U.S. Medical Eligibility Criteria for Contraceptive Use, 2024: A Guide to the Guidance

This describes CDC's 2024 edition of the guidance, which replaced the 2016 edition. The full recommendations are in the report's appendix tables; check CDC's contraceptive guidance pages for the current version. It is guidance for health care providers, not advice for an individual — talk to a provider about your own situation.

The U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) tells health care providers which contraceptive methods can be used safely by people with particular characteristics — age, for instance, or having recently given birth — or medical conditions such as diabetes or high blood pressure. Its stated aims are to remove medical barriers to contraception that are not needed, and to support counselling and services that centre on the person and involve no coercion.

It has a companion, the U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), on how to provide methods and manage side effects and problems. Both were adapted from World Health Organization (WHO) guidance, which was written for countries and programs to adapt. CDC first published U.S. MEC in 2010, after adapting the WHO guidance during 2008–2010, and updated it in 2016.

What changed in 2024

• New: recommendations for people with chronic kidney disease — nephrotic syndrome, hemodialysis and peritoneal dialysis.
• Revised: recommendations for breastfeeding, postpartum and postabortion; obesity; surgery; a history of deep venous thrombosis or pulmonary embolism, with or without anticoagulant therapy; thrombophilia; superficial venous thrombosis; valvular heart disease; peripartum cardiomyopathy; systemic lupus erythematosus; cirrhosis; liver tumour; sickle cell disease; and solid organ transplantation.
• Revised in 2020 and included: recommendations for people at high risk for HIV infection, and for drug interactions with antiretrovirals now covering HIV prevention as well as treatment.
• New methods: new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills and levonorgestrel intrauterine devices (IUDs), and the vaginal pH modulator.

The document uses gender-inclusive language throughout, except where it reports studies that described their participants by gender.

How it was made

Since 2016, CDC and WHO have watched for new research through a shared system, Continuous Identification of Research Evidence, which runs automated PubMed searches every week so that reviews and recommendations can be updated as evidence warrants. For this edition CDC checked every 2016 recommendation against the new evidence.

• Public comment. A Federal Register notice on August 19, 2021, invited suggestions until October 18, 2021; CDC received 46 submissions from members of the public, professional organisations, academic institutions and industry.
• Scoping. Virtual meetings in January 2022 brought together 27 invited participants with expertise in contraception, adolescent health and thrombosis, and partner organisations, to decide what to update. Everything not chosen was judged up to date.
• Evidence reviews. CDC staff and invited authors wrote systematic reviews on each topic, following PRISMA reporting guidelines and rating the certainty of evidence with the GRADE approach as high, moderate, low or very low. Where direct evidence was thin, indirect evidence and theoretical concerns were weighed.
• Patient voices. In November and December 2022, listening sessions with 18 people, speaking for themselves or for patient advocacy organisations, covered the experiences and needs of young people, LGBTQI+ people, people with disabilities and people with chronic conditions.
• Expert meeting. In Atlanta on January 25–27, 2023, 40 invited participants — clinicians, researchers, reproductive justice experts and two patient representatives — gave their individual views on the evidence, with six topic specialists (a kidney disease expert, for example) joining for their subjects only.
• Decision and review. CDC then set the recommendations itself, and four outside reviewers who had not attended the meetings commented on their accuracy, feasibility and clarity.

Participants' potential conflicts of interest were collected and published with the report; none was excluded for them, and the CDC staff who decided the recommendations reported no relevant commercial ties. CDC will keep monitoring evidence with WHO, review the guidance periodically, and publish updates in MMWR and on its website. It also notes that evidence on many conditions is limited and that studies have not always included the full range of people who use contraception.

The four categories

Each condition is rated, for each method, in one of four categories.

The report's own example is smoking and combined oral contraceptives:

• a person under 35 who smokes can generally use them (category 2);
• for a person 35 or older who smokes fewer than 15 cigarettes a day, they are usually not recommended (category 3);
• a person 35 or older who smokes 15 or more a day should not use them, mainly because of the risk of heart attack and stroke (category 4).

Ratings can differ for starting a method and continuing it — which matters when a condition appears or worsens while someone is already using it. The recommendations concern contraception only, not the use of these methods to treat medical conditions. Health systems may apply the categories differently; in some, category 3 may call for a special consultation.

The tables cover IUDs (copper and levonorgestrel); progestin-only methods (implants, depot medroxyprogesterone acetate injections and progestin-only pills); combined hormonal methods (pills, patches and vaginal rings); barrier methods (external and internal condoms, spermicides and the vaginal pH modulator, and the diaphragm or cervical cap with spermicide); fertility awareness–based methods; the lactational amenorrhea method; withdrawal; tubal surgery and vasectomy; and emergency contraception (the copper IUD and emergency contraceptive pills).

The person decides

CDC puts personal autonomy first. It points to past and continuing coercion in U.S. reproductive care, especially in marginalised communities — forced sterilisation, enrolment in contraceptive trials without informed consent — and to subtler forms: providers favouring particular methods over a patient's own goals, counselling that is not centred on the person, and incentives to take up certain methods. Providers should recognise structural inequities and their own possible bias.

Everyone should be counselled about the full range of methods for which they are medically eligible. A person may weigh safety, effectiveness, availability and cost, side effects, control, reversibility and ease of stopping. Person-centred care treats the patient as the decision-maker, including a decision not to use contraception or to stop.

Two things to raise with everyone

• Sexually transmitted infections. Most methods — hormonal methods, IUDs, permanent contraception — do not protect against STIs, including HIV. Consistent and correct use of external latex condoms reduces the risk; internal condoms may also protect, though evidence is limited. Pre-exposure prophylaxis (PrEP), taken as prescribed, is highly effective against HIV.
• Pregnancy risks. For some conditions pregnancy itself carries higher health risks, and some conditions are treated with drugs that can harm a pregnancy. Counselling should cover these alongside a method's risks, and access to care for a high-risk pregnancy — while still offering every option and respecting the person's choices.

Sources

Based on "U.S. Medical Eligibility Criteria for Contraceptive Use, 2024," by Antoinette T. Nguyen and colleagues (CDC), MMWR Recommendations and Reports 73(4), published by the Centers for Disease Control and Prevention; rewritten in hubnx's own words.

• The report's detailed recommendation tables (its appendices) and its boxes are not reproduced.