Mini-Review

2016 Updates to US Medical Eligibility Criteria for Contraceptive

Use and Selected Practice Recommendations for Contraceptive
Use: Highlights for Adolescent Patients
Andrea J. Hoopes MD, MPH 1,*, Katharine B. Simmons MD, MPH 2,3 ,
Emily M. Godfrey MD, MPH, FAAFP 4 , Gina S. Sucato MD, MPH 5
1
Kaiser Permanente Washington, Seattle, Washington
2
Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
3
Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
4
Departments of Family Medicine and Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington
5
Kaiser Permanente Washington Health Research Institute, Seattle, Washington

a b s t r a c t

The US Medical Eligibility Criteria for Contraceptive Use (MEC) and US Selected Practice Recommendations for Contraceptive Use (SPR)
provide evidence-based guidance to safely provide contraception counseling and services. Both documents were updated in 2016 and are
endorsed by the North American Society for Pediatric and Adolescent Gynecology. The purpose of this mini-review is to highlight updates
to the US MEC and US SPR that are most relevant to health care providers of adolescents to support dissemination and implementation of
these evidence-based best practices. This document is intended to highlight these changes and to complement, not replace, the detailed
practice guidance within the US MEC and US SPR.
Key Words: Contraception, Pregnancy, Adolescent

Introduction contraceptive methods are considered safe among women

Pregnancy among adolescents in the United States is a
public health problem with 625 ,000 adolescents becoming
pregnant each year.1 Despite declines over the past
2 decades, the teen birth rate remains higher than in other
developed countries at 24 .2 per 1000 women age
15 -19 years.2 Contraceptive use among adolescents has
been credited as the primary proximal determinant of the
declines in adolescent pregnancy and birth rates in the
United States from 2007 to 2012.3 Prevention of adolescent
pregnancy and the associated health and social conse-
quences is one of ten “winnable battles” described by the US
Centers for Disease Control and Prevention (CDC), and
ensuring adolescents' access to contraceptive services is a
key component of meeting this challenge.4
Since 2010, the CDC has released 2 sets of contraceptive
guidance for health care providers. The US Medical Eligibility
Criteria for Contraceptive Use (MEC) was first published in
2010 as an adaptation of the World Health Organization
MEC, to support clinicians in determining which
Dr Hoopes has received a Young Investigator Grant supported by Bayer and the
North American Society of Pediatric and Adolescent Gynecology.
Dr Godfrey receives compensation as an instructor from Merck and serves on the
advisory board for EvoFem. The UW Department of Family Medicine receives
research funding from PrimaTemp, Merck, Bayer and TEVA.
Dr Sucato has received reimbursement for research-related activities from TEVA.
Dr Simmons indicate no conflicts of interest.
* Address correspondence to: Andrea J. Hoopes, MD, MPH, Kaiser Permanente
Washington Adolescent Center, 13 4 51 SE 3 6th Street, Bellevue, WA 98006; Phone:
4 25 -5 62-13 5 0.
E-mail address: hoopes.a@ghc.org (A.J. Hoopes).
1083 -3 188/$ - see front matter ! 2017 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jpag.2017.01.013
with preexisting medical conditions or characteristics.5 ,6 The
US Selected Practice Recommendations for Contraceptive
Use (SPR), also adapted from World Health Organization
guidance, was first published in 2013 and offers clinical
guidance for contraceptive management.7,8 The US MEC as
well as the US SPR were updated in 2016.
The North American Society of Pediatric and Adolescent
Gynecology has endorsed the US MEC and US SPR. Readers
unfamiliar with these CDC resources are referred to the
recent Journal of Pediatric and Adolescent Gynecology publi-
cation by Godfrey, which provides an orientation to their
use.9 Other useful resources for clinicians who prescribe
contraception to adolescents are the American Academy of
Pediatrics policy statement and accompanying technical
report on contraception for adolescents,10,11 and the CDC and
US Office of Population Affairs document, Providing Quality
Family Planning Services, which articulates a national stan-
dard of comprehensive family planning care for Title X and
other providers of family planning services.12 The purpose of
this mini-review is to highlight updates to the US MEC and
US SPR that are most relevant to health care providers of
adolescents to support dissemination and implementation of
these evidence-based best practices.
US MEC
The purpose of the US MEC is to reduce barriers to con-
traceptive use by providing evidence-based clinical guidance
