{"paper_id":"78654e7b-cd05-4075-9d3b-9247e9bcce90","body_text":"U.S. Medical Eligibility Criteria for Contraceptive Use, 2024  (U.S.\nMEC) provides recommendations for health care providers for safe use of\ncontraceptive methods for persons who have certain characteristics or medical\nconditions within the framework of removing unnecessary medical barriers to\naccessing and using contraception. U.S. MEC is a companion document to  U.S.\nSelected Practice Recommendations for Contraceptive Use, 2024  (U.S.\nSPR) ( 1 ), which provides\nrecommendations for health care providers that address provision of contraceptive\nmethods and management of side effects and issues related to contraceptive method\nuse ( 2 ). Both U.S. MEC and\nU.S. SPR were adapted from global guidance developed by the World Health\nOrganization (WHO) ( 3 , 4 ). WHO intended for the global\nguidance to be used by local or national policymakers, family planning program\nmanagers, and the scientific community as a reference when they develop family\nplanning guidance at the country or program level ( 3 ). CDC first published U.S. MEC in 2010, after a\nformal process during 2008–2010 to adapt the global guidance for use in the\nUnited States, which included rigorous identification and critical appraisal of the\nscientific evidence through systematic reviews and input from national experts on\nhow to translate that evidence into recommendations for U.S. health care providers\n( 5 ); a subsequent update\nwas published in 2016 ( 6 ).\nU.S. MEC and U.S. SPR recommendations are components of quality contraceptive\nservices and can be used in conjunction with other guidance documents such as\n Providing Quality Family Planning Services: Recommendations of CDC and\nthe U.S. Office of Population Affairs , which provides recommendations\nfor the content and delivery of services related to preventing or for achieving\npregnancy ( 7 – 9 ). Evidence-based guidance can\nsupport health care providers when providing person-centered counseling and\ncontraceptive services, including assisting persons in selecting and using\ncontraceptive methods safely and effectively.\nEquitable access to the full range of contraceptive methods for all those seeking\ncare is an essential component of high-quality sexual and reproductive health care.\nContraceptive services should be offered in a noncoercive manner that supports a\nperson’s values, goals, and reproductive autonomy through a shared\ndecision-making process with health care providers ( 10 – 14 ). Because of the history of and ongoing forced\nsterilization and reproductive coercion in the United States among persons of racial\nand ethnic minority groups, persons with disabilities, and other groups that have\nbeen marginalized, it is important that persons can select the method that best\nmeets their needs to promote reproductive autonomy ( 10 – 12 ).\nThis report replaces the 2016 version of U.S. MEC ( 6 ) with new and revised recommendations, on the\nbasis of new evidence and input from experts. This updated document uses\ngender-inclusive language throughout. However, when summarizing published evidence\nthat describes study populations by specific genders, the wording of the primary\nstudies has been maintained for accuracy. A summary of new and revised\nrecommendations from the 2016 U.S. MEC is provided ( Appendix A ). Notable updates include\naddition of recommendations for persons with chronic kidney disease,\nspecifically those with nephrotic syndrome, those receiving hemodialysis,\nand those receiving peritoneal dialysis;\nrevisions to recommendations for persons with certain characteristics or\nmedical conditions (i.e., breastfeeding, postpartum, postabortion, obesity,\nsurgery, history of deep venous thrombosis or pulmonary embolism with or\nwithout anticoagulant therapy, thrombophilia, superficial venous thrombosis,\nvalvular heart disease, peripartum cardiomyopathy, systemic lupus\nerythematosus, cirrhosis, liver tumor, sickle cell disease, and solid organ\ntransplantation);\nrevisions to recommendations for persons at high risk for HIV infection (this\nrecommendation was developed and published in 2020) ( 15 );\nrevisions to recommendations for drug interactions with antiretrovirals to\ninclude prevention in addition to treatment for HIV infection (this\nrecommendation was developed and published in 2020) ( 15 ); and\ninclusion of additional contraceptive methods, including new doses or\nformulations of combined oral contraceptives (COCs), contraceptive patches,\nvaginal rings, progestin-only pills (POPs), levonorgestrel intrauterine\ndevices (LNG-IUDs), and vaginal pH modulator.