1. U.S. Medical Eligibility Criteria for Contraceptive Use, 2010
Division of Reproductive Health
Centers for Disease Control and Prevention
August 1, 2013
National Center for Chronic Disease Prevention and Health Promotion
Division of Reproductive Health

2. Learning Objectives Participants will be able to:
Describe the US Medical Eligibility Criteria for Contraceptive Use, 2010 (US MEC) and updates
Identify the intended use and target audience for the guidance
Define the 4 classifications of recommendations in the US MEC
Apply the guidance in specific situations, based on clinical scenarios 2

3. The US Medical Eligibility Criteria for Contraceptive Use (or US MEC) was developed in 2010 by CDC and was published in the Morbidity and Mortality Weekly Report in June of 2010.

4. US Medical Eligibility Criteria for Contraceptive Use, 2010
Companion document to US Selected Practice Recommendations for Contraceptive Use, 2013 (US SPR)
Adapted from World Health Organization (WHO) MEC
Target audience: health-care providers
Purpose: to assist health care providers when they counsel patients about contraceptive use and to serve as a source of clinical guidance
Content: over 1800 recommendations for over 60 conditions
The US MEC is a companion document to the US Selected Practice Recommendations for Contraceptive Use which was published in the MMWR in June 2013.
These two family planning guidance documents were adapted from the World Health Organization for the US context.
The US MEC is an evidence-based source of clinical guidance for the safe use of contraceptive methods by women and men with various characteristics and medical conditions.
It is intended to assist health-care providers when they counsel women, men, and couples about contraceptive method choice.
These US MEC includes over 1800 recommendations for more than 60 conditions and also includes information on certain drug interactions.
Health-care providers should always consider the individual clinical circumstances of each person seeking family planning services.

5. Why is evidence-based guidance for contraceptive use needed?
To base family planning practices on the best available evidence
To address misconceptions regarding who can safely use contraception
To remove unnecessary medical barriers
To improve access and quality of care in family planning
Prior to the development of the WHO guidelines, most contraceptive guides around the world were based on medical textbooks or on the individual clinical practice of the author.
They also generally addressed contraceptive use for healthy women, with the result that in many places around the world including the US, women with medical conditions were denied access to contraceptive methods.
WHO, therefore, wanted to develop guidelines that were based on the best available evidence, that would address misconceptions regarding who can safely use contraception, which would remove unnecessary medical barriers, thereby improving access and quality of care in family planning.
With the adaptation, CDC has identified areas in which WHO guidance needed to be modified for current US practice and added new medical conditions that are not included in the WHO guidance.

6. Contraceptive Methods in US MEC
Combined hormonal contraceptives
Progestin-only contraceptives
Emergency contraceptive pills
Intrauterine devices
Barrier contraceptive methods
Fertility Awareness-Based Methods
Lactational Amenorrhea Method
Coitus Interruptus
Female and Male Sterilization
The US MEC contains recommendations regarding a full range of contraceptive methods shown here.
Combined hormonal contraceptives (contain estrogen and a progestin) include combined pills, patch and ring.
Progestin-only contraceptives include progestin-only pills, depo medroxyprogesterone acetate injections and etonorgestrel implants.
Emergency contraceptive pills include levonorgestrel and combined oral contraceptive pills.
Barrier contraceptive methods include male and female condoms, spermicides, diaphragm with spermicide and cervical cap.
Fertility Awareness-Based Methods include symptom-based and calendar-based methods.

7. US MEC Recommendations
Recommendations for use of contraceptive methods, based on specific conditions
Conditions defined as:
Individual’s characteristics
Known preexisting medical/pathologic condition
Refer to methods being used for contraception, not treatment of a medical condition
The tables in this document include recommendations for the use of contraceptive methods by women and men with particular characteristics or medical conditions.
Each condition was defined as representing either an individual’s characteristics (such as age or history of pregnancy) or a known preexisting medical/pathologic condition (such as diabetes and hypertension).
The recommendations refer to contraceptive methods being used for contraceptive purposes; the recommendations do not consider the use of contraceptive methods for treatment of medical conditions (e.g. combined oral contraceptive for treatment of endometriosis) because the balance of risks and benefits in these cases may differ.

