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Emergency contraception pt
Use Cu-IUD or ECPs for emergency contraception (defined as methods used after sexual intercourse to prevent pregnancy).1 - ECP options
◦ UPA 30-mg single dose
◦ LNG 1.5-mg single dose or split dose (1 dose of 0.75 mg followed by repeat dose in 12h)
◦ 2 doses COC (Yuzpe regimen): 1 dose of 100 mcg ethinyl estradiol + 0.5 mg LNG followed by repeat dose in 12h. (Least effective and most adverse effects)
Consider Cu-IUD w/in 5 days of unprotected intercourse.1 - When day of ovulation can be estimated, can be placed >5 days after unprotected intercourse, providing this is not >5 days after ovulation.1
- Highly effective/provides continued contraception1
- Category: if ≥20 yo or parous [1]; if <20 yo or nulliparous [2].2
- Generally safe/low risk, w/ the following exceptions (category may vary if initiating vs. continuing this method):3
◦ Known/suspected pregnancy [4]
◦ Current purulent cervicitis or GC/CT (initiating) [4] - Pts w/ known medical conditions may need additional exam/tests to determine if candidate for this method. Refer to CDC website for STI screening criteria and recommendations.4
Consider ECPs as soon as possible w/in 5 days of unprotected intercourse; more effective when given earlier.1 - Category [1]
- Generally safe/low risk, but relatively lower effectiveness if obesity2
Initiate regular contraception after ECPs.1 - If using LNG or COC regimen:
◦ Start/resume hormonal contraception immediately.
◦ After starting hormonal contraception, abstain from intercourse or use barrier method x7 days.
◦ Obtain pregnancy test if no withdrawal bleed w/in 3wk. - If using UPA:
◦ Start/resume hormonal contraception after ≥5 days.
◦ After starting hormonal contraception, abstain from intercourse or use barrier method x7 days or until next menses.
◦ Obtain pregnancy test if no withdrawal bleed w/in 3wk.
Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.2 - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.2
Footnotes 1 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
2 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
3 Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024. PDF
4 Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. Centers for Disease Control and Prevention. Reviewed June 13, 2023. Accessed August 8, 2024
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Considering options in light of med/surg hx, risks, effectiveness, preferences (nonemergency)
Long-acting reversible methods (IUDs, implant) preferred by pt Assess for appropriateness of IUDs or implant.1 - Consider risk for adverse health events due to pregnancy. Medical conditions that might make pregnancy an unacceptable health risk include:
◦ CA: breast, endometrial, ovarian, hepatoma
◦ Neph: CKD w/ nephrotic syndrome, on hemodialysis, or on peritoneal dialysis
◦ CV/Resp: DVT/PE, HTN (systolic ≥160 or diastolic ≥100 mm Hg), IHD, peripartum cardiomyopathy, complicated valvular heart dz, CF, stroke
◦ Hepatic: hepatocellular adenoma, schistosomiasis w/ liver fibrosis, decompensated cirrhosis
◦ DM: insulin-dependent; >20-yr duration; or w/ nephropathy/retinopathy/neuropathy/other vascular dz
◦ Surgery hx: bariatric surgery in past 2y, solid organ txp in past 2y
◦ ID: HIV (not clinically well or not on ART); TB; schistosomiasis w/ liver fibrosis
◦ Neuro: epilepsy, DM neuropathy, stroke
◦ Heme: sickle cell dz, thrombogenic mutations
◦ Other: GTD, SLE
- Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.
◦ Internal (female) condoms may protect against STIs, but data limited.
- Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.
Consider Cu-IUD. Effectiveness: 99.2%.2 Category: if ≥20 yo or parous [1]; if <20 yo or nulliparous [2].1 Generally safe/low risk, w/ the following exceptions (category may vary if initiating vs. continuing this method):3 - Pregnancy [4]
- Post pregnancy: postpartum sepsis [4]; immediate postseptic ab [4]
- Anatomic/Gyn: unexplained vag bleeding (initiating) [4]; distorted uterus incompatible w/ IUD placement [4]; GTD: confirmed + persistently ↑beta-hCG or malignant dz, w/ evidence/suspicion of intrauterine dz (initiating) [4]
- Heme/Onc: endometrial CA (initiating) [4]; cervical CA, awaiting tx (initiating) [4]; SLE w/ severe thrombocytopenia (initiating) [3]
- ID/Immune: current purulent cervicitis or GC/CT (initiating) [4]; PID current (initiating) [4]; pelvic TB (initiating) [4], (continuing) [3]
Consider LNG-releasing IUD. Effectiveness: 99.6% to 99.9%.2 Category: if ≥20 yo or parous [1]; if <20 yo or nulliparous [2].1 Generally safe/low risk, w/ the following exceptions (category may vary if initiating vs. continuing this method):3 - Pregnancy [4]
- Post pregnancy: postpartum sepsis [4]; immediate postseptic ab [4]
- Anatomic/Gyn: unexplained vag bleeding (initiating) [4]; distorted uterus incompatible w/ IUD placement [4]; GTD: confirmed + persistently ↑beta-hCG or malignant dz, w/ evidence/suspicion of intrauterine dz (initiating) [4]
- Heme/Onc: endometrial CA (initiating) [4]; cervical CA, awaiting tx (initiating) [4]; current breast CA [4]; past breast CA w/o dz x5y [3]
- ID/Immune: current purulent cervicitis or GC/CT (initiating) [4]; PID current (initiating) [4]; pelvic TB (initiating) [4], (continuing) [3]
- Hepatic: hepatoma [3]
- CV: current/hx IHD (continuing, due to theoretical effect on lipids1) [3]
Consider implant (progestin). Effectiveness: 99.9%.2 Category [1].1 Generally safe/low risk, w/ the following exceptions (category may vary if initiating vs. continuing this method):3 - Heme/Onc: current breast CA [4]; past breast CA w/o dz x5y [3]
- Gyn: unexplained vag bleeding [3]
- CV: current/hx IHD (continuing, due to theoretical effect on lipids1) [3]; stroke (continuing) [3]
- Hepatic: hepatoma [3]
Footnotes 1 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
2 Centers for Disease Control and Prevention. Contraception and Birth Control Methods. Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024
3 Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024. PDF
Hormone-based pill/patch/ring/injectable preferred by pt Assess for appropriateness of progestin-only or combined (w/ estrogen) hormonal contraceptives.1 - Consider risk for adverse health events due to pregnancy. Medical conditions that might make pregnancy an unacceptable health risk include:
◦ CA: breast, endometrial, ovarian, hepatoma
◦ Neph: CKD w/ nephrotic syndrome, on hemodialysis, or on peritoneal dialysis
◦ CV/Resp: DVT/PE, HTN (systolic ≥160 or diastolic ≥100 mm Hg), IHD, peripartum cardiomyopathy, complicated valvular heart dz, CF, stroke
◦ Hepatic: hepatocellular adenoma, schistosomiasis w/ liver fibrosis, decompensated cirrhosis
◦ DM: insulin-dependent; >20-yr duration; or w/ nephropathy/retinopathy/neuropathy/other vascular dz
◦ Surgery hx: bariatric surgery in past 2y, solid organ txp in past 2y
◦ ID: HIV (not clinically well or not on ART); TB; schistosomiasis w/ liver fibrosis
◦ Neuro: epilepsy, DM neuropathy, stroke
◦ Heme: sickle cell dz, thrombogenic mutations
◦ Other: GTD, SLE
- Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.