\nU.S. MEC recommendations are meant to serve as a source of evidence-based clinical\nguidance for health care providers and can support the provision of person-centered\ncontraceptive counseling and services in a noncoercive manner. Health care providers\nshould always consider the individual clinical circumstances of each person seeking\ncontraceptive services. This report is not intended to be a substitute for\nprofessional medical advice for individual patients; when needed, patients should\nseek advice from their health care providers about contraceptive use.\n\nSince publication of the 2016 U.S. MEC, CDC has monitored the literature for new\nevidence relevant to the recommendations through the WHO/CDC Continuous\nIdentification of Research Evidence (CIRE) system ( 16 ). This system identifies new evidence as it is\npublished and allows WHO and CDC to update systematic reviews and facilitate updates\nto recommendations as new evidence warrants. Automated searches are run in PubMed\nweekly, and the results are reviewed. Abstracts that meet specific criteria are\nadded to the web-based CIRE system, which facilitates coordination and peer review\nof systematic reviews for both WHO and CDC. For this update, CDC reviewed all\nexisting recommendations in the 2016 U.S. MEC for new evidence identified by CIRE\nthat had the potential to lead to a changed recommendation. To obtain comments from\nthe public about revisions to CDC’s contraception recommendations (U.S. MEC\nand U.S. SPR), CDC published a notice in the Federal Register (86 FR 46703) on\nAugust 19, 2021, requesting public comment on content to consider for revision or\naddition to the recommendations and how to improve the implementation of the\nguidance documents ( 17 ). The\ncomment period closed on October 18, 2021. CDC received 46 submissions from the\ngeneral public, including private persons, professional organizations, academic\ninstitutions, and industry. CDC reviewed each of the submissions and carefully\nconsidered them when revising the recommendations.\nDuring January 21, 25, and 26, 2022, CDC held virtual scoping meetings that included\n27 participants with expertise in contraception, adolescent health, and thrombosis,\nas well as representatives from partner organizations, to solicit their individual\ninput on the scope for updating both the 2016 U.S. MEC and 2016 U.S. SPR. The 27\ninvited participants represented various types of health care providers and health\ncare provider organizations. Lists of participants and potential conflicts of\ninterests are provided at the end of this report. Meeting participants discussed\ntopics to be addressed in the update of U.S. MEC on the basis of the presentation of\nnew evidence published since 2016 (identified through the CIRE system), submissions\nreceived through the Federal Register notice, and feedback CDC received from other\nsources (e.g., health care providers and others through e-mail, public inquiry, and\nquestions received at conferences). CDC identified multiple topics to consider when\nupdating the guidance, including revision of existing recommendations for certain\ncharacteristics or medical conditions (postpartum, postabortion, obesity,\nanticoagulant therapy, known thrombogenic mutations, viral hepatitis, cirrhosis,\nliver tumors, sickle cell disease, and solid organ transplantation), addition of\nrecommendations for new characteristics or medical conditions (chronic kidney\ndisease and antiphospholipid syndrome), and addition of recommendations for new\ncontraceptive methods (including new formulations of COCs, contraceptive patches,\nvaginal rings, POPs, LNG-IUDs, and vaginal pH modulator). CDC determined that all\nother recommendations in the 2016 U.S. MEC were up to date and consistent with the\nexisting body of evidence for that recommendation.\nIn preparation for a subsequent expert meeting held during January 25–27,\n2023, to review the scientific evidence for potential recommendations, CDC staff\nmembers and other invited authors conducted systematic reviews for each of the\ntopics being considered. The purpose of these systematic reviews was to identify\ndirect and indirect evidence about the safety of contraceptive method use by persons\nwith selected characteristics or medical conditions (e.g., risk for disease\nprogression or other adverse health effects in persons with chronic kidney disease\nwho use combined hormonal contraceptives [CHCs]). Person-centered outcomes that\nmight represent contraceptive users’ values and preferences (e.g., method\ncontinuation and