about the safe use of contraceptive methods for women and
15 0 A.J. Hoopes et al. / J Pediatr Adolesc Gynecol 30 (2017) 149e155
men with specific characteristics or medical conditions.
Consistent with the structure of the World Health Organi-
zation MEC document from which it is adapted, recom-
mendations are categorized by medical condition or
characteristic, within which each method is given a numeric
rating of 1-4 . Category 1 indicates that a method can be used
without restriction, and category 4 indicates that using the
method is an unacceptable health risk (Table 1).
The 2016 updates to the US MEC introduce recommen-
dations for 4 new medical conditions: cystic fibrosis (CF),
multiple sclerosis, use of selective serotonin reuptake
inhibitors (SSRIs), and use of St. John's wort. The recom-
mendations for emergency contraception (EC) have been
revised and now include ulipristal acetate (UPA). For hor-
monal methods, recommendations were revised for women
with migraine headaches, superficial venous disease, dys-
lipidemias, and women using antiretroviral drugs. For
intrauterine device (IUD) users, there are revisions to
recommendations on gestational trophoblastic disease,
women with HIV, and factors related to sexually trans-
mitted diseases (STDs). There are also revisions to the rec-
ommendations for postpartum and breastfeeding women,
emphasizing the safety of immediate postpartum IUD
insertion, which has been shown to reduce rapid repeat
pregnancy rates among adolescent mothers.13 e15 Full rec-
ommendations and updates are available in the CDC
guidance.16 This mini-review will focus on those updates
most relevant to adolescents, including recommendations
on CF, migraine headache, and STDs.
Addition of CF to the 2016 US MEC
CF is a respiratory and digestive disease that was his-
torically fatal in childhood. However, with improved med-
ical therapies, more than half of CF patients in the United
States are older than the age of 18 years, and many of them
are women in need of contraception.17 Evidence supporting
the 2016 US MEC recommendations for women with CF is
outlined in a recent systematic review.18
CF is an autosomal recessive genetic disorder that affects
normal production or functioning of a protein responsible for
regulating the flow of chloride and fluids in and out of the
cells within the lung, gut, reproductive system, and other
organs. Mutations in the CF gene lead to buildup of thick
mucus, resulting in persistent lung infections, destruction of
the pancreas, and complications in other organs, including
reproductive organs. Despite the abnormalities, all but 20% of
women with CF are fertile.19 Additionally, women with CF
Table 1
Numeric Scheme Used to Describe Recommendations in the US MEC
Category US MEC Guidance
1 A condition for which there is no restriction for the use of the
contraceptive method
2 A condition for which the advantages of using the method
generally outweigh the theoretical or proven risks
3 A condition for which the theoretical or proven risks usually
outweigh the advantages of using the method
4 A condition that represents an unacceptable health risk if the
contraceptive method is used
MEC, Medical Eligibility Criteria for Contraceptive Use
who become pregnant are at risk of adverse health outcomes
as a result of pregnancy, so contraception is necessary for
women with CF who do not desire pregnancy.19
Theoretical safety issues using contraception in the setting
of CF include changes in disease status related to exogenous
hormone use, risks of venous thromboembolism for those
using combined (estrogen and progestin) methods, and low
bone density for women using depot medroxyprogesterone
acetate (DMPA). Contraceptive effectiveness is also a theo-
retical concern with oral contraceptives, the contraceptive
method most commonly prescribed to patients with CF,
because reduced absorption in the gut has the potential to
interfere with oral contraceptive metabolism.20 Additionally,
certain drugs to treat CF (eg, lumacaftor) might reduce
effectiveness of hormonal contraceptives, including oral,
injectable, transdermal, and implantable contraceptives.20
Most antimicrobial drugs used to treat secondary infections
in CF patients do not interfere with hormonal contraception;
drug interaction guidelines are available in the US MEC.
Updates to Headache Categories in the 2016 US MEC
The 2016 US MEC divides the condition of headache into
3 categories: nonmigraine, migraine without aura, and
migraine with aura, with no differentiation according to
age. This is a change from the 2010 MEC, which separately
classified migraine recommendations for women older and
younger than age 3 5 years. Recommendations in the 2016
US MEC for headache rely on proper classification of the
headache, using the following guidelines.21
