What Is the Safest Contraceptive Method for Your Patient?
On May 28, 2010, the Centers for Disease Control and Prevention (CDC) issued new practice guidelines for the safe use of contraceptives.1 These are recommendations for or against certain contraceptive methods according to the patient characteristics and specific medical conditions. Based on World Health Organization (WHO) recommendations, 2 the document was modified for US practitioners and their patients. The guidelines were developed by OB/GYNs, pediatricians, family physicians, nurse-midwives, nurse practitioners, epidemiologists, and other experts.
Many factors should be considered when choosing the appropriate contraceptive. The CDC practice guidelines focus primarily on the safety of a given modality for an individual but do not necessarily imply that the method is the best choice for that person. Other factors, such as effectiveness, availability, and acceptability are also important in optimizing the choice. The CDC guidelines can help guide providers in personalizing this important component of women’s care. The Table discusses the meaning of and precautions for each category applied to all contraceptive methods.
Postpartum Patients
No hormonal or intrauterine devices (IUDs) are off limits postpartum, except for IUDs in women who have had puerperal sepsis. For women who are at least 1 month postpartum, the methods with the strongest recommendations (category 1) for breastfeeding women include the progestin-only pill (POP), depot medroxyprogesterone acetate (DMPA) injections, etonogestrel implants, and the copper intrauterine device (Cu-IUD); the combined oral contraceptive/patch/ ring (COC/P/R) and levo norgestrelreleasing intrauterine device (LNGIUD) are category 2, because their advantages are considered to generally outweigh their risks. For women who are not breastfeeding, the recommendations are the same, except that COC/P/R becomes category 1 after 21 weeks postpartum.
In the immediate postpartum period (up to 1 month), POP, DMPA, and implants are category 2 and COC/P/R are category 3.
Immediate postpartum Cu-IUD insertion is associated with a lower expulsion rate compared with delayed insertion up to 72 hours postpartum. There are no data examining times beyond 72 hours, and no evidence is available comparing different insertion times for the LNG-IUD.
Reproductive Tract Disorders
The preferred methods of contraception are detailed according to vaginal bleeding patterns, endometriosis, reproductive tract malignancies, benign tumors, gestational trophoblastic disease, cervical neoplasias and ectropion, uterine fibroids, anatomic abnormalities, pelvic inflammatory disease (PID), and sexually transmitted infections (STIs).
For most of these conditions, all contraceptive choices are acceptable. The exceptions are:
- Unexplained vaginal bleeding (suspicious for a serious condition)—IUDs are not recommended
- Gestational trophoblastic disease with persistently elevated beta-hCG levels or malignancy—IUDs are not recommended
- Cervical cancer (awaiting treatment)— initiation of IUDs is not recommended but continuation is acceptable
- Breast cancer—for current patients with cancer and those with a history of breast cancer, no hormonal contraception or LNG-IUD is considered safe; instead, the Cu-IUD is recommended (category 1); for women with breast cancer, hormonal methods and LNG-IUD pose unacceptable risk (category 4); for women without active disease for at least 5 years, the risks still outweigh the benefits (category 3)
- Patients with ovarian cancer—hormonal methods are safe (category 1); IUDs should not be used
- Anatomic abnormalities—IUDs should not be used for women with distorted uterine cavities; for those with other abnormalities not distorting the uterine cavity or interfering with IUD insertion, IUDs are acceptable (category 2)
- PID—is a contraindication for initiating an IUD but continuation of IUD is acceptable; for women with a history of PID (assuming no current risks for STIs), all contraceptive methods are category 1
- STIs—women with current purulent cervicitis, chlamydial infection, or gonorrhea should not be started on an IUD but continuation is acceptable; it is controversial to initiate an IUD in women at increased risk for STIs (category 2/3), although continuation is acceptable (category 2).
Thromboembolism
For women with a history of deepvenous thrombosis (DVT) or pulmonary embolism (PE) who are not receiving anticoagulant therapy, Cu- IUD is considered the safest method (category 1). This is true for women deemed at high risk for recurrent DVT/PE (ie, at least 1 risk factor) and at lower risk (ie, no risk factors). Risk factors in clude history of estrogenassociated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, known thrombophilia, and active cancer (ie, metastatic, on therapy, or within 6 months after clinical remission). COC/P/R has category 4 status for the higher-risk group and for patients with acute DVT/PE, and category 3 status for the lower-risk group. All other methods are category 2.
