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:
- Use this method: There is no restriction for the use of the contraceptive method.
- Generally used this method: The advantages of using the method generally outweigh the theoretical or proven risks.
- 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.
- 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
I am finding nothing on the mental health website relating to catamenial epilepsy patterns and contraceptives or catamenial epilepsy patterns and PMS and PMDD.
I have had catamenial epilepsy since 2000. The epilepsy is post traumatic epilepsy from a tbi. However, I had documented that the pattern is definitely catamenial and unfortunately falls under all 3 of Dr. Herzog’s patterns. An endocrinologist at Hospital of University of xxx in 2001 recommended Leuprolide, but given that I was only 21 at that time, my gynecologist thought that suggestion was a sledge hammer approach. In hindsight, I probably would have needed progesterone and estrogen add ons, and the estrogen in combined birth control pills we found over the years is a big trigger for my seizures. Before we knew the effects of estrogen, my gynecologist prescribed Seasonale. Within the window of taking this medication I had my first status epilepticus in Jan. 2005. I had epilepsy surgery in 2006, Still, I was having intense PMDD and some break through seizures. I consulted a neuroendocrinologist in fall of 2006. He prescribed natural progesterone for me, Prometrium. However, the method regimen of dosing was too difficult for me because of my memory, and my periods were irregular.Also, I bled constantly. I developed a uti in December, but I think because my gabapentin dose was so high, I did feel effects of the uti. I passed out at a brain injury get together, thankfully close to xxx Hospital. I was admitted to ER and had a very high temperature and chills / shaking. My blood pressure dropped to dangerously low levels and I was move quickly to the cardiac ICU. There they treated me with pressors It turned out the bacteria had been a very common one, but I had developed urosepsis and pyelonephritis). I was referred by my epileptologist and to a nephrologist and internist who treated many patients with neurological disorders. He said it was not uncommon for patients with underlying neurological conditions to go awry with those functions regulated by the lower brain / brain stem. When discussing the Prometium tablets with him, he mused aloud to my mother and me if perhaps a progesterone IUD would be helpful rather than oral natural progesterone. However, after this bad experience with hormone treatment, I stayed away from hormones for a long time. With my mother looking back at my medical records 2007 and after a progesterone IUD was recommended to me by the nephrologist above, an epileptologist whose specialty was women with epilepsy, and two gynecologists. However, it wasn’t until November 2012 that I had a progesterone IUD inserted that. In order to begin Claravis (accutane) for my acne in Jan. 2013, I had to name two forms of birth control–I chose Mirena Progesterone IUD and condoms. Miraculously, my number of seizures, falls, bedwets (viewed as overnight seizure) were greatly reduced. My gynecologist and epileptologist both said I couldn’t attribute the change to the Progesterone IUD, because it wasn’t systemic. I remain unconvinced. In 2017, the first
Mirena IUD was taken out and another Mirena IUD with the same dosage was inserted on 10/23/17. Now, though, seizures and pmdd seem to be coming back with hormonal changes about the same time each month. I don’t know what the difference is.
Thank you for taking the time to share your experiences. Very interesting. Obviously your situation is very complicated, and we are by no means epileptologists, but I have some thoughts.
1. The levels of certain anticonvulsants, specifically lamotrigine, are affected by levels of estrogen. So as the estrogen levels rise and fall during your menstrual cycle, the levels of anticonvulsants may be fluctuating and may make you more vulnerable to seizures during certain parts of your cycle.
2. Although Mirena is thought to act locally, we definitely see women who have side effects which suggest that enough of the hormone is absorbed to affect organs at distant sites. Mirena also partially suppresses ovulation, so you may not have the typical rising and falling levels of estrogen and progesterone which are associated with a normal cycle.
3. I have no idea why the first Mirena worked and the second one did not. You might want to contact the manufacturer.
4. If you have PMDD, SSRIs are the most effective treatment for PMDD.