned the same recommendations for Sino-implant (II) as for the other LNG implants.

PROGESTOGEN-ONLY CONTRACEPTIVES (POCs)

POCs do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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	CATEGORY I = initiation, C = continuation						CLARIFICATIONS/EVIDENCE

	POP		DMPA/NET-EN		LNG/ETG

^† recommendations reviewed for the MEC 5th edition, further details after this table * additional comments after this table	POP = progestogen-only pill LNG/ETG = levonorgestrel and etonogestrel (implants) DMPA = depot medroxyprogesterone acetate (injectable) NET-EN = norethisterone enanthate (injectable)
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY

PREGNANCY	NA		NA		NA		NA = not applicable Clarification: Use of POCs is not required. There is no known harm to the woman, the course of her pregnancy, or the fetus if POCs are accidentally used during pregnancy. However, the relationship between DMPA use during pregnancy and its effects on the fetus remains unclear.

AGE							Evidence: Most studies have found that women lose bone mineral density (BMD) during DMPA use, but recover BMD after discontinuation. Limited evidence shows a weak association with fracture, although 1 large study suggests that women who choose DMPA may be at higher risk for fracture even prior to initiation of the method (16). It is unclear whether adult women with long durations of DMPA use can regain BMD to baseline levels before entering menopause and whether adolescents can reach peak bone mass after discontinuation of DMPA. The relationship between these changes in BMD during the reproductive years and future fracture risk is unknown. Studies generally find no effect of POCs other than DMPA on BMD (5, 12, 16–60).
a) Menarche to < 18 years	1		2		1
b) 18 to 45 years	1		1		1
c) > 45 years	1		2		1

PARITY
a) Nulliparous	1		1		1
b) Parous	1		1		1

BREASTFEEDING ^†							Clarification: There is theoretical concern about the potential exposure of the neonate to DMPA/NET-EN during the first 6 weeks postpartum. In many settings, however, pregnancy-related morbidity and mortality risks are high, and access to services is limited. In such settings, DMPA/NET-EN may be among the few methods widely available and accessible to breastfeeding women immediately postpartum. Evidence: Direct evidence demonstrates no harmful effect of POCs on breastfeeding performance (61–109) and generally demonstrates no harmful effects on infant growth, health or development (74, 76, 89, 99); however, these studies have been inadequately designed to determine whether a risk of long-term effects exists. Animal data suggest an effect of progesterone on the developing brain; whether similar effects occur following progestogen exposure in humans is unclear (110–112).
a) < 6 weeks postpartum	2		3		2
b) ≥ 6 weeks to < 6 months postpartum (primarily breastfeeding)	1		1		1
c) ≥ 6 months postpartum	1		1		1

POSTPARTUM (NON-BREASTFEEDING WOMEN)
a) < 21 days	1		1		1
b) ≥ 21 days	1		1		1

POST-ABORTION							Clarification: POCs may be started immediately post-abortion. Evidence: Limited evidence suggests that there are no adverse side-effects when an LNG implant or NET-EN are initiated after first-trimester abortion (113–116).
a) First trimester	1		1		1
b) Second trimester	1		1		1
c) Immediate post-septic abortion	1		1		1

PAST ECTOPIC PREGNANCY*	2		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							Clarification: There is evidence for differential weight gain among normal-weight and obese adolescents who use DMPA, but not among those using NET-EN. However, NET-EN is Category 2 due to evidence regarding potential effects of NET-EN on BMD among adolescents (see row: Age). Evidence: Among adult women, there is generally no association between baseline weight and weight gain among DMPA users compared with non-users. Evidence is mixed for adolescent DMPA users, with some studies observing greater weight gain among obese compared with normal-weight users, but other studies showing no association. Methodological differences across studies may account for the differences in findings. Data on other POC methods and other adverse outcomes are limited (10, 117–133).
a) ≥ 30 kg/m² BMI	1		1		1
b) Menarche to < 18 years and ≥ 30 kg/m² BMI	1		2		1

BLOOD PRESSURE MEASUREMENT UNAVAILABLE	NA		NA		NA		NA = not applicable Clarification: It is desirable to have blood pressure measurements taken before initiation of POC use. However, in some settings blood pressure measurements are unavailable. In many of these settings, pregnancy-related morbidity and mortality risks are high, and POCs are among the few methods widely available. In such settings, women should not be denied use of POCs 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)	2		3		2		Clarification: When multiple major risk factors exist, the risk of cardiovascular disease may increase substantially. Some POCs may increase the risk of thrombosis, although this increase is substantially less than with combined oral contraceptives (COCs). The effects of DMPA and NET-EN may persist for some time after discontinuation.

HYPERTENSION* For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, the risk of cardiovascular disease may increase substantially. A single reading of blood pressure level is not sufficient to classify a woman as hypertensive.

a) History of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy)	2		2		2		Clarification: It is desirable to have blood pressure measurements taken before initiation of POC use. However, in some settings blood pressure measurements are unavailable. In many of these settings, pregnancy-related morbidity and mortality risks are high, and POCs are among the few types of methods widely available. In such settings, women should not be denied the use of POCs simply because their blood pressure cannot be measured.
b) Adequately controlled hypertension, where blood pressure CAN be evaluated	1		2		1		Clarification: Women adequately treated for hypertension are at reduced risk of acute myocardial infarction (MI) and stroke as compared with untreated women. Although there are no data, POC users with adequately controlled and monitored hypertension should be at reduced risk of acute MI and stroke compared with untreated hypertensive POC users.
c) Elevated blood pressure levels (properly taken measurements)							Evidence: Limited evidence suggests that among women with hypertension, those who used POPs or progestogen-only injectables (POIs) had a small increased risk of cardiovascular events compared with women who did not use these methods (134).
i) systolic 140–159 or diastolic 90–99 mm Hg	1		2		1
ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg	2		3		2
d) Vascular disease	2		3		2

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	2		2		2
b) Acute DVT/PE	3		3		3		Evidence: There is no direct evidence on the use of POCs among women with DVT/PE on anticoagulant therapy. Although evidence on the risk of venous thrombosis with the use of POCs is inconsistent in otherwise healthy women, any small increased risk is substantially less than that with COCs (134–136).
c) DVT/PE and established on anticoagulant therapy	2		2		2		Evidence: There is no direct evidence on the use of POCs among women with DVT/PE on anticoagulant therapy. Although evidence on the risk of venous thrombosis with the use of POCs is inconsistent in otherwise healthy women, any small increased risk is substantially less than that with COCs (134–136). Limited evidence indicates that intramuscular injections of DMPA in women on chronic anticoagulation therapy does not pose a significant risk of haematoma at the injection site or increase the risk of heavy or irregular vaginal bleeding (137, 138).
d) Family history (first-degree relatives)	1		1		1
e) Major surgery
i) with prolonged immobilization	2		2		2
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)	2		2		2		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*	I	C			I	C

	2	3	3		2	3

STROKE* (HISTORY OF CEREBROVASCULAR ACCIDENT)	I	C			I	C

	2	3	3		2	3

KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORS	2		2		2		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		1

RHEUMATIC DISEASES

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)*

People with SLE are at increased risk of ischaemic heart disease, stroke and venous thromboembolism. Categories assigned to such conditions in the Medical eligibility criteria for contraceptive use should be the same for women with SLE who present with these conditions. For all categories of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors. Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives (139–156).

			I	C

a) Positive (or unknown) antiphospholipid antibodies	3		3	3	3		Evidence: Antiphospholipid antibodies are associated with a higher risk for both arterial and venous thrombosis (157–159).
b) Severe thrombocytopenia	2		3	2	2
c) Immunosuppressive treatment	2		2	2	2
d) None of the above	2		2	2	2

NEUROLOGIC CONDITIONS

HEADACHES*	I	C	I	C	I	C
HEADACHES*
a) Non-migrainous (mild or severe)	1	1	1	1	1	1	Clarification: Classification depends on accurate diagnosis of those severe headaches that are migrainous and those that are not. Any new headaches or marked changes in headaches should be evaluated. Classification is for women without any other risk factors for stroke. Risk of stroke increases with age, hypertension and smoking.
b) Migraine
i) without aura
age < 35 years	1	2	2	2	2	2
age ≥ 35 years	1	2	2	2	2	2
ii) with aura, at any age	2	3	2	3	2	3

EPILEPSY	1		1		1		Clarification: If a woman is taking anticonvulsants, refer to the last section of this table, on drug interactions. Certain anticonvulsants lower POC effectiveness.

DEPRESSIVE DISORDERS

DEPRESSIVE DISORDERS	1		1		1		Clarification: The classification is based on data for women with selected depressive disorders. No data on bipolar disorder or postpartum depression were available. There is a potential for drug interactions between certain antidepressant medications and hormonal contraceptives. Evidence: POC use did not increase depressive symptoms in women with depression compared with baseline (160–163).

REPRODUCTIVE TRACT INFECTIONS AND DISORDERS

VAGINAL BLEEDING PATTERNS*
a) Irregular pattern without heavy bleeding	2		2		2
b) Heavy or prolonged bleeding (includes regular and irregular patterns)	2		2		2		Clarification: Unusually heavy bleeding should raise the suspicion of a serious underlying condition.

UNEXPLAINED VAGINAL BLEEDING* (suspicious for serious condition)							Clarification: If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation.
Before evaluation	2		3		3

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		2		2		Evidence: Among women with persistent human papillomavirus (HPV) infection, long-term DMPA use (≥ 5 years) may increase the risk of carcinoma in situ and invasive carcinoma (164).

CERVICAL CANCER* (awaiting treatment)	1		2		2

BREAST DISEASE*
a) Undiagnosed mass	2		2		2		Clarification: Evaluation should be pursued as early as possible.
b) Benign breast disease	1		1		1
c) Family history of cancer	1		1		1
d) Breast cancer
i) current	4		4		4
ii) past and no evidence of current disease for 5 years	3		3		3

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

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		Evidence: Evidence suggests that there may be an increased risk of chlamydial cervicitis among DMPA users at high risk of STIs. For other STIs, there is either evidence of no association between DMPA use and STI acquisition or too limited evidence to draw any conclusions. There is no evidence for other POCs (165–172).

HIV/AIDS

HIGH RISK OF HIV	1		1		1		Clarification for asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) and severe or advanced HIV clinical disease (WHO stage 3 or 4): Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to the last section of this table, on drug interactions. Evidence for asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) and severe or advanced HIV clinical disease (WHO stage 3 or 4): Out of 6 available studies, 5 suggest no association between use of POIs and progression of HIV, as measured by CD4 count < 200 cells/mm3, initiation of antiretroviral therapy (ART), or mortality (186–190). One randomized trial found an increased risk of a composite outcome of declining CD4 count or death among oral contraceptive users (COCs and POPs) when compared with users of copper-bearing IUDs; this study, however, had significant loss to follow-up and method switching among groups, limiting its interpretation (188, 191). One study found no difference in ART initiation or CD4 count between users and non-users of the LNG-IUD (192). Two prospective observational studies directly assessed the effects of different hormonal contraceptive methods on female-to-male HIV transmission by measuring seroconversions in male partners of women living with HIV and known to be using hormonal contraceptives. One study reported a statistically significant association between use of POIs and female-to-male transmission of HIV (180), while another study did not find a statistically significant association between use of DMPA and female-to-male HIV transmission (184). The findings of studies indirectly assessing the effects of various hormonal contraceptive methods on female-to-male HIV transmission by measuring genital viral shedding as a proxy for infectivity have been mixed. Most of indirect studies measuring whether various hormonal contraceptive methods affect plasma HIV viral load have found no effect (189, 193–207).

ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE (WHO STAGE 1 OR 2)	1		1		1		Clarification for asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) and severe or advanced HIV clinical disease (WHO stage 3 or 4): Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to the last section of this table, on drug interactions. Evidence for asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) and severe or advanced HIV clinical disease (WHO stage 3 or 4): Out of 6 available studies, 5 suggest no association between use of POIs and progression of HIV, as measured by CD4 count < 200 cells/mm3, initiation of antiretroviral therapy (ART), or mortality (186–190). One randomized trial found an increased risk of a composite outcome of declining CD4 count or death among oral contraceptive users (COCs and POPs) when compared with users of copper-bearing IUDs; this study, however, had significant loss to follow-up and method switching among groups, limiting its interpretation (188, 191). One study found no difference in ART initiation or CD4 count between users and non-users of the LNG-IUD (192). Two prospective observational studies directly assessed the effects of different hormonal contraceptive methods on female-to-male HIV transmission by measuring seroconversions in male partners of women living with HIV and known to be using hormonal contraceptives. One study reported a statistically significant association between use of POIs and female-to-male transmission of HIV (180), while another study did not find a statistically significant association between use of DMPA and female-to-male HIV transmission (184). The findings of studies indirectly assessing the effects of various hormonal contraceptive methods on female-to-male HIV transmission by measuring genital viral shedding as a proxy for infectivity have been mixed. Most of indirect studies measuring whether various hormonal contraceptive methods affect plasma HIV viral load have found no effect (189, 193–207).

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

OTHER INFECTIONS

SCHISTOSOMIASIS
a) Uncomplicated	1		1		1		Evidence: Among women with uncomplicated schistosomiasis, limited evidence showed that DMPA use had no adverse effects on liver function (208).
b) Fibrosis of the liver (if severe, see cirrhosis)	1		1		1

TUBERCULOSIS
a) Non-pelvic	1		1		1		Clarification: If a woman is taking rifampicin, refer to the last section of this table, on drug interactions. Rifampicin is likely to decrease the effectiveness of some POCs.
b) Pelvic	1		1		1

MALARIA	1		1		1

ENDOCRINE CONDITIONS

DIABETES*
a) History of gestational disease	1		1		1		Evidence: POCs had no adverse effects on serum lipid levels in women with a history of gestational diabetes in 2 small studies (209, 210). There is only limited and inconsistent evidence regarding the development of non-insulin-dependent diabetes among users of POCs with a history of gestational diabetes (211–214).
b) Non-vascular disease							Evidence: Among women with insulin- or non-insulin-dependent diabetes, limited evidence on the use of progestogen-only methods (POPs, DMPA injectable, LNG implant) suggests that these methods have little effect on short-term or long-term diabetes control (e.g. HbA1c levels), haemostatic markers or lipid profile (215–218).
i) non-insulin dependent	2		2		2
ii) insulin dependent	2		2		2
c) Nephropathy/retinopathy/neuropathy	2		3		2
d) Other vascular disease or diabetes of > 20 years' duration	2		3		2

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	2		2		2
ii) medically treated	2		2		2
iii) current	2		2		2
b) Asymptomatic	2		2		2

HISTORY OF CHOLESTASIS*
a) Pregnancy-related	1		1		1
b) Past-COC related	2		2		2

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)	3		3		3

LIVER TUMOURS*
a) Benign
i) focal nodular hyperplasia	2		2		2		Evidence: There is limited, direct evidence that hormonal contraceptive use does not influence either progression or regression of liver lesions among women with focal nodular hyperplasia (219–221).
ii) hepatocellular adenoma	3		3		3
b) Malignant (hepatoma)	3		3		3

ANAEMIAS

THALASSAEMIA	1		1		1

SICKLE CELL DISEASE	1		1		1		Evidence: Among women with sickle cell disease, POC use did not have adverse effects on haematological parameters and, in some studies, was beneficial with respect to clinical symptoms (222–229).

