This page summarizes CDC's U.S. Selected Practice Recommendations for Contraceptive Use, 2024 (U.S. SPR), written for health care providers. It is an overview, not medical advice; the full report gives the exact regimens, timings and evidence.
The U.S. SPR answers common but sometimes complicated practical questions about starting and using particular contraceptive methods: when a method can be started, whether back-up contraception is needed, which examinations and tests are required first, what follow-up is needed, and how to handle problems such as missed pills and bleeding changes. It replaces the 2016 edition.
It is the companion to the U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (U.S. MEC), which says which methods are safe for people with particular medical conditions and characteristics. Both were adapted from World Health Organization (WHO) guidance, first in 2012–2013 and updated in 2016.
The aim: remove unnecessary barriers
The guidance is built around removing medical barriers that keep people from getting and using contraception, such as:
- unneeded exams or tests before starting a method, for example a pelvic exam before starting combined oral contraceptives (COCs);
- being unable to get the method at the same visit, while waiting for tests that may not be needed or for the next menstrual cycle;
- trouble keeping supplied, through limits on how many pill packs are given at once or unneeded follow-up.
Care should be person-centered and noncoercive. Because of the history, and ongoing reality, of forced sterilization and reproductive coercion in the United States among racial and ethnic minority groups, people with disabilities and other marginalized groups, the report stresses that people should choose the method that best fits their needs, including the choice not to use contraception or to stop. The 2024 edition uses gender-inclusive language, while keeping the wording of the studies it summarizes.
What is new in 2024
| Change | Recommendation |
|---|---|
| Updated: medications for IUD placement | Misoprostol is not recommended routinely, though it may help in selected cases, such as after a recent failed placement. Lidocaine, as a paracervical block or topically, might reduce pain |
| Updated: bleeding changes with the implant | Counsel before placement: spotting or light bleeding is common, some users stop bleeding altogether (amenorrhea), heavy bleeding is uncommon, and the changes are generally not harmful. If treatment is wanted, options include hormonal treatment (20–30 µg ethinyl estradiol COCs or estrogen) or tranexamic acid for 5 days, which may help while taken, and NSAIDs (celecoxib, ibuprofen or mefenamic acid) for 5–7 days or tamoxifen for 7–10 days, whose effect may last for some time after. Amenorrhea needs no treatment. Remove the implant whenever the patient asks |
| New: testosterone and pregnancy | Counsel transgender, gender diverse and nonbinary people with a uterus that testosterone might not prevent pregnancy, and offer contraception to those at risk who do not want to become pregnant |
| New: self-injection | Self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) should be available as an additional way to use injectable contraception (first published in 2021) |
CDC also reviewed and reaffirmed its recommendations on bleeding with the levonorgestrel (LNG) IUD and on starting regular contraception after ulipristal acetate (UPA) emergency contraception.
Why the testosterone guidance. In a national survey of transgender, gender diverse and nonbinary people assigned female or intersex at birth, 54% of pregnancies were unintended. Some regimens of testosterone may suppress fertility, but testosterone has never been studied as contraception, and it is teratogenic. In the one study found, which followed 16 continuing and six new testosterone users for 12 weeks, one participant (5%) ovulated by the main definition, and 36% by a lower threshold; the certainty of that evidence was very low.
How the update was made
- CDC and WHO track new studies through the Continuous Identification of Research Evidence (CIRE) system, with weekly PubMed searches.
- A Federal Register notice in August 2021 drew 46 public comments.
- Virtual scoping meetings in January 2022 with 18 participants chose the topics to revisit.
- Listening sessions in November and December 2022 with 18 patient participants and advocates brought in perspectives from youth, LGBTQI+ people, people with disabilities and people with chronic conditions.
- Systematic reviews were graded with GRADE, and a meeting in Atlanta on January 25–27, 2023, heard from 40 participants, two of them patient representatives. Four external reviewers then commented.
Starting a method
Being reasonably certain someone is not pregnant. A careful history is usually the most accurate check. A provider can be reasonably certain if the patient has no signs or symptoms of pregnancy and meets any one of these:
- 7 days or fewer since the start of normal menses;
- no sex since the start of the last normal menses;
- correct and consistent use of a reliable contraceptive method;
- 7 days or fewer after a spontaneous or induced abortion;
- within 4 weeks after giving birth;
- fully or nearly fully breastfeeding (85% or more of feeds), without periods, and under 6 months after giving birth.
These criteria rule out pregnancy with a negative predictive value of 99%–100%. Routine pregnancy testing for everyone is unnecessary. For methods other than IUDs, even when pregnancy cannot be ruled out, the provider can consider starting the method at any time with a follow-up pregnancy test in 2–4 weeks; for an IUD, give another method until pregnancy can be reasonably ruled out. After unprotected sex in the past 5 days, consider offering emergency contraception.
Exams and tests. Most healthy people need few or none. Tests are rated Class A (essential), B (contributes substantially) or C (does not contribute substantially to safe, effective use). Starting contraception should not wait for results of other preventive screening.
Supplies. Provide or prescribe up to a 1-year supply of COCs (for example, 13 28-day packs) at first and return visits; more packs were linked to people continuing their pills.
Problems during use
Figure 1 of the 2024 U.S. SPR: recommended actions after late or missed combined oral contraceptives. Figure: CDC.
The report gives step-by-step guidance for missed or late pills, patches and rings, for vomiting or diarrhea on COCs, and for bleeding changes with each method. Because changes in bleeding are one of the main reasons people stop contraception, much of the guidance addresses them.
Emergency contraception
Four options are available in the United States:
- the copper IUD, placed within 5 days of the first unprotected sex, or later if ovulation can be estimated, provided placement is no more than 5 days after ovulation;
- UPA, 30 mg in one dose;
- LNG, 1.5 mg in one dose or 0.75 mg twice 12 hours apart;
- the combined estrogen–progestin Yuzpe regimen.
Pills should be taken as soon as possible within 5 days. An advance supply may be provided. After UPA, hormonal contraception should start or resume no sooner than 5 days later, with abstinence or barrier methods for the next 7 days after starting or until the next period, whichever comes first; nonhormonal methods can start at once.
Other guidance
- Protection from infections. Most contraceptives do not protect against sexually transmitted infections (STIs), including HIV. Everyone should hear about condoms, and that HIV pre-exposure prophylaxis (PrEP) taken as prescribed is highly effective.
- Permanent methods. The report covers when tubal surgery and vasectomy can be relied on.
- Age. People over 44 who want to avoid pregnancy still need contraception; providers should weigh the risks of pregnancy at that age against the risks of continuing a method.
Most people can start most methods at any time, with few if any tests beforehand. Routine follow-up mostly means checking satisfaction, concerns, and any changes in health or medicines that affect eligibility.
Sources
- Curtis KM, Nguyen AT, Tepper NK, et al. "U.S. Selected Practice Recommendations for Contraceptive Use, 2024." MMWR Recommendations and Reports 73(3). https://www.cdc.gov/mmwr/volumes/73/rr/rr7303a1.htm
- CDC contraceptive guidance for health care providers, with tools and updates: https://www.cdc.gov/contraception/hcp/contraceptive-guidance
- Supplementary evidence appendix: https://stacks.cdc.gov/view/cdc/156517
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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