Features of migraine include unilateral location, moderate
to severe intensity, and associated symptoms such as nausea,
photophobia, and phonophobia. Migraines occurring solely
with menses are classified as menstrual migraines and are
considered migraine without aura according to the Interna-
tional Headache Society Classification System.22 Approxi-
mately a third of people with migraines experience auras,
which are neurological symptoms occurring before or at
the onset of a headache and lasting for 5 -60 minutes; the
neurological symptoms might be visual, sensory, or speech-
related. Migraine with aura is associated with an increased
relative risk (RR) of ischemic stroke in individuals younger
than the of 4 5 years (RR, 2.65 ; 95 % confidence interval [CI],
1.41-4 .97); however the absolute risk of ischemic stroke in
women younger than 4 5 years with migraine with aura is
still very low.23 The attributable risk for ischemic stroke
among women with migraine ranges from 1.8 to 4 .0 addi-
tional cases per 10,000 woman-years. These estimates are
not specific to adolescents. Because of the increased risk of
stroke associated with migraine with aura, contraception
recommendations differ depending on the presence of aura,
regardless of age.
Updates to STD Categories in the 2016 US MEC
Categories for STDs in the 2016 US MEC have been
streamlined to include the following: (1) current purulent
cervicitis or chlamydial or gonococcal infection; (2) vagi-
nitis including trichomonas vaginalis and bacterial vagino-
sis; and (3 ) other factors related to STDs. The category
 A.J. Hoopes et al. / J Pediatr Adolesc Gynecol 30 (2017) 149e155
“increased risk for [sexually transmitted infections]” was
removed in the 2016 US MEC. In a systematic review, the
CDC reported that algorithms to assess STD risk on the basis
of demographic characteristics, history, and examination
findings have very low predictive value for the diagnosis of
gonococcal and chlamydial infection.24 Instead, if STD
screening has not been performed according to CDC STD
guidelines at the time of a contraceptive initiation visit,
screening can be performed at that time.25 Provision of
contraception, including IUDs, should not be delayed or
restricted for asymptomatic women at risk for STDs.
US SPR
The US SPR provides evidence-based recommendations
for common, yet sometimes complex contraceptive man-
agement questions when a method is deemed safe. The
2016 updates to this document include guidance for start-
ing ongoing contraception after the use of UPA for EC, and
medications to ease IUD insertion. Further detail is provided
in the Method-Specific sections.
Method-Specific Updates: Long-acting Reversible Methods
IUDs
IUDs are endorsed by the American Academy of Pediatrics
and the American College of Obstetricians and Gynecologists
as first-line contraceptive options for nulliparous adoles-
cents. After the first 21 days after insertion, IUDs have not
been shown to increase rates of STDs or pelvic inflammatory
disease.26 There are 2 general types of US Food and Drug
Administration-approved IUDs in the United States: the
nonhormonal copper IUD and the hormonal levonorgestrel-
releasing IUD.
The copper T3 80-A IUD (ParaGard; Teva North America,
North Wales, PA) is approved for 10 years of use, but has
been shown to be effective for 12 years.27 It has a failure rate
of 0.8% with typical method use.28 Typical method use de-
scribes the percentage of women who experience an acci-
dental pregnancy during the first year if they do not stop
use for any other reason. In the large, prospective CHOICE
study in St. Louis, 1-year copper IUD continuation was 75 .6%
among participating adolescent women attempting to avoid
pregnancy.29
Levonorgestrel hormonal IUDs are also very effective
methods with typical use failure rates of less than 0.2%.28 Four
hormonal IUDs are currently approved in the United States
and differ primarily by the amount of levonorgestrel: Mirena
(5 2 mg levonorgestrel; Bayer HealthCare Pharmaceuticals Inc,
Wayne, NJ), Liletta (5 2 mg levonorgestrel; Medicines3 60, San
Francisco, CA/Allergan, Dublin Ireland), Kyleena (19.5 mg
levonorgestrel; Bayer HealthCare Pharmaceuticals Inc), and
Skyla (13 .5 mg levonorgestrel; Bayer HealthCare Pharma-
ceuticals Inc). These levonorgestrel IUDs are approved for
3 -5 years of use.3 0e3 2 In the Contraceptive CHOICE Project
(CHOICE) study, 1-year levonorgestrel IUD continuation
among adolescents was 80.6%.29
151
IUD MEC Updates
CF: category 1. A recent systematic review reported no
direct evidence for the safety of IUDs in women with CF.18
The recommendation is on the basis of extrapolation of
data from other methods.
Migraine: category 1 regardless of age or presence of aura.
A recent systematic review reported no studies that directly