◦ Internal (female) condoms may protect against STIs, but data limited. - Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.
Consider depot medroxyprogesterone acetate (DMPA). Effectiveness: 96%.2 Category: if 18-45 yo [1]; if <18 yo or >45 yo [2].3 Generally safe/low risk, w/ the following exceptions (category may vary if initiating vs. continuing this method): - Gyn: unexplained vag bleeding [3]3
- Heme/Onc: current breast CA [4], past breast CA w/o dz x5y [3]; SLE w/ severe thrombocytopenia (initiating) [3];3 thrombophilia: factor V Leiden mutation, prothrombin mutation, protein S, C, or antithrombin deficiencies, or antiphospholipid syndrome [3]; sickle cell dz: if severe and ↑thrombosis risk [3]1
- CV/Resp: DVT/PE hx +/- anticoag tx (ppx dose), w/ risk factors* [3]; current/hx IHD [3]; stroke [3]; multiple risk factors for CV dz: older age, smoking, DM, HTN, low HDL, high LDL, high TGs [3]; HTN: systolic ≥160 or diastolic ≥100 mm Hg or assoc w/ vascular dz [3];3 peripartum cardiomyopathy: NYHA class III/IV [3]1
- Immune: SLE: antiphospholipid antibody (+) or unknown [3], severe thrombocytopenia (initiating) [3];3 solid organ txp: on immunosuppressive tx w/ risks/hx of nontraumatic fx [3]; RA: on immunosuppressive tx w/ risks/hx of nontraumatic fx [3]1
- GI/Endo: DM: nephropathy, retinopathy, or neuropathy [3], >20-yr duration or other vascular dz [3]; severe cirrhosis [3]; liver tumors: hepatocellular adenoma/hepatoma [3]3
- Neph: CKD w/ nephrotic syndrome, hemodialysis, or peritoneal dialysis [3]3
Consider progestin-only pill. Effectiveness: 93%.2 Category [1].3 Generally safe/low risk, w/ the following exceptions (category may vary if initiating vs. continuing this method): - Onc: current breast CA [4], past breast CA w/o dz x5y [3]3
- CV: current/hx IHD (continuing, due to theoretical effect on lipids1) [3]; stroke (continuing) [3]3
- GI/Endo: malabsorption post bariatric surgery [3]; hepatoma [3]3
- Neph: CKD w/ nephrotic syndrome, hemodialysis, or peritoneal dialysis: if hyperkalemia [4]1
- Meds: anticonvulsants: phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine [3]; rifampin/rifabutin [3]3
Consider combination estrogen/progestin (CHC) (pill/patch/ring). Effectiveness: 93%.2 Category: if <40 yo [1]; if ≥40 yo [2].3 Generally safe/low risk, w/ the following exceptions (category may vary if initiating vs. continuing this method): - Post pregnancy: <21 days post partum [4]; breastfeeding: 21-30 days post partum, or 31-42 days post partum w/ VTE risk factors,† [3], nonbreastfeeding: 21-42 days post partum w/ VTE risk factors† [3]3
- Heme/Onc: current breast CA [4], past breast CA w/o dz x5y [3]; sickle cell dz [4];3 thrombophilia: factor V Leiden mutation, prothrombin mutation, protein S, C, or antithrombin deficiencies, or antiphospholipid syndrome [4]1
- CV/Resp: smoking: age ≥35 yo and <15 cigarettes/day [3], ≥15 cigarettes/day [4]; current/hx IHD [4]; stroke [4]; multiple risk factors for CV dz: older age, smoking, DM, HTN, low HDL, high LDL, high TGs [3][4]; HTN: [3], unless systolic ≥160 or diastolic ≥100 mm Hg or assoc w/ vascular dz [4]; valvular heart dz: complicated (pulmonary HTN, SBE hx, afib risk1) [4]; current/hx DVT/PE on anticoag tx (therapeutic dose) [3]; hx DVT/PE on anticoag tx (ppx dose): w/ risk factors* [4], w/o risk factors [3]; hx DVT/PE and no anticoag tx: w/ risk factors* [4], w/o risk factors [3]; superficial venous thrombosis [3],3 peripartum cardiomyopathy: NYHA class I/II and <6mo post partum [4] or ≥6mo post partum [3], NYHA class III/IV [4]1
- Neuro/Immune: SLE: antiphospholipid antibody (+) or unknown [4]; solid organ txp: graft failure [4]; MS w/ prolonged immobility [3]; major surgery w/ prolonged immobility [4]; migraine w/ aura [4]3
- GI/Endo: DM: if nephropathy, retinopathy, or neuropathy [3][4], if >20-yr duration or other vascular dz [3][4];3 IBD w/ VTE risk factors‡ [3];1 current gallbladder dz [3], hx gallbladder dz medically treated [3]; past COC-related cholestasis [3]; acute/flare viral hepatitis (initiating) [3][4]; severe cirrhosis [4]; liver tumors: hepatocellular adenoma/hepatoma [4]; malabsorption post bariatric surgery (COCs) [3]3
- Neph: CKD w/ nephrotic syndrome, hemodialysis, or peritoneal dialysis [4]3
- Meds: fosamprenavir [3]; anticonvulsants: phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine [3]; rifampin/rifabutin [3]3
Footnotes * DVT/PE risk factors:
• hx estrogen-assoc DVT/PE (if not on anticoag tx)
• pregnancy-assoc DVT/PE (if not on anticoag tx)
• idiopathic DVT/PE (if not on anticoag tx)
• thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; antiphospholipid syndrome)
• active CA (metastatic, on tx, or w/in 6mo of clinical remission), excluding nonmelanoma skin CA
• hx recurrent DVT/PE
Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
† Postpartum VTE risk factors:
• age ≥35 yo
• previous VTE
• thrombophilia
• immobility
• transfusion at delivery
• peripartum cardiomyopathy
• BMI ≥30 kg/m 2
