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Contraceptive Challenges in Women With Common Medical Conditions

      Abstract

      Women have the opportunity to meet personal contraceptive goals with convenient, highly reliable, and easily reversible methods. Long-acting reversible contraception represents an increasingly popular option for most women throughout the reproductive lifespan. Nonetheless, many women and their health care providers are challenged by coexisting medical issues. We aim to help clinicians individualize contraception and use shared decision-making to enhance patient satisfaction and continuation with their method.

      Abbreviations and Acronyms:

      BMI (body mass index), CDC (Centers for Disease Control and Prevention), CHC (combined hormonal contraceptives), COC (combined oral contraceptives), CVA (cerebral vascular event), DMPA (depot medroxyprogesterone acetate), EIN (endometrial intraepithelial neoplasia), IUC (intrauterine contraception), IUD (intrauterine device), IUS (intrauterine contraceptive system), LARC (long-acting reversible contraception), LNG (levonorgestrel), MI (myocardial infarction), POP (progestin only pill), STI (sexually transmitted infection), USMEC (United States Medical Eligibility Criteria for Contraceptive Use), USSPR (US Selected Practice Recommendations for Contraceptive Use), VTE (venous thromboembolism)
      CME Activity
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      Credit Statement: Mayo Clinic College of Medicine and Science designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s).™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.
      MOC Credit Statement: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1 MOC point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
      Learning Objectives: On completion of this article, the reader should be able to: 1) define the four categories of method suitability as defined by the US Medical Eligibility Criteria for Contraceptive Use; 2) review timely issues in contraception, current contraceptive methods, and typical failure rates; and 3) discuss safe methods of contraception for common medical conditions.
      Disclosures: As a provider accredited by ACCME, Mayo Clinic College of Medicine and Science (Mayo School of Continuous Professional Development) must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course Director(s), Planning Committee members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty also will disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. Disclosure of this information will be published in course materials so that those participants in the activity may formulate their own judgments regarding the presentation.
      In their editorial and administrative roles, Karl A. Nath, MBChB, Terry L. Jopke, Kimberly D. Sankey, and Jenna M. Pederson, have control of the content of this program but have no relevant financial relationship(s) with industry. Dr Casey has Grant/Research Support (secondary investigators need not disclose) from Merck for RCT nexplanon-related bleeding. The other authors report no competing interests. Off-label drugs include: Levonorgestrel IUD/Mirena/Lilleta used for hormone therapy in menopause; (Bayer, Allergan/Medicine).
      Method of Participation: In order to claim credit, participants must complete the following:
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        Read the activity.
      • 2.
        Complete the online CME Test and Evaluation. Participants must achieve a score of 80% on the CME Test. One retake is allowed.
      Visit www.mayoclinicproceedings.org, select CME, and then select CME articles to locate this article online to access the online process. On successful completion of the online test and evaluation, you can instantly download and print your certificate of credit.
      Estimated Time: The estimated time to complete each article is approximately 1 hour.
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      Date of Release: 11/2/2020
      Expiration Date: 10/31/2022 (Credit can no longer be offered after it has passed the expiration date.)
      Questions? Contact [email protected].
      Contraceptive choice is personal, requiring careful consideration and comfort. Women with coexisting health issues require a comprehensive assessment and plan for safe, effective contraception using shared decision-making. The Centers for Disease Control and Prevention (CDC) has published the United States Medical Eligibility Criteria for Contraceptive Use (USMEC) which includes evidence-based recommendations for contraceptive management in women with coexisting medical conditions.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      While it does not replace individualized management, the USMEC classifies method suitability from category 1 to 4 as follows: (1) no restrictions in use; (2) advantages generally outweigh the theoretical or proven risks; (3) theoretical or proven risks usually outweigh the advantages; or (4) unacceptable health risk (should not to be used).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Complementary to the USMEC is the 2016 US Selected Practice Recommendations for Contraceptive Use (USSPR) which addresses a select group of common yet potentially controversial or complex issues regarding contraception initiation and use.
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      The USSPR serves as an evidence-based clinical guidance to providers. Also complementary to the USMEC and USSPR are the Quality Family Planning Services which provide for contraceptive counseling/family planning to achieve desired timing of childbirth and infant outcomes.
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      ,
      • Gavin L.
      • Pazol K.
      • Ahrens K.
      Update: providing quality family planning services – recommendations from CDC and the US Office of Population Affairs, 2017.
      A useful app updated in 2020, developed from the CDC Morbidity and Mortality Weekly Report by the Division of Reproductive Health covering medical conditions (USMEC) and numerous clinical scenarios (USSPR), assists clinicians in counseling women and their partners about contraceptive options and use.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      Ongoing education using the USMEC assists in the development of evidence-based training bridging knowledge gaps to deliver high-quality contraceptive care.
      • Zapata L.B.
      • Morgan I.A.
      • Curtis K.M.
      • Folger S.G.
      • Whiteman M.K.
      Changes in US health care provider attitudes related to contraceptive safety before and after the release of national guidance.