8. US Medical Eligibility Criteria: Categories1
No restriction for the use of the contraceptive method for a woman with that condition 2
Advantages of using the method generally outweigh the theoretical or proven risks 3
Theoretical or proven risks of the method usually outweigh the advantages – not usually recommended unless more appropriate methods are not available or acceptable 4
Unacceptable health risk if the contraceptive method is used by a woman with that condition
Each combination of a medical condition or characteristic with a contraceptive method has a recommendation for use, which is provided as a numeric classification- 1, 2, 3 or 4.
A number 1 means that there is no restriction in using a particular contraceptive method for a woman with a particular condition.
A number 2 means that most evidence suggests that it is generally safe for someone with the particular condition to use a particular method, and that the advantages of using the method generally outweigh the theoretical or proven risks.
A number 3 means that the theoretical or proven risks of the method usually outweigh the benefits of using that method, and other methods should be considered, if possible.
A number 4 means that the risk of using a particular contraceptive method for a woman with a particular medical condition is unacceptable and alternative methods should be chosen.
For some conditions, the numeric classification does not entirely capture the recommendation and a clarification statement is given.
Evidence summaries are also given where evidence exists.
The recommendations without evidence cited are based on expert opinion from either the WHO or US expert working group meetings and selected recommendations have comment statements that generally come from those working groups.

9. Example: Smoking and Contraceptive Use
Condition
COC/P/R
POP
DMPA
Implants
Cu-IUD
LNG- IUD
Smoking
a. Age <35 2 1
b. Age≥35
i. <15 cigarettes/day 3
II.≥15 cigarettes/day 4
This is an example of the recommendations for Smoking and Contraceptive Use.
Down the left side, you can see that smoking is broken into categories by age and level of smoking.
Across the top are the various contraceptive methods.
For CHCs (combined hormonal contraceptives) which include combined oral contraceptives, the patch and the ring, you can see that the recommendations reflect increasing safety risks with CHC use and smoking, as age and the level of smoking increases.
A smoker aged <35 years generally can use CHCs (Category 2).
For a smoker 35 years or older who smokes <15 cigarettes per day, however, the use of CHCs is usually not recommended unless other methods are not available or acceptable to her (Category 3).
For smokers >35 years who smoke 15 or more cigarettes, the use of CHCs poses unacceptable health risks, primarily, the risk for myocardial infarction and stroke (Category 4).
Safety risks vary depending on methods and conditions.

10. Initiation and Continuation
Separate columns if recommendations differ for:
Initiation criteria (preexisting conditions)
Continuation criteria (condition develops or worsens)
Combined Hormonal Contraceptives
Headache
Initiation
Continuation
Non-migrainous (mild or severe) 1 2
Migraine
Without aura
Age < 35 years 3
Age >= 35 years 4
With aura, at any age
If the recommendations for initiating a method and continuing a method are different, separate recommendations are given in different columns.
Initiation refers to whether the woman had the condition at the time she starts the method (a preexisting condition).
Continuation criteria are clinically relevant whenever a woman develops a health condition while she is using a method.
This is an example for the condition of headache and use of combined hormonal contraceptives.
For women 35 years or older who experience migraines without aura, the use of combined hormonal contraceptives usually is not recommended unless other methods are not available or acceptable to her (Category 3).
However for women 35 years or older who develop migraines either with or without aura while using combined hormonal contraceptives, continuing the method is not recommended (Category 4) as it poses an unacceptable health risk of stroke.