IRON-DEFICIENCY ANAEMIA*	1		1		1

DRUG INTERACTIONS

ANTIRETROVIRAL THERAPY (ART)
a) Nucleoside reverse transcriptase inhibitors (NRTIs)							Evidence: NRTIs do not appear to have significant risk of interactions with hormonal contraceptive methods (230, 231).
Abacavir (ABC)	1		1		1
Tenofovir (TDF)	1		1		1
Zidovudine (AZT)	1		1		1
Lamivudine (3TC)	1		1		1
Didanosine (DDI)	1		1		1
Emtricitabine (FTC)	1		1		1
Stavudine (D4T)	1		1		1
b) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)							Clarification: Antiretroviral drugs have the potential to either decrease or increase the levels of steroid hormones in women using hormonal contraceptives. Pharmacokinetic data suggest potential drug (particularly some NNRTIs and ritonavir-boosted PIs) and some hormonal contraceptives. These interactions may reduce the effectiveness of the hormonal contraceptive. Evidence: One retrospective chart review of women using efavirenz-containing ART showed increased contraceptive failure rates for women using LNG implants (232). Based primarily on pharmacokinetic data, the effectiveness of DMPA is likely not affected by NNRTIs, and vice versa (233, 234).
Efavirenz (EFV)	2		DMPA=1 NET-EN=2		2
Etravirine (ETR)	1		1		1
Nevirapine (NVP)	2		DMPA=1 NET-EN=2		2
Rilpivirine (RPV)	1		1		1
c) Protease inhibitors (PIs)							Clarification: Antiretroviral drugs have the potential to either decrease or increase the levels of steroid hormones in women using hormonal contraceptives. Pharmacokinetic data suggest potential drug interactions between some antiretroviral drugs (particularly some NNRTIs and ritonavir-boosted PIs) and some hormonal contraceptives. These interactions may reduce the effectiveness of the hormonal contraceptive. Evidence: Pharmacokinetic data suggest decreases in progestogen levels when COCs are used in combination with ritonavir and ritonavir-boosted PIs (235, 236). In women using the combined patch, co-administration resulted in higher progestogen levels (237). One study found higher progestogen levels with concurrent PI use in users of POPs (238). Based primarily on pharmacokinetic data, the effectiveness of DMPA is likely not affected by PIs, and vice versa (233, 234).
Ritonavir-boosted atazanavir (ATV/r)	2		DMPA=1 NET-EN=2		2
Ritonavir-boosted lopinavir (LPV/r)	2		DMPA=1 NET-EN=2		2
Ritonavir-boosted darunavir (DRV/r)	2		DMPA=1 NET-EN=2		2
Ritonavir (RTV)	2		DMPA=1 NET-EN=2		2
d) Integrase inhibitors							Evidence: The integrase inhibitor raltegravir does not appear to interact with norelgestromin-containing COCs (239, 240).
Raltegravir (RAL)	1				1

ANTICONVULSANT THERAPY
a) Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)	3		DMPA=1 NET-EN=2		2		Clarification: Although the interaction of certain anticonvulsants with POPs, NET-EN and LNG/ETG implants is not harmful to women, it is likely to reduce the effectiveness of POPs, NET-EN and LNG/ETG implants. Whether increasing the hormone dose of POPs alleviates this concern remains unclear. Use of other contraceptives should be encouraged for women who are long-term users of any of these drugs. Use of DMPA is Category 1 because its effectiveness is not decreased by the use of certain anticonvulsants. Evidence: Use of certain anticonvulsants may decrease the effectiveness of POCs (241–243).
b) Lamotrigine	1		1		1		Evidence: No drug interactions have been reported among women with epilepsy taking lamotrigine and using POCs (244).

ANTIMICROBIAL THERAPY
a) Broad-spectrum antibiotics	1		1		1
b) Antifungals	1		1		1
c) Antiparasitics	1		1		1
d) Rifampicin or rifabutin therapy	3		DMPA=1 NET-EN=2		2		Clarification: Although the interaction of rifampicin or rifabutin with POPs, NET-EN and LNG/ETG implants is not harmful to women, it is likely to reduce the effectiveness of POPs, NET-EN and LNG/ETG implants. Whether increasing the hormone dose of POPs alleviates this concern remains unclear. Use of other contraceptives should be encouraged for women who are long-term users of any of these drugs. Use of DMPA is Category 1 because its effectiveness is not decreased by the use of rifampicin or rifabutin.

RECOMMENDATIONS REVIEWED FOR FIFTH EDITION

ADDITIONAL COMMENTS

PAST ECTOPIC PREGNANCY

POPs have a higher absolute rate of ectopic pregnancy compared with other POCs, but still less than using no method. The 75 μg desogestrel-containing pill inhibits ovulation in most cycles, which suggests a low risk of ectopic pregnancy.

HYPERTENSION

Vascular disease: There is concern regarding hypo-estrogenic effects and reduced high-density lipoprotein (HDL) levels, particularly among users of DMPA and NET-EN. However, there is little concern about these effects with regard to POPs or LNG/ETG implants. The effects of DMPA and NET-EN may persist for some time after discontinuation.

DEEP VEIN THROMBOSIS/PULMONARY EMBOLISM

Women on anticoagulation therapy who have a history of haemorrhagic ovarian cysts may benefit from DMPA use.

CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE

There is concern regarding hypo-estrogenic effects and reduced HDL levels, particularly among users of DMPA and NET-EN. However, there is little concern about these effects with regard to POPs or LNG/ETG implants. The effects of DMPA and NET-EN may persist for some time after discontinuation.

STROKE

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Severe thrombocytopenia increases the risk of bleeding. POCs may be useful in the treatment of menorrhagia in women with severe thrombocytopenia. However, given the increased or erratic bleeding that may be seen on initiation of DMPA and its irreversibility for 11–13 weeks after administration, initiation of this method in women with severe thrombocytopenia should be done with caution.

HEADACHES

There is concern that severe headaches may increase with use of NET-EN, DMPA and implants. The effects of NET-EN and DMPA may persist for some time after discontinuation.

VAGINAL BLEEDING PATTERNS

Irregular menstrual bleeding patterns are common among healthy women. POC use frequently induces an irregular bleeding pattern. Implant use may induce irregular bleeding patterns, especially during the first 3–6 months, but these patterns may persist longer. ETG users are more likely than LNG users to develop amenorrhoea.

UNEXPLAINED VAGINAL BLEEDING

POCs may cause irregular bleeding patterns, which may mask symptoms of underlying pathology. The effects of DMPA and NET-EN may persist for some time after discontinuation.

CERVICAL CANCER (AWAITING TREATMENT)

There is some theoretical concern that POC use may affect prognosis of the existing disease. While awaiting treatment, women may use POCs. In general, treatment of this condition renders a woman sterile.

BREAST DISEASE

Breast cancer: Breast cancer is a hormonally sensitive tumour, and the prognosis of women with current or recent breast cancer may worsen with POC use.

ENDOMETRIAL CANCER

While awaiting treatment, women may use POCs. In general, treatment of this condition renders a woman sterile.

OVARIAN CANCER

While awaiting treatment, women may use POCs. In general, treatment of this condition renders a woman sterile.

UTERINE FIBROIDS

POCs do not appear to cause growth of uterine fibroids.

PELVIC INFLAMMATORY DISEASE (PID)

Whether POCs, like COCs, reduce the risk of PID among women with STIs is unknown, but they do not protect against HIV or lower genital tract STIs.

DIABETES

Nephropathy/retinopathy/neuropathy, other vascular disease, or diabetes of > 20 years' duration: There is concern regarding hypo-estrogenic effects and reduced HDL levels, particularly among users of DMPA and NET-EN. The effects of DMPA and NET-EN may persist for some time after discontinuation. Some POCs may increase the risk of thrombosis, although this increase is substantially less than with COCs.

HISTORY OF CHOLESTASIS

Theoretically, a history of COC-related cholestasis may predict subsequent cholestasis with POC use. However, this has not been documented.

LIVER TUMOURS

There is no evidence regarding hormonal contraceptive use among women with hepatocellular adenoma.

Given that COC use in healthy women is associated with development and growth of hepatocellular adenoma, it is not known whether other hormonal contraceptives have similar effects.

IRON-DEFICIENCY ANAEMIA

Changes in the menstrual pattern associated with POC use have little effect on haemoglobin levels.

References

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239.: Anderson MS, Hanley WD, Moreau AR, Jin B, Bieberdorf FA, Kost JT, et al. Effect of raltegravir on estradiol and norgestimate plasma pharmacokinetics following oral contraceptive administration in healthy women. Br J Clin Pharmacol. 2011;71(4):616–20. [PMC free article: PMC3080652] [PubMed: 21395656]
240.: Song I, Mark S, Borland J, Chen S, Wajima T, Peppercorn A, et al. Dolutegravir has no effect on the pharmacokinetics of methadone or oral contraceptives with norgestimate and ethinyl estradiol; 20th Conference on Retroviruses and Opportunistic Infections; Atlanta (GA). 3–6 March 2013.
241.: Odlind V, Olsson SE. Enhanced metabolism of levonorgestrel during phenytoin treatment in a woman with Norplant implants. Contraception. 1986;33:257–61. [PubMed: 3087695]
242.: Schindlbeck C, Janni W, Friese K. Failure of Implanon contraception in a patient taking carbamazepine for epilepsia. Arch Gynecol Obstet. 2006;273(4):255–6. [PubMed: 16208481]
243.: Shane-McWhorter L, Cerven JD, MacFarlane LL, Osborn C. Enhanced metabolism of levonorgestrel during phenobarbital treatment and resultant pregnancy. Pharmacotherapy. 1998;18:1360–4. [PubMed: 9855340]
244.: Reimers A, Helde G, Brodtkorb E. Ethinyl estradiol, not progestogens, reduces lamotrigine serum concentrations. Epilepsia. 2005;46(9):1414–7. [PubMed: 16146436]

2.7.3. Emergency contraceptive pills (ECPs)

EMERGENCY CONTRACEPTIVE PILLS (ECPs)
ECPs do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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	CATEGORY			CLARIFICATIONS/EVIDENCE
	COC	LNG	UPA ^†
^† recommendations reviewed for the MEC 5th edition, further details after this table * additional comments after this table	COC = combined oral contraceptive LNG = levonorgestrel contraceptive UPA = ulipristal acetate
PREGNANCY	NA	NA	NA	NA = not applicable Clarification: Although this method is not indicated for a woman with a known or suspected pregnancy, there is no known harm to the woman, the course of her pregnancy, or the fetus if ECPs are accidentally used.
BREASTFEEDING	1	1	2	Clarification: Breastfeeding is not recommended for 1 week after taking UPA since it is excreted in breast-milk. Breast-milk should be expressed and discarded during that time (1).
PAST ECTOPIC PREGNANCY	1	1	1
OBESITY ^†	1	1	1	Clarification: ECPs may be less effective among women with BMI ≥ 30 kg/m² than among women with BMI < 25 kg/m². Despite this, there are no safety concerns. Evidence: There is limited evidence from 1 study that suggests obese women with BMI ≥ 30 kg/m² experience an increased risk of pregnancy after use of LNG compared with women with BMI < 25 kg/m² (2). Two studies suggest obese women may also experience an increased risk of pregnancy after use of UPA compared with non-obese women, though this increase was not significant in 1 study (2, 3).
HISTORY OF SEVERE CARDIOVASCULAR DISEASE* (ischaemic heart disease, cerebrovascular attack, or other thromboembolic conditions)	2	2	2
MIGRAINE*	2	2	2
SEVERE LIVER DISEASE* (INCLUDING JAUNDICE)	2	2	2
CYP3A4 INDUCERS ^† (e.g. rifampicin, phenytoin, phenobarbital, carbamazepine, efavirenz, fosphenytoin, nevirapine, oxcarbazepine, primidone, rifabutin, St John's wort/hypericum perforatum)	1	1	1	Clarification: Strong CYP3A4 inducers may reduce the effectiveness of ECPs. Evidence: According to labelling information, rifampicin markedly decreases UPA levels by 90% or more which may decrease its efficacy (1, 4). Theoretical concerns therefore extend to use of other CYP3A4 inducers as well as to COC and LNG ECPs, which have similar metabolic pathways to UPA. A small pharmacokinetic study found that concomitant efavirenz use decreased LNG levels in women taking LNG ECP (0.75 mg) by 56% compared with LNG ECP alone (5).
REPEATED ECP USE	1	1	1	Clarification: Repeated ECP use is an indication that the woman requires further counselling on other contraceptive options. Frequently repeated ECP use may be harmful for women with conditions classified as Category 2, 3 or 4 for combined hormonal contraception (CHC) or POC use.
RAPE*	1	1	1

RECOMMENDATIONS REVIEWED FOR FIFTH EDITION

These recommendations were reviewed according to WHO requirements for guideline development, as part of the preparation of the Medical eligibility criteria for contraceptive use, fifth edition. The population, intervention, comparator, outcome (PICO) questions developed by the Guideline Development Group (GDG) and the databases searched to retrieve the evidence, which guided the preparation of systematic reviews, are described in greater detail in Part I of this document. Additionally, GRADE evidence profiles, the overall GRADE assessment of the quality of the evidence, summaries of the evidence supporting the recommendation(s), and other supplementary remarks from the GDG regarding the recommendations, are available in Part I.

ADDITIONAL COMMENTS

History of severe cardiovascular disease, migraine, and severe liver disease (including jaundice)

The duration of use of ECPs is less than that of regular use of COCs or POPs and thus would be expected to have a lower risk for adverse health outcomes.

