Update your practice: Check new WHO Medical Eligibility Criteria
Review changes to ensure your contraceptive guidelines are current
The new World Health Organization (WHO) Medical Eligibility Criteria (MEC) for Contraceptive Use are being released this spring. The changes made will dramatically affect the provision of contraceptives throughout the world.
Here are the 10 recommendations that have changed the most:
1. Continued use of an intrauterine device (IUD) by a woman diagnosed with pelvic inflammatory disease (PID).
Perhaps most important are the MEC for using an IUD in a variety of clinical situations. The new MEC suggest that an IUD may be left in place for a woman who already has an IUD and develops PID if her PID is treated "using appropriate antibiotics. There is usually no need for removal of the IUD if the client wishes to continue its use" (WHO:2, changed from a 4).1 (See Four classifications of the WHO Medical Eligibility Criteria at the end of this article.) This change is based on three studies demonstrating that there is no difference in the clinical course of the PID whether the IUD is removed or left in place during treatment.2
The new WHO MEC continue to recommend that an IUD not be inserted for a woman seen with current PID; a woman with AIDS who is not clinically well on antiretroviral therapy; or a woman with a chlamydial infection, gonorrhea, or purulent cervicitis. All receive a 4 in the WHO MEC.
Women deemed at increased risk for sexually transmitted infections (STIs) received a 3 in the 2000 WHO MEC. If a woman is deemed to be at very high risk for gonorrhea or chlamydia, the condition remained classified as a 3. However, high risk for other STIs receives a 2 in the 2004 WHO MEC. Women at increased risk of STIs who already have an IUD moved from a 3 to a 2 in 2004.
Two other conditions may apply to the teenager wanting to consider IUD use. The 2004 and the previous WHO MEC recommend that a woman who is nulliparous may use an IUD and that a woman who is younger than 20 years of age may use an IUD.3
2. IUD insertion and continuation and HIV/AIDS.
The new MEC developed by experts working with WHO suggest that an IUD may be used:
- by a woman at high risk for HIV (WHO:2, changed from a 3);
- by a woman who is infected with HIV (WHO:2, changed from a 3);
- by a woman with AIDS (WHO:2, changed from a 3).
3. Hormonal contraceptives and HIV/AIDS.
In another decision related to HIV/AIDS, the Expert Working Group concluded that evidence does not support any restrictions on hormonal contraceptives for women at high risk of HIV or HIV infection, including those with AIDS. These health conditions remain category 1 for all hormonal methods.
4. Fibroids and IUD insertion.
The new MEC suggest that an IUD may be used by a woman with fibroids that do not distort the uterine cavity (WHO:1, changed from a 2).
5. Known thrombogenic mutations and use of pills.
The new criteria from WHO strongly discourage (WHO:4) the use of combined pills, patches, vaginal rings, and combined injectables for a woman known to have a thrombogenic mutation (Leiden mutation, prothrombin Factor, protein S, and protein C). However, the Expert Working Group specifically cautions that routine screening is not appropriate because of the rarity of the condition and the high cost of screening. As for all the MEC, the classifications refer to known conditions and do not necessarily imply that screening is necessary or advisable.1 As testing becomes more readily available and cheaper, known thrombogenic disorders may become important reasons to avoid pill use.
6. Depressive disorders.
Past WHO MEC have not covered the initiation of contraceptives for women with depression. The October 2003 MEC meeting concluded there is no need for restriction on the use of combined or progestin-only hormonal contraceptives for women with depression (WHO:1). Conclusions could not be reached regarding postpartum depression or bipolar disorders because current evidence is inadequate.
Spermicidal products containing nonoxynol-9 (N-9) should not be used by women at high risk for HIV (WHO:4, changed from 2), women who already are HIV-infected (WHO:4, changed from 2), or women with AIDS (WHO:4, changed from 2), according to the new MEC. Data on the use of spermicides from women using spermicides several times a day, usually sex workers, demonstrated a greater likelihood of developing an HIV infection than women having sex as often but not using a spermicide.4 However, data among women having sex less frequently found an increased risk for becoming HIV-positive, but the increase was not statistically significant.4 For women having sex less frequently than sex workers, the risk of developing HIV increased as the frequency of use of spermicides increased.
8. Diaphragms used with spermicides and cervical caps.
For women at high risk for HIV, women who are HIV-infected, or women with AIDS, the new WHO MEC recommend that diaphragms and cervical caps generally not be used (WHO:3, changed from 1).
The anticonvulsants phenytoin, carbamazepine, barbiturates, and primidone previously had received a 3 from the Expert Working Group for the use of combined pills, progestin-only pills, Norplant (Leiras Pharmaceuticals, Turku, Finland), Jadelle (Leiras Pharmaceuticals), and Implanon (Organon Pharmaceuticals, West Orange, NJ). They have received two additions: topiramate and oxcarbazepine. Depo-Provera (depot medroxyprogesterone acetate or DMPA, Pfizer, New York City) continues to receive a 1 for the use of all these anticonvulsants.
Combined pills, the patch (Ortho Evra, Ortho-McNeil Pharmaceutical, Raritan, NJ), the vaginal ring (NuvaRing, Organon Pharmaceuticals, West Orange, NJ), and progestin-only pills receive a 2 rather than a 3 in the new WHO MEC if a woman is on griseofulvin.
By Robert A. Hatcher, MD, MPH, Senior Author, Contraceptive Technology, Professor of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta
• World Health Organization (WHO):1. A condition for which there is no restriction for the use of a contraceptive method. The method may be used in any circumstance.
• WHO:2. A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. The method is generally or broadly usable.
• WHO:3. A condition for which the theoretical or proven risks usually outweigh the advantages, so the prospective user should be advised that another method would be preferable, but if she accepts the risks and the alternative methods cannot be used, the method may be used with caution and with additional care/follow-up.
• WHO:4. A condition that represents an unacceptable health risk. Do not use.
Source: Word Health Organization, Geneva.
1. World Health Organization (WHO). "Improving Access to Quality Care in Family Planning." In: Medical Eligibility Criteria for Contraceptive Use. 3rd ed. Geneva, Switzerland: 2003.
2. Rinehart W. WHO updates medical eligibility criteria for contraceptives. Info Reports. Baltimore: Johns Hopkins University Population Information Program; April 2004.
3. Summary tables of latest medical eligibility criteria accessed at: www.who.int/reproductive-health/publications/ MEC_3/.
4. Wilkinson D, Ramjee G, Tholandi M, et al. Nonoxynol-9 for preventing vaginal acquisition of HIV infection by women from men (Cochrane Review). The Cochrane Library 2004; 2.