• postpartum hemorrhage
• postcesarean delivery
• preeclampsia
• smoking
Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
‡ VTE risk factors w/ IBD:
• active/extensive dz
• surgery
• immobilization
• steroid use
• vit deficiencies
• fluid depletion
Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
Citations
1 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
2 Centers for Disease Control and Prevention. Contraception and Birth Control Methods. Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024
3 Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024. PDF
Barrier and/or behavioral methods preferred by pt Medical conditions that might make pregnancy an unacceptable health risk include:1 - CA: breast, endometrial, ovarian, hepatoma
- Neph: CKD w/ nephrotic syndrome, on hemodialysis, or on peritoneal dialysis
- CV/Resp: DVT/PE, HTN (systolic ≥160 or diastolic ≥100 mm Hg), IHD, peripartum cardiomyopathy, complicated valvular heart dz, CF, stroke
- Hepatic: hepatocellular adenoma, schistosomiasis w/ liver fibrosis, decompensated cirrhosis
- DM: insulin-dependent; >20-yr duration; or w/ nephropathy/retinopathy/neuropathy/other vascular dz
- Surgery hx: bariatric surgery in past 2y, solid organ txp in past 2y
- ID: HIV (not clinically well or not on ART); TB; schistosomiasis w/ liver fibrosis
- Neuro: epilepsy, DM neuropathy, stroke
- Heme: sickle cell dz, thrombogenic mutations
- Other: GTD, SLE
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.1 Consider diaphragm (w/ spermicide)/cervical cap. Effectiveness: 83% (diaphragm); 78% (cap).2 Category: if nulliparous [1]; if parous [2]. Generally safe/low risk, w/ the following exceptions:1 - Unsuitable anatomy: post partum until uterine involution complete; 6wk after 2nd-trimester ab; if cervical prolapse (diaphragm); if distorted cervical anatomy (cap)
- High risk for HIV, as repeated and high-dose use of spermicide nonoxynol-9 is assoc w/ ↑risk for genital lesions, which may ↑ HIV infection risk [4]
- HIV, as spermicide use may disrupt cervical mucosa, increasing viral shedding and HIV transmission [3]
- Latex allergy [3]
- Hx toxic shock syndrome [3]
Consider external (male) condom. Effectiveness: 87%.2 ↓ HIV and STI risk. Category [1]. Generally safe/low risk, w/ the following exceptions:1 Consider internal (female) condom. Effectiveness: 79%.2 May ↓ STI risk. Category [1]. Generally safe/low risk, w/ the following exceptions:1 Consider withdrawal method. Effectiveness: 78%. Consider fertility awareness–based methods. Effectiveness: 77% to 98%.2 Use is more complex in certain situations. - Sx -based (cervical mucus, symptothermal, TwoDay) methods:1
◦ Caution if: post menarchal, perimenopausal, breastfeeding ≥6wk/after menses resume, post ab, chronic dz w/ ↑body temp, using drugs that affect cycle regularity, hormones, or fertility signs.
◦ Delay/use other methods if: breastfeeding <6wk post partum, nonbreastfeeding <4wk post partum, irregular vaginal bleeding/discharge, acute dz w/ ↑body temp, using drugs that affect cycle regularity, hormones, or fertility signs. - Calendar-based method:1
◦ Caution if: post menarchal, perimenopausal, breastfeeding after menses begin (delay until after 3 postpartum menses + regular cycle resumes), using drugs that affect cycle regularity, hormones, or fertility signs.
◦ Delay/use other methods if: breastfeeding, post partum before 3rd menses, post ab before menses resume, irregular vaginal bleeding, using drugs that affect cycle regularity, hormones, or fertility signs. - Counseling points:1
◦ Caution that sx-based and calendar-based methods do not protect against STIs, including HIV.
Consider spermicide. Effectiveness: 79%.2 Category [1]. Generally safe/low risk, w/ the following exceptions:1 - High risk for HIV, as repeated and high-dose use of spermicide nonoxynol-9 is assoc w/ ↑risk for genital lesions, which may ↑ HIV infection risk [4]. But vaginal pH modulator safe for use [1].
- HIV, as spermicide use may disrupt cervical mucosa, increasing viral shedding and HIV transmission [3]. But vaginal pH modulator safe for use [1].
Consider lactational amenorrhea method. Effective only if all criteria met: amenorrhea, fully/nearly fully breastfeeding (<4-6h between feeds), <6mo post partum. Not appropriate if breastfeeding not recommended.1 - Breastfeeding not recommended if HIV, untreated brucellosis, HTLV I/II positive, HSV lesions on breast, Ebola virus dz, mpox, or use of specific drugs/radioactive compounds.
Footnotes 1 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
2 Centers for Disease Control and Prevention. Contraception and Birth Control Methods. Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024
Assess for appropriateness of tubal sterilization or vasectomy. Effectiveness: 99.5% (female)/99.85% (male). Consider risks and benefits compared w/ alternative (reversible) methods. Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk. - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.