Rape

There are no restrictions for the use of ECPs in cases of rape.

References

1.: ellaOne® ulipristal acetate. Abbreviated prescribing information (UK). London: HRA Pharma UK & Ireland Ltd; 2013. [23 October 2014]. http://www.ellaone.co.uk/hcp/abbreviated-prescribing-information-uk.
2.: Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011;84(4):363–7. [PubMed: 21920190]
3.: Moreau C, Trussell J. Results from pooled Phase III studies of ulipristal acetate for emergency contraception. Contraception. 2012;86(6):673–80. [PMC free article: PMC3766836] [PubMed: 22770793]
4.: Full prescribing information: ELLA (ulipristal acetate) tablet. Charleston (SC): Afaxys, Inc; Jun, 2014. [9 March 2015]. updated. http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/022474s004lbl.pdf.
5.: Carten ML, Kiser JJ, Kwara A, Mawhinney S, Cu-Uvin S. Pharmacokinetic interactions between the hormonal emergency contraception, levonorgestrel (Plan B), and Efavirenz. Infect Dis Obstet Gynecol. 2012;2012:137192. [PMC free article: PMC3299227] [PubMed: 22536010]

2.7.4. Intrauterine devices (IUDs)

INTRAUTERINE DEVICES (IUDs)

IUDs do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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	CATEGORY I = initiation, C = continuation				CLARIFICATIONS/EVIDENCE

	Cu-IUD		LNG-IUD

^† recommendations reviewed for the MEC 5th edition, further details after this table * additional comments after this table	Cu-IUD = copper-bearing IUD LNG-IUD = levonorgestrel-releasing IUD (20 µg/24 hours)
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 of serious pelvic infection and septic spontaneous abortion.

AGE					Evidence: Risks of pregnancy, infection and perforation are low among IUD users of any age. Heavy bleeding or removals for bleeding do not seem to be associated with age. Young women using Cu-IUDs may have an increased risk of expulsion compared with older Cu-IUD users (1–15).
a) Menarche to < 20 years	2		2
b) ≥ 20 years	1		1

PARITY					Evidence: Risks of pregnancy, infection, perforation and expulsion are low among all IUD users, and differences by parity may not be clinically meaningful. Data do not suggest an increased delay in return to fertility for nulliparous IUD users (1, 3, 7–10).
a) Nulliparous	2		2
b) Parous	1		1

POSTPARTUM ^† (breastfeeding or non-breastfeeding women, including caesarean section)
a) < 48 hours including insertion immediately after delivery of the placenta					Evidence: Immediate postpartum Cu-IUD insertion, particularly when insertion occurs immediately after delivery of the placenta, is associated with lower expulsion rates than delayed postpartum insertion. Additionally, post-placental placement at the time of caesarean section has lower expulsion rates than post-placental vaginal insertions. Insertion complications of perforation and infection are not increased by IUD placement at any time during the postpartum period (16–29). One randomized controlled trial found that immediate insertion of the LNG-IUD was associated with decreased breastfeeding duration compared with delayed insertion (30). Two other randomized controlled trials assessing early vs delayed initiation of progestogen-only contraceptives failed to show a difference in breastfeeding outcomes (31, 32). In other studies, initiation of LNG-IUD at 4 weeks postpartum or later demonstrated no detrimental effect on breastfeeding outcomes (33–35).
i) breastfeeding	1		2
ii) non-breastfeeding	1		1
b) ≥ 48 hours to < 4 weeks	3		3
c) ≥ 4 weeks	1		1
d) Puerperal sepsis	4		4

POST-ABORTION*
a) First trimester	1		1		Clarification: IUDs can be inserted immediately after first-trimester, spontaneous or induced abortion. Evidence: There was no difference in risk of complications for immediate vs delayed insertion of an IUD after abortion. Expulsion was greater when an IUD was inserted following a second-trimester abortion vs a first-trimester abortion. There were no differences in safety or expulsions for post-abortion insertion of an LNG-IUD compared with a Cu-IUD (36–48).
b) Second trimester	2		2
c) Immediate post-septic abortion	4		4

PAST ECTOPIC PREGNANCY*	1		1

HISTORY OF PELVIC SURGERY (see postpartum, including caesarean section)	1		1

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

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

BLOOD PRESSURE MEASUREMENT UNAVAILABLE	NA		NA		NA = not applicable Clarification: While a blood pressure measurement may be appropriate for good preventive health care, it is not materially related to safe and effective IUD use. Women should not be denied use of IUDs 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		2

HYPERTENSION* For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, the risk of cardiovascular disease may increase substantially. A single reading of blood pressure level is not sufficient to classify a woman as hypertensive.

a) History of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy)	1		2
b) Adequately controlled hypertension, where blood pressure CAN be evaluated	1		1
c) Elevated blood pressure levels (properly taken measurements)
i) systolic 140–159 or diastolic 90–99 mm Hg	1		1
ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg	1		2
d) Vascular disease	1		2

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

DEEP VEIN THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)*
a) History of DVT/PE	1		2
b) Acute DVT/PE	1		3		Evidence: Although evidence on the risk of venous thrombosis with the use of progestogen-only contraceptives (POCs) is inconsistent, any small increased risk is substantially less than that with combined oral contraceptives (COCs) (49–51).
c) DVT/PE and established on anticoagulant therapy	1		2		Evidence: Although evidence on the risk of venous thrombosis with the use of POCs is inconsistent, any small increased risk is substantially less than that with COCs (49–51). Limited evidence indicates that insertion of the LNG-IUD does not pose major bleeding risks in women on chronic anticoagulant therapy (52–54).
d) Family history (first-degree relatives)	1		1
e) Major surgery
i) with prolonged immobilization	1		2
ii) without prolonged immobilization	1		1
f) Minor surgery without immobilization	1		1

KNOWN THROMBOGENIC MUTATIONS (e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)	1		2		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
b) Superficial venous thrombosis	1		1

CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE*	1		I	C

			2	3

STROKE* (history of cerebrovascular accident)	1		2

KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORS	1		2		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
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)	2		2		Clarification: Prophylactic antibiotics to prevent endocarditis are advised for insertion.

RHEUMATIC DISEASES

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) People with SLE are at increased risk of ischaemic heart disease, stroke and venous thromboembolism. Categories assigned to such conditions in the Medical eligibility criteria for contraceptive use should be the same for women with SLE who present with these conditions. For all categories of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors. Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives (54–71).

a) Positive (or unknown) antiphospholipid antibodies	I	C			Evidence: Antiphospholipid antibodies are associated with a higher risk for both arterial and venous thrombosis (72, 73).

	1	1	3
b) Severe thrombocytopenia	3	2	2		Clarification: Severe thrombocytopenia increases the risk of bleeding. The category should be assessed according to the severity of the thrombocytopenia and its clinical manifestations. In women with very severe thrombocytopenia who are at risk for spontaneous bleeding, consultation with a specialist and certain pretreatments may be warranted. Evidence: The LNG-IUD may be a useful treatment for menorrhagia in women with severe thrombocytopenia (54).
c) Immunosuppressive treatment	2	1	2
d) None of the above	1	1	2

NEUROLOGIC CONDITIONS

HEADACHES*			I	C	Clarification: Any new headaches or marked changes in headaches should be evaluated.
HEADACHES*
a) Non-migrainous (mild or severe)	1		1	1
b) Migraine
i) without aura
age < 35 years	1		2	2
age > 35 years	1		2	2
ii) with aura, at any age	1		2	3

EPILEPSY	1		1

DEPRESSIVE DISORDERS

DEPRESSIVE DISORDERS	1		1		Clarification: The classification is based on data for women with selected depressive disorders. No data on bipolar disorder or postpartum depression were available. There is a potential for drug interactions between certain antidepressant medications and hormonal contraceptives.

REPRODUCTIVE TRACT INFECTIONS AND DISORDERS

VAGINAL BLEEDING PATTERNS			I	C
VAGINAL BLEEDING PATTERNS
a) Irregular pattern without heavy bleeding	1		1	1
b) Heavy or prolonged bleeding (includes regular and irregular patterns)	2		1	2	Clarification: Unusually heavy bleeding should raise the suspicion of a serious underlying condition. Evidence: Evidence from studies examining the treatment effects of the LNG-IUD among women with heavy or prolonged bleeding reported no increase in adverse effects and found the LNG-IUD to be beneficial in the treatment of menorrhagia (74–81).

UNEXPLAINED VAGINAL BLEEDING (suspicious for serious condition)	I	C	I	C	Clarification: If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation. There is no need to remove the IUD before evaluation.

Before evaluation	4	2	4	2

ENDOMETRIOSIS	2		1		Evidence: LNG-IUD use among women with endometriosis decreased dysmenorrhoea, pelvic pain and dyspareunia (82–86).

BENIGN OVARIAN TUMOURS (including cysts)	1		1

SEVERE DYSMENORRHOEA*	2		1

GESTATIONAL C TROPHOBLASTIC DISEASE					Evidence: Limited evidence suggests that women using an IUD following uterine evacuation for a molar pregnancy are not at increased risk of developing post-molar trophoblastic disease when compared to women using other methods of contraception (87–90).
a) Decreasing or undetectable β-hCG levels	3		3
b) Persistently elevated β-hCG levels or malignant disease	4		4

CERVICAL ECTROPION	1		1

CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)*	1		2

CERVICAL CANCER* (awaiting treatment)	I	C	I	C

	4	2	4	2

BREAST DISEASE*
a) Undiagnosed mass	1		2
b) Benign breast disease	1		1
c) Family history of cancer	1		1
d) Breast cancer
i) current	1		4
ii) past and no evidence of current disease for 5 years	1		3

ENDOMETRIAL CANCER*	I	C	I	C

	4	2	4	2

OVARIAN CANCER*	I	C	I	C

	3	2	3	2

UTERINE FIBROIDS*					Evidence: Among women with fibroids, there were no adverse health events with LNG-IUD use, and there was a decrease in symptoms and size of fibroids for some women (91–97).
a) Without distortion of the uterine cavity	1		1
b) With distortion of the uterine cavity	4		4

ANATOMICAL ABNORMALITIES*
a) Distorted uterine cavity (any congenital or acquired uterine abnormality distorting the uterine cavity in a manner that is incompatible with IUD insertion	4		4
b) Other abnormalities (including cervical stenosis or cervical lacerations) not distorting the uterine cavity or interfering with IUD insertion	2		2

PELVIC INFLAMMATORY DISEASE (PID)*
a) Past PID (assuming no current risk factors for STIs)	I	C	I	C
a) Past PID (assuming no current risk factors for STIs)
i) with subsequent pregnancy	1	1	1	1
ii) without subsequent pregnancy	2	2	2	2
b) PID – current	4	2	4	2	Clarification for continuation: Treat the PID using appropriate antibiotics. There is usually no need for removal of the IUD if the client wishes to continue its use (see WHO publication Selected practice recommendations for contraceptive use)¹. Continued use of an IUD depends on the woman's informed choice and her current risk factors for STIs and PID. Evidence: Among IUD users treated for PID, there was no difference in clinical course if the IUD was removed or left in place (98–100).

STIs ^†	I	C	I	C
STIs ^†
a) Current purulent cervicitis or chlamydial infection or gonorrhoea	4	2	4	2	Clarification for continuation: Treat the STI using appropriate antibiotics. There is usually no need for removal of the IUD if the client wishes to continue its use. Continued use of an IUD depends on the woman's informed choice and her current risk factors for STIs and PID. Evidence: There is no evidence regarding whether IUD insertion among women with STIs increases the risk of PID compared with no IUD insertion. Among women who have an IUD inserted, the absolute risk of subsequent PID was low among women with STI at the time of insertion but greater than among women with no STI at the time of IUD insertion (101–108).
b) Other STIs (excluding HIV and hepatitis)	2	2	2	2
c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)	2	2	2	2
d) Increased risk of STIs	2/3	2	2/3	2	Clarification: IUD insertion may further increase the risk of PID among women at increased risk of STIs, although limited evidence suggests that this risk is low. Current algorithms for determining increased risk of STIs have poor predictive value. Risk of STIs varies by individual behaviour and local STI prevalence. Therefore, while many women at increased risk of STIs can generally have an IUD inserted, some women at increased risk (very high individual likelihood) of STIs should generally not have an IUD inserted until appropriate testing and treatment occur. Evidence: Using an algorithm to classify STI risk status among IUD users, 1 study reported that 11% of high-STI-risk women experienced IUD-related complications compared with 5% of those not classified as high risk (104). In another small study, the incidence of PID after IUD insertion was low (2.2%) in a cohort of women considered to be high-risk based on high background rates of STIs in the general population (109).

HIV/AIDS ^†

HIGH RISK OF HIV	I	C	I	C	Evidence: Among women at risk for HIV, Cu-IUD use did not increase risk of HIV acquisition (110–120).

	2	2	2	2

ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE (WHO STAGE 1 OR 2)	2	2	2	2	Evidence: Among IUD users, limited evidence shows no increased risk of overall complications or infectious complications when comparing women living with HIV to women not living with HIV. IUD use did not adversely affect progression of HIV when compared to hormonal contraceptive use among women living with HIV. Furthermore, IUD use among women living with HIV was not associated with increased risk of sexual transmission from female to male partners (121–128). One study found no difference in initiation of antiretroviral therapy (ART) or CD4 count between users and non-users of the LNG-IUD (129).

SEVERE OR ADVANCED HIV CLINICAL DISEASE (WHO STAGE 3 OR 4)	3	2	3	2	Clarification for continuation: IUD users with severe or advanced HIV clinical disease should be closely monitored for pelvic infection. Evidence: One study found no difference in ART initiation or CD4 count between users and non-users of the LNG-IUD (129).