      Timely Issues in Contraception

      Since publication of the original USMEC in 2016, contraceptive experts systematically reviewed timely issues including mood, obesity, heart disease, venous thromboembolism (VTE), injectable contraceptives in adolescents, opioids, and antibiotics. For example, limited evidence found no consistent associations between hormonal contraceptives and postpartum depression.
      • Ti A.
      • Curtis K.M.
      Postpartum hormonal contraception use and incidence of postpartum depression: a systematic review.
      Data showed absolute differences in combined oral contraceptives (COCs) failure by weight and body mass index (BMI) to be small but there was decreased efficacy of the contraceptive patch in the setting of increasing BMI.
      • Dragoman M.V.
      • Simmons K.B.
      • Paulen M.E.
      • Curtis K.M.
      Combined hormonal contraceptive (CHC) use among obese women and contraceptive effectiveness: a systemic review.
      Women with a history of heart failure can use long-acting reversible contraception (LARC) or permanent sterilization whereas those with a history of uncomplicated cardiac transplantation may use most forms of contraception.
      • Maroo A.
      • Chahine J.
      Contraception strategies in women with heart failure or with cardiac transplantation.
      In complicated cardiac transplantation, combined hormonal contraceptives (CHCs) and de novo intrauterine system (IUS) insertion are discouraged.
      • Maroo A.
      • Chahine J.
      Contraception strategies in women with heart failure or with cardiac transplantation.
      In reviewing venous thrombosis among COC users, it is noted that the use of progestogen containing COCs other than levonorgestrel could be associated with a small increased risk of VTE.
      • Dragoman M.V.
      • Tupper N.K.
      • Fu R.
      • Curtis K.M.
      • Chow R.
      • Gaffield M.E.
      A systemic review and meta-analysis of venous thrombosis risk among users of combined oral contraception.
      More than 95% of public-sector providers and office-based physicians consider depomedroxyprogesterone acetate (DMPA) safe for adolescents with only 64% to 89% prescribing DMPA based on factors such as medical specialty, working in settings without government funding, whether offering family planning services, timing of completing medical training, and patient preference for another method.
      • Ermias Y.
      • Morgan I.A.
      • Curtis K.M.
      • Whiteman M.K.
      • Horton L.G.
      • Zapata L.B.
      Factors associated with provision of depo medroxyprogesterone acetate to adolescents by US health care providers.
      Women can use opioids and contraception with little concern for interactions.
      • Ti A.
      • Stone R.H.
      • Whiteman M.
      • Curtis K.M.
      Safety and effectiveness of hormonal contraception for women who use opioids: a systematic review.
      Evidence from clinical and pharmacokinetic studies does not support the existence of drug interactions between hormonal contraceptives and non-rifamycin antibiotics.
      • Simmons K.B.
      • Haddad L.B.
      • Nanda K.
      • Curtis K.M.
      Drug interactions between non-rifamycina antibiotics and hormone contraception: a systemic review.

      Current Contraceptive Use

      For young, nulliparous women and reproductive women between pregnancies or who have completed childbearing, LARC should be the first consideration, with associated US Food and Drug Administration–approved lifespan, including levonorgestrel (LNG) IUS Mirena 52 mg (5 years), Liletta 52 mg (6 years), Kyleena 19.5 mg (5 years), and Skyla 13.5 mg (3 years), the copper TCu380A intrauterine device (IUD) Paragard (10 years), and etonogestrel subdermal implant Nexplanon (3 years).
      Committee on Practice Bulletin-Gynecology, Long-Acting Reversible Contraception Work Group
      Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices.
      Reported failure rates yearly are 0.05% to 0.8%. Nearly 1 in 4 postpartum women (22.5%) report use of LARC.
      • Oduyebo T.
      • Zapata L.B.
      • Boutot M.E.
      • et al.
      Factors associated with postpartum use of long-acting reversible contraception.
      Factors that affect use of LARC include age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance.
      • Oduyebo T.
      • Zapata L.B.
      • Boutot M.E.
      • et al.
      Factors associated with postpartum use of long-acting reversible contraception.
      Postpartum sterilization, an option when childbirth is complete, is also highly effective (0.5% failure rate).
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      In the 65% of women aged 15 to 49 years using contraception, sterilization is used by 18.6%, oral contraceptive pill by 12.6%, and male condoms by 8.7%.
      • Daniels K.
      • Abma J.
      NCHS Data Brief, No. 327, Dec 2018.
      Injections and CHC (including estrogen and progestin pills, ring, and patch) have failure rates of 6% to 9% with typical use.
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      Barrier methods (condoms, diaphragm, cervical cap, and sponge) and fertility awareness methods have reported failure rates of 12% to 28%.
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      This evidence-based review focuses on common medical conditions that can make contraception choices challenging for women and clinicians. Although barrier and other methods are less efficacious than LARC, for some women they may be more acceptable and should be included in discussion regarding shared decision-making. We will discuss contraceptive methods for each condition, listing the methods from most to least effective with typical use.