11. Contraceptive Methods in US MEC
Combined hormonal contraceptives (CHCs)
Progestin-only contraceptives
Emergency contraceptive pills
Intrauterine contraception
Barrier contraceptive methods
Fertility Awareness-Based Methods (FAB)
Lactational Amenorrhea Method
Coitus Interruptus
Female and Male Sterilization
The full range of contraceptive methods addressed in the US MEC are again shown here.
The first five types of methods shown in white follow the 1-4 classification system.
Information for the methods shown in yellow are also included in the US MEC with brief descriptions.
A separate recommendation system is provided for Fertility Awareness-Based Methods (FAB).
These methods do not follow the 1-4 classification since FAB methods can generally be used without concern for health effects. The classification for certain conditions or characteristics and the use of FAB methods include A for accept (no medical reason to deny the particular FB method), C for caution (extra preparation and precautions including special counseling to ensure correct use of method) and D for delay (delay until condition evaluated or corrected).

12. Contraceptive Effectiveness Chart
Tier 1
Tier 2
Tier 3
This figure shows currently available contraceptive methods, ranked by typical effectiveness, meaning how effective the method is at preventing pregnancy with real-world use.
Incorrect or inconsistent use can impact the effectiveness of the contraceptive method.
Many factors need to be considered when choosing the most appropriate contraceptive method.
These include safety, effectiveness, availability and acceptability; with pregnancy prevention as a goal of contraceptive use, effectiveness is one of the most important considerations.
The US MEC recommendations focus primarily on the safety of a given method for women with medical conditions or characteristics.
The 1-4 recommendations generally do not take effectiveness into account.
While a Category 1 recommendation means the method can be used with no restrictions in regards to safety, that method may not be the best option for that person while considering these other factors. For example, the use of spermicide in a woman with complicated valvular heart disease is category 1, meaning the use of spermicide is safe to use with her condition and will not worsen her condition. However, the use of a more effective method will reduce her risk for adverse health events as a result of unintended pregnancy.

13. Conditions Associated with Increased Risk for Adverse Heath Events as a Result of Unintended Pregnancy
Breast cancer
Malignant liver tumors (hepatoma) and hepatocellular carcinoma of the liver
Complicated valvular heart disease
Peripartum cardiomyopathy
Diabetes: insulin dependent; with nephropathy/retinopathy/neuropathy or other vascular disease; or of >20 years’ duration
Schistosomiasis with fibrosis of the liver
Endometrial or ovarian cancer
Severe (decompensated) cirrhosis
Epilepsy
Sickle cell disease
Hypertension (systolic > 160 mm Hg or diastolic > 100 mm Hg)
Solid organ transplantation within the past 2 years
History of bariatric surgery within past 2 years
Stroke
HIV/AIDS
Systemic lupus erythematosus
Ischemic heart disease
Thrombogenic mutations
Malignant gestational trophoblastic disease
Tuberculosis
Shown here is a list of medical conditions identified in the US MEC that may be worsened should an unintended pregnancy occur.

14. Conditions Associated with Increased Risk for Adverse Heath Events as a Result of Unintended Pregnancy
Breast cancer
Malignant liver tumors (hepatoma) and hepatocellular carcinoma of the liver
Complicated valvular heart disease
Peripartum cardiomyopathy
Diabetes: insulin dependent; with nephropathy/retinopathy/neuropathy or other vascular disease; or of >20 years’ duration
Schistosomiasis with fibrosis of the liver
Endometrial or ovarian cancer
Severe (decompensated) cirrhosis
Epilepsy
Sickle cell disease
Hypertension (systolic > 160 mm Hg or diastolic > 100 mm Hg)
Solid organ transplantation within the past 2 years
History of bariatric surgery within past 2 years
Stroke
HIV/AIDS
Systemic lupus erythematosus
Ischemic heart disease
Thrombogenic mutations
Malignant gestational trophoblastic disease
Tuberculosis
Should consider long-acting, highly-effective contraception for these patients
For women with these conditions and others that may make unintended pregnancy an unacceptable health risk, long-acting highly effective contraceptive methods may be the best choice.
Sole use of barrier and behavior-based methods may not be the most appropriate choice because of their relatively higher typical-use rates of failure.