OTHER INFECTIONS

SCHISTOSOMIASIS
a) Uncomplicated	1		1
b) Fibrosis of the liver (if severe, see cirrhosis)	1		1

TUBERCULOSIS*	I	C	I	C
TUBERCULOSIS*
a) Non-pelvic	1	1	1	1
a) Pelvic	4	3	4	3

MALARIA	1		1

ENDOCRINE CONDITIONS

DIABETES
a) History of gestational disease	1		1
b) Non-vascular disease
i) non-insulin-dependent	1		2		Evidence: Limited evidence on the use of the LNG-IUD among women with insulin- or non-insulin-dependent diabetes suggests that these methods have little effect on short-term or long-term diabetes control (e.g. HbA1c levels), haemostatic markers or lipid profile (130, 131).
ii) insulin-dependent	1		2
c) Nephropathy/retinopathy/neuropathy	1		2
d) Other vascular disease or diabetes of > 20 years' duration	1		2

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

GASTROINTESTINAL CONDITIONS

GALL BLADDER DISEASE
a) Symptomatic
i) treated by cholecystectomy	1		2
ii) medically treated	1		2
iii) current	1		2
b) Asymptomatic	1		2

HISTORY OF CHOLESTASIS*
a) Pregnancy-related	1		1
b) Past-COC related	1		2

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

CIRRHOSIS
a) Mild (compensated)	1		1
b) Severe (decompensated)	1		3

LIVER TUMOURS*
a) Benign
i) focal nodular hyperplasia	1		2
ii) hepatocellular adenoma	1		3
b) Malignant (hepatoma)	1		3

ANAEMIAS

THALASSAEMIA*	2		1

SICKLE CELL DISEASE*	2		1

IRON-DEFICIENCY ANAEMIA*	2		1

DRUG INTERACTIONS

ANTIRETROVIRAL THERAPY (ART)					Clarification: There is no known interaction between ART and IUD use. However, severe or advanced HIV clinical disease (WHO stage 3 or 4) as a condition is classified as Category 3 for initiation and Category 2 for continuation. Asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) is classified as Category 2 for both initiation and continuation.
a) Nucleoside reverse transcriptase inhibitors (NRTIs)	I	C	I	C
a) Nucleoside reverse transcriptase inhibitors (NRTIs)
Abacavir (ABC)	2/3	2	2/3	2
Tenofovir (TDF)	2/3	2	2/3	2
Zidovudine (AZT)	2/3	2	2/3	2
Lamivudine (3TC)	2/3	2	2/3	2
Didanosine (DDI)	2/3	2	2/3	2
Emtricitabine (FTC)	2/3	2	2/3	2
Stavudine (D4T)	2/3	2	2/3	2
b) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)	I	C	I	C
b) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Efavirenz (EFV)	2/3	2	2/3	2
Etravirine (ETR)	2/3	2	2/3	2
Nevirapine (NVP)	2/3	2	2/3	2
Rilpivirine (RPV)	2/3	2	2/3	2
c) Protease inhibitors (PIs)
Ritonavir-boosted atazanavir (ATV/r)	2/3	2	2/3	2
Ritonavir-boosted lopinavir (LPV/r)	2/3	2	2/3	2
Ritonavir-boosted darunavir (DRV/r)	2/3	2	2/3	2
Ritonavir (RTV)	2/3	2	2/3	2
d) Integrase inhibitors
Raltegravir (RAL)	2/3	2	2/3	2

ANTICONVULSANT THERAPY
a) Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)	1		1		Evidence: Limited evidence suggests that use of certain anticonvulsants does not interfere with the contraceptive effectiveness of the LNG-IUD (132).
b) Lamotrigine	1		1		Evidence: No drug interactions have been reported among women with epilepsy taking lamotrigine and using the LNG-IUD (133).

ANTIMICROBIAL THERAPY
a) Broad-spectrum antibiotics	1		1
b) Antifungals	1		1
c) Antiparasitics	1		1
d) Rifampicin or rifabutin therapy	1		1		Evidence: One cross-sectional survey found that rifabutin had no impact on the effectiveness of LNG-IUD (132).

RECOMMENDATIONS REVIEWED FOR FIFTH EDITION

These recommendations were reviewed according to WHO requirements for guideline development, as part of the preparation of the Medical eligibility criteria for contraceptive use, fifth edition. The population, intervention, comparator, outcome (PICO) questions developed by the Guideline Development Group (GDG) and the databases searched to retrieve the evidence, which guided the preparation of systematic reviews, are described in greater detail in Part I of this document. Additionally, GRADE evidence profiles, the overall GRADE assessment of the quality of the evidence, summaries of the evidence supporting the recommendation(s), and other supplementary remarks from the GDG regarding the recommendations, are available in Part I.

ADDITIONAL COMMENTS

Puerperal sepsis

Insertion of an iud may substantially worsen the condition.

Post-abortion

Immediate post-septic abortion: insertion of an iud may substantially worsen the condition.

Past ectopic pregnancy

The absolute risk of ectopic pregnancy is extremely low due to the high effectiveness of iuds. However, when a woman becomes pregnant during iud use, the relative likelihood of ectopic pregnancy is greatly increased.

Hypertension

There is theoretical concern about the effect of levonorgestrel (LNG) on lipids. There is no restriction for copper-bearing IUDs (Cu-IUDs).

Deep vein thrombosis/pulmonary embolism

The LNG-IUD may be a useful treatment for menorrhagia in women on chronic anticoagulation therapy.

Current and history of ischaemic heart disease

There is theoretical concern about the effect of LNG on lipids. There is no restriction for Cu-IUDs.

Stroke

There is theoretical concern about the effect of LNG on lipids. There is no restriction for Cu-IUDs.

Headaches

Aura is a specific focal neurologic symptom. For more information on this and other diagnostic criteria, see: headache classification subcommittee of the international headache society. The international classification of headache dis-orders, 2nd edition. Cephalalgia. 2004;24(Suppl 1):1–150.¹⁴

Severe dysmenorrhoea

Dysmenorrhoea may intensify with Cu-IUD use. LNG-IUD use has been associated with reduction of dysmenorrhoea.

Cervial intraepithelial neoplasia (CIN)

There is some theoretical concern that LNG-IUDs may hasten the progression of CIN.

Cervical cancer (awaiting treatment)

There is concern about the increased risk of infection and bleeding at insertion. The IUD will likely need to be removed at the time of treatment but, until then, the woman is at risk of pregnancy.

Breast disease

Breast cancer: breast cancer is a hormonally sensitive tumour. Concerns about progression of the disease may be less with lng-iuds than with combined oral contraceptives (cocs) or higher-dose progestogen-only contraceptives (POCs).

Endometrial cancer

There is concern about the increased risk of infection, perforation and bleeding at insertion. The iud will likely need to be removed at the time of treatment but, until then, the woman is at risk of pregnancy.

Ovarian cancer

The IUD will likely need to be removed at the time of treatment but, until then, the woman is at risk of pregnancy.

Uterine fibroids

Without distortion of the uterine cavity: Women with heavy or prolonged bleeding should be assigned the category for that condition.

With distortion of the uterine cavity: Pre-existing uterine fibroids that distort the uterine cavity may be incompatible with insertion and proper placement of the IUD.

Anatomical abnormalities

Distorted uterine cavity: In the presence of an anatomic abnormality that distorts the uterine cavity, proper IUD placement may not be possible.

Pelvic inflammatory disease (PID)

IUDs do not protect against STI/HIV/PID. In women at low risk of STIs, IUD insertion poses little risk of PID. Current risk of STIs and desire for future pregnancy are relevant considerations.

Tuberculosis

Pelvic: Insertion of an IUD may substantially worsen the condition.

History of cholestasis

There is concern that a history of cholestasis related to combined hormonal contraceptives (CHCs) may predict subsequent cholestasis with LNG use. Whether there is any risk with use of an LNG-IUD is unclear.

Liver tumours

There is no evidence regarding hormonal contraceptive use among women with hepatocellular adenoma. Given that COC use in healthy women is associated with development and growth of hepatocellular adenoma, it is not known whether other hormonal contraceptives have similar effects.

Thalassaemia, sickle cell disease, iron-deficiency anaemia

There is concern about a risk of increased blood loss with Cu-IUDs.

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105.: Pap-Akeson M, Solheim F, Thorbert G, Akerlund M. Genital tract infections associated with the intrauterine contraceptive device can be reduced by inserting the threads into the uterine cavity. Br J Obstet Gynaecol. 1992;99(8):676–9. [PubMed: 1390474]
106.: Sinei SK, Schulz KF, Lamptey PR, Grimes DA, Mati JK, Rosenthal SM, et al. Preventing IUCD-related pelvic infection: the efficacy of prophylactic doxycycline at insertion. Br J Obstet Gynaecol. 1990;97(5):412–9. [PubMed: 2196934]
107.: Skjeldestad FE, Halvorsen LE, Kahn H, Nordbo SA, Saake K. IUD users in Norway are at low risk for genital C. trachomatis infection. Contraception. 1996;54(4):209–12. [PubMed: 8922873]
108.: Walsh TL, Bernstein GS, Grimes DA, Frezieres R, Bernstein L, Coulson AH. Effect of prophylactic antibiotics on morbidity associated with IUD insertion: results of a pilot randomized controlled trial. IUD Study Group. Contraception. 1994;50(4):319–27. [PubMed: 7813220]
109.: Cropsey KL, Matthews C, Campbel S, Ivey S, Adawadkar S. Long-term, reversible contraception use among high-risk women treated in a university-based gynecology clinic: comparison between IUD and depo-provera. J Womens Health (Larchmt). 2010;19(2):349–53. [PubMed: 20109106]
110.: Carael M, Van de Perre PH, Lepage PH, Allen S, Nsengumuremyi F, Van Goethem C, et al. Human immunodeficiency virus transmission among heterosexual couples in Central Africa. AIDS. 1988;2(3):201–5. [PubMed: 3134914]
111.: European Study Group on Heterosexual Transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ. 1992;304(6830):809–13. [PMC free article: PMC1881672] [PubMed: 1392708]
112.: Mann JM, Nzilambi N, Piot P, Bosenge N, Kalala M, Francis H, et al. HIV infection and associated risk factors in female prostitutes in Kinshasa, Zaire. AIDS. 1998;2:249–54. [PubMed: 3140830]
113.: Kapiga SH, Lyamuya EF, Lwihula GK, Hunter DJ. The incidence of HIV infection among women using family planning methods in Dar es Salaam, Tanzania. AIDS. 1998;12(1):75–84. [PubMed: 9456257]
114.: Kapiga SH, Shao JF, Lwihula GK, Hunter DJ. Risk factors for HIV infection among women in Dar-es-Salaam, Tanzania. J Acquir Immune Defic Syndr. 1994;7(3):301–9. [PubMed: 8106970]
115.: Martin HL Jr., Nyange PM, Richardson BA, Lavreys L, Mandaliya K, Jackson DJ, et al. Hormonal contraception, sexually transmitted diseases, and risk of heterosexual transmission of human immunodeficiency virus type 1. J Infect Dis. 1998;178(4):1053–9. [PubMed: 9806034]
116.: Mati JK, Hunter DJ, Maggwa BN, Tukei PM. Contraceptive use and the risk of HIV infection in Nairobi, Kenya. Int J Gynaecol Obstet. 1995;48(1):61–7. [PubMed: 7698385]
117.: Nicolosi A, Correa Leite ML, Musicco M, Arici C, Gavazzeni G, Lazzarin A. The efficiency of male-to-female and female-to-male sexual transmission of the human immunodeficiency virus: a study of 730 stable couples. Italian Study Group on HIV Heterosexual Transmission. Epidemiology. 1994;5(6):570–5. [comment] [PubMed: 7841237]
118.: Plourde PJ, Plummer FA, Pepin J, Agoki E, Moss G, Ombette J, et al. Human immunodeficiency virus type 1 infection in women attending a sexually transmitted diseases clinic in Kenya. J Infect Dis. 1992;166(1):86–92. [comment] [PubMed: 1607711]
119.: Sinei SK, Fortney JA, Kigondu CS, Feldblum PJ, Kuyoh M, Allen MY, et al. Contraceptive use and HIV infection in Kenyan family planning clinic attenders. Int J STD AIDS. 1996;7(1):65–70. [PubMed: 8652717]
120.: Spence MR, Robbins SM, Polansky M, Schable CA. Seroprevalence of human immunodeficiency virus type I (HIV-1) antibodies in a family-planning population. Sex Transm Dis. 1991;18(3):143–5. [PubMed: 1948510]
121.: Mostad SB, Overbaugh J, DeVange DM, Welch MJ, Chohan B, Mandaliya K, et al. Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina. Lancet. 1997;350:922–7. [PubMed: 9314871]
122.: Sinei SK, Morrison CS, Sekadde-Kigondu C, Allen M, Kokonya D. Complications of use of intrauterine devices among HIV-1 infected women. Lancet. 1998;351:1238–41. [PubMed: 9643743]
123.: Richardson BA, Morrison CS, Sekadde-Kigondu C, Sinei SK, Overbaugh J, Panteleeff DD, et al. Effect of intrauterine device use on cervical shedding of HIV-1 DNA. AIDS. 1999;13:2091–7. [PubMed: 10546862]
124.: Kovacs A, Wasserman SS, Burns D, Wright DJ, Cohn J, Landay A, et al. Determinants of HIV-1 shedding in the genital tract of women. Lancet. 2001;358:1593–601. [PubMed: 11716886]
125.: Morrison CS, Sekadde-Kigondu C, Sinei SK, Weiner DH, Kwok C, Kokonya D. Is the intrauterine device appropriate contraception for HIV-1 infected women? BJOG. 2001;108:784–90. [PubMed: 11510700]
126.: Heikinheimo O, Lehtovirta P, Suni J, Paavonen J. The levonorgestrel-releasing intrauterine system (LNG-IUS) in HIV-infected women – effects on bleeding patterns, ovarian function and genital shedding of HIV. Hum Reprod. 2006;21:2857–61. [PubMed: 16880227]
127.: Stringer EM, Kaseba C, Levy J, Sinkala M, Goldenberg RL, Chi BH, et al. A randomized trial of the intrauterine contraceptive device vs hormonal contraception in women who are infected with the human immunodeficiency virus. Am J Obstet Gynecol. 2007;197:144.e1–8. [PMC free article: PMC2730754] [PubMed: 17689627]
128.: Lehtovirta P, Paavonen J, Heikinheimo O. Experience with the levonorgestrel-releasing intrauterine system among HIV-infected women. Contraception. 2007;75:37–9. [PubMed: 17161122]
129.: World Health Organization; Task Force for Epidemiological Research on Reproductive Health; Special Programme of Research, Development, and Research Training in Human Reproduction. Progestogen-only contraceptives during lactation: II. Infant development. Contraception. 1994;50(1):55–68. [PubMed: 7924322]
130.: Rogovskaya S, Rivera R, Grimes DA, Chen P-L, Pierre-Louis B, Prilepskaya V, et al. Effect of a levonorgestrel intrauterine system on women with type 1 diabetes: a randomized trial. Obstet Gynecol. 2005;105:811–5. [PubMed: 15802410]
131.: Grigoryan OR, Grodnitskaya EE, Andreeva EN, Shestakova MV, Melnichenko GA, Dedov II. Contraception in perimenopausal women with diabetes mellitus. Gynecol Endocrinol. 2006;22(4):198–206. [PubMed: 16723306]
132.: Bounds W, Guillebaud J. Observational series on women using the contraceptive Mirena concurrently with anti-epileptic and other enzyme-inducing drugs. J Fam Plann Reprod Health Care. 2002;28:78–80. [PubMed: 12396777]
133.: Reimers A, Helde G, Brodtkorb E. Ethinyl estradiol, not progestogens, reduces lamotrigine serum concentrations. Epilepsia. 2005;46(9):1414–7. [PubMed: 16146436]

2.7.5. Copper-bearing IUD for emergency contraception (E-IUD)

Use of a copper-bearing IUD (Cu-IUD) for emergency contraception (E-IUD) is highly effective for preventing pregnancy. For this purpose, a Cu-IUD can be inserted within five days of unprotected intercourse. However, when the time of ovulation can be estimated, the Cu-IUD can be inserted beyond five days after intercourse, if necessary, as long as the insertion does not occur more than five days after ovulation.

