EXECUTIVE SUMMARY
Updates to the U.S. Medical Eligibility Criteria for Contraceptive Use 2016 (US MEC 2016) and the U.S. Selected Practice Recommendations for Contraceptive Use 2016 (US SPR 2016) have just been released.
- The 2016 US MEC contains more than 1,800 recommendations for more than 60 conditions. New additions include recommendations for women with cystic fibrosis, women with multiple sclerosis, and women using certain psychotropic drugs or St. John’s wort, as well as revisions to the recommendations for emergency contraception, including the addition of ulipristal acetate.
- The 2016 US SPR Includes New Recommendations For Medications To Ease Iud Insertion. Recommendations Also Have Been Updated Regarding When To Start Regular Contraception After Emergency Contraceptive Use Of Ulipristal Acetate.
Time to update your practice. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 (US MEC 2016) and the U.S. Selected Practice Recommendations for Contraceptive Use, 2016 (US SPR 2016) have new information.1,2
The CDC published the first guidance to provide recommendations on the safe use of contraceptive methods for women with various medical conditions and other characteristics in 2010.3 It was adapted from global guidance developed by the WHO. The new US MEC 2016 contains more than 1,800 recommendations for more than 60 conditions, says Kathryn Curtis, PhD, a health scientist in the CDC’s Women’s Health and Fertility Branch in the Division of Reproductive Health. Curtis recently presented on the updates at the 2016 National Reproductive Health Conference in Chicago.3
In formatting the 2016 US MEC, the decision was made to list methods in order of contraceptive effectiveness. Other notable updates to the guidance include the following:
- the addition of recommendations for women with cystic fibrosis, women with multiple sclerosis, and women using certain psychotropic drugs or St. John’s wort;
- revisions to the recommendations for emergency contraception, including the addition of ulipristal acetate;
- revisions to the recommendations for postpartum women, women who are breastfeeding, and women with known dyslipidemias, migraine headaches, superficial venous disease, gestational trophoblastic disease, STIs, HIV, or who are using antiretroviral therapy.
“The US MEC can help providers decrease barriers to choosing contraceptive methods,” notes Curtis. “Most women can safely use most contraceptive methods.”
Certain conditions are associated with increased risk for adverse health events as a result of unintended pregnancy, says Curtis. Women, men, and couples should be informed of the full range of methods to decide what will be best for them, she advises.
The 2016 updated guidance from the CDC regarding contraception will be an important resource for clinicians who provide care to reproductive-age women, says Andrew Kaunitz, MD, University of Florida Research Foundation professor and associate chairman of the department of obstetrics and gynecology at the University of Florida College of Medicine–Jacksonville. The 2016 recommendations include new guidance for women with cystic fibrosis, multiple sclerosis, and those taking certain psychotropic drugs, as well as St. John’s wort, he notes.
Clinicians who previously have not used CDC contraceptive guidance may find the color-coordinated Summary Chart available at the CDC website easiest to use, observes Kaunitz. For providers who don’t have the free US MEC/SPR app or guidance links bookmarks, the guidance is easy to find online by typing “CDC contraception” into a search engine, Kaunitz notes.
Changes to US SPR
The 2016 US SPR includes new recommendations for medications to ease the insertion of IUDs, notes Curtis.Misoprostol is not recommended for routine use before IUD insertion; however, it might be helpful in select circumstances, such as with women who have a recently failed insertion. A paracervical block with lidocaine might reduce patient pain during IUD insertion, the guidance notes.2
Recommendations also have been updated regarding when to start regular contraception after ulipristal acetate (UPA) emergency contraceptive pills:
- Advise the woman to start or resume hormonal contraception no sooner than five days after UPA use, and provide or prescribe the regular contraceptive method as needed. For methods requiring a visit to a healthcare provider, such as depo-medroxyprogesterone acetate, implants, and IUDs, starting the method at the time of UPA use may be considered. The risk that the regular contraceptive method might decrease the effectiveness of UPA must be weighed against the risk of not starting a regular hormonal contraceptive method, the guidance notes.