      Common Medical Conditions

      Cardiac Disease/Hypertension/Diabetes

      Approximately 1 in 16 women older than 19 years have coronary artery disease whereas approximately 5.6% of women aged 18 to 39 years and 29.4% of those aged 40 to 59 years have hypertension.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      The prevalence of controlled hypertension is 48.3%.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Diabetes affects 15 million women in the United States.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Levonorgestrel (LNG) IUS and TCu380A IUD (together intrauterine contraception [IUC]) are category 1-2 for cardiac disease.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      The LNG IUS and implant are category 3 for continuation in ischemic heart disease given the theoretical concern of progestins on lipids.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Intrauterine contraception and implant are category 1 for complicated and uncomplicated valvular heart disease and category 1-2 in diabetes and hypertension.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Grigoryan O.R.
      • Grodnitskaya E.E.
      • Andreeva E.N.
      • Shestakova M.V.
      • Melnichenko G.A.
      • Dedov I.I.
      Contraception in perimenopausal women with diabetes mellitus.
      Depot medroxyprogesterone acetate (DMPA) is category 1 for valvular heart disease and category 3 for ischemic disease, category 1-2 in diabetes and hypertension with category 3 in vascular disease.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Progestin-only pill (POP) is category 1 in valvular disease, category 2-3 in ischemic heart disease, and category 1-2 in diabetes and hypertension.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Certain progestin-only contraceptives (POP and DMPA) may increase the risk for thrombosis, although this risk is less than with combined hormonal contraceptives (CHCs).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Kemmeren J.M.
      • Tanis B.C.
      • van den Bosch M.A.
      • et al.
      Risk of arterial thrombosis in relation to oral contraceptives (RATIO) study: oral contraceptives and risk of ischemic stroke.
      The effects of DMPA may persist for some time after discontinuation.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Kemmeren J.M.
      • Tanis B.C.
      • van den Bosch M.A.
      • et al.
      Risk of arterial thrombosis in relation to oral contraceptives (RATIO) study: oral contraceptives and risk of ischemic stroke.
      CHC are category 3 for uncomplicated valvular disease, blood pressure less than 140 to 159/90 to 99 mm Hg, diabetes without vascular disease and category 4 for a history of multiple risk factors for arterial cardiovascular disease including smokers older than 35 years (15 or more cigarettes daily), women with long-term diabetes or with vascular complications, uncontrolled hypertension, previous myocardial infarction (MI) or cerebrovascular accident (CVA), known ischemic heart or cerebrovascular disease, or complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, and history of subacute bacterial endocarditis).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Kemmeren J.M.
      • Tanis B.C.
      • van den Bosch M.A.
      • et al.
      Risk of arterial thrombosis in relation to oral contraceptives (RATIO) study: oral contraceptives and risk of ischemic stroke.
      ,
      • Khader Y.S.
      • Rice J.
      • John L.
      • Abueita O.
      Oral contraceptives use and the risk of myocardial infarction: a meta-analysis.
      No data exist, but CHC users with adequately controlled and monitored hypertension should be at reduced risk for acute MI and CVA compared with untreated hypertensive CHC users.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      In women with hypertension, COC users were at higher risk than nonusers for CVA, acute MI, and peripheral arterial disease.
      • Kemmeren J.M.
      • Tanis B.C.
      • van den Bosch M.A.
      • et al.
      Risk of arterial thrombosis in relation to oral contraceptives (RATIO) study: oral contraceptives and risk of ischemic stroke.
      ,
      • Khader Y.S.
      • Rice J.
      • John L.
      • Abueita O.
      Oral contraceptives use and the risk of myocardial infarction: a meta-analysis.
      With hyperlipidemia, CHC is category 2-3.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      It may be beneficial for women with complex cardiac disease, diabetes, and hypertension to be referred to subspecialty care by cardiologists, nephrologists, and gynecologists.

      Venous Thromboembolism

      Approximately 5% to 8% of the US population has one or more inherited thrombophilias, increasing the risk for thrombosis.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      As many as 900,000 people in the United States yearly may be affected by VTE (1-2/1000) with 60,000 to 100,000 dying of VTE yearly.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      IUS and implant are category 1-2 for VTE.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      In a case-controlled study, DMPA had an odds ratio of 2.2 for VTE whereas LNG IUS, implant, and POP did not show an increased risk.
      • Bergendal A.
      • Persson I.
      • Odeberg J.
      • et al.
      Association of venous thromboembolism with hormonal contraception and thrombophilic genotypes.
      The USMEC classifies all progestin only methods as category 2 given that pregnancy confers a much greater risk for VTE. Routine screening for inherited or acquired thrombophilias is not necessary because of the rarity of the conditions and cost of screening.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Screening women with a family history of a specific thrombophilia is reasonable.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      CHC is category 3 with a history of VTE at low risk for recurrence (eg, postoperative).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Combined hormonal contraceptives (so are category 4 with a current VTE, history of VTE with a risk for recurrence (eg, current malignancy), known thrombogenic mutation(s), or upcoming major surgery with prolonged immobilization.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.