examined the risk of stroke in women with migraine using
hormonal IUDs, but IUD users do not have an increased risk
of ischemic stroke compared with nonusers.21
STDs: IUD insertion is category 4 in women with current
purulent cervicitis or chlamydial/gonorrhea infection and
category 2 in the setting of vaginitis including trichomonas
and bacterial vaginosis. IUD placement should not be delayed
to await the results of screening tests in asymptomatic ado-
lescents. Adolescents found to have an STD after IUD place-
ment can undergo treatment for the STD without removal of
the IUD; refer to the US SPR for further guidance on man-
agement of STDs or pelvic inflammatory disease in IUD users.
IUD SPR Updates
Adolescents and their providers might anticipate painful
or difficult IUD insertion, which creates a barrier to IUD use
in this population. The use of misoprostol to ease IUD
insertion is not recommended for routine use in adolescent
or adult populations. Ten randomized trials summarized in
2 systematic reviews concluded that misoprostol does not
improve the ease of insertion, improve insertion success, or
reduce the need for adjunctive insertion measures. In fact,
misoprostol can increase pain and side effects, particularly
gastrointestinal side effects.3 3 ,3 4 However, for women or
adolescents with a recent failed insertion, misoprostol might
increase insertion success with a second insertion attempt.3 5
Providers can consider use of a paracervical block with
1% lidocaine before IUD insertion, because limited evi-
dence suggests that this might reduce patient pain during
tenaculum placement or IUD insertions.3 6,3 7 Finally, there
is insufficient and inconclusive evidence to recommend
routine use of nonsteroidal anti-inflammatory drugs or
nitric oxide to ease IUD insertion, because limited evi-
dence suggested no beneficial effect.3 3 ,3 4 Nonsteroidal
anti-inflammatory drugs might be considered to reduce
post-IUD insertion cramping.3 4
Progestin Implants
The etonogestrel single-rod implant Nexplanon (Merck,
Whitehouse Station, NJ) is a highly effective method with
typical use failure rates of 0.05 % and 12-month continuation
among adolescents of 82.2%.28,29 The etonogestrel implant
is approved for up to 3 years of use but appears to be
effective for at least 4 years.3 8,3 9
Progestin Implant MEC Updates
CF: category 1. A recent systematic review reported no
direct evidence for the safety of progestin implants in
women with CF; recommendation is on the basis of extrap-
olation of data from other methods.18 Certain drugs used to
treat CF (eg, lumacaftor) might reduce the effectiveness of
hormonal contraceptives, including progestin implants.20
15 2 A.J. Hoopes et al. / J Pediatr Adolesc Gynecol 30 (2017) 149e155
Migraine: category 1 for all women with migraine
regardless of age or presence of aura. Although no studies
directly examined the risk of stroke in women with migraine
using implants, implant users do not have an increased risk
of ischemic stroke compared with nonusers.21
STDs: category 1, no updates; no restrictions related to
STDs.
Progestin Implant SPR Updates
No updates to existing recommendations related to
implant use and management of bleeding side effects.
Method-Specific Updates: Shorter-acting Methods
Progestin-Only Injectable Contraception (DMPA)
DMPA is administered as a single injection every 12 weeks
(up to 15 weeks) as either 15 0 mg delivered intramuscularly
or 104 mg delivered subcutaneously. Failure rates with
typical use are 6% and 1-year continuation rates among
adolescents in the CHOICE project was 4 7.3 %.28,29
DMPA MEC Updates
CF: category 2. Adults with CF experience a higher
prevalence of osteopenia, osteoporosis, and fractures than
the general population. It is not known whether DMPA
affects bone health in women with CF, and if bone changes
developed, whether they would be reversible. In a recent
systematic review, 2 studies examined outcomes in women
with CF using DMPA.18 In 2 women with CF initiating DMPA,
there was no worsening of diabetic control (n 5 1) or
development of diabetes (n 5 1) after initiating DMPA.4 0
A second study reported no contraceptive failures in 3
women with CF using DMPA over 1 year.4 1 No identified
studies directly addressed bone health with DMPA and CF.
Certain drugs used to treat CF (eg, lumacaftor) might reduce
the effectiveness of hormonal contraceptives, including
injectable contraceptives.
Migraine: category 1 for all women with migraine
regardless of age or aura. Although no studies directly
examined the risk of stroke in women with migraine using
DMPA, DMPA users do not have an increased risk of
ischemic stroke compared with nonusers.21
STDs: category 1, no updates. DMPA can be given
regardless of STD risk or presence.
SPR Updates
No updates to existing recommendations related to