Footnotes 1 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
Testosterone use and pregnancy risk Counsel that testosterone use might not prevent pregnancy among transgender, gender diverse, and nonbinary pts w/ a uterus. - Although certain testosterone regimens might suppress fertility, testosterone tx hasn’t been studied as contraception.
Offer contraceptive counseling and services to those who are at risk for and don’t desire pregnancy. - Evidence on safety and effectiveness of hormonal contraceptive use among transgender, gender diverse, and nonbinary pts w/ a uterus who are using testosterone is limited.
- Certain organizations provide info on contraceptive and reproductive health care for transgender, gender diverse, and nonbinary pts:
◦ World Professional Association for Transgender Health (WPATH) Standards of Care
◦ ACOG Committee Opinion on Health Care for Transgender and Gender Diverse Individuals
◦ American Society for Emergency Contraception – Emergency Contraception for Transgender and Nonbinary Pts
◦ Society of Family Planning Clinical Recommendations
Footnotes 1 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
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Ready to begin chosen method (IUD, implant, injection, pill, patch, ring, behavioral, sterilization, etc.) (nonemergency)
Can start anytime and use in all age groups.1 Review exceptions/contraindications to category [1]. Category may vary if initiating vs. continuing this method:2 - Pregnancy [4]
- Post pregnancy: postpartum sepsis [4]; immediate postseptic ab [4]
- Anatomic/Gyn: unexplained vag bleeding (initiating) [4]; distorted uterus incompatible w/ IUD placement [4]; GTD: confirmed + persistently ↑beta-hCG or malignant dz, w/ evidence/suspicion of intrauterine dz (initiating) [4]
- Heme/Onc: endometrial CA (initiating) [4]; cervical CA, awaiting tx (initiating) [4]; SLE w/ severe thrombocytopenia (initiating) [3]
- ID/Immune: current purulent cervicitis or GC/CT (initiating) [4]; PID current (initiating) [4]; pelvic TB: (initiating) [4], (continuing) [3]
Place Cu-IUD. Effectiveness: 99.2%.3 - Place anytime if reasonable certainty pt is not pregnant—i.e., has no pregnancy s/sx and meets any one of the following criteria:4
◦ ≤7 days after start of normal menses
◦ No sexual intercourse since start of last normal menses
◦ Correctly/consistently using reliable contraception
◦ ≤7 days post spontaneous/induced ab
◦ ≤4wk post partum
◦ Fully/nearly fully breastfeeding (≥85% of feeds) + amenorrheic + <6mo post partum - Routine pregnancy testing not required but may be considered.1
- Can place w/in 5 days of unprotected intercourse as ECP.1
◦ When day of ovulation can be estimated, can be placed >5 days after unprotected intercourse, providing this is not >5 days after ovulation. - Prior to placement, perform bimanual exam/cervical inspection + STI screen if at risk.4 Pts w/ known medical conditions may need additional exam/tests to determine if candidate for this method. Refer to CDC website for STI screening criteria and recommendations.5
- Consider baseline weight/BMI.4
- Counsel about potential changes in bleeding patterns.1
◦ Spotting/light bleeding and heavy/prolonged bleeding during the first 3-6mo of Cu-IUD use is common. Generally not harmful and ↓ w/ continued Cu-IUD use.
◦ However, if new-onset heavy/prolonged bleeding after a few months, consider factors such as Cu-IUD displacement, STI, pregnancy, thyroid d/o, or new pathologic uterine condition (e.g., polyps, fibroids). - Provision of meds for IUD placement1
◦ Misoprostol not recommended routinely but may be useful in selected circumstances—e.g., in pts w/ recent failed placement.
◦ Lidocaine (paracervical block or topical) for IUD placement may ↓ pain. - Prophylactic abx not recommended1
- No back-up contraception needed after placement1
- No routine f/u visit required; assess the following at other routine visits:4
◦ satisfaction/concerns w/ method
◦ health status changes
◦ presence of IUD strings
◦ weight changes
Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.6 - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.6
Footnotes 1 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
2 Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024. PDF
3 Centers for Disease Control and Prevention. Contraception and Birth Control Methods. Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024
4 Centers for Disease Control and Prevention. When to Start Contraceptive Methods and Routine Follow-Up. Centers for Disease Control and Prevention. Accessed August 8, 2024. PDF
5 Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. Centers for Disease Control and Prevention. Reviewed June 13, 2023. Accessed August 8, 2024
6 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
Can start anytime and use in all age groups.1 Review exceptions/contraindications to category [1]. Category may vary if initiating vs. continuing this method:2 - Pregnancy [4]
- Post pregnancy: postpartum sepsis [4]; immediate postseptic ab [4]
- Anatomic/Gyn: unexplained vag bleeding (initiating) [4]; distorted uterus incompatible w/ IUD placement [4]; GTD: confirmed + persistently ↑beta-hCG or malignant dz, w/ evidence/suspicion of intrauterine dz (initiating) [4]
- Heme/Onc: endometrial CA (initiating) [4]; cervical CA, awaiting tx (initiating) [4]; current breast CA [4]; past breast CA w/o dz x5y [3]
- ID/Immune: current purulent cervicitis or GC/CT (initiating) [4]; PID current (initiating) [4]; pelvic TB (initiating) [4], (continuing) [3]
- Hepatic: hepatoma [3]
- CV: current/hx IHD (continuing, due to theoretical effect on lipids3) [3]
Place LNG-IUD. Effectiveness: 99.6% to 99.9%.4 - Place anytime if reasonable certainty pt is not pregnant—i.e., has no pregnancy s/sx and meets any one of the following criteria:5
◦ ≤7 days after start of normal menses
◦ No sexual intercourse since start of last normal menses
◦ Correctly/consistently using reliable contraception
◦ ≤7 days post spontaneous/induced ab
◦ ≤4wk post partum
◦ Fully/near fully breastfeeding (≥85% of feeds) + amenorrheic + <6mo post partum - Routine pregnancy testing not required but may be considered.1
- Prior to placement, perform bimanual exam/cervical inspection + STI screen if at risk.5 Pts w/ known medical conditions may need additional exam/tests to determine if candidate for this method. Refer to CDC website for STI screening criteria and recommendations.6
- Consider baseline weight/BMI.5
- Counsel about potential changes in bleeding patterns.1
◦ Spotting/light bleeding expected during first 3-6mo of LNG-IUD use. Generally not harmful and ↓ w/ use; however, heavy/prolonged bleeding uncommon.