patient satisfaction) were considered where relevant and available\nfor each of the systematic reviews. Preferred Reporting Items for Systematic Reviews\nand Meta-Analyses (PRISMA) guidelines were followed for reporting systematic reviews\n( 18 ). The Grading of\nRecommendations Assessment, Development and Evaluation (GRADE) approach was used to\nassess the certainty of the evidence ( 19 , 20 ). Certainty of evidence was rated as high,\nmoderate, low, or very low depending on criteria including study design, risk for\nbias, indirectness, imprecision, and inconsistency. Outcomes evaluated in randomized\nclinical trials (RCTs) are considered to have high certainty of evidence and those\nin observational studies to have low certainty; these ratings are adjusted according\nto the previously mentioned criteria. When direct evidence was limited or not\navailable, indirect evidence (e.g., evidence on proxy outcomes or among healthy\npersons) and theoretical issues were considered. Reviews are referenced and cited\nthroughout this report; the full reviews will be submitted to peer-reviewed journals\nand will contain the details of each review, including the systematic review\nquestion, literature search protocol (registered in  https://www.crd.york.ac.uk/PROSPERO ), inclusion and exclusion\ncriteria, evidence tables, and quality assessments. Brief summaries of the evidence\nand GRADE tables are included (Supplementary Appendix,  https://stacks.cdc.gov/view/cdc/156516 ). CDC staff members continued\nto monitor new evidence identified through the CIRE system during the preparation\nfor the January 2023 meeting.\nIn addition to the preparation of the systematic reviews, CDC included patient\nperspectives in the guideline update process to better consider how the resulting\nupdated recommendations could meet patient preferences and needs. Consideration of\npatient perspectives can center discussions on the evidence in a person-centered\ncare model, can support inclusion of patient perspectives along with provider\nperspectives on the evidence, and has the potential to shape recommendations ( 14 , 21 , 22 ). In November and December 2022, listening\nsessions were held with a different group of 18 participants, representing\nthemselves or patient advocacy organizations, who provided perspectives from patient\npopulations such as youths; lesbian, gay, bisexual, transgender, queer, and intersex\n(LGBTQI+) persons; persons with disabilities; and persons with chronic medical\nconditions. The goal of the listening sessions was to gather insights about\nparticipants’ experiences, values, preferences, and information needs related\nto contraceptive choice and decision-making.\nDuring January 25–27, 2023, in Atlanta, Georgia, CDC held a meeting with 40\nparticipants who were invited to provide their individual perspectives on the\nscientific evidence presented and the implications for practice for U.S. MEC.\nThirty-eight participants represented a wide range of expertise in contraception\nprovision, research, and reproductive justice and included obstetricians and\ngynecologists, pediatricians, family physicians, internal medicine physicians, nurse\npractitioners, epidemiologists, and others with research and clinical practice\nexpertise in contraceptive safety, effectiveness, and management. Two participants\nwere patient representatives who provided their individual perspectives on the\ntopics discussed throughout the meeting. Six additional participants with expertise\nrelevant to specific topics on the meeting agenda provided information and\nparticipated in the discussion on their topic of expertise only (e.g., an expert in\nkidney disease was asked to provide general information about the condition and to\nassist in interpreting the evidence and any theoretical concerns on the use of\ncontraceptive methods in persons with the condition). During the meeting, a summary\nof the information from the patient listening sessions was presented, and the two\npatient representatives presented information on their individual experiences and\nperspectives related to receipt of contraceptive services. The evidence from the\nsystematic review for each topic was presented, including direct evidence and any\nindirect evidence or theoretical concerns. Meeting participants provided their\nindividual perspectives on topics discussed throughout the meeting and on using the\nevidence to develop recommendations that would meet the needs of U.S. health care\nproviders and the patients they serve. Participants also provided feedback on the\ncertainty of evidence, the balance of benefits and harms, and values and\npreferences. Areas of research that need additional investigation also were\nconsidered during the meeting. Lists of participants and potential conflicts of\ninterest are provided at the end of this report.