15. Keeping Guidance Up to Date
CIRE system: Continuous Identification of Research Evidence
UPDATE: Revised Recommendations for the Use of Contraceptive Methods During the Postpartum Period1
UPDATE: Revised Recommendations for the Use of Hormonal Contraception Among Women at High Risk for HIV Infection or Infected with HIV2
Keeping guidance up to date is a challenge, but imperative.
Through the CIRE system (Continuous Identification of Research Evidence) any new published articles that may pertain to family planning guidelines are reviewed together by WHO and CDC researchers.
If newly identified evidence does not support current recommendations, meetings are held to discuss the entire body of evidence and updated recommendations may be released.
Since the US MEC was published in 2010, two updates have been published, one regarding recommendations for contraception in the postpartum period and another regarding hormonal contraception among women at high risk for HIV infection or infected with HIV.
Recommendations otherwise are updated every 4 to 5 years at large expert meetings.
1. CDC, MMWR 2011; 60:
2. CDC. MMWR 2012;61:

16. Dissemination, Implementation and Evaluation
Adopted by Title X Family Planning Program
All Title X clinics are expected to use
Incorporated into revised Title X Clinical Guidelines
Endorsed by ACOG
Committee Opinion, September 2011
Incorporated into national standards and protocols
Reprinted in 20th Edition of Contraceptive Technology and Managing Contraception
National Guidelines Clearinghouse (guidelines.gov)
Baseline and follow-up evaluation
Dissemination, implementation, and evaluation activities are also critical to this effort.
Because CDC does not directly provide any FP services, CDC relies on its partners to help disseminate the guidance with education and training activities, as well as job aids and tools to help providers use the guidance.
The guidance has been adopted by the Title X Family Planning Program, has been endorsed by the American College of Obstetricians and Gynecologists through a 2011 Committee Opinion and has been reprinted in popular contraceptive texts.
The US MEC is also accessible through the National Guidelines Clearinghouse.
A baseline evaluation of family planning providers attitudes and practices around MEC has also been conducted and follow-up evaluation is underway.
ACOG Committee Opinion, No 505, 2011.

17. How to use the US MEC

18. Provider Tools and Learning Aids
Summary tables in English, Spanish
US MEC Wheel
iPhone and iPad app
Continuing Education Activities
Speaker-ready slides
Contraceptive Effectiveness Chart
Tools and learning aids that are available include:
Summary tables of US MEC recommendations in both English and Spanish
A US MEC wheel which works like a pregnancy wheel to highlight a subset of commonly used recommendations
An iPhone and iPad app
Continuing education activities
Speaker-ready slides including this set to view or use for presentations at any time
And the Contraceptive Effectiveness Chart to aide in teaching or counseling

19. Locating CDC contraception guidance
To access this guidance, search for CDC contraception to reach CDC’s page on Contraceptive Guidance for Healthcare Providers.

20. CDC Contraceptive Guidance for Health Care Providers
This is the introductory page, with links to both the US MEC and the US SPR.
There are also badges available on the right to add to a website which will link directly to the US MEC and US SPR sites.

21. The US MEC site is seen here.
Information about the US MEC is given along with Resources, Video Commentary, Links to the app and other CDC and WHO resources associated with the US MEC.

22. To further demonstrate how the guidance can be used, we will now go through several clinical scenarios for which the guidance may be useful.
CLINICAL SCENARIOS

23. Scenario 1
28 year old G1P0 female is pregnant and being counseled for postpartum family planning. She is not planning on breastfeeding. What options are available to her postpartum?
A. IUD (copper or levonorgestrel)
B. Progestin-only methods (pill, injectable, implant)
C. Combined hormonal methods (pill, patch, ring)