◦ If spotting/light bleeding or heavy/prolonged bleeding and clinically indicated, consider factors such as LNG-IUD displacement, STI, pregnancy, thyroid d/o, or new pathologic uterine condition (e.g., polyps, fibroids).
◦ If abrupt change to amenorrhea, r/o pregnancy if clinically indicated. - Provision of meds for IUD placement1
◦ Misoprostol not recommended routinely but may be useful in selected circumstances—e.g., in pts w/ recent failed placement.
◦ Lidocaine (paracervical block or topical) for IUD placement may ↓ pain. - Prophylactic abx not recommended1
- Back-up contraception/abstinence required x7 days after placement in certain situations. Use barrier method or abstain x7 days if:
◦ IUD placed >7 days after start of menses1
◦ amenorrheic (not post partum)1
◦ ≥21 days post partum and menses not returned1
◦ post partum, menses have returned, and >7 days since menstrual bleeding began1
◦ IUD placed following 1st- or 2nd-trimester ab3 (unless placed immediately after ab completion)1 - No routine f/u visit required; assess the following at other routine visits:5
◦ satisfaction/concerns w/ method
◦ health status changes
◦ presence of IUD strings
◦ weight changes
Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.3 - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.3
Footnotes 1 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
2 Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024. PDF
3 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
4 Centers for Disease Control and Prevention. Contraception and Birth Control Methods. Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024
5 Centers for Disease Control and Prevention. When to Start Contraceptive Methods and Routine Follow-Up. Centers for Disease Control and Prevention. Accessed August 8, 2024. PDF
6 Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. Centers for Disease Control and Prevention. Reviewed June 13, 2023. Accessed August 8, 2024
Review exceptions/contraindications to category [1]. Category may vary if initiating vs. continuing this method:1 - Heme/Onc: current breast CA [4]; past breast CA w/o dz x5y [3]
- Gyn: unexplained vag bleeding [3]
- CV: current/hx IHD (continuing, due to theoretical effect on lipids2) [3]; stroke (continuing) [3]
- Hepatic: hepatoma [3]
Place implant. Effectiveness: 99.9%.3 - Place anytime if reasonable certainty pt is not pregnant4—i.e., has no pregnancy s/sx and meets any one of the following criteria:5
◦ ≤7 days after start of normal menses
◦ No sexual intercourse since start of last normal menses
◦ Correctly/consistently using reliable contraception
◦ ≤7 days post spontaneous/induced ab
◦ ≤4wk post partum
◦ Fully/near fully breastfeeding (≥85% of feeds) + amenorrheic + <6mo post partum - Routine pregnancy testing not required but may be considered.4
- If pregnancy possible, consider starting anytime and obtain pregnancy test in 2-4wk.5
- If pt healthy, no exams/tests required before initiation.5
◦ Pts w/ known medical conditions may need additional exams/tests to determine if candidate for this method.4 - Consider baseline weight/BMI.5
- Counsel about potential changes in bleeding patterns.4
◦ Spotting/light bleeding common; certain users experience amenorrhea. Generally not harmful and may or may not ↓ w/ continued use; however, heavy bleeding uncommon.
◦ If spotting/light bleeding or heavy/prolonged bleeding and clinically indicated, consider factors such as interaction(s) w/ other med(s), STI, pregnancy, thyroid d/o, or new pathologic uterine condition (e.g., polyps, fibroids).
◦ If abrupt change to amenorrhea, r/o pregnancy if clinically indicated. - Back-up contraception/abstinence required x7 days after placement in certain situations. Use barrier method or abstain x7 days if:
◦ implant placed >5 days after start of menses4
◦ amenorrheic (not post partum)4
◦ ≥21 days post partum and menses not returned4
◦ post partum, menses have returned, and >5 days since menstrual bleeding began4
◦ implant placed following 1st- or 2nd-trimester ab2 (unless placed at time of ab)4 - For postpartum pts, barrier method/abstaining not needed if ALL of the following are met:4
◦ <6mo post partum
◦ amenorrheic
◦ fully/nearly fully breastfeeding (≥85% of feeds are breastfeeds) - For pts who are <21 days post partum and not breastfeeding, no additional contraception needed.4
- No routine f/u visit required; assess the following at other routine visits:5
◦ satisfaction/concerns w/ method
◦ health status changes
◦ weight changes
Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.2 - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.2 Tx options for bleeding irregularities4 - Hormonal tx (e.g., 20-30 mcg ethinyl estradiol COCs or estrogen)
◦ Bleeding likely to recur after tx cessation
◦ May repeat prn - Antifibrinolytic agents (e.g., tranexamic acid) x5 days
◦ Bleeding likely to recur after tx cessation
◦ May repeat prn - NSAIDs (e.g., celecoxib, ibuprofen, mefenamic acid) x5-7 days
◦ Effects may persist for some time after tx cessation
◦ May repeat prn - Selective estrogen receptor modulators (SERMs; e.g., tamoxifen) x7-10 days
◦ Effects may persist for some time after tx cessation
◦ May repeat prn
Footnotes 1 Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024. PDF
2 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
3 Centers for Disease Control and Prevention. Contraception and Birth Control Methods. Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024
4 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
5 Centers for Disease Control and Prevention. When to Start Contraceptive Methods and Routine Follow-Up. Centers for Disease Control and Prevention. Accessed August 8, 2024. PDF
