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Contraception
Corner
Contraceptive Safety From a Global Perspective:
The 2004 WHO Medical Eligibility Criteria for Contraception
Anita L. Nelson, MD; Miriam Zieman, MD
Periodically, the World Health Organization (WHO) reviews the world’s
literature on contraception and updates its Medical Eligibility
Criteria for contraceptive use. These criteria are developed to
provide guidance to national family planning health programs in
the preparation of guidelines for service delivery of contraceptives.
The WHO cautions that these criteria should not be used as actual
guidelines but rather as a reference. The most recent WHO work
group comprised of 36 participants from 18 countries and met in
October 2003; they recently released the Tables for the third edition
of these criteria, which reflected their recommendations. It is
heartening to notice that, in general, the safety of most of the
methods of birth control has been recognized in these criteria.
The WHO uses a 4-point scale to classify recommendations. Because
the availability of medical care varies so dramatically around
the world, ratings are made both for situations in which clinical
judgment is available and when access to medical care is limited.
In the United States, where most methods are available only by
prescription, clinical judgment is always accessible. The relevant
ratings used by WHO for the United States are:
| WHO classification |
Recommendations |
| 1 |
Use method in any circumstances |
| 2 |
Generally use the method |
| 3 |
Use of method not usually
recommended unless other more appropriate methods are
not available or acceptable |
| 4 |
Method not to be used |
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In this latest round of recommendations, spermicide use was significantly
down-rated, especially in women with conditions that place them
at high risk for human immunodeficiency virus (HIV) and those who
had HIV/acquired immunodeficiency syndrome (AIDS), where it received
a "4" rating. In those same groups, the use of a diaphragm
or cervical cap with spermicide was rated a "3." This
reflects the group’s concern about the results from studies
of professional sex workers in Africa, which demonstrated an increased
risk of seroconversion in women using devices (including the sponge)
with spermicide.1
The contraceptives that are relevant to US clinicians are low-dose
(< 35 mcg ethinyl estradiol) combined oral contraceptives (COCs),
progestin-only pills, injectable progestin (depot medroxyprogesterone
acetate; DMPA), the copper intrauterine device, and the le-vonorgestrel-releasing
intrauterine system (LNG IUS). The transdermal patches and the
vaginal rings were given the same ratings as the low-dose oral
contraceptives (OCs).
A few new categories were added: known thrombogenic mutations,
depressive disorders, and AIDS-clinically well on antiretroviral
therapy. For the known thrombogenic mutations, estrogen-containing
contraceptives were rated as "4" and progestin-containing
OCs were a "2." The copper IUD was rated as a "1." Women
with depressive disorders had no restrictions to the use of any
methods; all methods received a "1" rating for these
women. Similarly, use of every method in women with AIDS who were
clinically well on antiretroviral therapy was rated "2."
There were also other changes important to practitioners:
- While obesity (BMI > 30 kg/m2) continued to be rated "2" for
COC use, its rating for DMPA and the LNG IUS was raised to a "1."
- Fibroids that do not distort the uterine cavity pose no problems
for IUD use. Both the Cu-T380A and LNG IUS received "1."
- Other notable changes were seen in IUD use. Current pelvic
inflammatory disease or infection with sexually transmitted infection
in IUD users was rated "2" for continued use while
IUD initiation in the condition was still precluded by a rating
of "4."
- Women with AIDS were given ratings of "1" for all
the hormonal methods.
- IUD initiation was rated "3," but IUD continuation
a "2" for women with AIDS.
Underscoring that there are only a few drug-drug interactions that
can affect systemic hormonal contraceptive users, only rifampin and
certain anticonvulsants (barbiturates, carbamazepine, oxcarbazepine,
phenyt-oin, primidone, and topiramate) were rated "3" for
low-dose contraceptives. It should be noted that these recommendations
do not cover OCs with doses of ethinyl estradiol of 35 mcg or higher.
The use of DMPA in women using any of these drugs was rated "2," while
use of both IUDs was rated "1" in the face of those drugs.
Griseofulvin was even more liberally rated; low-dose OC use was a "2," but
all the other US methods were rated "1." Very importantly,
the use of any other antibiotic was rated "1" for all of
the methods.
In this column, we have reported the significant changes that were
made between the 2000 and 2004 editions of the WHO Medical Eligibility
Criteria for Contraceptive Use to help summarize the results of recent
reports in the literature. These changes can be found at http://
www.who.int/reproductive-health/ publications/MEC_3/changes_tables.html.
A full listing of all the ratings for each social and medical condition
for each method, as well as for methods that may soon be made available
in the United States (eg, contraceptive implants), is available elsewhere
on the same WHO Web site.
References
- Nonoxynol-9 spermicide contraception
use—United States, 1999. MMWR. 2002;51(18):389-392.
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