CDC discusses patient-centered framework
By Melinda Young
The latest updates to contraceptive guidelines by the Centers for Disease Control and Prevention (CDC) include recommendations for people with chronic kidney disease, human immunodeficiency syndrome (HIV) infection risk, chronic diseases, and conditions such as obesity, surgery, breastfeeding, and postabortion. They also address bleeding irregularities during implant use, testosterone use and pregnancy risk, and self-administration of injectable contraception.1,2
Last published in 2016, the 2024 updated guidance is based on new evidence and input from experts.1,2
“The CDC publishes two sets of contraceptive user recommendations. The first is U.S. Medical Eligibility Criteria for Contraceptive Use, which includes safe use of contraceptive methods for people with personal characteristics like AIDS [acquired immunodeficiency syndrome] and smoking status and diabetes,” says Kathryn Curtis, PhD, a health scientist in the division of reproductive health at the National Center for Chronic Disease Prevention and Health Promotion of the CDC in Atlanta.
The second set of guidelines provides recommendations about how to start a contraceptive method and how to manage side effects of some methods, she says.
“Both were recently updated and published, and it’s important for healthcare providers to know these documents exist because they contain evidence-based recommendations to improve contraceptive care and to eliminate barriers to contraceptive use,” Curtis says. “Healthcare providers can use these recommendations to support person-centered contraceptive counseling and shared decision-making and thinking about supporting their patients’ reproductive decisions.”
New language in the 2024 updates focuses on patient decision-making and a patient-centered framework that recognizes the patient’s own expertise.
“We have a process in place where we look at the evidence and talk with a wide group of experts, including patient representatives, and — on a regular basis — we update the recommendations as needed,” Curtis explains. “We looked at new evidence since 2016.”
Here are some of the guideline changes:
Contraceptive decision-making: The CDC focuses on personal autonomy in contraceptive decision-making, citing the historical context of contraceptive coercion and reproductive mistreatment. These include human rights violations involving forced sterilization and enrollment in contraceptive trials without informed consent.1,3-5
The CDC suggests people have equitable access to a full range of contraceptive methods and be counseled in a noncoercive manner. Healthcare providers also should consider each individual’s clinical and social factors when discussing reproductive desires, expectations, preferences, and priorities in contraceptive counseling. The goal is a person-centered approach that prioritizes a person’s preferences and reproductive autonomy rather than singularly focusing on pregnancy prevention. Voluntary informed consent of contraceptive methods is essential.1
Bleeding irregularities: “One of the side effects that some people experience when using implants are bleeding irregularities,” Curtis says.
“So, we’ve had a recommendation about different ways to manage irregularities during implant use, and we’ve reviewed the evidence and tweaked those recommendations,” she says. “Also, we have more about patient-centered counseling and talking with patients about whether they want to continue the implant or discontinue it, and if they do continue, whether they want some medical management of bleeding irregularities.”
Before providers begin implant placement, they need to provide counseling about potential changes in bleeding patterns while the implant is in place. For example, spotting or light bleeding is common with implant use, and some implant users experience amenorrhea. Providers also can inform patients that bleeding patterns might decrease with continued implant use, and heavy bleeding is uncommon during implant use.2
Testosterone use: The CDC guidelines suggest providers counsel patients that testosterone use might not prevent pregnancy among transgender, gender diverse, and nonbinary persons with a uterus who are using testosterone. Providers can offer contraceptive counseling and services to these patients who are at risk of pregnancy and do not desire pregnancy.2
Self-administration of subcutaneous injectable contraception: Reproductive health and family planning clinics should make available self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) as an additional approach to deliver injectable contraception, the guidelines say.2
“That was a stand-alone recommendation published in 2021, and now it’s incorporated in the comprehensive update,” Curtis says.
“We reviewed the literature and evidence of the safety of self-administered DMPA, and several studies globally and in the United States show it is safe to use, and so there is a body of evidence behind that,” she explains. “We heard from experts that self-administered injections have the potential to improve contraceptive access.”
Both self-administered and provider-administered DMPA should be available as contraceptive options.2
Chronic kidney disease: “The main new recommendation in the medical eligibility criteria for contraceptive use is we added recommendations for people with chronic kidney disease, which we didn’t have before, and we made some other changes,” Curtis says. “The bottom line is the same, and that is that most people — including those with certain medical conditions — can safely use most contraceptive methods. That’s the take-home message.”1
REFERENCES
- Nguyen AT, Curtis KM, Tepper NK, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep 2024;73:1-126.
- Curtis KM, Nguyen AT, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024; Recommendations and Reports. MMWR Recomm Rep 2024;73:1-77.
- American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women, Contraceptive Equity Expert Work Group, and Committee on Ethics. Patient-centered contraceptive counseling: ACOG committee statement number 1. Obstet Gynecol 2022;139:350-353.
- American Public Health Association. Opposing coercion in contraceptive access and care to promote reproductive health equity. American Public Health Association. Oct. 26, 2021. https://www.apha.org/Policies-and-Advocacy/Public-Health-Policy-Statements/Policy-Database/2022/01/07/Contraceptive-Access
- Holt K, Reed R, Crear-Perry J, et al. Beyond same-day long-acting reversible contraceptive access: A person-centered framework for advancing high-quality, equitable contraceptive care. Am J Obstet Gynecol 2020;222:S878.e1-e6.