Depot medroxyprogesterone acetate (DMPA) Review exceptions/contraindications to category [1]. Category may vary if initiating vs. continuing this method:1 - Gyn: unexplained vag bleeding [3]1
- Heme/Onc: current breast CA [4], past breast CA w/o dz x5y [3]; SLE w/ severe thrombocytopenia (initiating) [3];1 thrombophilia: factor V Leiden mutation, prothrombin mutation, protein S, C, or antithrombin deficiencies, or antiphospholipid syndrome [3]; sickle cell dz: if severe and ↑thrombosis risk [3]2
- CV/Resp: DVT/PE hx +/- anticoag tx (ppx dose), w/ risk factors* [3]; current/hx IHD [3]; stroke [3]; multiple risk factors for CV dz: older age, smoking, DM, HTN, low HDL, high LDL, high TGs [3]; HTN: systolic ≥160 or diastolic ≥100 mm Hg or assoc w/ vascular dz [3];1 peripartum cardiomyopathy: NYHA class III/IV [3]2
- Immune: SLE: antiphospholipid antibody (+) or unknown [3], severe thrombocytopenia (initiating) [3];1 solid organ txp: on immunosuppressive tx w/ risks/hx of nontraumatic fx [3]; RA: immunosuppressive tx w/ risks/hx of nontraumatic fx [3]2
- GI/Endo: DM: nephropathy, retinopathy, or neuropathy [3], >20-yr duration or other vascular dz [3]; severe cirrhosis [3]; liver tumors: hepatocellular adenoma/hepatoma [3]1
- Neph: CKD w/ nephrotic syndrome, hemodialysis, or peritoneal dialysis [3]1
Give injection. Effectiveness: 96%.3 - Give 1st injection anytime, providing reasonable certainty pt is not pregnant3—i.e., has no pregnancy s/sx and meets any one of the following criteria:4
◦ ≤7 days after start of normal menses
◦ No sexual intercourse since start of last normal menses
◦ Correctly/consistently using reliable contraception
◦ ≤7 days post spontaneous/induced ab
◦ ≤4wk post partum
◦ Fully/near fully breastfeeding (≥85% of feeds) + amenorrheic + <6mo post partum - Routine pregnancy testing not required but may be considered.3
- If pregnancy possible, consider starting anytime and obtain pregnancy test in 2-4wk.4
- If pt healthy, no exams/tests required before initiation.4
◦ Pts w/ known medical conditions may need additional exams/tests to determine if candidate for this method.3 - Consider baseline weight/BMI.4
- Offer self-administered DMPA subcutaneous injection as alternative, using shared decision-making.3
◦ May improve contraceptive access and ↑ reproductive autonomy
◦ Recommendations same as for clinician-administered DMPA
◦ No f/u needed
◦ Self-administration is “off-label”
◦ Higher rates of continuation vs. clinician-administered DMPA
◦ Pregnancy rates low, similar to clinician-administered DMPA
◦ May have higher rate of injection-site reactions but no ↑ in other side effects/adverse events - Counsel about potential changes in bleeding patterns.3
◦ Spotting/light bleeding common; heavy/prolonged bleeding can occur. Generally not harmful and may ↓ w/ continued use.
◦ If spotting/light bleeding or heavy/prolonged bleeding and clinically indicated, consider factors such as interaction(s) w/ other med(s), STI, pregnancy, thyroid d/o, or new pathologic uterine condition (e.g., polyps, fibroids).
◦ If abrupt change to amenorrhea, r/o pregnancy if clinically indicated. - Back-up contraception/abstinence required x7 days after injection in certain situations. Use barrier method or abstain x7 days if:
◦ initiated >7 days after start of menses3
◦ amenorrheic (not post partum)3
◦ ≥21 days post partum and menses not returned3
◦ post partum, menses have returned, and >7 days since menstrual bleeding began3
◦ initiated following 1st- or 2nd-trimester ab2 (unless injection given at time of ab)3 - For postpartum pts, barrier method/abstaining not needed if ALL of the following are met:3
◦ <6mo post partum
◦ amenorrheic
◦ fully/nearly fully breastfeeding (≥85% of feeds are breastfeeds) - For pts who are <21 days post partum and not breastfeeding, no additional contraception needed.3
- Provide repeat injection q3mo.3
◦ Can give up to 15wk from prior injection, although q13wk is recommended. - No routine f/u visit required; assess the following at other routine visits:4
◦ satisfaction/concerns w/ method
◦ health status changes
◦ weight changes
Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.2 - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.2
Footnotes * DVT/PE risk factors:
• hx estrogen-assoc DVT/PE (if not on anticoag tx)
• pregnancy-assoc DVT/PE (if not on anticoag tx)
• idiopathic DVT/PE (if not on anticoag tx)
• thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; antiphospholipid syndrome)
• active CA (metastatic, on tx, or w/in 6mo of clinical remission), excluding nonmelanoma skin CA
• hx recurrent DVT/PE
Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
Citations
1 Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024. PDF
2 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
3 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
4 Centers for Disease Control and Prevention. When to Start Contraceptive Methods and Routine Follow-Up. Centers for Disease Control and Prevention. Accessed August 8, 2024. PDF
Review exceptions/contraindications to category [1]. Category may vary if initiating vs. continuing this method:1 - Onc: current breast CA [4], past breast CA w/o dz x5y [3]1
- CV: current/hx IHD (continuing, due to theoretical effect on lipids2) [3]; stroke (continuing) [3]1
- GI/Endo: malabsorption post bariatric surgery [3]; hepatoma [3]1
- Neph: CKD w/ nephrotic syndrome, hemodialysis, or peritoneal dialysis: if hyperkalemia [4]2
- Meds: anticonvulsants: phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine [3]; rifampin/rifabutin [3]1
Start progestin-only pill. Effectiveness: 93%.3 - Start anytime if reasonable certainty pt is not pregnant3—i.e., has no pregnancy s/sx and meets any one of the following criteria:4