24. Why is postpartum contraception important?
Avoid unintended pregnancy and short birth interval
May be ideal time to provide contraception
Motivation
Access to health care services, especially during delivery hospitalization
Prevent repeat adolescent pregnancies
20% of adolescent births are repeat births
Postpartum contraception is important for many reasons:
It allows for birth spacing and avoiding an unintended pregnancy.
It may be an ideal time to provide contraception while a woman is accessing services and may be motivated to start a contraceptive method.
Postpartum contraception may be particularly important for adolescents as a recent CDC Morbidity and Mortality Weekly Report found that 20% of adolescent births are repeat births and for teens this may be an ideal time to prevent a repeat teen pregnancy.
Vital signs: Repeat births among teens - United States, MMWR 2013 Apr 5;62(13):

25. Systematic Review: Postpartum VTE
3 studies directly compared postpartum risk of deep vein thrombosis to non-pregnant women
Risk is 22 to 84 times as high in postpartum women than non-pregnant women
Rate ratio comparing rates of venous thromboembolism (VTE) among postpartum and non-pregnant women calculated for 3 studies
Rate Ratio: 2.5 to 21.5 in postpartum women
3 studies provided weekly data
Indicated that risk decreases markedly after first 3 to 4 weeks postpartum
Most studies convey no significant increase after 6 weeks
Because postpartum women are at increased risk of venous thromboembolism (VTE), there is concern that the use of combined hormonal methods (pill, patch and ring) may further increase the risk of VTE.
The recommendations for hormonal contraceptives (both combined and progestin-only) in the postpartum period are based on a systematic review published in 2011.
New evidence indicated that risk of VTE in the postpartum period was greater and lasted longer than previously thought.
Jackson et al. Obstetrics and Gynecology 2011;117:

26. Hormonal methods for non-breastfeeding postpartum women
Postpartum (non-breastfeeding)
CHCs
Progestin-only methods
<21 days 4 1
21-42 days
With other risk factors for VTE 3*
Without other risk factors for VTE 2
>42 days
Here are recommendations for hormonal methods among non-breastfeeding postpartum women.
For these women, risks of using combined hormonal contraceptives (CHCs which include combined pills, the patch and the ring) are primarily for thrombosis.
Combined hormonal contraceptives may further increase the risk of venous thromboembolism in postpartum women.
Therefore combined methods should not be used immediately postpartum.
All progestin-only methods are category 1 at anytime postpartum.
*Clarification: Other risk factors might increase classification to “4”

27. Postpartum IUD insertion
Postpartum (breastfeeding or non-breastfeeding, including post cesarean section)
LNG-IUD
Cu-IUD
<10 min after delivery of placenta 2 1
10 min to <4 weeks
>4 weeks
Puerperal sepsis 4
The postpartum IUD insertion recommendations include the placement of IUDs in the postpartum period and recommendations are based on timing from delivery as well.
The timing is separated into immediate placement (within 10 minutes after placental delivery), delayed placement (from 10 minutes through four weeks postpartum) and interval placement (4 weeks or more from delivery)
Recommendations are the same for breastfeeding and non-breastfeeding women and for post vaginal or post cesarean deliveries.
IUDs can be placed at anytime postpartum, although there may be an increased risk of expulsion (Category 1 or 2) if placed less than 4 weeks from delivery.
IUDs should not be placed in women with puerperal sepsis (Category 4).

28. Systematic Review of Postpartum IUD
Identified 15 articles of poor to fair quality
Outcomes from copper IUD insertions
Postpartum time period compared to other time intervals
Routes of postpartum insertion (vaginal or via hysterotomy)
No studies of levonorgestrel IUDs were identified
Immediate IUD insertion is safe
Lower Expulsion Rates
Immediate insertion compared to delayed postpartum insertion
Interval insertion compared to immediate postpartum
Postplacental placement during cesarean delivery compared to postplacental vaginal insertion
The postpartum IUD insertion recommendations are also based on a systematic review that identified 15 articles assessing outcomes after postpartum Copper IUD placement.
Overall findings were that immediate IUD insertion is safe and that there is no increase in the risk of complications if inserted during the postpartum period.
Expulsion rates were found to be decreased for the listed comparisons.
Kapp and Curtis. Contraception 2009;80:

