DR QASBA is Family Planning Fellow, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut. She has no conflict of interest to report in respect to the content of this article.
DR STANWOOD is Section Chief, Family Planning, and Director, Fellowship in Family Planning, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut. She reports receiving salary/honoraria from Merck.
As ob/gyns, one of our most important preventative health interventions is providing effective contraceptive care. Family planning allows a woman to choose if and when to have a pregnancy that is planned and hopefully healthy.
For women with underlying medical conditions, the decision of if and when to become pregnant presents us with greater complexity both in preconception counseling and in selecting a contraceptive method that is safe. The woman with long standing insulin-dependent diabetes with resultant impaired renal function and vascular disease requires careful preconception counseling. This includes understanding the contraindications to common contraceptive methods if she feels that now is not the time to become pregnant.
For some medications, we can rely on FDA labels to include evidence-based contraindications. This is not the case, however, for many hormonal contraceptive methods. With the FDA’s policy of attaching “class labeling” to categories of medications, all hormonal methods are labeled with the contraindications to estrogen, including the progestin-only methods.1-3
Fortunately, the US Centers for Disease Control and Prevention (CDC) has developed an evidence-based guide for busy clinicians in approaching contraceptive options. The CDC’s US Medical Eligibility Criteria for Contraceptive Use (MEC), adapted from guidance developed by the World Health Organization (WHO) and first issued in May 2010 and updated in July 2016, provides structured guidance on choosing a safe contraception method based on women’s medical conditions.4 The American College of Obstetricians and Gynecologists (ACOG) has endorsed the US MEC guidelines.5
MEC categories in practice
Contraceptive methods are classified into 4 categories based on their safety in specific medical conditions. The categories are:
1. No restriction (method can be used)
2. Advantages generally outweigh theoretical or proven risks
3. Theoretical or proven risks usually outweigh the advantages
4. Unacceptable health risk (method not to be used)
The CDC also released an update to the US Selected Practice Recommendations for Contraceptive Use (SPR) in July 2016, also based on WHO guidance, as a companion to the MEC.6 While the MEC assists in determining what methods are safe, the SPR focuses on how to use those methods most effectively. It addresses important issues such as:
• What information or screening is needed before method initiation
• How to implement “quick start”
• How soon the woman can rely on the method to protect against pregnancy
• What routine follow-up, if any, is recommended
• How to manage common problems and side effects
Following are 2 cases that will allow you to apply the clinical guidelines of the MEC and the SPR to illustrate their use. We present the most effective contraceptive options first.