About this wheel

This wheel contains the medical eligibility criteria for starting use of contraceptive methods. It is based on Medical Eligibility Criteria for Contraceptive Use, 3rd edition (2004) and its 2008 Update, one of WHOs evidence-based guidelines. It tells family planning providers if a woman presenting with a known medical or physical condition is able to use various contraceptive methods safely and effectively. The wheel includes recommendations on initiating use of six common types of contraceptives: 1. Combined pills (low dose combined oral contraceptives, with < 35 g ethinylestradiol) 2. Combined injectable contraceptives (Cyclofem and Mesigyna) 3. Progestogen-only pills 4. Progestogen-only injectables, DMPA (a 3-monthly injectable) and NET-EN (a 2-monthly injectable) 5. Progestogen-only implants (Norplant, Jadelle, and Implanon) 6. Copper-bearing IUD The guidance in the wheel applies to initiation of contraceptive methods. Recommendations for continuation of method use, when a woman develops a medical condition while using the method, can be found in the Medical Eligibility Criteria for Contraceptive Use guideline.

WHO Library Cataloguing-in-Publication Data WHO medical eligibility criteria wheel for contraceptive use - 2008 update. 1.Contraception - methods. 2.Family planning services - methods. 3.Eligibility determination - standards. 4.Guidelines. I.World Health Organization. II.Title: Medical eligibility criteria wheel for contraceptive use. ISBN 978 92 4 154771 0 (NLM classification: WP 630)

WHO MEDICAL ELIGIBILITY CRITERIA WHEEL FOR CONTRACEPTIVE USE 2008 UPDATE

World Health Organization 2009

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in

How to use this wheel

The wheel matches up the contraceptive methods, shown on the inner disk, with specific medical conditions shown around the outer rim. The numbers shown in the viewing slot tell you whether the woman who has this known condition is able to start use of the contraceptive method: 1 = Yes: Use the method in any circumstance 2 = Yes: Generally use the method 3 = No: Use of the method is not usually recommended unless other more appropriate methods are not available or acceptable 4 = No: Method NOT to be used Categories 1 and 4 are clearly defined recommendations. For categories 2 or 3, greater clinical judgement will be needed and careful follow-up may be required. If clinical judgement is limited, categories 1 and 2 both mean the method can be used, and categories 3 and 4 both mean the method should not be used. No restrictions for some conditions: There are many medical conditions when ALL methods can be used (that is, all the methods are either a category 1 or 2). These conditions are listed on the back of the wheel.

EXUALLY TRANSMITTED HIV/ Y S R INFECTIONS O T AID MA S M A r S e T h L t I s O I a n e c F o r h e ased IN EASE Gonorr iaC H n d a I C V SM I r i d infe sk of LV DIS Chlamy Past OK vaginitis or AI ction STI E PE D ING Age S L nt A e < r r N NG 35 u I C G I 1 Combin Ag VA EED ined CICs) e> & L ed p a l s C B p
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Acknowledgements
The Medical Eligibility Criteria for Contraceptive Use and this version of the Medical Eligibility Criteria Wheel were developed by the World Health Organizations Department of Reproductive Health and Research. This wheel is based on similar medical eligibility criteria wheels developed independently in Ghana and Jordan. We would like to thank the responsible groups for their innovative work: Ghana: The Department of Obstetrics and Gynaecology at the Korle Bu Teaching Hospital, part of the University of Ghana Medical School; and the WHO country office in Ghana. Further technical or financial support was provided by: the Ghana Health Service, UNFPA/Ghana, Gold Fields Ghana Ltd., JHPIEGO, EngenderHealth, WHO/AFRO, USAID, and WHO/Eritrea. Jordan: The Jordan Health Communication Partnership and the Near East Division, led by the late Dr Alfred Yassa, in the Health Communication Partnership at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, in collaboration with the Jordan Ministry of Health, and with support from USAID. We would like to thank the following individuals for their work on the original wheel: Dr Charles Fleischer-Djoleto, WHO/Ghana; Dr Enyonam Kwawukume, Korle Bu Teaching Hospital; Mr Ward Rinehart of the INFO Project, JHSPH/CCP; Dr Therese Lesikel, WHO/AFRO; Dr Kathryn Curtis, Centers for Disease Control and Prevention; Ms Kathryn Church, Dr Catherine dArcangues, Dr Nuriye Ortayli, Ms Sarah Johnson, and Dr Paul Van Look, Department of Reproductive Health and Research, WHO. Dr Mario Festin, Dr Mary Lyn Gaffield, and Ms Sarah Johnson were responsible for this 2008 Update. Layout and design: Ms Cath Hamill and Ms Janet Petitpierre.