The eligibility criteria for general Cu-IUD insertion also apply for the insertion of E-IUDs (see section 2.7.4 on IUDs, pp. 175–188).

COPPER IUD FOR EMERGENCY CONTRACEPTION (E-IUD)

IUDs for emergency contraception do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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	CLARIFICATIONS/EVIDENCE
PREGNANCY	4	Clarification: The IUD is not indicated during pregnancy and should not be used because of the risk of serious pelvic infection and septic spontaneous abortion.

RAPE*
a) High risk of STI	3
b) Low risk of STI	1

ADDITIONAL COMMENTS

Rape

IUDs do not protect against STI/HIV or pelvic inflammatory disease (PID). Among women with chlamydial infection or gonorrhoea, the potential increased risk of PID with IUD insertion should be avoided. The concern is less for other STIs.

2.7.6. Progesterone-releasing vaginal ring (PVR) for breastfeeding women

The progesterone-releasing vaginal ring (PVR) is a contraceptive method for women who are actively breastfeeding at least four times a day. It consists of a flexible ring that releases 10 µg/day of progesterone. During use, average plasma concentrations of 20 nmol/L are achieved, which are similar to those detected in the average luteal phase in normal fertile women. The PVR is worn continuously for three-month periods (approximately 90 days) and can be initiated at six weeks after childbirth. Use of the PVR during breastfeeding requires replacing the used ring with a new ring at three-month intervals (± two weeks). The mechanism of contraceptive action of the PVR is through the inhibition of ovulation (1, 2).

PROGESTERONE-RELEASING VAGINAL RING FOR BREASTFEEDING WOMEN
PVRs do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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 ^† recommendations reviewed for the MEC 5th edition, further details after this table	CATEGORY	CLARIFICATIONS/EVIDENCE
PREGNANCY	NA	NA = not applicable Clarification: Use of PVRs is not required. There is no known harm to the woman, the course of her pregnancy, or the fetus if PVRs are accidentally used during pregnancy.
BREASTFEEDING ≥ 4 WEEKS POSTPARTUM †	1	Clarification: The woman must be actively breastfeeding (i.e. at least 4 breastfeeding episodes per day) during PVR use to maintain efficacy. Evidence: No differences were observed between various measures of breastfeeding performance among PVR users compared with users of non-hormonal or progestogen-only (synthetic progesterone) contraceptives during 12 months of observation (3–8). No statistically significant differences in infant weight gain were observed among PVR users compared with women using a non-hormonal or progestogen-only contraceptives (5, 7, 9), and similar patterns of infant weight gain were observed in another study that compared PVR and IUD users (8). One study reported no significant difference in infant health (8).

RECOMMENDATIONS REVIEWED FOR FIFTH EDITION

These recommendations were reviewed according to WHO requirements for guideline development, as part of the preparation of the Medical eligibility criteria for contraceptive use, fifth edition. The population, intervention, comparator, outcome (PICO) questions developed by the Guideline Development Group (GDG) and the databases searched to retrieve the evidence, which guided the preparation of systematic reviews, are described in greater detail in Part I of this document. Additionally, GRADE evidence profiles, the overall GRADE assessment of the quality of the evidence, summaries of the evidence supporting the recommendation(s), and other supplementary remarks from the GDG regarding the recommendations, are available in Part I.

References

1.: Diaz S, Aravena R, Cardenas H, Casado ME, Miranda P, Schiappacasse V, et al. Contraceptive efficacy of lactational amenorrhea in urban Chilean women. Contraception. 1991;43(4):335–52. [PubMed: 1855380]
2.: Nath A, Sitruk-Ware R. Progesterone vaginal ring for contraceptive use during lactation. Contraception. 2010;82(5):428–34. [PubMed: 20933116]
3.: Diaz S, Jackanicz TM, Herreros C, Juez G, Peralta O, Miranda P, et al. Fertility regulation in nursing women: VIII. Progesterone plasma levels and contraceptive efficacy of a progesterone-releasing vaginal ring. Contraception. 1985;32(6):603–22. [PubMed: 3912105]
4.: Diaz S, Reyes MV, Zepeda A, Gonzalez GB, Lopez JM, Campino C, et al. Norplant® implants and progesterone vaginal rings do not affect maternal bone turnover and density during lactation and after weaning. Human reproduction (Oxford, England). 1999;14(10):2499–505. [PubMed: 10527977]
5.: Diaz S, Zepeda A, Maturana X, Reyes MV, Miranda P, Casado ME, et al. Fertility regulation in nursing women. IX. Contraceptive performance, duration of lactation, infant growth, and bleeding patterns during use of progesterone vaginal rings, progestin-only pills, Norplant implants, and Copper T 380-A intrauterine devices. Contraception. 1997;56(4):223–32. [PubMed: 9408703]
6.: Massai R, Miranda P, Valdes P, Lavin P, Zepeda A, Casado ME, et al. Preregistration study on the safety and contraceptive efficacy of a progesterone-releasing vaginal ring in Chilean nursing women. Contraception. 1999;60(1):9–14. [PubMed: 10549447]
7.: Shaaban MM. Contraception with progestogens and progesterone during lactation. J Steroid Biochem Mol Biol. 1991;40(4–6):705–10. [PubMed: 1835650]
8.: Sivin I, Diaz S, Croxatto HB, Miranda P, Shaaban M, Sayed EH, et al. Contraceptives for lactating women: a comparative trial of a progesterone-releasing vaginal ring and the copper T 380A IUD. Contraception. 1997;55(4):225–32. [PubMed: 9179454]
9.: Chen JH, Wu SC, Shao WQ, Zou MH, Hu J, Cong L, et al. The comparative trial of TCu 380A IUD and progesterone-releasing vaginal ring used by lactating women. Contraception. 1998;57(6):371–9. [PubMed: 9693396]

2.7.7. Barrier methods (BARR)

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	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.

: ß-hCG: beta-human chorionic gonadotropin; BMI: body mass index; COC: combined oral contraceptive; PID: pelvic inflammatory disease; STI: sexually transmitted infections.

ADDITIONAL COMMENTS

Obesity

Severe obesity may make diaphragm and cap placement difficult.

Valvular heart disease

Risk of urinary tract infection with the diaphragm may increase in a client with subacute bacterial endocarditis.

Cervical cancer (awaiting treatment)

Repeated and high-dose use of nonoxynol-9 can cause vaginal and cervical irritation or abrasions.

High risk of HIV

Category 4 for diaphragm use is assigned due to concerns about the spermicide, not the diaphragm.

Asymptomatic or mild HIV clinical disease (WHO stage 1 or 2)

Use of spermicides and/or diaphragms (with spermicide) can disrupt the cervical mucosa, which may lead to increased viral shedding and HIV transmission to uninfected sexual partners.

Severe or advanced hiv clinical disease (WHO stage 3 or 4)

Use of spermicides and/or diaphragms (with spermicide) can disrupt the cervical mucosa, which may lead to increased viral shedding and HIV transmission to uninfected sexual partners.

History of toxic shock syndrome

Toxic shock syndrome has been reported in association with diaphragm use.

Urinary tract infection

There is a potential increased risk of urinary tract infection with diaphragms and spermicides.

References

1.: Wilkinson D, Ramjee G, Tholandi M, Rutherford G. Nonoxynol-9 for preventing vaginal acquisition of HIV infection by women from men. Cochrane Database Syst Rev. 2002;4 (CD003936) [PMC free article: PMC8407148] [PubMed: 12519622]

2.7.8. Fertility awareness-based (FAB) methods

Fertility awareness-based (FAB) methods of family planning involve identification of the fertile days of the menstrual cycle, whether by observing fertility signs such as cervical secretions and basal body temperature (i.e. symptoms-based methods) or by monitoring cycle days (calendar-based methods).

Symptom-based methods

Symptoms-based methods include the cervical mucus method (also called the ovulation method) and the TwoDay Method, which are both based on the evaluation of cervical mucus, and the sympto-thermal method, which is a double-check method based on evaluation of cervical mucus to determine the first fertile day and evaluation of cervical mucus and temperature to determine the last fertile day.

Calendar-based methods

Calendar-based methods include the Calendar Rhythm Method and the Standard Days Method, which avoids intercourse on cycle days 8–19.

FAB methods can be used in combination with abstinence or barrier methods during the fertile time. If barrier methods are used, refer to section 2.7.7 on barrier methods (BARR), see pp. 200–211.

There are no medical conditions that become worse because of use of FAB methods. In general, these methods can be provided without concern for health effects to people who choose them; therefore, the 1–4 recommendation categories do not apply to these methods. However, there are a number of conditions that make their use more complex. The existence of these conditions suggests that (i) use of FAB methods should be delayed until the condition is corrected or resolved, or (ii) use of FAB methods will require special counselling for the client, and a more highly trained provider is generally necessary to ensure correct use. The need for caution or delay in the use of these FAB methods is noted in the categories assigned in the table, per condition.

FERTILITY AWARENESS-BASED (FAB) METHODS

Fertility awareness-based (FAB) methods do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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	CATEGORY^a A = accept, C = caution, D = delay		CLARIFICATIONS/EVIDENCE

	SYM	CAL

* additional comments after this table	SYM = symptoms-based method CAL = calendar-based method
Women with conditions that make pregnancy an unacceptable risk should be advised that FAB methods for pregnancy prevention may not be appropriate for them because of their relatively higher typical-use failure rates.

PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY

PREGNANCY	NA	NA	NA = not applicable Clarification: FAB methods are not relevant during pregnancy.

LIFE STAGE			Clarification: Menstrual irregularities are common in post-menarche and perimenopause and may complicate the use of FAB methods.
a) Post-menarche	C	C
b) Perimenopause	C	C

BREASTFEEDING*
a) < 6 weeks postpartum	D	D
b) ≥ 6 weeks	C	D
c) After menses begins	C	C

POSTPARTUM* (in non-breastfeeding women)
a) < 4 weeks	D	D
b) ≥ 4 weeks	A	D

POST-ABORTION*	C	D

REPRODUCTIVE TRACT INFECTIONS AND DISORDERS

IRREGULAR VAGINAL BLEEDING*	D	D

VAGINAL DISCHARGE*	D	A

OTHER

USE OF DRUGS THAT AFFECT CYCLE REGULARITY, HORMONES AND/OR FERTILITY SIGNS*	C/D	C/D

DISEASES THAT ELEVATE BODY TEMPERATURE*
a) Chronic diseases	C	A
b) Acute diseases	D	A

a

Further explanation of A, C and D categories:

A = accept: There is no medical reason to deny the particular FAB method to a woman in this circumstance.
C = caution: The method is normally provided in a routine setting, but with extra preparation and precautions. For FAB methods, this usually means that special counselling may be needed to ensure correct use of the method by a woman in this circumstance.
D = delay: Use of this method should be delayed until the condition is evaluated or corrected. Alternative temporary methods of contraception should be offered.

ADDITIONAL COMMENTS

Breastfeeding

Fertility awareness-based (FAB) methods during breastfeeding may be less effective than when not breastfeeding.

< 6 weeks postpartum: Women who are exclusively breastfeeding and are amenorrhoeic are unlikely to have sufficient ovarian function to produce detectable fertility signs and hormonal changes during the first six weeks postpartum. However, the likelihood of resumption of fertility increases with time postpartum and with substitution of breast-milk by other foods.

After menses begin: When the woman notices fertility signs (particularly cervical secretions), she can use a symptoms-based method. First postpartum menstrual cycles in breastfeeding women vary significantly in length. It takes several cycles for the return to regularity. When she has had at least three postpartum menses and her cycles are regular again, she can use the Calendar Rhythm Method. When she has had at least four postpartum menses and her most recent cycle was 26–32 days long, she can use the Standard Days Method. Prior to that time, a barrier method should be offered if the woman plans to use a FAB method later.

Postpartum

< 4 weeks: Non-breastfeeding woman are not likely to have sufficient ovarian function to either require a FAB method or have detectable fertility signs or hormonal changes prior to four weeks postpartum. Although the risk of pregnancy is low, a method that is appropriate for the postpartum period should be offered.

≥ 4 weeks: Non-breastfeeding women are likely to have sufficient ovarian function to produce detectable fertility signs and/or hormonal changes at this time; the likelihood increases rapidly with time postpartum. A woman can use calendar-based methods as soon as she has completed at least three postpartum menses and her cycles are regular again. A woman can use the Standard Days Method when she has had at least four postpartum menses and her most recent cycle was 26–32 days long. Methods appropriate for the postpartum period should be offered prior to that time.

Post-abortion

Post-abortion women are likely to have sufficient ovarian function to produce detectable fertility signs and/or hormonal changes; the likelihood increases with time post-abortion. A woman can start using calendar-based methods after she has had at least one post-abortion menses; if most of her cycles prior to this pregnancy were 26–32 days long, she can use the Standard Days Method. Methods appropriate for the post-abortion period should be offered prior to that time.

2.7.9. Lactational amenorrhoea method (LAM)

The lactational amenorrhoea method (LAM) does not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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.

Women with conditions that make pregnancy an unacceptable risk should be advised that the LAM may not be appropriate for them because of its relatively higher typical-use failure rates.

The Bellagio Consensus provided the scientific basis for defining the conditions under which breastfeeding can be used safely and effectively for birth-spacing purposes, and programmatic guidelines were developed for the use of the LAM in family planning. These guidelines include the following three criteria, all of which must be met to ensure adequate protection from an unplanned pregnancy:

amenorrhoea
fully or nearly fully breastfeeding
less than six months postpartum.