29. Scenario 1
28 year old G1P0 female is pregnant and being counseled for postpartum family planning. She is not planning on breastfeeding. What options are available to her immediately postpartum?
A. IUD (copper or levonorgestrel)
B. Progestin-only methods (pill, injectable, implant)
C. Combined hormonal methods (pill, patch, ring)
(Wait until days postpartum, depending on VTE risk factors)
She can have an IUD or implant placed immediately or start an injectable or progestin only pills prior to leaving the hospital.
If she wants a combined hormonal contraceptive, she will need to wait until days postpartum, depending on VTE risk factors. However, she can be given the method or a prescription before she leaves the hospital.
If she is planning to breastfeed, please refer to the US MEC recommendations for breastfeeding.

30. Scenario 2
38 year old G2P2 female with diabetes has been using condoms for contraception and is looking for a more effective method. What methods are safe for her to use?
A. IUD (copper or levonorgestrel)
B. Progestin-only methods (pill, injectable, implant)
C. Combined hormonal methods (pill, patch, ring)

31. Evidence
Use of COCs among women with history of gestational diabetes does not increase risk of developing noninsulin-dependent diabetes
Use of COCs among women with insulin- or noninsulin-dependent diabetes:
Limited effect on daily insulin requirements
No effect on long-term diabetes control
No effect on progression to retinopathy
The evidence summaries for the recommendations for history of gestational disease and nonvascular disease are based on several studies and are summarized here.
No evidence regarding safety was found for the use of contraceptives for women with diabetes with nephropathy/retinopathy/neuropathy or other vascular disease or diabetes of >20 years duration.
Most of the decisions about medical eligibility criteria in these situations were often based on:
Extrapolations from studies that primarily included healthy women
Theoretical considerations about risks and benefits
Expert opinion
CDC, MMWR 2010; 59, No RR-4

32. Diabetes Condition COC/P/R POP DMPA Implants LNG- IUD Cu-IUD 1 2 3/4†
History of gestational disease 1
Nonvascular disease
Noninsulin-dependent 2
Insulin-dependent§
Nephropathy/retinopathy/ neuropathy§
3/4† 3
Other vascular disease or diabetes of >20 yrs' duration§
For this example, assume the woman was diagnosed 2 years ago and is insulin dependent, with no vascular disease or other end-organ disease.
Recommendations for diabetes depend on the subgroup of diabetes, which have different risks.
Insulin-dependent diabetes and diabetes complicated by nephropathy, retinopathy, neuropathy, vascular disease or lasting more than 20 years are conditions that expose a woman to increased risk as a result of unintended pregnancy.
While insulin-dependent diabetes has all category 1 and 2 recommendations, complicated diabetes subgroups have category 3 recommendations for DMPA and a mixed recommendation of 3/4 for combined hormonal methods according to the severity of the complicated diabetes.
§ Condition that exposes a woman to increased risk as a result of unintended pregnancy
† This category should be assessed according to the severity of the condition

33. Scenario 2
38 year old G2P2 female with diabetes has been using condoms for contraception and is looking for a more effective method. You now know that she is non-insulin dependent and has no vascular disease. What methods are safe for her to use?
A. IUD (copper or levonorgestrel)
B. Progestin-only methods (pill, injectable, implant)
C. Combined hormonal methods (pill, patch, ring)
ALL OF THE ABOVE
While all methods are safe, an unintended pregnancy in a woman with diabetes may have increased risk of adverse events and thus effectiveness should be emphasized when discussing method options.

34. Scenario 3
A 30 year old female has a history of bariatric surgery 1 year ago. She was using COCs before her surgery and desires to restart them. What do you need to know before deciding whether to recommend this method?
A. How much weight has she lost?
B. What type of surgery did she have?
C. What pill formulation did she use
previously?
History of Bariatric surgery within the past 2 years is another condition identified as one associated with increased risk for adverse health events as a result of unintended pregnancy. 34

35. Bariatric surgery Restrictive procedures:
Decrease storage capacity of stomach
Ex: vertical banded gastroplasty, laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy
Malabsorptive procedures:
Decrease absorption of nutrients and calories by shortening functional length of small intestine
Ex: Roux-en-Y gastric bypass (most common in US), biliopancreatic diversion
Briefly, there are two types of bariatric procedures, restrictive and malabsorptive.
Restrictive procedures decrease the storage capacity of the stomach.
Malabsorptive procedures shorten the functional length of the small intestine and therefore decrease the absorption of nutrients and calories.