◦ ≤7 days after start of normal menses
◦ No sexual intercourse since start of last normal menses
◦ Correctly/consistently using reliable contraception
◦ ≤7 days post spontaneous/induced ab
◦ ≤4wk post partum
◦ Fully/near fully breastfeeding (≥85% of feeds) + amenorrheic + <6mo post partum - Routine pregnancy testing not required but may be considered.3
- If pregnancy possible, consider starting anytime and obtain pregnancy test in 2-4wk.4
- If pt healthy, no exams/tests required before initiation.4
◦ Pts w/ known medical conditions may need additional exams/tests to determine if candidate for this method.3 - Consider baseline weight/BMI.4
- Norethindrone or norgestrel POPs: Back-up contraception/abstinence required x2 days after initiation in certain situations. Use barrier method or abstain x2 days if:
◦ initiated >5 days after start of menses3
◦ amenorrheic (not post partum)3
◦ ≥21 days post partum and menses not returned3
◦ post partum, menses have returned, and >5 days since menstrual bleeding began3
◦ initiated following 1st- or 2nd-trimester ab2 (unless started at time of ab)3 - Drospirenone POPs: Back-up contraception/abstinence required x7 days after initiation in certain situations. Use barrier method or abstain x7 days if:
◦ initiated >1 day after start of menses3
◦ amenorrheic (not post partum)3
◦ ≥21 days post partum and menses not returned3
◦ post partum, menses have returned, and >1 day since menstrual bleeding began3
◦ initiated following 1st- or 2nd-trimester ab2 (unless started at time of ab)3 - For postpartum pts who are breastfeeding, barrier method/abstaining not needed if ALL of the following are met:3
◦ <6mo post partum
◦ amenorrheic
◦ fully/nearly fully breastfeeding (≥85% of feeds are breastfeeds) - For pts who are <21 days post partum and not breastfeeding, no additional contraception needed.3
- Provide up to 1-yr supply at initial/return visits.3
- No routine f/u visit required; assess the following at other routine visits:4
◦ satisfaction/concerns w/ method
◦ health status changes
◦ weight changes
Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.2 - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.2
Footnotes 1 Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024. PDF
2 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
3 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
4 Centers for Disease Control and Prevention. When to Start Contraceptive Methods and Routine Follow-Up. Centers for Disease Control and Prevention. Accessed August 8, 2024. PDF
Combined hormone (pill, patch, ring) Review exceptions/contraindications to category [1]. Category may vary if initiating vs. continuing this method:1 - Post pregnancy: <21 days post partum [4]; breastfeeding: 21-30 days post partum, or 31-42 days post partum w/ VTE risk factors* [3]; nonbreastfeeding: 21-42 days post partum w/ VTE risk factors* [3]
- Heme/Onc: current breast CA [4], past breast CA w/o dz x5y [3]; sickle cell dz [4];1 thrombophilia: factor V Leiden mutation, prothrombin mutation, protein S, C, or antithrombin deficiencies, or antiphospholipid syndrome [4]2
- CV/Resp: smoking: age ≥35 yo and <15 cigarettes/day [3], ≥15 cigarettes/day [4]; current/hx IHD [4]; multiple risk factors for CV dz: older age, smoking, DM, HTN, low HDL, high LDL, high TGs [3][4]; HTN: [3], unless systolic ≥160 or diastolic ≥100 mm Hg or assoc w/ vascular dz [4]; valvular heart dz: complicated (pulmonary HTN, SBE hx, afib risk2) [4]; current/hx DVT/PE on anticoag tx (therapeutic dose) [3]; hx DVT/PE on anticoag tx (ppx dose): w/ risk factors† [4], w/o risk factors† [3]; hx DVT/PE and no anticoag tx: w/ risk factors† [4], w/o risk factors† [3]; superficial venous thrombosis [3];1 peripartum cardiomyopathy: NYHA class I/II and <6mo post partum [4] or ≥6mo post partum [3], NYHA class III/IV [4]2
- Neuro/Immune: SLE: antiphospholipid antibody (+) or unknown [4]; solid organ txp: graft failure [4]; MS w/ prolonged immobility [3]; major surgery w/ prolonged immobility [4]; migraine w/ aura [4]1
- GI/Endo: DM: if nephropathy, retinopathy, or neuropathy [3][4], if >20-yr duration or other vascular dz [3][4];1 IBD w/ VTE risk factors‡ [3];2 current gallbladder dz [3], hx gallbladder dz medically treated [3]; past COC-related cholestasis [3]; acute/flare viral hepatitis (initiating) [3][4]; severe cirrhosis [4]; liver tumors: hepatocellular adenoma/hepatoma [4]; malabsorption post bariatric surgery (COCs) [3]1
- Neph: CKD w/ nephrotic syndrome, hemodialysis, or peritoneal dialysis [4]1
- Meds: fosamprenavir [3]; anticonvulsants: phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine [3]; rifampin/rifabutin [3]1
Start combined hormone (pill, patch, ring). Effectiveness: 93%.3 - Start anytime if reasonable certainty pt is not pregnant3—i.e., has no pregnancy s/sx and meets any one of the following criteria:4
◦ ≤7 days after start of normal menses
◦ No sexual intercourse since start of last normal menses
◦ Correctly/consistently using reliable contraception
◦ ≤7 days post spontaneous/induced ab
◦ ≤4wk post partum
◦ Fully/near fully breastfeeding (≥85% of feeds) + amenorrheic + <6mo post partum - Routine pregnancy testing not required but may be considered.3
- If pregnancy possible, consider starting anytime and obtain pregnancy test in 2-4wk.4
- If pt healthy, few exams/tests required before initiation.3
◦ Measure BP before initiation.4
◦ Consider baseline weight/BMI.4
◦ Pts w/ known medical conditions may need additional exams/tests to determine if candidate for this method.3 - Counsel about potential changes in bleeding patterns.3
◦ Spotting/light bleeding common during first 3-6mo. Generally not harmful and may ↓ w/ continued use.