\nAfter the January 2023 meeting, CDC determined the recommendations in this report,\ntaking into consideration the individual perspectives provided by the meeting\nparticipants. Feedback also was received from a group of four external reviewers,\ncomposed of health care providers and researchers who had not participated in the\nscoping or update meetings. These external reviewers were asked to provide comments\non the accuracy, feasibility, and clarity of the recommendations.\n\nAs with any evidence-based guidance document, a key challenge is keeping the\nrecommendations up to date as new scientific evidence becomes available. Working\nwith WHO, CDC uses the CIRE system to ensure that WHO and CDC guidance is based on\nthe best available evidence and that a mechanism is in place to update guidance when\nnew evidence becomes available ( 16 ). CDC will continue to work with WHO to identify and\nassess all new relevant evidence and determine whether changes in the\nrecommendations are warranted. CDC will completely review U.S. MEC periodically.\nUpdates to the guidance will published in CDC’s  Morbidity and\nMortality Weekly Report  ( MMWR ) and posted on the CDC\nwebsite ( https://www.cdc.gov/contraception/hcp/contraceptive-guidance ) .\nAs part of the process to update these recommendations, CDC identifies gaps in the\nevidence for the recommendations considered. Evidence is often limited on the safety\nof contraceptive methods among persons with certain characteristics or medical\nconditions. Generalizability of the published evidence to all persons seeking\ncontraceptive services presents a challenge because of biases about who might be\nincluded in studies on contraceptive safety. New, high-quality research on\ncontraception that addresses priority research gaps inclusive of diverse populations\ncan further strengthen these recommendations and improve clinical practice.\n\nThe recommendations in this report are intended to help health care providers\ndetermine the safe use of contraceptive methods among persons with certain\ncharacteristics and medical conditions. Providers can use the information in these\nrecommendations during contraceptive counseling with patients. The tables include\nrecommendations for the use of contraceptive methods by persons with certain\ncharacteristics or medical conditions. Each condition is defined as representing\neither a person’s characteristics (e.g., age or postpartum status) or a known\nmedical condition (e.g., diabetes or hypertension). The recommendations refer to\ncontraceptive methods being used for contraceptive purposes; the recommendations do\nnot consider the use of contraceptive methods for treatment of medical conditions\nbecause the eligibility criteria in these situations might differ. The conditions\naffecting eligibility for the use of each contraceptive method are classified into\none of four categories ( Box 1 ).\nU.S. MEC 1 = A condition for which there is no restriction for the\nuse of the contraceptive method\nU.S. MEC 2 = A condition for which the advantages of using the\nmethod generally outweigh the theoretical or proven risks\nU.S. MEC 3 = A condition for which the theoretical or proven risks\nusually outweigh the advantages of using the method\nU.S. MEC 4 = A condition that represents an unacceptable health\nrisk if the contraceptive method is used\nAbbreviation:  U.S. MEC =  U.S. Medical Eligibility Criteria\nfor Contraceptive Use .\nCDC acknowledges the paramount importance of personal autonomy in contraceptive\ndecision-making. This is critically important because of the context of\nhistorical and ongoing contraceptive coercion and reproductive mistreatment in\nthe United States, especially among communities that have been marginalized,\nincluding human rights violations such as forced sterilization and enrollment in\ncontraceptive trials without informed consent ( 10 – 12 ). Coercive practices in the health care\nsystem can include provider bias for certain contraceptive methods over a\npatient’s reproductive goals and preferences, lack of person-centered\ncounseling and support, and policies or incentives for uptake of certain\ncontraceptive methods ( 11 ). For health care providers and the settings in\nwhich they work, it is important to acknowledge the structural systems that\ndrive inequities (e.g., discrimination because of race, ethnicity, disability,\nsex, gender, and sexual orientation), work to mitigate harmful impacts, and\nrecognize that provider bias (unconscious or explicit) might affect\ncontraceptive counseling and provision of services ( 12 ). All persons seeking contraceptive\ncare need access to appropriate counseling and services that support the\nperson’s values, goals, and reproductive autonomy ( 10 – 14 ). Health care providers can support the\ncontraceptive needs of all persons by using a person-centered framework and\nrecognizing the many factors that influence individual decision-making about\ncontraception ( 10 , 12 , 14 ).