      Anticoagulation/Bleeding Diathesis

      Bleeding disorders affect approximately 1% of US women and often lead to heavy menses.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Levonorgestrel IUS can be useful to induce amenorrhea while supplying contraception for a known or suspected bleeding diathesis (ie, von Willebrand disease) or during anticoagulation (category 1).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      Committee on Practice Bulletin-Gynecology, Long-Acting Reversible Contraception Work Group
      Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices.
      ,
      • Chi C.
      • Huq F.Y.
      • Kadir R.A.
      Levonorgestrel-releasing intrauterine system for the management of heavy menstrual bleeding in women with inherited bleeding disorders: long-term follow-up.
      Any LNG IUS (52 mg, 19.5 mg, and 13.5 mg) can be used, but there may be more breakthrough or persistent menses with lower-dose LNG IUS.
      Committee on Practice Bulletin-Gynecology, Long-Acting Reversible Contraception Work Group
      Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices.
      TCu380A IUD, implant, DMPA, and POP are category 1-2. Combined hormonal contraceptives are category 1 for irregular or heavy menses. Combined hormonal contraceptives may be of benefit beyond contraception for women at risk for VTE who use anticoagulation and are at risk of heavy menses.
      • Martinelli I.
      • Lensing A.W.
      • Middeldorp S.
      • Levi M.
      • Beyer-Westendorf J.
      • van Bellen B.
      Recurrent venous thromboembolism and abnormal uterine bleeding with anticoagulant and hormone therapy use.
      Use should be individualized. For thalassemias and sickle cell disease, all methods are category 1-2.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Fewer sickle cell crises and fewer anemias have been reported with progestin-only contraceptives, especially DMPA.
      • Legardy J.K.
      • Curtis K.M.
      Progestin-only contraceptive use among women with sickle anemia: a systematic review.

      Liver Disease

      Liver disease affects approximately 4.5 million Americans yearly.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      The number of deaths from liver disease is greater than 41,000 yearly.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      TCu380A IUD is category 1 in severe liver cirrhosis, hepatocellular adenoma, and malignant hepatoma.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Levonorgestrel IUS, implant, DMPA, and POP are category 3 in severe liver disease.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Combined hormonal contraceptives are category 4 in women with severe (decompensated) cirrhosis, hepatocellular adenoma, or malignant hepatoma.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      For focal nodular hyperplasia (benign), all hormonal contraceptives are category 1-2, whereas for mild (compensated) cirrhosis, all hormonal methods are category 1.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      In acute hepatitis, IUC, implant, DMPA, and POP are category 1.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Combined hormonal contraceptives are category 3-4 for an acute flare of hepatitis but category 2 if already being used. For chronic hepatitis, all methods are category 1.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      With a history of pregnancy-related cholestasis, CHC is category 2 with other methods category 1.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      With a history of cholestasis related to estrogen, CHC is category 3.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      When gallbladder disease is a current issue or is being medically treated, CHC is category 3 whereas other methods are category 1-2.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.

      Inflammatory Bowel Disease

      Crohn disease and ulcerative colitis affect 1.3% of the US population.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Intrauterine contraceptives and implant are category 1 with DMPA and POP being category 2.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Although CHC has been associated with an increased risk for Crohn disease and ulcerative colitis, causation has not been demonstrated.
      • Ortizo R.
      • Lee S.Y.
      • Nguyen E.T.
      • Jamal M.M.
      • Bechtold M.M.
      • Nguyen D.L.
      Exposure to oral contraceptives increases the risk for development of inflammatory bowel disease: a meta-analysis of case-controlled and cohort studies.
      Combined hormonal contraceptives may be continued in women with stable bowel disease (category 2-3).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.

      Common Connective Tissue Diseases

      Rheumatoid arthritis (RA) is the most common autoimmune arthritis and affects more than 1.5 million Americans with 75% of RA in women.

      National Institutes of Health. Autoimmune Diseases of Rheumatoid Arthritis and Lupus. https://www.nih.gov/research-training/accelerating-medicines-partnership-amp/autoimmune-diseases-rheumatoid-arthritis-lupus. Accessed October 21, 2020.

      Intrauterine contraceptives, implant, POP, and CHC are category 1-2 in women on immunosuppressive therapy.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Depot medroxyprogesterone acetate is category 2-3 in women with RA on immunosuppressives.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      In RA not requiring immunosuppression all methods are category 1-2.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      It is estimated that 1.5 million Americans have systemic lupus erythematosus (SLE) with 90% being women and the disease often diagnosed between the ages 15 and 44 years.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      In the setting of SLE with known or suspected antiphospholipid antibody syndrome (APAS), TCu380A IUD is category 1.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      Levonorgestrel IUS, implant, and POP are category 3 in known or suspected APAS, and CHC is category 4 in APAS.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      In the setting of SLE with or without immunosuppressive use and no evidence of APAS, all methods are category 1-2.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      In SLE with severe thrombocytopenia, TCu380A IUD and DMPA are category 3 for initiation with all other methods being category 2.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      TCu380A IUD used in severe thrombocytopenia may be associated with increased bleeding compared with LNG IUS.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      Progestin-only contraceptives may be useful in women with severe thrombocytopenia. However, DMPA can cause erratic or increased bleeding on initiation and can be irreversible for 11 to 13 weeks.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Initiation should be considered carefully.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.

      Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome

      At the end of 2016, it was estimated that 1.1 million people aged 13 or older have HIV in the United States including an estimated 162,500 (14%) whose infections had not yet been diagnosed.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      USMEC guidelines were updated for contraception in HIV patients with IUS and DMPA listed as category 1 along with implant, POP, and CHC clarifying that all methods are safe.
      • Tepper N.K.
      • Curtis K.M.
      • Cox S.
      • Whiteman M.K.
      Update to US medical eligibility criteria for contraceptive US, 2016: updated recommendations for the use of contraception among women at high risk for HIV infection.
      There is no evidence of greater viral shedding or risk of transmission to an uninfected partner.
      • Heikinheimo O.
      • Lehtovirta P.
      • Aho I.
      • Ristola M.
      • Paavonen J.
      The levonorgestrel-releasing intrauterine system in human immunodeficiency virus-infected women: a 5-year follow-up study.
      Limited data show no increased risk of IUC use and pelvic inflammatory disease (PID), but given the risk of concurrent sexually transmitted infections (STIs) in HIV, the USSPR recommends screening for STIs according to CDC guidelines.
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      All methods may be used with antiretrovirals and are listed as category 1-2; CHC is category 3 with use of fosamprenavir.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.

      Sexually Transmitted Diseases/Infections/Pelvic Inflammatory Disease

      The CDC reported in its Sexually Transmitted Disease Surveillance Report in 2019 that sexually transmitted diseases for the fifth consecutive year had increased with 2.5 million combined cases of chlamydia, gonorrhea, and syphilis in 2018.
      2018 STD Surveillance Report.
      While sexually transmitted diseases are increasing, PID is declining potentially related to earlier identification and treatment of chlamydia and gonorrhea with availability of single-dose therapies to enhance adherence to treatment.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      ,
      2018 STD Surveillance Report.
      Intrauterine contraceptives are category 4 for initiation when there is any current suspicion for PID, presence of purulent cervicitis, or known chlamydial or gonococcal infection.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      If PID develops with IUC in place, it can usually be treated without device removal.
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      ,
      Committee on Practice Bulletin-Gynecology, Long-Acting Reversible Contraception Work Group
      Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices.
      If a woman is not improved after 48 to 72 hours on antibiotics, consideration can be given to IUC removal.
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      Intrauterine contraceptives are category 2 for evidence of vaginitis with trichomonas and bacterial vaginosis.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      The CDC’s recommended screening for STIs should be up-to-date before insertion of IUC based on age and risk factors.
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      Delay in insertion is not necessary unless PID is suspected.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Implant, DMPA, POP, and CHC are category 1 with STIs, vaginitis, and in women at increased risk of STIs.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      There is no indication for antibiotic prophylaxis for IUC insertion.
      Committee on Practice Bulletin-Gynecology, Long-Acting Reversible Contraception Work Group
      Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices.

      Solid Organ Transplant(s)/Immunosuppression

      In the United States, the most commonly transplanted organs are kidneys, liver, heart, lungs, pancreas, and intestines.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      There are approximately 75,000 people on the active transplant list.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      At least 3% to 4% of the US population is immunosuppressed because of transplantation.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      For women with solid organ transplant(s), limited studies do not report higher infection rates for immunosuppressed IUC users.
      • Browne H.
      • Manipalviratn S.
      • Armstrong A.
      Using an intrauterine device in immunocompromised women.
      ,
      • Huguelet P.S.
      • Sheehan C.
      • Spitzer R.F.
      • Scott S.
      Use of levonorgestrel 52-mg intrauterine system in adolescent and young adult solid organ transplant recipients: a case series.
      Hormonal and non-hormonal IUCs may be initiated and continued in uncomplicated solid organ transplantation as category 2 whereas IUC initiation is category 3 in complicated solid organ transplantation.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Huguelet P.S.
      • Sheehan C.
      • Spitzer R.F.
      • Scott S.
      Use of levonorgestrel 52-mg intrauterine system in adolescent and young adult solid organ transplant recipients: a case series.
      If the IUS is already in place in complicated solid organ transplantation, it may remain in place (category 2).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Huguelet P.S.
      • Sheehan C.
      • Spitzer R.F.
      • Scott S.
      Use of levonorgestrel 52-mg intrauterine system in adolescent and young adult solid organ transplant recipients: a case series.
      Implant, DMPA, and POP are category 2.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Combined hormonal contraceptives are category 4 for complicated organ transplant but may be used in uncomplicated organ transplant (category 2).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.