DMPA use and management of bleeding side effects.
Combined Hormonal Contraceptives
Combined oral contraceptives (CHCs), the contraceptive
vaginal ring (NuvaRing; Merck), and the transdermal con-
traceptive patch (Xulane; Mylan, Canonsburg, PA) are
grouped in the same category for the purposes of the US
MEC because they are all combined estrogen-progestin
methods with similar risk profiles. All 3 of these CHCs
have typical use failure rates of 9% per year.28 In the CHOICE
project, adolescents had higher failure rates with these
methods than adult women,4 2 and 1-year continuation
rates among adolescents ranged from 3 1.0% for the trans-
dermal contraceptive patch to 4 6.7% for oral contraceptive
pills.29 There are more medical conditions for which CHCs
are considered unsafe than for nonestrogen-containing
methods; however, many of these medical conditions are
relatively rare in adolescents (eg, cardiovascular disease,
gynecologic cancer, liver disease). Readers are referred to
the US MEC for a full list.
CHC MEC Updates
CF: category 1. A systematic review, on the basis of 6
studies, concluded that hormonal contraception does not
worsen CF disease severity (level II-2, fair-quality evidence),
and that CF does not impair the effectiveness of hormonal
contraception (level II-3 , poor-quality evidence).18 There was
no evidence on bone health or thrombosis risk with CHCs.
Certain drugs used to treat CF (eg, lumacaftor) might reduce
the effectiveness of hormonal contraceptives, including CHCs.
Migraine: category 2 without aura, category 4 with aura
regardless of age. The primary concern with CHC use with
migraine is risk of stroke. Use of CHCs is associated with an
increased risk of ischemic stroke compared with nonuse of
these methods, although the absolute risk is small especially
in young women.4 3 ,4 4 Two recent meta-analyses did not find
an association between migraine without aura and stroke,
whereas migraine with aura is associated with an increased
risk of ischemic stroke.4 5 ,4 6 Unfortunately, most studies of
safety outcomes with CHCs in women with migraine did not
differentiate between migraine with and without aura. US
MEC recommendations are therefore on the basis of this
limited evidence in combination with evidence of stroke risk
according to migraine type in non-CHC users.
STDs: category 1, no updates. CHCs can be given
regardless of STD risk or presence.
SPR Updates
No updates to existing information including manage-
ment of late or missed doses, side effects, vomiting or severe
diarrhea, and management of bleeding irregularities during
extended or continuous CHC use.
Progestin-Only Pills
Progestin-only pills (POPs; also called “mini-pills”) pre-
vent pregnancy primarily by thickening cervical mucus, not
by inhibiting ovulation. Failure rates with typical use are 9%
and 1-year continuation was 4 6.7% when categorized
within CHCs in the CHOICE project.28,29 However, because
of the importance of small variations in pill administration
timing and the potential for ovulation, POPs are generally
considered to be less effective than CHCs.10 POPs provide an
option to adolescents for whom estrogen is contraindicated,
including during the immediate postpartum period.
POP MEC Updates
CF: category 1. A recent systematic review reported no
direct evidence for the safety or effectiveness of POPs in
women with CF. Recommendation is on the basis of
extrapolation of data from other hormonal methods and 1
small pharmacokinetic study, in which systemic levels of an
 A.J. Hoopes et al. / J Pediatr Adolesc Gynecol 30 (2017) 149e155
oral progestin were the same in women with and without
CF, which might imply a similar contraceptive effect.
Migraine: category 1 for all women with migraine
regardless of age or presence of aura. Although no studies
directly examined the risk of stroke in women with
migraine using POPs, POP users do not have an increased
risk of ischemic stroke compared with nonusers.21 Certain
drugs used to treat CF (eg, lumacaftor) might reduce the
effectiveness of hormonal contraceptives, including POPs.
STDs: category 1, no updates. POPs can be given regardless
of STD risk or presence.
SPR Updates
No updates to existing information including manage-
ment of missed POPs, and vomiting or diarrhea that occurs
within 3 hours of taking a pill.
EC
There are 4 options for EC in the United States, including
the copper IUD (ParaGard; Teva North America), oral UPA
(Ella; Watson Pharma Inc, Morristown, NJ), which is an oral
selective progesterone receptor modulator, oral levonor-
gestrel (PlanB One-Step, Teva North America; Next Choice
One-Dose, Watson Pharma, Inc, Corona, CA), and the Yuzpe
regimen of high-dose combined estrogen-progestin oral
contraceptive pills. The most effective EC method is Cu-IUD