\nThe U.S. MEC and U.S. SPR recommendations can be used to support a\nperson’s contraceptive decision-making ( Box 2 ). Persons should have equitable access to the full\nrange of contraceptive methods and be given the information they need for\ncontraceptive decision-making in a noncoercive manner. Patient-centeredness has\nbeen defined by the Institute of Medicine as “providing care that is\nrespectful of and responsive to individual patient preferences, needs, and\nvalues and ensuring that patient values guide all clinical decisions”\n( 23 ). Shared\ndecision-making and person-centered approaches to providing health care\nrecognize the expertise of both the medical provider and the patient ( 10 , 12 , 23 ).\nCDC acknowledges the paramount importance of personal autonomy in\ncontraceptive decision-making.\nPersons should have equitable access to the full range of\ncontraceptive methods.\nContraceptive services should be offered in a noncoercive manner that\nhonors a person’s values, goals, and reproductive\nautonomy.\nShared decision-making and person-centered approaches recognize the\nexpertise of both the health care provider and the person.\nA person-centered approach to contraceptive decision-making\nº prioritizes a person’s preferences and\nreproductive autonomy rather than a singular focus on\npregnancy prevention,\nº respects the person as the main decision-maker in\ncontraceptive decisions, and\nº includes respecting the decision not to use\ncontraception or to discontinue contraceptive method\nuse.\nU.S. MEC and U.S. SPR recommendations can be used by health care\nproviders to support persons in contraceptive decision-making.\nU.S. MEC and U.S. SPR recommendations can be used by health care\nproviders to remove unnecessary medical barriers to accessing and\nusing contraception.\nAbbreviations:  U.S. MEC =  U.S. Medical\nEligibility Criteria for Contraceptive Use ; U.S.\nSPR =  U.S. Selected Practice Recommendations for\nContraceptive Use .\nHealth care providers should always consider the individual clinical and social\nfactors of each person seeking contraceptive services and discuss reproductive\ndesires, expectations, preferences, and priorities regarding contraception. A\nperson might consider and prioritize many elements when choosing an acceptable\ncontraceptive method, such as safety, effectiveness ( 24 ), availability (including accessibility\nand affordability), side effects, user control, reversibility, and ease of\nremoval or discontinuation. In addition, a person’s health risks\nassociated with pregnancy and access to comprehensive health care services\nshould be considered in these discussions. A person-centered approach to\ncontraceptive decision-making prioritizes a person’s preferences and\nreproductive autonomy rather than a singular focus on pregnancy prevention and\nrespects the person as the main decision-maker in contraceptive decisions,\nincluding the decision not to use contraception or to discontinue contraceptive\nmethod use ( 12 , 25 ). Voluntary informed\nchoice of contraceptive methods is an essential guiding principle, and\ncontraceptive counseling, where applicable, might be an important contributor to\nthe successful use of contraceptive methods. Key resources provide additional\ninformation on person-centered contraceptive counseling and care ( 7 , 10 , 12 , 26 ).\nHealth care providers can use the eligibility categories when assessing the\nsafety of contraceptive method use for persons with certain characteristics or\nmedical conditions. Category 1 comprises conditions for which no restrictions\nexist for use of the contraceptive method. However, category 1 does not imply\nthat the method is the most appropriate choice for a person, who might be\nprioritizing other factors when considering contraception. Classification of a\nmethod or condition as category 2 indicates the method generally can be used,\nwith additional discussion about risks and benefits, and careful follow-up might\nbe required. For a method or condition classified as category 3, use of that\nmethod usually is not recommended unless other more appropriate methods are not\navailable or acceptable. The severity of the condition and the availability,\npracticality, and acceptability of alternative methods should be considered, and\ncareful follow-up is required. Hence, provision of a contraceptive method to a\nperson with a condition classified as category 3 requires careful clinical\njudgment and might warrant additional counseling, consultation, or follow-up.