The main indications for breastfeeding remain the need to provide an ideal food for the infant and to protect it against disease. There are no medical conditions in which the use of the LAM is restricted and there is no documented evidence of its negative impact on maternal health. However, certain conditions or obstacles which affect breastfeeding may also affect the duration of amenorrhoea, making this a less useful choice for family planning purposes. These include:

HIV

Breastfeeding should be promoted, protected and supported in all populations, for all women who are HIV-negative or of unknown HIV status. A woman living with HIV, however, can transmit the virus to her child through breastfeeding. Yet breastfeeding, and especially early and exclusive breastfeeding, is one of the most critical factors for improving child survival. Breastfeeding also confers many other benefits in addition to reducing the risk of death.

There is now strong evidence that giving antiretroviral medications (ARVs) to either the HIV-positive mother or the HIV-exposed infant or both can significantly reduce the risk of transmitting HIV through breastfeeding.¹⁵ This transforms the landscape in which decisions should be made by national health authorities and individual mothers. In the presence of ARVs – either lifelong antiretroviral therapy (ART) to the mother or other ARV interventions to the mother or infant – the infant can receive all the benefits of breastfeeding with little risk of acquiring HIV. In some well-resourced countries with low infant and child mortality rates, avoidance of all breastfeeding will still be appropriate.

Mothers living with HIV should receive the appropriate ARV interventions and should exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and should continue breastfeeding their infants for the first 12 months of life. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast-milk can be provided. When mothers decide to stop breastfeeding, they should stop gradually within one month and infants should be provided with safe and adequate replacement feeds to enable normal growth and development.

If the infant is HIV-negative or of unknown HIV status

A mother known to be living with HIV should only give commercial infant formula milk as a replacement feed to this infant when all of the following specific conditions are met:

safe water and sanitation are assured at the household level and in the community, and
the mother or other caregiver can reliably provide sufficient infant formula milk to support normal growth and development of the infant, and
the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition, and
the mother or caregiver can, in the first six months, exclusively give infant formula milk, and
the family is supportive of this practice, and
the mother or caregiver can access health care that offers comprehensive child health services.

If the infant is known to be HIV-positive

The mother is strongly encouraged to exclusively breastfeed for the first six months of the infant's life and to continue breastfeeding as per the recommendations for the general population, that is up to two years or beyond.

Women who are living with HIV should receive skilled counselling to help them. They should also have access to follow-up care and support, including family planning and nutritional support.

Medication used during breastfeeding

In order to protect infant health, breastfeeding is not recommended for women using such drugs as: anti-metabolites, bromocriptine, certain anticoagulants, corticosteroids (high doses), ciclosporin, ergotamine, lithium, mood-altering drugs, radioactive drugs and reserpine.

Conditions affecting the newborn

Congenital deformities of the mouth, jaw or palate; newborns who are small-for-date or premature and needing intensive neonatal care; and certain metabolic disorders of the infant can all make breastfeeding difficult.

2.7.10. Coitus interruptus (CI)

Coitus interruptus (CI) does not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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.

Women with conditions that make pregnancy an unacceptable risk should be advised that CI may not be appropriate for them because of its relatively higher typical-use failure rates.

Coitus interruptus (CI), also known as withdrawal, is a traditional family planning method in which the man completely removes his penis from the vagina, and away from the external genitalia of the female partner, before he ejaculates. CI prevents sperm from entering the woman's vagina, thereby preventing contact between spermatozoa and the ovum.

This method may be appropriate for couples:

who are highly motivated and able to use this method effectively;
with religious or philosophical reasons for not using other methods of contraception;
who need contraception immediately and have entered into a sexual act without alternative methods available;
who need a temporary method while awaiting the start of another method;
who have intercourse infrequently.

Some benefits of CI are that the method, if used correctly, does not affect breastfeeding and is always available for primary use or use as a back-up method. In addition, CI involves no economic cost or use of chemicals. There are no health risks associated directly with CI.

Men and women who are at high risk of STI/HIV infection should use a condom with each act of intercourse.

CI is unforgiving of incorrect use, and its effectiveness depends on the willingness and ability of the couple to use withdrawal with every act of intercourse.

2.7.11. Surgical sterilization procedures (STER)

Given that sterilization is a surgical procedure that is intended to be permanent, special care must be taken to assure that every client makes a voluntary, informed choice of the method. Particular attention must be given in the case of young people, nulliparous women, men who have not yet been fathers and clients with mental health problems, including depressive conditions. All clients should be carefully counselled about the intended permanence of sterilization and the availability of alternative, long-term, highly effective methods. This is of extra concern for young people. The national laws and existing norms for the delivery of sterilization procedures must be considered in the decision process.

Transcervical methods of female sterilization are not addressed in these recommendations.

There is no medical condition that would absolutely restrict a person's eligibility for sterilization, although some conditions and circumstances will require that certain precautions are taken, including those where the recommendation is assigned as Category C (caution), D (delay) or S (special). For some of these conditions and circumstances, the theoretical or proven risks may outweigh the advantages of undergoing sterilization, particularly female sterilization. Where the risks of sterilization outweigh the benefits, long-term, highly effective contraceptive methods are a preferable alternative. Decisions in this regard will have to be made on an individual basis, considering the risks and benefits of sterilization versus the risks of pregnancy, and the availability and acceptability of highly effective, alternative methods.

Sterilization procedures should only be performed by well-trained providers in appropriate clinical settings using proper equipment and supplies. Appropriate service-delivery guidelines, including infection-prevention protocols, should be followed to maximize client safety.

FEMALE SURGICAL STERILIZATION

Sterilization does not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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^a A = accept, C = caution, D = delay, S = special	CLARIFICATIONS/EVIDENCE
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY

PREGNANCY	D

YOUNG AGE	C	Clarification: Young women, like all women, should be counselled about the permanency of sterilization and the availability of alternative, long-term, highly effective methods. Evidence: Studies show that up to 20% of women sterilized at a young age later regret this decision, and that young age is one of the strongest predictors of regret (including request for referral information and obtaining reversal) that can be identified before sterilization (1–19).

PARITY*
a) Nulliparous	A
b) Parous	A

BREASTFEEDING	A

POSTPARTUM*
a) < 7 days	A
7 to < 42 days	D
≥ 42 days	A
b) Pre-eclampsia/eclampsia
i) mild pre-eclampsia	A
ii) severe pre-eclampsia/eclampsia	D
c) Prolonged rupture of membranes, 24 hours or more	D
d) Puerperal sepsis, intrapartum or puerperal fever	D
e) Severe antepartum or postpartum haemorrhage	D
f) Severe trauma to the genital tract (cervical or vaginal tear at time of delivery)	D
g) Uterine rupture or perforation	S	Clarification: If exploratory surgery or laparoscopy is conducted and the patient is stable, repair of the problem and tubal sterilization may be performed concurrently if no additional risk is involved.

POST-ABORTION*
a) Uncomplicated	A
b) Post-abortal sepsis or fever	D
c) Severe post-abortal haemorrhage	D
d) Severe trauma to the genital tract (cervical or vaginal tear at time of abortion)	D
e) Uterine perforation	S	Clarification: If exploratory surgery or laparoscopy is conducted and the patient is stable, repair of the problem and tubal sterilization may be performed concurrently if no additional risk is involved.
f) Acute haematometra	D

PAST ECTOPIC PREGNANCY	A

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

OBESITY		Clarification: The procedure may be more difficult. There is an increased risk of wound infection and disruption. Obese women may have limited respiratory function and may be more likely to require general anaesthesia. Evidence: Obese women were more likely to have complications when undergoing sterilization (20–23).
a) ≥ 30 kg/m² BMI	C
b) Menarche to < 18 years and ≥ 30 kg/m² BMI	C

CARDIOVASCULAR DISEASE

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

HYPERTENSION For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, the risk of cardiovascular disease may increase substantially. A single reading of blood pressure level is not sufficient to classify a woman as hypertensive.

a) Hypertension: adequately controlled	C
b) Elevated blood pressure levels (properly taken measurements)		Clarification: Elevated blood pressure should be controlled before surgery. There are increased anaesthesia-related risks and an increased risk of cardiac arrhythmia with uncontrolled hypertension. Careful monitoring of blood pressure intraoperatively is particularly necessary in this situation.
i) systolic 140–159 or diastolic 90–99 mm Hg	C
ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg	S
c) Vascular disease	S

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

DEEP VENOUS THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)		Clarification: To reduce the risk of DVT/PE, early ambulation is recommended.
a) History of DVT/PE	A
b) Acute DVT/PE	D
c) DVT/PE and established on anticoagulant therapy	S
d) Family history (first-degree relatives)	A
e) Major surgery
i) with prolonged immobilization	D
ii) without prolonged immobilization	A
f) Minor surgery without immobilization	A

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

CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE*
a) Current ischaemic heart disease	D
b) History of ischaemic heart disease	C

STROKE (history of cerebrovascular accident)	C

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

VALVULAR HEART DISEASE
a) Uncomplicated	C	Clarification: The woman requires prophylactic antibiotics.
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)	S	Clarification: The woman is at high risk for complications associated with anaesthesia and surgery. If the woman has atrial fibrillation that has not been successfully managed or current subacute bacterial endocarditis, the procedure should be delayed.

RHEUMATIC DISEASES

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) People with SLE are at increased risk of ischaemic heart disease, stroke and venous thromboembolism. Categories assigned to such conditions in the MEC should be the same for women with SLE who present with these conditions. For all categories of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors. Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives (24–42).

a) Positive (or unknown) antiphospholipid antibodies	S
b) Severe thrombocytopenia	S
c) Immunosuppressive treatment	S
d) None of the above	C

NEUROLOGIC CONDITIONS

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

EPILEPSY	C

DEPRESSIVE DISORDERS

DEPRESSIVE DISORDERS	C

REPRODUCTIVE TRACT INFECTIONS AND DISORDERS

VAGINAL BLEEDING PATTERNS
a) Irregular pattern without heavy bleeding	A
b) Heavy or prolonged bleeding (includes regular and irregular patterns)	A

UNEXPLAINED VAGINAL BLEEDING (suspicious for serious condition)		Clarification: The condition must be evaluated before the procedure is performed.
a) Before evaluation	D

ENDOMETRIOSIS	S

BENIGN OVARIAN TUMOURS (including cysts)	A

SEVERE DYSMENORRHOEA	A

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

CERVICAL ECTROPION	A

CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)	A

CERVICAL CANCER* (awaiting treatment)	D

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

ENDOMETRIAL CANCER*	D

OVARIAN CANCER*	D

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

PELVIC INFLAMMATORY DISEASE (PID)*
a) Past PID (assuming no current risk factors for STIs)		Clarification: A careful pelvic examination must be performed to rule out recurrent or persistent infection and to determine the mobility of the uterus.
i) with subsequent pregnancy	A
ii) without subsequent pregnancy	C
b) PID – current	D

STIS*
a) Current purulent cervicitis or chlamydial infection or gonorrhoea	D	Clarification: If no symptoms persist following treatment, sterilization may be performed.
b) Other STIs (excluding HIV and hepatitis)	A
c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)	A
d) Increased risk of STIs	A

HIV/AIDS

HIGH RISK OF HIV	A	Clarification: No routine screening is needed. Appropriate infection prevention procedures, including universal precautions, must be carefully observed with all surgical procedures. The use of condoms is recommended following sterilization.

ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE (WHO STAGE 1 OR 2)	A	Clarification: No routine screening is needed. Appropriate infection prevention procedures, including universal precautions, must be carefully observed with all surgical procedures. The use of condoms is recommended following sterilization.

SEVERE OR ADVANCED HIV CLINICAL DISEASE (WHO STAGE 3 OR 4)	S	Clarification: The presence of an AIDS-related illness may require that the procedure be delayed.

OTHER INFECTIONS

SCHISTOSOMIASIS
a) Uncomplicated	A
b) Fibrosis of the liver (if severe, see cirrhosis)	C	Clarification: Liver function may need to be evaluated.

TUBERCULOSIS
a) Non-pelvic	A
b) Pelvic	S

MALARIA	A

ENDOCRINE CONDITIONS

DIABETES*		Clarification: If blood glucose is not well controlled, referral to a higher-level facility is recommended.
a) History of gestational disease	A
b) Non-vascular disease		Clarification: There is a possible decrease in healing and an increased risk of wound infection. Use of prophylactic antibiotics is recommended.
i) non-insulin-dependent	C
ii) insulin-dependent	C
c) Nephropathy/retinopathy/neuropathy	S	Evidence: Diabetic women were more likely to have complications when undergoing sterilization (20).
d) Other vascular disease or diabetes of > 20 years' duration	S

THYROID DISORDERS*
a) Simple goitre	A
b) Hyperthyroid	S
c) Hypothyroid	C

GASTROINTESTINAL CONDITIONS

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

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

VIRAL HEPATITIS*		Clarification: Appropriate infection-prevention procedures, including universal precautions, must be carefully observed with all surgical procedures.
a) Acute or flare	D
b) Carrier	A
c) Chronic	A

CIRRHOSIS		Clarification: Liver function and clotting might be altered. Liver function should be evaluated.
a) Mild (compensated)	A
b) Severe (decompensated)	S

LIVER TUMOURS		Clarification: Liver function and clotting might be altered. Liver function should be evaluated.
a) Benign
i) focal nodular hyperplasia	A
ii) hepatocellular adenoma	C
b) Malignant (hepatoma)	C

ANAEMIAS

THALASSAEMIA	C

SICKLE CELL DISEASE*	C

IRON-DEFICIENCY ANAEMIA		Clarification: The underlying disease should be identified. Both preoperative haemoglobin (Hb) level and operative blood loss are important factors in women with anaemia. If peripheral perfusion is inadequate, this may decrease wound healing.
a) Hb < 7 g/dl	D
a) Hb ≥ 7 to < 10 g/dl	C

OTHER CONDITIONS RELEVANT ONLY FOR FEMALE SURGICAL STERILIZATION

LOCAL INFECTION	D	Clarification: There is an increased risk of postoperative infection.

COAGULATION DISORDERS*	S

RESPIRATORY DISEASES
a) Acute (bronchitis, pneumonia)	D	Clarification: The procedure should be delayed until the condition is corrected. There are increases in anaesthesia-related and other perioperative risks.
b) Chronic
i) asthma	S
ii) bronchitis	S
iii) emphysema	S
iv) lung infection	S

SYSTEMIC INFECTION OR GASTROENTERITIS*	D

FIXED UTERUS DUE TO PREVIOUS SURGERY OR INFECTION*	S

ABDOMINAL WALL OR UMBILICAL HERNIA	S	Clarification: Hernia repair and tubal sterilization should be performed concurrently if possible.