placement, with a failure rate of less than 1% (compared
with up to 15 % with levonorgestrel EC).4 7e5 0 Oral UPA and
levonorgestrel have similar effectiveness when taken up to
72 hours after unprotected intercourse. However, UPA has
greater efficacy than levonorgestrel EC on days 3 -5 after an
episode of unprotected sex and might be more effective in
people who weigh more than 165 pounds.4 8,5 1
MEC Updates
The 2016 US MEC includes a revised section on EC with
recommendations for all 4 methods. All EC recommenda-
tions in the US MEC are category 1 or 2, including for
combined estrogen-progestin methods, because the dura-
tion of EC pill use is less than that of regular contraception
and is expected to have less clinical effect. The only excep-
tion is the placement of a copper IUD in women with
complicated solid organ transplantation, which is category
3 . All methods, including levonorgestrel (LNG) and UPA, are
safe for repeat use (category 1). However, recurrent EC use
is an indication that the woman might benefit from addi-
tional contraceptive counseling, and recurrent use of com-
bined hormonal pills for EC might be harmful for women
with medical conditions classified as category 3 or 4 for
general CHC use.
SPR Updates
The 2016 US SPR includes updated recommendations on
the initiation of regular contraception after using UPA for
EC. This topic was selected for update on the basis of 1 study
that showed that UPA effectiveness might be reduced if
hormonal contraception was started the next day.5 2 On the
15 3
basis of this study and other expert opinion, the new
recommendation states that women using UPA for EC
should resume or start hormonal contraception no sooner
than 5 days after UPA, because of possible concerns of
decreased effectiveness of UPA if hormonal contraception is
started sooner. This might require a repeat visit to clinic for
contraceptive initiation if the chosen method requires
insertion by a provider. Of note, recommendations for
initiation of contraception after other EC pills are un-
changed. Regular contraception can be started immediately
after the use of levonorgestrel or combined estrogen/pro-
gestin EC pills. In all cases, women should be advised to
abstain from intercourse or use a barrier method for 7 days
after starting or resuming hormonal contraception, or until
next menses, whichever comes first. They should also be
advised to take a pregnancy test if no withdrawal bleed
occurs within 3 weeks of using EC.
Limitations and Research Gaps
Subsequent to the publication of the 2016 US MEC and
US SPR, a published review highlighted research gaps, some
of which are relevant to adolescent patients and pro-
viders.5 3 For example, for postpartum teens who might
wish to breastfeed, although the current body of evidence
does not support a detrimental effect on breastfeeding
outcomes or infant health when progestin-only contracep-
tives are started in the first 6 weeks postpartum, more
information is needed about the potential effects of
progestin-only contraception on milk supply and on infant
growth and development.
Additionally, because of the prevalence of mental
health conditions in adolescents, more data are needed
about potential interactions between hormonal con-
traceptives and psychotropic medications including
SSRIs, serotonin-norepinephrine reuptake inhibitors, and
other Cytochrome P4 5 0 1A2 substrates.5 3 On the basis of
limited existing data, use of SSRIs with all hormonal
contraception is category 1. Use of St. John's wort is
category 2 for implants, POPs, and CHCs because of
concern that St. John's wort might decrease effectiveness
of hormonal contraceptives, including increased risk for
breakthrough bleeding and ovulation.5 4
There are scant data regarding whether hormonal
contraception can affect baseline mood or the development
of a mood disorder. A recent study received publicity for
noting a small but statistically significant association be-
tween initiation of CHCs and first diagnosis of depression (RR,
1.1; 95 % CI, 1.08-1.14 ) and initiation of a prescription antide-
pressant (RR, 1.2; 95 % CI, 1.22-1.25 ) compared with nonusers
of hormonal contraception.5 5 The systematic review that
informed the 2016 US MEC reported no evidence for wors-
ening of disease status for women with preexisting depres-
sive or bipolar disorders using hormonal contraception.5 4
Another area of clinical practice in need of evidence-based
guidance is the care of transgender patients, particularly
those taking gender-affirming hormones. There is currently
no evidence-based guidance for this population, and further
research is needed. Finally, it should be noted that adoles-
cents, including those with chronic disease or developmental
15 4 A.J. Hoopes et al. / J Pediatr Adolesc Gynecol 30 (2017) 149e155