\nCategory 4 comprises conditions that represent an unacceptable health risk if\nthe method is used. For example, a person who smokes and is aged <35 years\ngenerally can use COCs (category 2). However, for a person aged ≥35 years\nwho smokes <15 cigarettes per day, the use of COCs usually is not recommended\nunless other methods are not available or acceptable (category 3). A person aged\n≥35 years who smokes ≥15 cigarettes per day should not use COCs\nbecause of unacceptable health risks, primarily the risk for myocardial\ninfarction and stroke (category 4). The implementation of this clinical guidance\nmight vary within different health systems, clinics, or settings. For example,\nin certain settings, category 3 might mean that a special consultation is\nwarranted. Health departments and medical societies or organizations can provide\ninformation on implementation through additional guidance or clinical\nprotocols.\nThe recommendations address medical eligibility criteria for the initiation and\ncontinued use of all contraceptive methods evaluated. The issue of medical\neligibility criteria for continuation of a contraceptive method is clinically\nrelevant whenever a medical condition develops or worsens during use of a\ncontraceptive method. When the categories differ for initiation and\ncontinuation, these differences are noted. When different initiation and\ncontinuation recommendations are not given, the category is the same for\ninitiation and continuation of use.\nOn the basis of this classification system, the eligibility criteria for\ninitiating and continuing use of a specific contraceptive method are presented\nin tables ( Appendices A, B,\nC, D, E, and J ). In these tables, the first column indicates the\ncondition. Multiple conditions are divided into subconditions to differentiate\nbetween varying condition types or severity. The next columns provide\nclassifications of the condition for initiation, continuation, or both into\ncategories 1, 2, 3, or 4 for specific contraceptive methods. For certain\nconditions, the last column further clarifies the numeric category in cases\nwhere the numeric classification does not adequately capture the recommendation.\nThese clarifications are considered a necessary element of the recommendation.\nThe last column also summarizes the evidence for the recommendation if evidence\nexists. The recommendations for which no evidence is cited might be based on\ninformation from sources other than systematic reviews and might take into\naccount individual perspectives from either the WHO or U.S. expert meetings in\nwhich these recommendations were developed. For certain recommendations,\ncomments in the third column can provide additional rationale or other\ninformation about the recommendation. Information provided along with the\nnumeric recommendation (i.e., clarifications, evidence, and comments) is\nadditional detail that providers can use as part of their counseling and\nreferrals, as needed.\nU.S. MEC recommendations comprise one aspect of contraceptive counseling. All\npersons should be counseled about the full range of contraceptive options for\nwhich they are medically eligible. Voluntary informed choice of contraceptive\nmethods is an essential guiding principle of these recommendations, and\nperson-centered contraceptive counseling can help to ensure a person’s\ncontraceptive needs are met successfully.\nThe classifications for whether persons with certain characteristics or medical\nconditions can safely use specific contraceptive methods are provided for\nintrauterine devices (IUDs), including the copper IUD (Cu-IUD) and LNG-IUD\n( Appendix B ); progestin-only\ncontraceptives (POCs), including progestin-only implants, depot\nmedroxyprogesterone acetate injections, and POPs ( Appendix C ); CHCs, including COCs, combined transdermal\npatches, and combined vaginal rings ( Appendix\nD ); barrier contraceptive methods, including external (male) and\ninternal (female) condoms, spermicides and vaginal pH modulator, and diaphragm\nwith spermicide or cervical cap with spermicide ( Appendix E ); fertility awareness–based methods ( Appendix F ); lactational amenorrhea method\n( Appendix G ); coitus interruptus\n( Appendix H ); permanent\ncontraception, including tubal surgery and vasectomy ( Appendix I ); and emergency contraception, including\nemergency use of the Cu-IUD and emergency contraceptive pills (Appendix J). A\ntable at the end of this report summarizes the classifications for the hormonal\nand intrauterine methods (Appendix K).