CDC's 2016 Practice Recommendations for Contraceptive Use: The Essentials

About 45% of U.S. pregnancies are unintended, with higher shares among adolescents and young women, racial and ethnic minority women, and women with less education and income. Unintended pregnancies raise the risk of poor outcomes for mothers and babies, and in 2010 cost U.S. government health programs $21 billion. About half occur in women not using contraception; the other half, in women who became pregnant despite using it.

The U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), published by CDC in MMWR, tell health care providers how to use contraceptive methods safely and effectively once a method has been judged medically appropriate. It is the companion to the U.S. Medical Eligibility Criteria (U.S. MEC), which covers who can safely use which method. First published in 2013 and adapted from World Health Organization guidance, it was updated in 2016 after systematic reviews and a meeting of 29 experts in Atlanta on August 26–28, 2015. The guidance is meant for clinicians and does not replace individual medical advice. CDC has since published an update to these recommendations, so this page describes the 2016 edition.

What changed in 2016

• Starting regular contraception after ulipristal acetate (UPA) emergency pills. Start or resume hormonal contraception no sooner than 5 days after taking UPA. For methods that need a clinic visit — the injectable DMPA, implants and IUDs — starting at the time of UPA may be considered, weighing the chance the method weakens UPA against the risk of not starting. Abstain or use barrier contraception for 7 days after starting (or until the next period, whichever comes first). Nonhormonal methods can start right away. Take a pregnancy test if there's no withdrawal bleed within 3 weeks.
• Easing IUD insertion. Misoprostol is not recommended routinely (though it may help in some cases, such as after a failed insertion), and a paracervical lidocaine block might reduce pain.

Guiding principles

• Choice matters. Safety, effectiveness, availability, affordability and acceptability all weigh in, and voluntary, informed choice is essential.
• Effectiveness depends on the method and on its use. IUDs and implants — long-acting reversible contraception (LARC) — are highly effective because they don't depend on regular action by the user, and are appropriate for most women, including adolescents and women who have never given birth. Everyone should hear about the full range of options they are eligible for.
• Contraception is not STD protection. Hormonal methods and IUDs don't prevent HIV or other sexually transmitted diseases; consistent, correct condom use lowers that risk, and everyone should be counseled about it.
• Remove unnecessary barriers, such as needless exams before starting pills, making people wait for tests or for their next period, limits on how many pill packs they can get, routine antibiotics at IUD insertion, and unnecessary follow-up visits.

Effectiveness of family planning methods: the percentage of women with a pregnancy in the first year of typical use (CDC).

Being reasonably sure a woman isn't pregnant

A careful history is usually the best guide; routine pregnancy testing for everyone is not necessary. A provider can be reasonably certain a woman is not pregnant if she has no signs or symptoms of pregnancy and meets any one of these criteria:

• 7 days or fewer since the start of a normal period;
• no sex since the start of her last normal period;
• correct, consistent use of a reliable contraceptive method;
• 7 days or fewer since a miscarriage or abortion;
• within 4 weeks after giving birth;
• fully or nearly fully breastfeeding (at least 85% of feeds), with no periods, and less than 6 months after giving birth.

These criteria rule out pregnancy with a negative predictive value of 99–100%. Urine tests have limits: they can't detect a very recent pregnancy and may stay positive for weeks after one ends. For methods other than IUDs, the benefits of starting usually outweigh the risks even when pregnancy can't be ruled out, with a follow-up test in 2–4 weeks. For an IUD, a woman should use another method until pregnancy can be ruled out, because pregnancies with an IUD in place carry more complications.

Starting each method

Every method below can be started at any time if the provider is reasonably certain the woman is not pregnant.

"Backup" means avoiding sex or using additional protection, such as condoms.

Exams and tests before starting

Healthy women need few or no tests:

• IUDs: a bimanual pelvic exam and inspection of the cervix are needed. STD screening, if due under screening guidelines, can be done at insertion. Prophylactic antibiotics are generally not recommended.
• Combined hormonal methods: blood pressure should be measured, because women with high blood pressure generally shouldn't use them.
• Implants, DMPA and progestin-only pills: no exams or tests are needed.
• For any method, weight and BMI at baseline can help track changes, but screening for obesity isn't needed to start.

Staying on track

• Pill supplies. Provide or prescribe up to a year's supply (for example, 13 packs of 28 pills), as the woman prefers; more packs are linked to people continuing their pills.
• DMPA timing. Repeat injections every 3 months (13 weeks). An injection can be given early, or up to 2 weeks late (15 weeks) without backup. Later than that, it can still be given if pregnancy is reasonably ruled out, with 7 days of backup.
• Missed progestin-only pills (more than 3 hours late): take one as soon as possible, keep taking one a day at the usual time, and use backup until pills have been taken correctly for 2 days in a row. The same applies after vomiting or diarrhea within 3 hours of a pill. Emergency contraception (other than UPA) should be considered after unprotected sex.
• Late or missed combined pills, patch or ring follow detailed charts in the guidance.

Recommended actions after late or missed combined oral contraceptives (CDC).

Emergency contraception

Four options are available in the United States:

• the copper IUD, inserted within 5 days of unprotected sex — or later, if ovulation can be dated, as long as it is no more than 5 days after ovulation;
• ulipristal acetate pills (30 mg, one dose);
• levonorgestrel pills (1.5 mg once, or two 0.75 mg doses 12 hours apart);
• combined estrogen and progestin pills in two doses 12 hours apart (the Yuzpe regimen).

Pills should be taken as soon as possible within 5 days, and an advance supply may be given so they're on hand. After levonorgestrel or combined pills, any regular method can start immediately, with 7 days of backup.

Other methods

• Standard Days Method (a fertility-awareness method): avoid unprotected sex on days 8–19 of the cycle. It suits women whose cycles run 26–32 days; women with two or more cycles outside that range in a year should consider another method.
• Female sterilization: reliable immediately after laparoscopic or abdominal procedures. After hysteroscopic sterilization, an x-ray dye test (hysterosalpingogram) at 3 months must confirm both tubes are blocked before relying on it.
• Vasectomy: a semen analysis 8–16 weeks later should confirm success; until then, use other protection. Avoid ejaculation for about a week afterward.
• When to stop: women over 44 who want to avoid pregnancy still need contraception.

Sources

• Curtis KM, Jatlaoui TC, Tepper NK, et al. "U.S. Selected Practice Recommendations for Contraceptive Use, 2016," MMWR Recommendations and Reports Vol. 65, No. RR-4, CDC; a work of the United States government in the public domain.