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CDC Guideline Ranks Contraceptives' Efficacy and Risks


 

From Morbidity and Mortality Weekly Report

A new guideline issued by the Centers for Disease Control and Prevention aims to help physicians balance the safety and efficacy of different contraceptive methods for all women, whether they are healthy or have an illness that may preclude the use of a specific method.

The Medical Eligibility Criteria for Contraceptive Use 2010 is adapted from a similar evidence-based guideline created by the World Health Organization. The U.S. document, however, includes information on disorders that were not included in the international guideline and updated scientific evidence. It was also formulated to agree with practice guidelines endorsed by U.S. health provider organizations.

A multispecialty board reviewed the WHO document and the extant literature to develop the new guideline. Dr. Robert W. Rebar, the executive director of the American Society for Reproductive Medicine, was a member of the panel. “The [Centers for Disease Control and Prevention] also asked us to recommend some particular diseases that were not covered by the WHO document, but which are relevant in the United States, among them obesity and arthritis,” Dr. Rebar said in an interview.

“Our intent was to provide guidance for physicians as to what kind of contraception appears to be safe and appropriate for these patients,” he said.

The new guideline addresses the use of hormonal contraceptives, emergency contraceptive pills, intrauterine devices for both pregnancy prevention and emergency contraception, barrier methods, sterilization, and “natural methods,” including coitus interruptus, lactational amenorrhea, and fertility awareness. Each method is examined in light of its effect on different groups of patients, and the conditions are ranked according to the related risk (MMWR 2010;59[RR-4]:1-86):

A condition for which there is no restriction for the use of the contraceptive method.

A condition for which the advantages of using the method generally outweigh the theoretical or proven risks.

A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.

A condition that represents an unacceptable health risk if the contraceptive method is used.

The guideline takes into account not only the safety of each method, but its efficacy as well, Dr. Rebar said. “We attempted to balance the risks of pregnancy—which are not inconsiderable—and the risks of contraception. In each case, physicians can use the guideline to provide patients with an evaluation of the risk, so they can choose” the method that best fits their particular situation and personal needs.

For example, while coitus interruptus is a safe method for any woman, regardless of her physical state, its relative ineffectiveness may not make it a good choice.

“Coitus interruptus is unforgiving of incorrect use, and its effectiveness depends on the willingness and ability of the couple to use withdrawal with every act of intercourse. Women with conditions that make pregnancy an unacceptable risk should be advised that [coitus interruptus] might not be appropriate for them because of its relatively higher typical-use failure rates,” according to the document.

The document also includes a summary of the evidence about potential drug interactions between hormonal contraceptives and antiretroviral therapy. Although there are limited data on the topic, those that do exist suggest that some antiretroviral drugs—particularly the ritonavir-boosted protease inhibitors—can suppress contraceptive steroid blood levels and increase the chance of pregnancy. Other studies suggest that oral contraceptives can increase the likelihood of antiretroviral drug toxicity.

The final pages are devoted to a chart of physical conditions that must be considered when recommending contraceptives, and the possible implications of each method for each reproductive age group. Health care providers can use the summary table as a quick reference guide to the classifications for hormonal contraceptive methods and intrauterine contraception and to compare classifications across these methods.

Disclosures: No conflicts of interest were reported.

The MMWR document is available for free at www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

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