Ordering copies and further information Detailed information on the medical eligibility criteria, including guidance on other contraceptive methods, appears in the Medical Eligibility Criteria for Contraceptive Use, 3rd edition, 2004 and the 2008 Update. This can be accessed at http://www.who.int/reproductive-health or copies can be ordered from the address below. Sample copies of the wheel can be ordered from: Documentation Centre Department of Reproductive Health and Research World Health Organization 1211 Geneva 27 Switzerland Fax: +41 22 791 4189. Phone: +41 22 791 4447. Email: rhrpublications@who.int Bulk orders to supply programmes can be ordered from: WHO Press World Health Organization 1211 Geneva 27 Switzerland Fax: +41 22 791 48 57. Phone: +41 22 791 32 64. Email: bookorders@who.int Order online: http://www.who.int/bookorders

6 weeks to Puerper a 6 months and pos l Brea tcanc st abortion (curr er ent) 3

EXUALLY TRANSMITTED HIV/ Y S R INFECTIONS O T AID MA S M A r S e T h L t I s O I a n e c F o r h eased IN EASE Gonorr iaC n d a C SM I r isk of d HIV LV DIS Chlamy Past OK vaginitis infec STI E PE t ING Age L or AI ion nt A e < r D r N NG S 3 u I 5 C 1 G I 1 1 Ag VA EED ined 1G 1 e> L a B expl 35 2 n 1 1 U 1 1 1G 1 3I 2 1 1 1 1 1 1 1G 2 1 1 1 1 1 1 1G 3 1 1 1 1 1 3 D F
2 3
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1

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1 4 1 2 A 4 1

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Major surgery

with prolonged immobilization

POSTPARTUM EDING BREASTFE

Up to 6 weeks

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CARD I O V A SCU ALR D ISE AS E

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Conditions that are category 1 and 2 for all methods (method can be used)
Age 1839 Anaemias, including sickle-cell disease and thalassaemia Benign ovarian tumors, including cysts Breast disease: family history, benign breast disease and undiagnosed mass Depression Dysmenorrhoea Endometriosis Epilepsy High risk for HIV History of gestational diabetes History of high blood pressure during pregnancy History of pelvic surgery, including caeserean section Irregular, heavy or prolonged menstrual bleeding Malaria Mild cirrhosis Past ectopic pregnancy Post-abortion (no sepsis) Schistosomiasis (bilharzia) Surgery without prolonged immobilization Taking antibiotics (excluding rifampicin/rifabutin) Thyroid disorders Tuberculosis (but if pelvic, cannot use IUD) Uncomplicated valvular heart disease Varicose veins Viral hepatitis (carrier or chronic)

Notes to the conditions

A Can insert copper IUD < 48 hrs after delivery or > 4 weeks. B If she had no subsequent pregnancy, IUD = 2. C Or other forms of purulent cervicitis. D If she develops this condition while using the IUD, she can keep using it during treatment. E If at increased risk of STIs or HIV, advise condom use. F If very high likelihood of exposure to gonorrhoea or chlamydia = 3. G If on ARV Therapy = 2, except ritonavir-boosted ARVs = 3. H AIDS, but not clinically well on ARV Therapy = 3 for insertion. I COCs and heavy smoking = 4. CICs and light smoking = 2. J If blood pressure cannot be measured, and she has no known history of hypertension, all methods can be used. K The same category applies to controlled hypertension. L Risk factors include: older age, smoking, diabetes, hypertension. M To check if migraine has aura, ask: Do you see a bright spot in your vision before bad headaches? N Migraine without aura and < 35 years old, COCs and CICs = 2. Migraine without aura and > 35 years old, COCs and CICs = 3. O For complicated diabetes, or having diabetes for more than 20 years, COCs, CICs, DMPA and NET-EN = 34. P COCs = 3; CICs = 2. Q Phenytoin, carbamezepine, barbiturates, primidone, topiramate, oxcarbazepine. For lamotrigine COCs/CICs = 3. Other methods = 1. R If she is not clinically well, IUD = 3. S If the uterine cavity is distorted, cannot use IUD. T > 45 yrs. = 2. U If established on anticoagulant therapy = 2. V DMPA = 1; NET-EN = 2.

Developed in collaboration with:

Communication Partnership for Family Health

Johns Hopkins Center for Communication Programs

University of Ghana Medical School

World Health Organization, 2009

Comb ined pills and co mb i Pro ge

ICs) s&C C O s (C ble a t OP s ) c ll s (P i p nje i d nly ne n -o EN e g NETsto

A& P DM

Combin ed p ills and P r o g es com t og e bin n- o nl y ed DMPA pi l ls &N (

CICs) Cs & (CO les tab ec inj )

1 Use the method in any circumstance

Co

lants Imp UD er I p p

Impla nts Copp er I

ETEN

PO

Ps

UD

Use of the method not usually recommended unless other, more appropriate methods are not available or acceptable Method NOT to be used

2 Generally use the method

WHO Medical Eligibility Criteria Wheel

for contraceptive use (2008 update)
This wheel contains medical eligibility criteria for starting use of selected contraceptive methods. It is based on WHO's guideline Medical Eligibility Criteria for Contraceptive Use, 3rd edition, 2004 and its 2008 Update.