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RHO archives : Topics : Contraceptive Methods

Revised WHO Eligibility Criteria

The World Health Organization, in collaboration with medical experts and women's reproductive health advocates from around the world, has developed revised medical eligibility criteria that give sound guidance on the safety of contraceptive methods for various categories of users. These evidence-based criteria are designed to increase access to contraceptive use for appropriate candidates, while maintaining required levels of safety.

These eligibility criteria classify the suitability of different contraceptive methods for individuals with specific illnesses or health conditions, those at later ages, and those whose behavior poses added risks (for example, women who smoke or women and men with multiple sex partners). The eligibility criteria aim to ensure an adequate margin of safety to protect women and men from the potential adverse effects of contraceptives, while ensuring that they are not denied suitable choices.

The WHO Eligibility Criteria classify health conditions according to four categories:

    Category 1 Always usable
    Category 2 Broadly usable
    Category 3 Use with caution
    Category 4 Do not use

For a complete review of eligibility criteria for various methods, see the WHO guidelines (WHO 1996/2002) or a summary of the guidelines in Outlook 13(4) and 14(1). See also the newly updated third edition of the guidelines (WHO 2004).

Key conclusions from the Revised Medical Eligibility Criteria are:

  • Many of the common recommendations that have restricted method use among women with specific medical conditions or histories are unfounded or based on outdated information.
  • Criteria that restrict use of older high-dose oral contraceptives (OCs) should not be applied to newer low-dose OCs. Many of these restrictions do not apply to formulations containing lower doses of estrogen.
  • Nulliparous women should not be denied access to injectable contraceptives for fear it may affect future fertility. Medical evidence suggests that there is no basis for this restriction.
  • The eligibility criteria for progestin-only contraceptive methods generally are less restrictive than for methods containing both estrogen and progestin. Age should not restrict access to a contraceptive method.
  • Concerning age, the advantages of using a contraceptive method generally outweigh the theoretical or proven risks associated with method use at younger or older ages.
  • Eligibility criteria for women with vaginal bleeding differ for women with irregular menstrual bleeding and women with unexplained vaginal bleeding. Irregular menstrual bleeding generally is a Category 1 condition (always usable). Unexplained vaginal bleeding that could be related to pregnancy or pelvic malignancy is considered a Category 2 or 3 condition (broadly usable or use with caution) for all hormonal methods and IUDs.
  • For many specific medical conditions, such as thyroid disease and epilepsy, there are no restrictions on the use of any of the methods discussed.
  • As long as the client's history is taken correctly, clinical and laboratory diagnostic and screening tests generally are not considered mandatory for safe use of contraceptive methods.
  • Women using a hormonal method or intrauterine device (IUD) who are at risk of sexually transmitted infections (STIs) should be advised to use condoms in addition to their primary contraceptive method to protect themselves.
  • Access to tubal ligation or vasectomy should not be based on the client's age or parity; there is no medical basis for restricting access based on these factors.
  • Informed choice is at the foundation of the revised eligibility criteria for contraceptive methods. Informed choice means that a client can freely make an informed decision based on (1) accurate, useful information; (2) an understanding of their own needs; and (3) selection from a range of family planning methods.
  • The eligibility criteria will be revised periodically to update the recommendations as new information becomes available.

Most of the review findings resulted in eliminating unnecessary prescribing criteria. In a few cases, however, eligibility criteria were added or strengthened to ensure adequate client safety during method use. For example, the expert committee recommended that:

  • Women who have any risk of STIs should not use an IUD unless no other options are available.
  • Anyone with a risk factor for STIs should use dual protection: condoms to protect against STIs/HIV in combination with another effective method to protect against pregnancy.

In programs where clinical training and experience are limited, as in a community-based distribution system, the original WHO four-category system can be simplified to a two-category system. In this scenario field workers generally could provide a method to a woman with category 1 and 2 conditions, but not provide the method to women with category 3 or 4 conditions.

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WHO Medical Eligibility Criteria Updated

A recent review of the Medical Eligibility Criteria for Contraceptive Use by 35 experts at WHO in October 2003 has led to new family planning guidance in several areas.

A complete text of the 3rd edition of the Medical Eligibility Criteria for Contraceptive Use contains more than 1,700 recommendations on different method/condition combinations and includes recommendations on three new methods: the combined contraceptive patch, the combined vaginal ring, and etonogestrel implants. The online edition of the MEC can be accessed at www.who.int/reproductive-health/publications/RHR_00_2_medical_eligibility_criteria_3rd/.

Other key updates from this new edition of the eligibility criteria include:

  • Most women with HIV infection can generally use IUDs.
  • Women generally can take hormonal contraceptives while on antiretroviral therapy for HIV infection, though there are interactions between contraceptive hormones and some ARV drugs.
  • Women with clinical depression usually can take hormonal contraceptives.

For a description of the changes found in the 3rd edition, and their significance to family planning programs, see www.infoforhealth.org/inforeports/mec/index.shtml.

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