- Counsel the woman to abstain from sexual intercourse or use barrier contraception for the next seven days after starting or resuming regular contraception or until her next menses, whichever comes first.
- Any nonhormonal contraceptive method can be started immediately after the use of UPA.
- Advise the woman to have a pregnancy test if she does not have a withdrawal bleed within three weeks.2
6 Points to Remember
What are the take-home messages from the 2016 US SPR? Curtis lists the following:
- The guidance can help providers decrease medical barriers to initiating and using contraception.
- Most women can start most methods anytime.
- Few, if any, exams or tests are needed.
- Recommendations for anticipatory counseling for potential bleeding problems and proper management are provided.
- Routine follow-up generally is not required.
- Regular contraception should be started after emergency contraception.3
The CDC offers a wide array of resources that include the updated guidance documents on its website, http://bit.ly/29BzoSa. This page guides clinicians to the US MEC (http://bit.ly/2a5JdWN) and the US SPR (http://bit.ly/29KwzPB), as well as the 2016 US MEC and US SPR 2016 app, an easy-to-use reference that combines information from both CDC family planning guidances. The app features a streamlined interface so providers can access guidance information quickly and easily.
Another handy online resource is a one-page provider tool that contains quick information from the US SPR on how to be reasonably certain that a woman is not pregnant, when to start using a specific contraceptive method, and how to provide routine follow-up after contraceptive initiation.
An additional one-page tool contains recommended actions after a late or missed combined oral contraceptive, recommended actions after delayed application or detachment with a combined hormonal patch, and recommended actions after delayed insertion or reinsertion with a combined hormonal ring.
Two diagrams from the US SPR 2016 are included in a one-page tool to guide management of women with bleeding irregularities while using contraception, as well as the management of an IUD when a copper IUD or a levonorgestrel IUD user is found to have pelvic inflammatory disease (PID). All the materials are free. Information on ordering free materials is included on the web pages.
Research Gaps Remain
While the US MEC 2016 and US SPR 2016 are based on the latest clinical evidence, there are still knowledge gaps when it comes to certain subjects, according to scientists who participated in the documents’ publication.4
The current evidence leaves many important questions unanswered concerning the timing of IUD placement after treatment for STIs or PID, the researchers note. At the 2015 expert meeting to update the US MEC and US SPR, the group of family planning experts, along with CDC scientists, determined that the evidence was insufficient to make any recommendations. The current practice to wait three months after treatment for IUD insertion is based on the prescribing information; however, further research may help increase access to IUDs if studies determine that IUDs can be inserted safely sooner.4
Evidence also is lacking when it comes to safety issues of possible interactive effects of hormonal contraceptives and commonly used medications for behavioral or psychological disorders, according to the US MEC. After reviewing the evidence, the CDC added new recommendations for selective serotonin reuptake inhibitors to the drug interactions section of the 2016 US MEC. Due to the dearth of published research evaluating the safety of co-administration of most individual psychotropic drugs with hormonal contraceptives, the 2016 guidance does not include recommendations for any other category of psychotropic drugs.
The classifications for progestin-only contraceptive (POC) use in the 2010 US MEC were drawn from the understanding that such use generally is safe with respect to concerns about thromboembolism. However, emerging evidence raises potential concerns, and additional work on this issue is needed, the researchers note.
“Based on the evidence from the systematic review and additional background information on thrombosis risk among women of reproductive age, CDC determined that there was not sufficient evidence to change recommendations for use of POCs related to thrombosis risk at this time,” the scientists write. “Additional evidence of high quality is needed to inform recommendations for POC use among women who have risk factors for thrombosis.”
REFERENCES
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65(3):1-103.
- Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65(4):1-66.
- Curtis KM. Contraceptive resources from CDC: 2016 US MEC and US SPR updates. Presented at the 2016 National Reproductive Health Conference. Chicago; July 2016.
- Horton LG, Folger SG, Berry-Bibee E, et al. Research gaps from evidence-based contraception guidance: The U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 and the U.S. Selected Practice Recommendations for Contraceptive Use, 2016. Contraception 2016; doi: 10.1016/j.contraception.2016.07.017.