For patients using anticoagulant therapy for at least 3 months, all methods are category 2 (including Cu-IUD), except COC/P/R, which is not recommended at all (category 4) in higherrisk patients and is category 3 in lowerrisk patients.
For women with a first-degree relative with DVT/PE and for those with superficial venous thrombosis, all methods are acceptable. This is also the case for women undergoing minor or major surgery that does not require immobilization. Should prolonged immobilization be necessary, however, these patients should avoid COC/P/R, as should women with known thrombogenic mutations, such as factor von Leiden and antithrombin deficiencies.
Cardiovascular Issues
COC/P/R should not be prescribed to women with current ischemic heart disease, a history of ischemic heart disease or stroke, complicated valvular heart disease (ie, pulmonary hypertension, risk for atrial fibrillation, or history of subacute bacterial endocarditis), or peripartum cardiomyopathy.
This method is more controversial (category 2/3) for women with known hyperlipidemia. All other methods are acceptable in these groups and for women with uncomplicated valvular heart disease.
Any method is acceptable for women with diabetes that is nonvascular (insulin-dependent or non–insulindependent) or in those with a history of gestational diabetes, but COC/P/R should not be prescribed to patients with diabetes of at least 20 years duration, other vascular conditions, or complications from diabetes. Other methods are acceptable, but only the Cu-IUD is category 1.
For women with multiple risk factors for cardiovascular disease (eg, older age, smoking, diabetes, hypertension), COC/P/R is not recommended, nor is DMPA. The POP, etonogestrel implants, and LNG-IUD are acceptable (category 2), but the Cu-IUD is preferred (category 1).
Women with hypertension—whether adequately controlled or not—should not receive COC/P/R (category 3/4), but those with a history of high blood pressure during pregnancy can be prescribed any method.
Rheumatic Diseases
Systemic lupus erythematosus (SLE) with positive or unknown antiphospholipid antibodies is a contraindication for COC/P/R (category 4), for POP (category 3), and for LNG-IUD (category 3). The Cu-IUD is a safe (category 1) option in this group. For patients with SLE and severe thrombocytopenia, DMPA and LNG-IUD should be avoided. For SLE patients on immunosuppressive treatment and for those without antibodies or severe throm bocytopenia, any method is acceptable. For patients with rheumatoid arthritis, POP, etonogestrel implants, and IUDs are safe (category 1); COC/P/R is category 2; and DMPA is controversial.
Neurologic Conditions
Any method is acceptable for women with headaches that are not migrainous, but those with migraines should probably avoid COC/P/R. This method is contraindicated for migraine with aura, as is POP. For women without aura who are older than 35 years, COC/P/R is also contraindicated, but the recommendation is less stringent for younger women (category 2/3). The Cu-IUD is the only method with a category 1 recommendation in these women. All methods are considered safe for women with epilepsy or depression, although providers should consult the CDC document for possible drug interactions with anticonvulsants.
Cigarette Smokers
The only method not recommended for these women is COC/P/R for those aged ≥35 years who smoke ≥15 cigarettes daily (category 4) or <15 cigarettes daily (category 3). Younger women who smoke can receive a COC/P/R (category 2), although other methods are preferable (all category 1).
Miscellaneous Conditions
A number of conditions are common among women and can affect the choice of contraception. Although COC/P/R is acceptable for women with inflammatory bowel disease, there is some controversy (category 2/3); all other methods are category 2, but the Cu-IUD is the preferred choice.
All methods are safe (category 1) for women with thyroid disorders, those with chronic viral hepatitis or those who are carriers and have mild cirrhosis, women taking antimicrobial therapy (except rifampicin or rifabutin, in which case DMPA and IUDs are preferred), and those with irondeficiency anemia.
For women with HIV infection or AIDS, or those at risk for HIV, all hormonal methods are safe (category 1) and IUDs are category 2. There are some pos sible drug interactions with antiretroviral therapy, and the CDC guidelines should be consulted on this issue.
References
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promo tion; Centers for Disease Control and Prevention, Farr S, Folger SG, Paulen M, et al. U.S. medical eligibility criteria for contraceptive use, 2010: adapted from the World Health Organization. Medical Eligibility Criteria for Contraceptive Use, 4th ed. MMWR Recomm Rep. 2010;59:1-86. www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf. Accessed July 18, 2010.
- Department of Reproductive Health, World Health Organization. Medical Eligibility Criteria for Contracep tive Use, 4th ed, 2009. Geneva, Switzerland: World Health Organization; 2009. www.who.int/reproductivehealth/publications/family_planning/978924156388.... Accessed July 16, 2010.