DIAPHRAGMATIC HERNIA*	C

KIDNEY DISEASE*	C

SEVERE NUTRITIONAL DEFICIENCIES*	C

PREVIOUS ABDOMINAL OR PELVIC SURGERY	C	Evidence: Women with previous abdominal or pelvic surgery were more likely to have complications when undergoing sterilization (20, 22, 43–45).

STERILIZATION CONCURRENT WITH ABDOMINAL SURGERY
a) Elective	C
b) Emergency (without previous counselling)	D
c) Infectious condition	D

STERILIZATION CONCURRENT WITH CAESAREAN SECTION*	A

a

Further explanation of A, C, D and S categories:

A = accept: There is no medical reason to deny sterilization to a person with this condition.
C = caution: The procedure is normally conducted in a routine setting, but with extra preparation and precautions.
D = delay: The procedure is delayed until the condition is evaluated and/or corrected. Alternative temporary methods of contraception should be provided.
S = special: The procedure should be undertaken in a setting with an experienced surgeon and staff, equipment needed to provide general anaesthesia, and other back-up medical support. For these conditions, the capacity to decide on the most appropriate procedure and anaesthesia regimen is also needed. Alternative temporary methods of contraception should be provided if referral is required or there is otherwise any delay.

MALE SURGICAL STERILIZATION

Sterilization does not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, 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 ^a A = accept, C = caution, D = delay, S = special	CLARIFICATIONS/EVIDENCE
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY

YOUNG AGE	C	Clarification: Young men, like all men, should be counselled about the permanency of sterilization and the availability of alternative, long-term, highly effective methods. Evidence: Men who underwent vasectomy at young ages were more likely to have the procedure reversed than those who underwent vasectomy at older ages (2).

DEPRESSIVE DISORDERS

DEPRESSIVE DISORDERS	C

HIV/AIDS

HIGH RISK OF HIV	A	Clarification: No routine screening is needed. Appropriate infection prevention procedures, including universal precautions, must be carefully observed with all surgical procedures. The use of condoms is recommended following sterilization.

ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE (WHO STAGE 1 OR 2)	A	Clarification: No routine screening is needed. Appropriate infection prevention procedures, including universal precautions, must be carefully observed with all surgical procedures. The use of condoms is recommended following sterilization.

SEVERE OR ADVANCED HIV CLINICAL DISEASE (WHO STAGE 3 OR 4)	S	Clarification: The presence of severe or advanced HIV clinical disease may require that the procedure be delayed.

ENDOCRINE CONDITIONS

DIABETES*	C	Clarification: If blood glucose is not well controlled, referral to a higher-level facility is recommended.

ANAEMIAS

SICKLE CELL DISEASE*	A

OTHER CONDITIONS RELEVANT ONLY FOR MALE SURGICAL STERILIZATION

LOCAL INFECTION*
a) Scrotal skin infection	D
b) Active STI	D
c) Balanitis	D
d) Epididymitis or orchitis	D

COAGULATION DISORDERS*	S

PREVIOUS SCROTAL INJURY	C

SYSTEMIC INFECTION OR GASTROENTERITIS*	D

LARGE VARICOCELE*	C

LARGE HYDROOCELE*	C

FILIARIASIS; ELEPHANTIASIS*	D

INTRASCROTAL MASS*	D

CRYPTORCHIDISM	S

INGUINAL HERNIA*	S

a

Further explanation of A, C, D and S categories:

A = accept: There is no medical reason to deny sterilization to a person with this condition.
C = caution: The procedure is normally conducted in a routine setting, but with extra preparation and precautions.
D = delay: The procedure is delayed until the condition is evaluated and/or corrected. Alternative temporary methods of contraception should be provided.
S = special: The procedure should be undertaken in a setting with an experienced surgeon and staff, equipment needed to provide general anaesthesia, and other back-up medical support. For these conditions, the capacity to decide on the most appropriate procedure and anaesthesia regimen is also needed. Alternative temporary methods of contraception should be provided if referral is required or there is otherwise any delay.

ADDITIONAL COMMENTS FOR FEMALE STERILIZATION

Parity

Nulliparous women: Like all women, they should be counselled about the permanency of sterilization and the availability of alternative, long-term, highly effective methods.

Postpartum

< 7 days postpartum: Sterilization can be safely performed immediately postpartum.
7 to < 42 days: There is an increased risk of complications when the uterus has not fully involuted.
Pre-eclampsia/eclampsia: There are increased anaesthesia-related risks.
Prolonged rupture of membranes, 24 hours or more: There is an increased risk of postoperative infection.
Puerperal sepsis, intrapartum or puerperal fever: There is an increased risk of postoperative infection.
Severe antepartum or postpartum haemorrhage: The woman may be anaemic and unable to tolerate further blood loss.
Severe trauma to the genital tract (cervical or vaginal tear at the time of delivery): There may have been significant blood loss and anaemia.
Uterine rupture or perforation: There may have been significant blood loss or damage to abdominal contents.

Post-abortion

Post-abortal sepsis or fever: There is an increased risk of postoperative infection.
Severe post-abortal haemorrhage: The woman may be anaemic and unable to tolerate further blood loss.
Severe trauma to the genital tract (cervical or vaginal tear at the time of abortion): The woman may be anaemic and unable to tolerate further blood loss. The procedure may be more painful.
Uterine perforation: There may have been significant blood loss or damage to abdominal contents.
Acute haematometra: The woman may be anaemic and unable to tolerate further blood loss.

OTHER CONSIDERATIONS

Multiple risk factors for arterial cardiovascular disease

Concurrent presence of multiple risk factors: There may be a high risk of complications associated with anaesthesia and surgery.

Current and history of ischaemic heart disease

There is a high risk of complications associated with anaesthesia and surgery.

Cervical cancer (awaiting treatment), endometrial cancer, ovarian cancer

In general, the treatment renders a woman sterile.

Uterine fibroids

Depending on the size and location of the fibroids, it might be difficult to localize the tubes and mobilize the uterus.

Pelvic inflammatory disease (pid)

PID can lead to an increased risk of post-sterilization infection or adhesions.

STIs

There is an increased risk of postoperative infection.

Diabetes

There is a risk of hypoglycaemia or ketoacidosis when the procedure is performed, particularly if blood sugar is not well controlled before the procedure.

Thyroid disorders

There is a higher risk of complications associated with anaesthesia and surgery.

Viral hepatitis

There is a high risk for complications associated with anaesthesia and surgery.

Sickle cell disease

There is an increased risk of pulmonary, cardiac or neurologic complications and possible increased risk of wound infection.

Coagulation disorders

There is a higher risk of haematologic complications of surgery.

Systemic infection or gastroenteritis

There are increased risks of postoperative infection, complications from dehydration, and anaesthesia-related complications.

Fixed uterus due to previous surgery or infection

Decreased mobility of the uterus, fallopian tubes and bowel may make laparoscopy and minilaparotomy difficult and increase the risk of complications.

Diaphragmatic hernia

For laparoscopy, a woman may experience acute cardiorespiratory complications induced by pneumoperitoneum or the Trendelenburg position.

Kidney disease

Blood clotting may be impaired. There may be an increased risk of infection and hypovolemic shock. Condition may cause baseline anaemia, electrolyte disturbances, and abnormalities in drug metabolism and excretion.

Severe nutritional deficiencies

There may be an increased risk of wound infection and impaired healing.

Sterilization concurrent with caesarean section

There is no increased risk of complications in a surgically stable client.

ADDITIONAL COMMENTS FOR MALE STERILIZATION

Diabetes

Individuals with diabetes are more likely to get postoperative wound infections. If signs of infection appear, treatment with antibiotics needs to be given.

Local infection

There is an increased risk of postoperative infection.

Coagulation disorders

Bleeding disorders lead to an increased risk of postoperative haematoma formation, which, in turn, leads to an increased risk of infection.

Systemic infection or gastroenteritis

There is an increased risk of postoperative infection.

Large varicocele

The vas may be difficult or impossible to locate; a single procedure to repair varicocele and perform a vasectomy decreases the risk of complications.

Large hydrocele

The vas may be difficult or impossible to locate; a single procedure to repair hydrocele and perform a vasectomy decreases the risk of complications.

Filariasis; elephantiasis

If elephantiasis involves the scrotum, it may be impossible to palpate the spermatic cord and testis.

Intrascrotal mass

This may indicate underlying disease.

Inguinal hernia

Vasectomy can be performed concurrent with hernia repair.

Sickle cell disease

There is an increased risk of pulmonary, cardiac or neurologic complications and possible increased risk of wound infection.

References

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34.: McAlindon T, Giannotta L, Taub N, D'Cruz D, Hughes G. Environmental factors predicting nephristis in systemic lupus erythematosus. Annals of Rheumatic Diseases. 1993;52:720–4. [PMC free article: PMC1005168] [PubMed: 8257208]
35.: Manzi S, Meilahn EN, Rairie JE, Conte CG, Medsger TA Jr, Jansen-McWilliams L, et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. American Journal of Epidemiology. 1997;145:408–15. [PubMed: 9048514]
36.: Jungers P, Dougados M, Pelissier C, Kuttenn F, Tron F, Lesavre P, et al. Influence of oral contraceptive therapy on the activity of systemic lupus erythematosus. Arthritis and Rheumatism. 1982;25:618–23. [PubMed: 7092961]
37.: Julkunen HA, Kaaja R, Friman C. Contraceptive practice in women with systemic lupus erythematosus. British Journal of Rheumatology. 1993;32:227–30. [PubMed: 8448613]
38.: Julkunen HA. Oral contraceptives in systemic lupus erythematosus: side-effects and influence on the activity of SLE. Scandinavian Journal of Rheumatology. 1991;20:427–33. [PubMed: 1771400]
39.: Esdaile JM, Abrahamowicz M, Grodzicky T, Li Y, Panaritis C, du Berger R, et al. Traditional Framingham risk factors fail to fully account for accelerated atherosclerosis in systemic lupus erythematosus. Arthritis and Rheumatism. 2001;44:2331–7. [PubMed: 11665973]
40.: Chopra N, Koren S, Greer WL, et al. Factor V Leiden, prothrombin gene mutation, and thrombosis risk in patients with antiphospholipid antibodies. Journal of Rheumatology. 2002;29:1683–8. [PubMed: 12180730]
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2.7.12. Summary table (SUMM)

This summary table highlights the medical eligibility recommendations for combined hormonal contraceptives (COC, CIC, patch [P] and vaginal ring [CVR]), progestogen-only contraceptives (POP, DMPA/NET-EN injectables, and LNG/ETG implants) and intrauterine devices (Cu-IUD and LNG-IUD). For further information about these recommendations, please consult the corresponding method tables. Eligibility recommendations for emergency contraceptive pills (ECPs), IUDs for emergency contraception (E-IUD), progesterone-releasing vaginal rings (PVR), barrier methods (BARR), fertility awareness-based (FAB) methods, lactational amenorrhea method (LAM), coitus interruptus (CI) and surgical sterilization (STER) are presented in their respective sub-sections in this document.

SUMMARY TABLE

	COC//P/CVR		CIC		POP		DMPA/NET-EN		LNG/ETG/IMPLANTS		CU-IUD		LNG-IUD
PREGNANCY	NA^a		NA^a		NA^a		NA^a		NA^a		NA^a		NA^a

AGE	Menarche to		Menarche to		Menarche to		Menarche to		Menarche to		Menarche to		Menarche to
	< 40=1		< 40=1		< 18=1		< 18=2		< 18=1		< 20=2		< 20=2
	≥ 40=2		≥ 40=2		18-45=1		18-45=1		18-45=1		≥ 20=1		≥ 20=1
					> 45=1		> 45=2		> 45=1

PARITY
a) Nulliparous	1		1		1		1		1		2		2
b) Parous	1		1		1		1		1		1		1

BREASTFEEDING
a) < 6 weeks postpartum	4		4		2^a		3^a		2^a
b) ≥ 6 weeks to < 6 months (primarily breastfeeding)	3		3		1		1		1
c) ≥ 6 months postpartum	2		2		1		1		1

POSTPARTUM (non-breastfeeding women)
a) < 21 days					1		1		1
i) without other risk factors for venous thromboembolism (VTE)	3^a		3^a
ii) with other risk factors for VTE	4^a		4^a
b) ≥ 21 days to 42 days					1		1		1
i) without other risk factors for VTE	2^a		2^a
ii) with other risk factors for VTE	3^a		3^a
c) > 42 days	1		1		1		1		1

POSTPARTUM (breastfeeding or non-breastfeeding women, including after caesarean section)
a) < 48 hours including insertion immediately after delivery of the placenta											1		not BF=1; BF=2
b) ≥ 48 hours to < 4 weeks											3		3
c) ≥ 4 weeks											1		1
d) Puerperal sepsis											4		4

POST-ABORTION
a) First trimester	1^a		1^a		1^a		1^a		1^a		1^a		1^a
b) Second trimester	1^a		1^a		1^a		1^a		1^a		2^a		2^a
c) Immediate post-septic abortion	1^a		1^a		1^a		1^a		1^a		4		4

PAST ECTOPIC PREGNANCY	1		1		2		1		1		1		1

HISTORY OF PELVIC SURGERY (see postpartum, including caesarean section)	1		1		1		1		1		1		1

SMOKING
a) Age < 35 years	2		2		1		1		1		1		1
b) Age ≥ 35 years
i) < 15 cigarettes/day	3		2		1		1		1		1		1
ii) ≥ 15 cigarettes/day	4		3		1		1		1		1		1

OBESITY
a) ≥ 30 kg/m² BMI	2		2		1		1		1		1		1
b) Menarche to < 18 years and ≥ 30 kg/m² BMI	2		2		1		2^a		1		1		1

BLOOD PRESSURE MEASUREMENT UNAVAILABLE	NA^a		NA^a		NA^a		NA^a		NA^a		NA^a		NA^a

CARDIOVASCULAR DISEASE

MULTIPLE RISK FACTORS FOR ARTERIAL CARDIOVASCULAR DISEASE (such as older age, smoking, diabetes, hypertension and known dyslipidaemias)	3/4^a		3/4^a		2^a		3^a		2^a		1		2

