In the world of family planning the question “Which contraceptive method is best for me?” is a common one.  The World Health Organization (WHO) has tried to address this through a document called Medical Eligibility Criteria for Contraceptive Use (MEC).  This document, now in its fifth edition, provides guidance for choosing the safest contraceptive method given a woman’s health conditions and personal preferences. The MEC makes recommendations based on whether the contraceptive method can worsen certain medical conditions or create health risks and also whether the contraceptive would be less effective in the context of certain medical circumstances.

The MEC reviews the following family planning methods:

  • Low-dose (< 35 mcg ethinyl estradiol) combined (ethinyl estradiol and a progestogen) oral contraceptives (COCs)
  • Combined patch (P)
  • Combined vaginal ring (CVR)
  • Combined injectable contraceptives (CICs)
  • Progestogen-only pills (POPs)
  • Depot medroxyprogesterone acetate (DMPA)
  • Norethisterone enanthate (NET-EN)
  • Levonorgestrel (LNG) and etonogestrel (ETG) implants
  • Emergency contraceptive pills (ECPs)
  • Copper-bearing intrauterine devices (Cu-IUDs)
  • Levonorgestrel-releasing IUDs (LNG-IUDs)
  • Copper-IUD for emergency contraception (E-IUD)
  • Progesterone-releasing vaginal ring (PVR)
  • Barrier methods (BARR)
  • Fertility awareness-based methods (FAB)
  • Lactational amenorrhoea method (LAM)
  • Coitus interruptus (CI)
  • Female and male sterilization (STER).

The medical circumstances include, amongst others: age, weeks/months postpartum, breastfeeding status, venous thromboembolism, superficial venous disorders, dyslipidemias, puerperal sepsis, past ectopic pregnancy, history of severe cardiovascular disease, migraines, severe liver disease, use of CYP3A4 inducers, repeat use of ECPs, rape, obesity, increased risk of sexually transmitted infections, high risk of HIV infection, living with HIV, use of antiretroviral therapy.

Each contraceptive is evaluated with respect to the above medical circumstances and given one of the following four ratings:

  1. Use this method: There is no restriction for the use of the contraceptive method.
  2. Generally used this method: The advantages of using the method generally outweigh the theoretical or proven risks.
  3. Use of method not recommended unless other methods are not available or acceptable: The theoretical or proven risks usually outweigh the advantages of using the method.
  4. Don’t use this method: There is an unacceptable health risk if the contraceptive method is used.

 

While the information laid out in MEC is very helpful, this is a lengthy document. Fortunately, the WHO has summarized some of the 276-page document into a user friendly wheel which matches the use of nine most commonly used contraceptive methods with different medical circumstances and grades them from 1 to 4 as indicated above.  For example, a patient with bipolar disorder who is taking lamotrigine will find a score of 1 for Copper or Levonorgestrel IUDs, progestin-only injectables (DMPA), and progestogen-only pills but a score of 3 for combined hormonal contraceptives. (The “3” reflects the finding that estrogen can reduce lamotrigine levels and thus may diminish its effectiveness.)

For smartphone users, there are also apps for MEC for iOS and Android.

The aim of the MEC is to present a reference for decision-making which can be used by providers and should be used in accordance with provider consultation, as circumstances can differ from one patient to another (e.g. having two co-morbidities, taking multiple medications).

 

Edwin Raffi, MD, MPH