\nAll patients, regardless of contraceptive choice, should be counseled about the\nuse of condoms and the risk for sexually transmitted infections (STIs),\nincluding HIV infection ( 27 ). Most contraceptive methods, such as hormonal\nmethods, IUDs, and permanent contraception do not protect against STIs,\nincluding HIV infection. Consistent and correct use of external (male) latex\ncondoms reduces the risk for STIs, including HIV infection ( 27 ). Although evidence is\nlimited, use of internal (female) condoms can provide protection from\nacquisition and transmission of STIs ( 27 ). Patients also should be counseled that\npre-exposure prophylaxis (PrEP), when taken as prescribed, is highly effective\nfor preventing HIV infection ( 28 ). Additional information about prevention\nand treatment of STIs is available from CDC’s  Sexually\nTransmitted Infections Treatment Guidelines  ( https://www.cdc.gov/std/treatment-guidelines/default.htm ) ( 27 ), and information on\nPrEP for prevention of HIV infection is available from the U.S. Public Health\nService’s  Preexposure Prophylaxis for the Prevention of HIV\nInfection in the United States — 2021 Update: A Clinical Practice\nGuideline  ( https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf )\n( 28 ).\nDiscussion of health risks associated with pregnancy is an important aspect of\ncontraceptive counseling. For persons with certain medical conditions, pregnancy\nposes increased health risks. Conditions included in U.S. MEC that are\nassociated with increased risk for adverse health events as a result of\npregnancy are identified throughout the document ( Box 3 ). This is not a comprehensive list of all conditions\nthat could lead to adverse events during pregnancy. Certain medical conditions\nincluded in U.S. MEC recommendations also are treated with teratogenic drugs,\nwhich could have adverse effects when used during pregnancy. When applying U.S.\nMEC classifications during person-centered counseling, health care providers\nshould discuss the risks of a particular contraceptive method as well as the\nhealth risks associated with pregnancy. Even though permanent contraception and\nlong-acting, reversible contraceptive methods are highly effective, persons\nshould be provided with the full range of contraceptive options and supported in\ntheir autonomous decisions about pregnancy planning and contraceptive choices.\nDiscussions about pregnancy should include reviewing access to comprehensive\nhealth care services and subspecialists for a high-risk pregnancy ( 29 ).\nBreast cancer\nChronic kidney disease: with current nephrotic syndrome, receiving\nhemodialysis, or receiving peritoneal dialysis\nComplicated valvular heart disease\nCystic fibrosis\nDecompensated cirrhosis\nDeep venous thrombosis/pulmonary embolism\nDiabetes: insulin dependent; with nephropathy, retinopathy, or neuropathy or\nother vascular disease; or of >20 years’ duration\nEndometrial cancer\nEpilepsy\nGestational trophoblastic disease\nHepatocellular adenoma and malignant liver tumors (hepatocellular\ncarcinoma)\nHistory of bariatric surgery within the past 2 years\nHIV infection: not clinically well or not receiving antiretroviral\ntherapy\nHypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg)\nIschemic heart disease\nOvarian cancer\nPeripartum cardiomyopathy\nSchistosomiasis with fibrosis of the liver\nSickle cell disease\nSolid organ transplantation within the past 2 years\nStroke\nSystemic lupus erythematosus\nThrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation;\nprotein S, protein C, and antithrombin deficiencies; or antiphospholipid\nsyndrome)\nTuberculosis\n* Even though permanent contraception and long-acting, reversible\ncontraceptive methods are highly effective, persons should be provided with\nthe full range of contraceptive options and supported in their autonomous\ndecisions about pregnancy planning and contraceptive choices. Discussions\nabout pregnancy should include reviewing access to comprehensive health care\nservices and subspecialists for a high-risk pregnancy.","source_license":"Public-Domain","license_restricted":false}