Updates to the U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (U.S. MEC) and U.S. Selected Practice Recommendations for Contraceptive Use, 2024 (U.S. SPR) were published in August 2024, replacing the 2016 documents. Produced by the Centers for Disease Control and Prevention (CDC), these two documents provide meaningful and accessible guidance for health care providers on the initiation and use of the full range of contraceptive methods, including use for individuals with certain characteristics or medical conditions and the management of contraceptive side effects.
To update the U.S. SPR and U.S. MEC, authors prepared new and updated systematic reviews, reviewed public comments, met with national experts in 2022 and 2023, and, for the first time, held listening sessions with contraceptive users to ensure these guidance documents support person-centered contraceptive care. Both the U.S. SPR and U.S. MEC along with supporting provider tools are currently available on the CDC’s website. Some of the most important updates from the 2024 publications include:
IUD pain management
The 2024 U.S. SPR updates recommendations to include offering medications for pain management with IUD placement, specifically lidocaine as a paracervical block or applied topically to the cervix among other patient-centered approached. The updated U.S. SPR continues to recommend against the routine use of misoprostol for IUD placement but acknowledges that it may be considered in certain circumstances, such as for those who recently failed placement.
Management of irregular bleeding with the implant
Changes in bleeding patterns may occur following placement of the progestin-only contraceptive implant. Bleeding patterns with the implant typically range from spotting and light bleeding to amenorrhea; heavy bleeding is uncommon. Unlike other contraceptive methods, bleeding pattern changes with the implant may or may not improve with continued use. If clinically indicated, patients may be evaluated for conditions or interactions that may be contributing to bleeding irregularities, such as testing for pregnancy and STIs.
The decision to continue implant use is individualized. Some patients may wish to continue implant use with irregular bleeding patterns, and counseling for expectant management can be provided. For those who would prefer active management, the U.S. SPR recommends offering antifibrinolytics for 5 days or combined oral contraceptives to improve bleeding while the implant is in place and includes a handy provider tool to support implementation. With these methods, bleeding is likely to reoccur, but treatment may be repeated. Nonsteroidal anti-inflammatory drugs (NSAIDs) for 5-7 days or tamoxifen for 7-10 days may also be considered, and treatment effects may persist after treatment is completed. NSAID or tamoxifen treatment may also be repeated as needed.
Amenorrhea does not require treatment. If this is an abrupt change in the bleeding pattern, pregnancy should be ruled out. Other patients may find these irregular bleeding patterns unacceptable and request implant removal. Patients who request implant removal should have prompt access to removal.
Testosterone use and risk for pregnancy
Anyone with a uterus who is receiving testosterone therapy may still be at risk of pregnancy depending on their sexual partners and practices. The U.S. SPR now includes recommendations to offer person-centered contraceptive counseling and options to any pregnancy-capable individuals receiving testosterone therapy who are at risk for pregnancy.
Self-administered injectable contraception
Although not approved for self-administration by the FDA, there is an increasing body of evidence suggesting that self-administration of the injectable contraceptive subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is a safe and effective option, can increase access to DMPA continuation, and is highly acceptable to patients. In 2021, the CDC published an update to include DMPA-SC in the U.S. SPR. In the 2024 publication, it continues to be recommended that DMPA-SQ be made available to patients when possible.
New conditions added to the MEC
The updated U.S. MEC now includes recommendations for contraceptive use by people with chronic kidney diseases and revisions to recommendations for patients who are breastfeeding, postpartum, postabortion, have a BMI greater than 30mg/k2, post-surgery, history of a deep vein thrombosis or pulmonary embolism with or without anticoagulation therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk of HIV infection, cirrhosis, liver tumors, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals for prevention or treatment of HIV.
In addition to new disease states and conditions, new contraceptive methods were added to the U.S. MEC and Summary Charts, including new doses or formulations of combined oral contraceptives, the patch, vaginal ring, progestin-only pills, levonorgestrel IUD, and vaginal pH modulator.
Bottom line
The 2024 U.S. SPR and U.S MEC are evidence-based, person-centered clinical guidance documents and decision-making tools to support contraceptive counseling and method provision and management that support individuals’ reproductive well-being.