      Obesity

      Obesity rate (BMI>30 kg/m2) in the general population is 42.4% with obesity-related conditions including cardiac disease, CVA, type 2 diabetes, and certain cancers.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Of the 160 million Americans who are considered overweight (BMI>25 kg/m2) or obese, 60% are women.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Based on a 2016 Cochrane review, obese women can be offered all hormonal contraception as the efficacy of hormonal contraception is not significantly affected.
      • Lopez L.M.
      • Bernholc A.
      • Chen M.
      • et al.
      Hormonal contraceptives for contraception in overweight or obese women.
      More research is needed to better understand how obesity affects contraceptive efficacy, especially in women with BMI greater than 40 kg/m2.
      • Lopez L.M.
      • Bernholc A.
      • Chen M.
      • et al.
      Hormonal contraceptives for contraception in overweight or obese women.
      It may be possible that continuous COC or 30 to 35 μg estrogen-containing formulations may be more effective in obese women.
      • Edelman A.B.
      • Cherala G.
      • Munar M.Y.
      • McInnis M.
      • Stanczyk F.Z.
      • Jensen J.T.
      Correcting oral contraceptive pharmacokinetic alterations due to obesity: a randomized controlled trial.
      Evidence regarding efficacy of the patch and ring is limited, but both are more efficacious than barrier methods alone.
      • Dragoman M.V.
      • Simmons K.B.
      • Paulen M.E.
      • Curtis K.M.
      Combined hormonal contraceptive (CHC) use among obese women and contraceptive effectiveness: a systemic review.
      Concern for VTE risk with use of CHC is outweighed by VTE risk in pregnancy and postpartum.
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      Obese women have a greater risk of abnormal uterine bleeding and endometrial intraepithelial neoplasia (EIN)/hyperplasia.
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      Levonorgestrel 52 mg IUS or other progestin-containing contraception may provide endometrial stabilization and contraception (category 1).
      • Morelli M.
      • Di Cello A.
      • Venturella R.
      • Mocciaro R.
      • D’Alessandro P.
      • Zullo F.
      Efficacy of the levonorgestrel intrauterine system (LNG IUS) in the prevention of atypical endometrial hyperplasia and endometrial cancer: retrospective data from selected obese menopausal symptomatic women.
      If placement of IUC is challenging given high BMI and patient discomfort, sedation can be offered. TCu380A IUD and implant are category 1.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Depot medroxyprogesterone acetate is category 1 for women with BMI greater than 30 kg/m2 and category 2 for those with BMI greater than 30 kg/m2 and age younger than 18 years given risk for mild bone loss.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Depot medroxyprogesterone acetate may cause some women to gain up to 5% of their BMI within 6 months of initiation and further weight gain over the next 36 months, whereas other women do not gain weight on DMPA.
      • Curtis K.M.
      • Jatlaoui T.C.
      • Tepper N.K.
      • et al.
      US selected practice recommendations for contraceptive use, 2016.
      If weight gain is an issue, alternative contraception includes POP (category 1) and CHC (category 2).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      For women undergoing diverting bariatric procedures (Roux-en-Y gastric bypass or biliopancreatic diversion), the absorption of oral medications may be compromised and POP and CHC are category 3.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      American College of Obstetricians and Gynecologists
      ACOG Practice Bulletin No. 105: Bariatric surgery and pregnancy.
      Progestin only pill and CHC are category 1 in women with restrictive bariatric surgery (vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      American College of Obstetricians and Gynecologists
      ACOG Practice Bulletin No. 105: Bariatric surgery and pregnancy.

      Migraines

      Migraine headaches affect 17.1 of US women most commonly between ages 18 to 44 years.
      • Lipton R.B.
      • Bigal M.E.
      • Diamond M.
      • Freitag F.
      • Reed M.L.
      • Stewart W.F.
      AMPP advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy.
      It is important to determine the presence of an aura or focal neurological symptoms before migraine pain. Migraine without aura is most common, accounting for 75% of cases.
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      ,
      • Lipton R.B.
      • Bigal M.E.
      • Diamond M.
      • Freitag F.
      • Reed M.L.
      • Stewart W.F.
      AMPP advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy.
      Aura involves neurologic symptoms, usually visual, occurring generally before headache and lasting 5 to 60 minutes.
      Headache Classification Committee of the International Headache Society (HIS) the International Classification of Headache Disorders, 3rd edition.
      Symptoms include zigzag lines across the visual field, sensory symptoms as pins and needles, speech disturbances, or motor weakness.
      Headache Classification Committee of the International Headache Society (HIS) the International Classification of Headache Disorders, 3rd edition.
      All methods of contraception are category 1 in non-migraine (mild or severe) headaches.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Intrauterine contraceptives, implant, DMPA, and POP are category 1 in women with migraines, with and without aura.
      • Tepper N.K.
      • Whiteman M.K.
      • Zapata L.B.
      • Marchbanks P.A.
      • Curtis K.M.
      Safety of hormonal contraceptives among women with migraine: a systemic review.
      Combined hormonal contraceptives are category 2 in migraine without aura and no other risk factors for CVA.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Tepper N.K.
      • Whiteman M.K.
      • Zapata L.B.
      • Marchbanks P.A.
      • Curtis K.M.
      Safety of hormonal contraceptives among women with migraine: a systemic review.
      If migraines without aura are worsened during the inert week of CHC, continuous CHC may be helpful.
      • Faubion S.S.
      • Casey P.M.
      • Shuster L.T.
      Hormonal contraception and migraine: clinical considerations.
      Combined hormonal contraceptives are category 4 for women with migraines and aura due to increased CVA risk.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Tepper N.K.
      • Whiteman M.K.
      • Zapata L.B.
      • Marchbanks P.A.
      • Curtis K.M.
      Safety of hormonal contraceptives among women with migraine: a systemic review.
      The data regarding CVA with current COC formulations in migraines and aura is limited, but earlier formulations have been associated with a two- to four-fold increased CVA risk.
      • Tepper N.K.
      • Whiteman M.K.
      • Zapata L.B.
      • Marchbanks P.A.
      • Curtis K.M.
      Safety of hormonal contraceptives among women with migraine: a systemic review.