CDC Contracep!on 2016 App US MEC Summary Chart

• Available for download • Two-sided 8.5x14” color
for Apple and Android coded charts
devices • Available for prin!ng from
• Includes US MEC and US the CDC website
SPR, plus links to other • Limited laminated copies
CDC guidelines available for order through
CDC

US SPR Charts US MEC Wheel

• Two-sided 8.5x11” color coded • Hand-held wheel
charts addressing common including common
management ques!ons from the MEC condi!ons
US SPR • Limited copies
• Available for prin!ng from the available for order
CDC website through CDC
• Limited laminated copies
available for order through CDC

Fig. 1. Provider tools for the 2016 US Medical Eligibility Criteria for Contraceptive Use (MEC) and US Selected Practice Recommendations for Contraceptive Use (SPR). CDC, Centers
for Disease Control and Prevention.

disability, might be prescribed hormonal contraception for References

menstrual management. Contraception use for menstrual
management might result in a different risk/benefit balance
than when used for pregnancy prevention.
Limitations of the US SPR include a continued lack of
evidence-based interventions that successfully reduce pa-
tient pain and discomfort during IUD insertion, which is a
concern among some adolescents considering IUDs.5 6,5 7
Additionally, research gaps remain in how to reduce prob-
lems of irregular bleeding during use of the contraceptive
implant, which is reported to be a source of early discon-
tinuation of implants among adolescents.5 8 Finally, more
research is needed to understand the extent to which CDC
guidance has been adopted in practice, and to understand
the barriers to awareness and implementation.
Conclusion
Contraceptive care is an important component of
adolescent health care. The 2016 updates to the US MEC and
US SPR include content relevant to all primary care and
subspecialty health care providers of adolescents and young
women and have been endorsed by the North American
Society for Pediatric and Adolescent Gynecology. There are
numerous ways that health care providers can access these
guidelines, as outlined in Figure 1. Supporting implementa-
tion and dissemination of this updated guidance are integral
to ensure quality and equitable family planning services for
all adolescents.
Acknowledgments
The findings and conclusions in this report are those of the
authors and do not necessarily represent the official position
of the CDC. Use of trade names and commercial sources is for
identification only and does not imply endorsement by the
US Department of Health and Human Services.
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