36. Bariatric surgery Risks Postop complications- VTE/PE
Long term complications- protein calorie malnutrition, metabolic bone disease, hepatic dysfunction, vitamin and mineral deficiencies
Consensus to avoid pregnancy for months
Majority of weight loss and postop comps occur
Weight loss may increase fertility
Theoretical concerns for contraception
Effectiveness of oral methods from malabsorption, postop diarrhea or vomiting
VTE risk from major surgery and obesity
Risks for women who undergo the procedure include the postop complications such as VTE or PE as well as long term complications such as malnutrition, metabolic bone disease, hepatic dysfunction, and vitamin and mineral deficiencies.
There is a consensus that pregnancy should be avoided for the first 24 months because the majority of weight loss and postop complications will occur during that time.
It is important to remember that weight loss may increase fertility due to resumption of ovulation, and therefore contraception is of great importance particularly in the first 2 years following surgery when pregnancy is not recommended.
However, there are theoretical concerns for contraceptive use in these women.
For example, the malabsorption that can occur from the surgery itself and postop diarrhea or vomiting may affect effectiveness of oral contraceptives.
The VTE risk from major surgery with prolonged immobilization as well as obesity itself may be increased with use of combined methods.

37. Evidence
5 studies
Effectiveness: 2 studies showing conflicting evidence re pregnancies with OCs, no pregnancies in DMPA or IUD users
Safety: 1 case report, woman using OCs experienced stroke
PK: 2 studies showing lower plasma levels of hormones in women who had surgery
There is a small number of studies, all observational or pharmacokinetic (PK) or case reports that examined contraceptive use among women with a history of bariatric surgery.
There were conflicting results on OC effectiveness and no studies addressing safety other than 1 case report.

38. History of bariatric surgery
Condition
COC/P/R
POP
DMPA
Implants
Cu-IUD
LNG-IUD
Restrictive procedures 1
Malabsorptive procedures
COCs: 3
P/R: 3
Recommendations for women with a history of bariatric surgery are shown here and were based on limited evidence and expert opinion.
For malabsorptive procedures, combined oral contraceptives (COCs) and Progestin-only pills (POPs) are Category 3.
The concern is that decreased absorption from the procedure, possibly further decreased by postoperative complications such as long-term diarrhea and/or vomiting, will decrease effectiveness of the methods.
All other methods are Category 1 for malabsorptive procedures including the combined methods of patch and ring.
All methods including oral contraceptive pills are Category 1 for restrictive procedures. 38

39. Scenario 3
A 30 year old female has a history of bariatric surgery 1 year ago. She was using COCs before her surgery and desires to restart them. What do you need to know before deciding whether to recommend this method?
Answer:
What type of surgery did she have? If malabsorptive procedure, would not recommend OCs, unless other methods are not available or acceptable (Category 3). 39

40. Take Home Messages
US MEC provides evidence-based recommendations for safe use of contraceptive methods by women and men with various conditions
Most women can safely use most contraceptive methods
Certain conditions are associated with increased risk for adverse health events as a result of unintended pregnancy
Women at risk of unintended pregnancy need access to highly effective contraceptive methods
Women, men and couples should be informed of full range of methods to decide what will be best for them

41. Resources
CDC evidence-based family planning guidance documents:
Sign up to receive alerts!
WHO evidence-based family planning guidance documents:
US MEC information, tools and aides can be found at the listed website
You can also sign up for alerts to be up to date with any new guidance updates or new tools released from CDC
The WHO family planning website is also listed to access WHO family planning guidance