HYPERTENSION
a) History of hypertension where blood pressure CANNOT be evaluated (including hypertension during pregnancy)	3^a		3^a		2^a		2^a		2^a		1		2
b) Adequately controlled hypertension, where blood pressure CAN be evaluated	3^a		3^a		1^a		2^a		1^a		1		1
c) Elevated blood pressure levels (properly taken measurements)
i) systolic 140–159 or diastolic 90–99 mm Hg	3		3		1		2		1		1		1
ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg	4		4		2		3		2		1		2
d) Vascular disease	4		4		2		3		2		1		2

HISTORY OF HIGH BLOOD PRESSURE DURING PREGNANCY (where current blood pressure is measurable and normal)	2		2		1		1		1		1		1

DEEP VEIN THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)	4		4		2		2		2		1		2
a) History of DVT/PE	4		4		3		3		3		1		3
b) Acute DVT/PE	4		4		3		3		3		1		3
c) DVT/PE and established on anticoagulant therapy	4		4		2		2		2		1		2
d) Family history (first-degree relatives)	2		2		1		1		1		1		1
e) Major surgery
i) with prolonged immobilization	4		4		2		2		2		1		2
ii) without prolonged immobilization	2		2		1		1		1		1		1
f) Minor surgery without immobilization	1		1		1		1		1		1		1

KNOWN THROMBOGENIC MUTATIONS (e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)	4^a		4^a		2^a		2^a		2^a		1^a		2^a

SUPERFICIAL VENOUS DISORDERS
a) Varicose veins	1		1		1		1		1		1		1
b) Superficial venous thrombosis	2^a		2^a		1		1		1		1		1

CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE					I	C			I	C			I	C

	4		4		2	3	3		2	3	1		2	3

STROKE (history of cerebrovascular accident)					I	C			I	C

	4		4		2	3	3		2	3	1		2

KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORS	2^a		2^a		2^a		2^a		2^a		1^a		2^a

VALVULAR HEART DISEASE
a) Uncomplicated	2		2		1		1		1		1		1
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)	4		4		1		1		1		2^a		2^a

RHEUMATIC DISEASES

SYSTEMIC LUPUS ERYTHEMATOSUS							I	C			I	C
SYSTEMIC LUPUS ERYTHEMATOSUS
a) Positive (or unknown) antiphospholipid antibodies	4		4		3		3	3	3		1	1	3
b) Severe thrombocytopenia	2		2		2		3	2	2		3^a	2^a	2^a
c) Immunosuppressive treatment	2		2		2		2	2	2		2	1	2
d) None of the above	2		2		2		2	2	2		1	1	2

NEUROLOGIC CONDITIONS

HEADACHES	I	C	I	C	I	C	I	C	I	C			I	C
HEADACHES
a) Non-migrainous (mild or severe)	1^a	2^a	1^a	2^a	1^a	1^a	1^a	1^a	1^a	1^a	1^a		1^a	1^a
b) Migraine
i) without aura
age < 35 years	2^a	3^a	2^a	3^a	1^a	2^a	2^a	2^a	2^a	2^a	1^a		2^a	2^a
age ≥ 35 years	3^a	4^a	3^a	4^a	1^a	2^a	2^a	2^a	2^a	2^a	1^a		2^a	2^a
ii) with aura (at any age)	4^a	4^a	4^a	4^a	2^a	3^a	2^a	3^a	2^a	3^a	1^a		2^a	3^a

EPILEPSY	1^a		1^a		1^a		1^a		1^a		1^a		1^a

	If on treatment, see DRUG INTERACTIONS (last section of this table)

DEPRESSIVE DISORDERS

DEPRESSIVE DISORDERS	1^a		1^a		1^a		1^a		1^a		1^a		1^a

REPRODUCTIVE TRACT INFECTIONS AND DISORDERS

VAGINAL BLEEDING PATTERNS													I	C
VAGINAL BLEEDING PATTERNS
a) Irregular pattern without heavy bleeding	1		1		2		2		2		1		1	1
b) Heavy or prolonged bleeding (includes regular and irregular patterns)	1^a		1^a		2^a		2^a		2^a		2^a		1^a	2^a

UNEXPLAINED VAGINAL BLEEDING (suspicious for serious condition)											I	C	I	C

a) Before evaluation	2^a		2^a		2^a		3^a		3^a		4^a	2^a	4^a	2^a

ENDOMETRIOSIS	1		1		1		1		1		2		1

BENIGN OVARIAN TUMOURS (INCLUDING CYSTS)	1		1		1		1		1		1		1

SEVERE DYSMENORRHOEA	1		1		1		1		1		2		1

GESTATIONAL TROPHOBLASTIC DISEASE
a) Decreasing or undetectable β-hCG levels	1		1		1		1		1		3		3
b) Persistently elevated β-hCG levels or malignant disease	1		1		1		1		1		4		4

CERVICAL ECTROPION	1		1		1		1		1		1		1

CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)	2		2		1		2		2		1		2

CERVICAL CANCER (AWAITING TREATMENT)											I	C	I	C

	2		2		1		2		2		4	2	4	2

BREAST DISEASE
a) Undiagnosed mass	2^a		2^a		2^a		2^a		2^a		1		2
b) Benign breast disease	1		1		1		1		1		1		1
c) Family history of cancer	1		1		1		1		1		1		1
d) Breast cancer
i) current	4		4		4		4		4		1		4
ii) past and no evidence of current disease for 5 years	3		3		3		3		3		1		3

ENDOMETRIAL CANCER											I	C	I	C

	1		1		1		1		1		4	2	4	2

OVARIAN CANCER											I	C	I	C

	1		1		1		1		1		3	2	3	2

UTERINE FIBROIDS
a) Without distortion of the uterine cavity	1		1		1		1		1		1		1
b) With distortion of the uterine cavity	1		1		1		1		1		4		4

ANATOMICAL ABNORMALITIES
a) That distort the uterine cavity											4		4
b) That do not distort the uterine cavity											2		2

PELVIC INFLAMMATORY DISEASE (PID)
PELVIC INFLAMMATORY DISEASE (PID)
a) Past PID (assuming no current risk factors for sexually transmitted infections)											I	C	I	C

i) with subsequent pregnancy	1		1		1		1		1		1	1	1	1
ii) without subsequent pregnancy	1		1		1		1		1		2	2	2	2
b) PID – current	1		1		1		1		1		4	2^a	4	2^a

SEXUALLY TRANSMITTED INFECTIONS (STIS)											I	C	I	C
SEXUALLY TRANSMITTED INFECTIONS (STIS)
a) Current purulent cervicitis or chlamydial infection or gonorrhoea	1		1		1		1		1		4	2^a	4	2^a
b) Other STIs (excluding HIV and hepatitis)	1		1		1		1		1		2	2	2	2
c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)	1		1		1		1		1		2	2	2	2
d) Increased risk of STIs	1		1		1		1		1		2/3^a	2	2/3^a	2

HIV/AIDS											I	C	I	C

HIGH RISK OF HIV	1		1		1		1^a		1		2	2	2	2

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

SEVERE OR ADVANCED HIV CLINICAL DISEASE (WHO STAGE 3 OR 4)	1^a		1^a		1^a		1^a		1^a		3	2^a	3	2^a

OTHER INFECTIONS

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

TUBERCULOSIS											I	C	I	C
TUBERCULOSIS
a) Non-pelvic	1^a		1^a		1^a		1^a		1^a		1	1	1	1
b) Pelvic	1^a		1^a		1^a		1^a		1^a		4	3	4	3

MALARIA	1		1		1		1		1		1		1

ENDOCRINE CONDITIONS

DIABETES
a) History of gestational disease	1		1		1		1		1		1		1
b) Non-vascular disease
i) non-insulin-dependent	2		2		2		2		2		1		2
ii) insulin-dependent	2		2		2		2		2		1		2
c) Nephropathy/retinopathy/neuropathy	3/4^a		3/4^a		2		3		2		1		2

d) Other vascular disease or diabetes of > 20 years' duration	3/4^a		3/4^a		2		3		2		1		2

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

GASTROINTESTINAL CONDITIONS

GALL BLADDER DISEASE
a) Symptomatic
i) treated by cholecystectomy	2		2		2		2		2		1		2
ii) medically treated	3		2		2		2		2		1		2
iii) current	3		2		2		2		2		1		2
b) Asymptomatic	2		2		2		2		2		1		2

HISTORY OF CHOLESTASIS
a) Pregnancy-related	2		2		1		1		1		1		1
b) Past-COC-related	3		2		2		2		2		1		2

VIRAL HEPATITIS	I	C	I	C
VIRAL HEPATITIS
a) Acute or flare	3/4^a	2	3	2	1		1		1		1		1
b) Carrier	1	1	1	1	1		1		1		1		1
c) Chronic	1	1	1	1	1		1		1		1		1

CIRRHOSIS
a) Mild (compensated)	1		1		1		1		1		1		1
b) Severe (decompensated)	4		3		3		3		3		1		3

LIVER TUMOURS

a) Benign
i) focal nodular hyperplasia	2		2		2		2		2		1		2
ii) hepatocellular adenoma	4		3		3		3		3		1		3
b) Malignant (hepatoma)	4		3/4		3		3		3		1		3

ANAEMIAS
Thalassaemia	1		1		1		1		1		2		1
Sickle cell disease	2		2		1		1		1		2		1
Iron-deficiency anaemia	1		1		1		1		1		2		1

DRUG INTERACTIONS

ANTIRETROVIRAL THERAPY (ART)
ANTIRETROVIRAL THERAPY (ART)
a) Nucleoside reverse transcriptase inhibitors (NRTIs)											I	C	I	C
a) Nucleoside reverse transcriptase inhibitors (NRTIs)
Abacavir (ABC)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a
Tenofovir (TDF)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a
Zidovudine (AZT)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a
Lamivudine (3TC)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a
Didanosine (DDI)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a
Emtricitabine (FTC)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a
Stavudine (D4T)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a
b) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Efavirenz (EFV)	2^a		2^a		2^a		DMPA=1, NET-EN=2^a		2^a		2/3^a	2^a	2/3^a	2^a
Etravirine (ETR)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a
Nevirapine (NVP)	2^a		2^a		2^a		DMPA=1, NET-EN=2^a		2^a		2/3^a	2^a	2/3^a	2^a
Rilpirivine (RPV)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a
c) Protease inhibitors (PIs)
Ritonavir-boosted atazanavir (ATV/r)	2^a		2^a		2^a		DMPA=1, NET-EN=2^a		2^a		2/3^a	2^a	2/3^a	2^a
Ritonavir-boosted lopinavir (LPV/r)	2^a		2^a		2^a		DMPA=1, NET-EN=2^a		2^a		2/3^a	2^a	2/3^a	2^a
Ritonavir-boosted darunavir (DRV/r)	2^a		2^a		2^a		DMPA=1, NET-EN=2^a		2^a		2/3^a	2^a	2/3^a	2^a
Ritonavir (RTV)	2^a		2^a		2^a		DMPA=1, NET-EN=2^a		2^a		2/3^a	2^a	2/3^a	2^a
d) Integrase inhibitors
Raltegravir (RAL)	1		1		1		1		1		2/3^a	2^a	2/3^a	2^a

ANTICONVULSANT THERAPY
a) Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)	3^a		2		3^a		DMPA=1, NET-EN=2^a		2^a		1		1
b) Lamotrigine	3^a		3		1		1		1		1		1

ANTIMICROBIAL THERAPY
a) Broad-spectrum antibiotics	1		1		1		1		1		1		1
b) Antifungals	1		1		1		1		1		1
c) Antiparasitics	1		1		1		1		1		1		1
d) Rifampicin or rifabutin therapy	3^a		2^a		3^a		DMPA=1, NET-EN=2^a		2^a		1		1

a: Please consult the tables in the text for a clarification to this classification.

Footnotes

1: Report of the International Conference on Population and Development (Cairo, 5–13 September 1994). United Nations: 1994. [24 April 2015]. Programme of Action of the International Conference on Population and Development. para. 7.2 (A/CONF.171/13, http://www.un.org/popin/icpd/conference/offeng/poa.html..
2: Report of the Fourth World Conference on Women (Beijing, 4–15 September, 1995). United Nations: 1995. [17 April 2015]. Beijing Declaration and Platform for Action. para. 95 (A/CONF.177/20; http://www.un.org/documents/ga/conf177/aconf177–20en.htm..
3: Ensuring human rights in the provision of contraceptive information and services: guidance and recommendations. Geneva: World Health Organization; 2014. [24 April 2015]. http://apps.who.int/iris/bitstream/10665/102539/1/9789241506748_eng.pdf. [PubMed: 24696891].
4: Koenig MA. The impact of quality of care on contraceptive use: evidence from longitudinal data from rural Bangladesh. Baltimore (MD): Johns Hopkins University; 2003. .
5: Arends-Kuenning M, Kessy FL. The impact of demand factors, quality of care and access to facilities on contraceptive use in Tanzania. J Biosoc Sci. 2007;39:1–26. [PubMed: 16359581].
6: RamaRao S, Lacuest M, Costello M, Pangolibay B, Jones H. The link between quality of care and contraceptive use. Int Fam Plann Perspect. 2003;29(2):76–83 [PubMed: 12783771].
7: Sanogo D, RamaRao S, Johnes H, N'diaye P, M'bow B, Diop CB. Improving quality of care and use of contraceptives in Senegal. Afr J Reprod Health. 2003;7:57–73. [PubMed: 14677301].
8: This can be context specific. These may include high prevalence rates of STIs and HIV in the geographic area, and/or individual risk behaviour such as multiple partners without using condoms.
9: Resolution adopted by the United Nations General Assembly. United Nations: 2006. [24 April 2015]. United Nations Convention on the Rights of Persons with Disabilities. A/RES/61/106; http://www.un-documents.net/a61r106.htm..
10: World report on disability 2011. Geneva: World Health Organization; 2011. [9 April 2015]. http://www.who.int/disabilities/world_report/2011/report/en/ [PubMed: 26131540].
11: Ibid.
12: Available at: http://ihs-classification.org/en/02_klassifikation
13: Available at: http://ihs-classification.org/en/02_klassifikation
14: Available at: http://ihs-classification.org/en/02_klassifikation
15: Further information: http://www.who.int/hiv/topics/mtct

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Medical Eligibility Criteria for Contraceptive Use. 5th edition. Geneva: World Health Organization; 2015. II, Using the recommendations.
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Using the recommendations - Medical Eligibility Criteria for Contraceptive Use
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