◦ If clinically indicated, consider factors such as inconsistent use, interaction(s) w/ other med(s), cigarette smoking, STI, pregnancy, thyroid d/o, or new pathologic uterine condition (e.g., polyps, fibroids). - Back-up contraception/abstinence required x7 days after initiation in certain situations. Use barrier method or abstain x7 days if:
◦ initiated >5 days after start of menses3
◦ amenorrheic (not post partum)3
◦ ≥21 days post partum and menses not returned3
◦ post partum, menses have returned, and >5 days since menstrual bleeding began3
◦ initiated following 1st- or 2nd-trimester ab2 (unless started at time of ab)3 - For postpartum pts who are breastfeeding, barrier method/abstaining not needed if ALL of the following are met:3
◦ <6mo post partum
◦ amenorrheic
◦ fully/nearly fully breastfeeding (≥85% of feeds are breastfeeds) - For pts who are <21 days post partum and not breastfeeding, no additional contraception needed.3
- Provide up to 1-yr supply at initial/return visits.3
- No routine f/u visit required; assess the following at other routine visits:4
◦ satisfaction/concerns w/ method
◦ health status changes
◦ BP
◦ weight changes
Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.2 - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.2
Footnotes * Postpartum VTE risk factors:
• age ≥35 yo
• previous VTE
• thrombophilia
• immobility
• transfusion at delivery
• peripartum cardiomyopathy
• BMI ≥30 kg/m 2
• postpartum hemorrhage
• postcesarean delivery
• preeclampsia
• smoking
Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
† DVT/PE risk factors:
• hx estrogen-assoc DVT/PE (if not on anticoag tx)
• pregnancy-assoc DVT/PE (if not on anticoag tx)
• idiopathic DVT/PE (if not on anticoag tx)
• thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; antiphospholipid syndrome)
• active CA (metastatic, on tx, or w/in 6mo of clinical remission), excluding nonmelanoma skin CA
• hx recurrent DVT/PE
Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
‡ VTE risk factors w/ IBD:
• active/extensive dz
• surgery
• immobilization
• steroid use
• vit deficiencies
• fluid depletion
Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
Citations
1 Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024. PDF
2 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
3 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
4 Centers for Disease Control and Prevention. When to Start Contraceptive Methods and Routine Follow-Up. Centers for Disease Control and Prevention. Accessed August 8, 2024. PDF
Barrier methods (condom, spermicide, diaphragm) Review exceptions/contraindications to category [1]:1 - Diaphragm:
◦ Unsuitable anatomy: post partum until uterine involution complete; 6wk after 2nd-trimester ab; if cervical prolapse (diaphragm); if distorted cervical anatomy (cap)
◦ High risk for HIV, as repeated and high-dose use of spermicide nonoxynol-9 is assoc w/ ↑risk for genital lesions, which may ↑ HIV infection risk [4]
◦ HIV, as spermicide use may disrupt cervical mucosa, increasing viral shedding and HIV transmission [3]
◦ Latex allergy [3]
◦ Hx toxic shock syndrome [3] - Spermicide:
◦ High risk for HIV, as repeated and high-dose use of spermicide nonoxynol-9 is assoc w/ ↑risk for genital lesions, which may ↑ HIV infection risk [4]. But vaginal pH modulator safe for use [1].
◦ HIV, as spermicide use may disrupt cervical mucosa, increasing viral shedding and HIV transmission [3]. But vaginal pH modulator safe for use [1]. - External (male) and internal (female) condoms:
◦ Latex allergy [3]
Start barrier method. Effectiveness: diaphragm, 83%; external (male) condom, 87%; internal (female) condom, 79%; spermicide, 79%.2 - No exams or tests required before use of condom, spermicide, or vaginal pH modulator3
- Bimanual exam needed for diaphragm fitting3
- Bimanual exam and cervical inspection needed for cervical cap fitting3
Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.1 - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.1
Footnotes 1 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
2 Centers for Disease Control and Prevention. Contraception and Birth Control Methods. Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024
3 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
Fertility awareness, lactational amenorrhea, coitus interruptus (withdrawal) Review effectiveness/limitations: - Effectiveness: fertility awareness (77%-98%);1,2 coitus interruptus (78%)
- Lactational amenorrhea highly effective only if all conditions met: amenorrhea; fully/nearly fully breastfeeding (<4-6h between feeds);2 <6mo post partum3
◦ Breastfeeding not recommended if HIV, untreated brucellosis, HTLV I/II positive, HSV lesions on breast, Ebola virus dz, mpox, or use of specific drugs/radioactive compounds.3
Fertility-awareness methods cautions: - Sx-based (cervical mucus, symptothermal, TwoDay) methods:3
◦ Caution if: post menarchal, perimenopausal, breastfeeding ≥6wk/after menses resume, post ab, chronic dz w/ ↑body temp, using drugs that affect cycle regularity, hormones, or fertility signs.
◦ Delay/use other methods if: breastfeeding <6wk post partum, nonbreastfeeding <4wk post partum, irregular vaginal bleeding/discharge, acute dz w/ ↑body temp, using drugs that affect cycle regularity, hormones, or fertility signs. - Calendar-based method:3
◦ Caution if: post menarchal, perimenopausal, breastfeeding after menses begin (delay until after 3 postpartum menses + regular cycle resumes), using drugs that affect cycle regularity, hormones, or fertility signs.
◦ Delay/use other methods if: breastfeeding, post partum before 3rd menses, post ab before menses resume, irregular vaginal bleeding, using drugs that affect cycle regularity, hormones, or fertility signs. - Counseling points:3
◦ Caution that sx-based and calendar-based methods do not protect against STIs, including HIV.
Start chosen method.3 - Advise consistent condom use.
◦ Consistent and correct use of external (male) latex condoms ↓ HIV and STI risk.
◦ Internal (female) condoms may protect against STIs, but data limited. - Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.
Footnotes 1 Centers for Disease Control and Prevention. Contraception and Birth Control Methods. Centers for Disease Control and Prevention. August 6, 2024. Accessed August 8, 2024
2 Kennedy KI, et al. Consensus Statement on the Use of Breastfeeding as a Family Planning Method. Contraception. 1989 May;39(5):477-96. PubMed® abstract
3 Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(4):1-126. PDF
Sterilization (male, female) Sterilization may be achieved by hysteroscopic, laparoscopic, or abdominal approach in females, or by vasectomy in males. Intended to be irreversible. Effectiveness: female (99.5%); male (99.85%). - Counsel that sterilization is intended to be permanent and does not protect against STIs.
- After laparoscopic/abdominal sterilization: No additional contraception needed.
- After vasectomy: Advise additional contraception needed until semen analysis confirms success at 8-16wk post procedure.
- After vasectomy: Advise to avoid ejaculating x1wk.
Counsel that consistent and correct use of external (male) latex condoms ↓ HIV and STI risk. - Internal (female) condoms may protect against STIs, but data limited.
Counsel that pre-exposure ppx, when taken as prescribed, is highly effective for preventing HIV infection.
Footnotes 1 Curtis KM, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024 Aug 8;73(3):1-77. PDF
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