      Seizures and Anticonvulsants

      Approximately 3.4 million people in the United States have epilepsy.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Whereas anticonvulsant therapies challenge contraceptive choice, effective contraception is important because seizure activity may worsen in pregnancy and adversely affect maternal and fetal outcomes.
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      Intrauterine contraceptives are category 1 for women taking antiepileptic drugs (AEDs).
      • Bounds W.
      • Guillebaud J.
      Observational series on women using the contraceptive Mirena concurrently with antiepileptic and other enzyme-inducing drugs.
      Depotmedroxyprogesterone acetate (category 1) 150 mg every 3 months represents a dose substantially higher than needed to suppress ovulation and confers a benefit in raising the seizure threshold.
      • Davis A.R.
      • Pack A.M.
      • Dennis A.
      Contraception for Women With Epilepsy.
      Several AEDs induce hepatic enzymes, decreasing serum levels of CHC or POP (category 3) and increasing risk for unintended pregnancy (eg, carbamazepine, barbiturates, phenobarbital, phenytoin, primidone, topiramate, or oxcarbazepine).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      • Gaffield M.E.
      • Culwell K.R.
      • Lee C.R.
      The use of hormonal contraception among women taking anticonvulsant therapy.
      Combined hormonal contraceptives’ efficacy may be improved with 30 to 35 μg ethinyl estradiol formulations.
      • Davis A.R.
      • Pack A.M.
      • Dennis A.
      Contraception for Women With Epilepsy.
      It is unclear if the contraceptive ring and patch are similar in efficacy to CHC though the transvaginal and transdermal routes offer the advantage of less need for daily attention.
      • Gaffield M.E.
      • Culwell K.R.
      • Lee C.R.
      The use of hormonal contraception among women taking anticonvulsant therapy.
      Most anticonvulsants decrease the effectiveness of the implant (category 2) with some pregnancies reported, but the absolute risk of contraceptive failure remains low.
      • Maddox D.D.
      • Rahman Z.
      Etonogestrel (Implanon), another treatment option for contraception.
      Lamotrigine is the only AED known to have its metabolism affected by COC, reducing lamotrigine serum levels.
      • Davis A.R.
      • Pack A.M.
      • Dennis A.
      Contraception for Women With Epilepsy.
      Lamotrigine dosage needs to be adjusted with concurrent CHC use.
      • Davis A.R.
      • Pack A.M.
      • Dennis A.
      Contraception for Women With Epilepsy.
      The POP is category 1 with lamotrigine.
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      ,
      • Davis A.R.
      • Pack A.M.
      • Dennis A.
      Contraception for Women With Epilepsy.
      When lamotrigine is used for bipolar disease and other mental health disorders in conjunction with CHC, higher doses of lamotrigine may be needed.
      • Prabhavalkar K.S.
      • Poovanpallil N.B.
      • Bhatt L.K.
      Management of bipolar depression with lamotrigine: an antiepileptic mood stabilizer.

      Post Abortion

      Intrauterine contraceptives, implant, DMPA, POP, and CHC are category 1-2 and may be immediately used after spontaneous or induced abortion (medical or surgical).
      Committee on Practice Bulletin-Gynecology, Long-Acting Reversible Contraception Work Group
      Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices.
      Offering contraception or LARC on the same day of first- or second-trimester induced or spontaneous abortion is safe.
      Committee on Practice Bulletin-Gynecology, Long-Acting Reversible Contraception Work Group
      Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices.
      Risk for complications after immediate or delayed IUC insertion following abortion does not differ.
      Committee on Practice Bulletin-Gynecology, Long-Acting Reversible Contraception Work Group
      Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices.
      Intrauterine contraceptives expulsion is greater after a second trimester than first trimester abortion.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      Committee on Practice Bulletin-Gynecology, Long-Acting Reversible Contraception Work Group
      Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices.
      Intrauterine contraceptives insertion immediately post-septic abortion is contraindicated (category 4).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.

      Thyroid Disease

      Approximately 20 million Americans have some form of thyroid disease with women more often affected.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Intrauterine contraceptives, implant, DMPA, POP, and CHC are category 1 with simple goiter, hyperthyroidism, or hypothyroidism.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.

      Multiple Sclerosis

      Nearly 1 million Americans are living with multiple sclerosis with the prevalence related to latitude (47 per 100,000 population in Texas are affected and 109.5 per 100,000 in Ohio, per the CDC).
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Most people receive the diagnosis between 20 and 50 years of age with far more women than men diagnosed.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Intrauterine contraceptives, implant, POP, and CHC are category 1 when mobility is not an issue.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Depotmedroxyprogesterone acetate is category 2 with and without prolonged immobility whereas CHC is category 3 with prolonged immobility.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.

      Cervical Cancer

      Cervical cancer occurs in greater than 13,500 women yearly in the United States.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Cervical cancer is most frequently diagnosed in women between ages 35 and 44 years.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Intrauterine contraceptives are category 4 with known cervical cancer.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Implant, DMPA, POP, and CHC can be used while women are awaiting treatment (category 1-2).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      All methods can be used with cervical ectropion, cervical intraepithelial neoplasia, or dysplasia.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Depot medroxyprogesterone acetate or CHC use for 5 years or longer may increase the risk for carcinoma in situ and invasive cervical cancer in the setting of persistent human papillomavirus.
      • Smith J.S.
      • Green J.
      • Berrington de Gonzalez A.
      Cervical cancer and use of hormonal contraceptives: a systematic review.
      Limited evidence suggests that the implant does not increase risk.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Invasive cervical cancer may be reduced by 30% in women who have used IUCs.
      • Cortessis V.K.
      • Barrett M.
      • Brown Wade N.
      • et al.
      Intrauterine device use and cervical cancer risk: a systematic review and meta-analysis.

      Endometrial Cancer/Endometrial Hyperplasia or Endometrial Intraepithelial Neoplasia

      Endometrial cancer is on the rise in the United States with lifetime risk 3.1%.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Black women are disproportionately affected compared with White women.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      The increase in endometrial cancer reflects the prevalence of overweight and obese women along with other risk factors such as hypertension and diabetes.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Intrauterine contraceptives are category 4 in known endometrial cancer but endometrial hyperplasia/EIN may regress or remain stable while using 52 mg LNG IUS.
      • Morelli M.
      • Di Cello A.
      • Venturella R.
      • Mocciaro R.
      • D’Alessandro P.
      • Zullo F.
      Efficacy of the levonorgestrel intrauterine system (LNG IUS) in the prevention of atypical endometrial hyperplasia and endometrial cancer: retrospective data from selected obese menopausal symptomatic women.
      Implant, DMPA, POP, and CHC are category 1.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      Contraception (including COC and 52 mg LNG IUS) plays a dual role in minimizing the risk of endometrial cancer.
      • Morelli M.
      • Di Cello A.
      • Venturella R.
      • Mocciaro R.
      • D’Alessandro P.
      • Zullo F.
      Efficacy of the levonorgestrel intrauterine system (LNG IUS) in the prevention of atypical endometrial hyperplasia and endometrial cancer: retrospective data from selected obese menopausal symptomatic women.
      ,
      • Wentzensen N.
      • Berringtonde Gonzalez A.
      The Pill’s gestation: from birth control to cancer prevention.

      Gestational Trophoblastic Disease

      Gestational trophoblastic disease (GTD) occurs in approximately 1 per 1000 pregnancies.
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      Intrauterine contraceptives are category 1-2 in GTD but category 4 with persistently elevated beta–human chorionic gonadotropin (hCG) levels or malignant disease with suspicion of intrauterine involvement. Implant, DMPA, POP, and CHC are category 1 in GTD when beta-hCG levels are decreasing or undetectable and may be used with persistently elevated beta-hCG levels or malignant disease (category 1).
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.

      Ovarian Cancer

      The incidence of ovarian cancer in the United States results in 14,000 deaths annually.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Ovarian cancer continues to be diagnosed at an advanced stage in most women. Intrauterine contraceptives, implant, DMPA, POP, and CHC are category 1 in ovarian cancer. Data show that COC lessens the risk of ovarian cancer as does use of IUC in a new meta-analysis.
      • Wentzensen N.
      • Berringtonde Gonzalez A.
      The Pill’s gestation: from birth control to cancer prevention.
      ,
      • Wheeler L.J.
      • Desanto K.
      • Teal S.B.
      • Sheeder J.
      • Guntupalli S.R.
      Intrauterine device use and ovarian cancer risk: a systematic review and meta-analysis.

      Breast Cancer

      Breast cancer is the most common cancer in women.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      Lifetime risk of breast cancer is approximately 12.9%.
      National Center for Health Statistics and Prevalence of Disease, Data and Statistics.
      TCu380A IUD is category 1 in breast cancer. Levonorgestrel IUS, implant, DMPA, POP, and CHC are category 4 given that most breast cancers are hormonally active due to concern for worsened prognosis.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      In benign breast disease or with a family history of breast cancer, all methods are category 1.
      • Curtis K.M.
      • Tepper N.K.
      • Jatlaoui T.C.
      • et al.
      US medical eligibility criteria for contraceptive use.
      ,
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      Care for BRCA 1 and 2 carriers is more complex given their risk for breast and ovarian cancer. A systematic review recommended that BRCA carriers be informed that COC may reduce risk of ovarian cancer but potentially increase risk for breast cancer.
      • Huber D.
      • Seitz S.
      • Kast K.
      • Emons G.
      • Ortmann O.
      Use of oral contraceptives in BRCA mutation carriers and risk for ovarian cancer: a systematic review.

      Summary

      Women’s coexisting medical conditions often challenge contraceptive decisions as recommendations evolve. Long-acting reversible contraception should be the first line of options for most women throughout the reproductive lifespan given their efficacy, convenience, and safety. However, other methods should also be considered as they may confer a lower risk than unplanned pregnancy. Resources such as the USMEC, USSPR, and the USMEC app facilitate the contraceptive choice process by providing expert and evidence-based support for individualized assessment and shared decision-making.

      Conclusion

      It is important to individualize contraception through shared decision-making in women with chronic medical conditions.

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