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        Appendix L

        Summary of Classifications for Hormonal Contraceptive Methods and Intrauterine Devices


        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. See the full appendix for each method for clarifications to the numeric categories, as well as for summaries of the evidence and additional comments.

        BOX. Categories for Classifying Hormonal Contraceptives and IUDs

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

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

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

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

        TABLE. Summary of classifications for hormonal contraceptive methods and intrauterine devices*

        Condition

        COC/P/R

        POP

        DMPA

        Implants

        LNG-IUD

        Cu-IUD

        Personal Characteristics and Reproductive History

        Pregnancy

        Not applicable?

        Not applicable?

        Not applicable?

        Not applicable?

        4?

        4?

        Age

        Menarche to <40 yrs = 1

        Menarche to <18 yrs = 1

        Menarche to <18 yrs = 2

        Menarche to <18 yrs =1

        Menarche to <20 yrs = 2

        Menarche to <20 yrs = 2

        ≥40 yrs = 2

        18--45 yrs = 1

        18--45 yrs = 1

        18--45 yrs = 1

        ≥20 yrs = 1

        ≥20 yrs = 1

        >45 yrs = 1

        >45 yrs = 2

        >45 yrs = 1

        Parity

        a. Nulliparous

        1

        1

        1

        1

        2

        2

        b. Parous

        1

        1

        1

        1

        1

        1

        Breastfeeding

        a. <1 mo postpartum

        3?

        2?

        2?

        2?

        b. 1 mo to <6 mos

        2?

        1?

        1?

        1?

        c. ≥6 mos postpartum

        2?

        1?

        1?

        1?

        Postpartum (nonbreastfeeding women)

        a. <21 days

        3

        1

        1

        1

        b. ≥21 days

        1

        1

        1

        1

        Postpartum (breastfeeding or nonbreastfeeding women, including post-Cesarean section)

        a. <10 min after delivery of the placenta

        2

        1

        b. 10 min after delivery of the placenta to <4 wks

        2

        2

        c. ≥4 wks

        1

        1

        d. Puerperal sepsis

        4

        4

        Postabortion

        a. First trimester

        1?

        1?

        1?

        1?

        1?

        1?

        b. Second trimester

        1?

        1?

        1?

        1?

        2

        2

        c. Immediate postseptic abortion

        1?

        1?

        1?

        1?

        4

        4

        Past ectopic pregnancy

        1

        2

        1

        1

        1

        1

        History of pelvic surgery (see postpartum, including Cesarean section)

        1

        1

        1

        1

        1

        1

        Smoking

        a. Age <35 yrs

        2

        1

        1

        1

        1

        1

        b. Age ≥35 yrs

        i. <15 Cigarettes/day

        3

        1

        1

        1

        1

        1

        ii. ≥15 Cigarettes/day

        4

        1

        1

        1

        1

        1

        TABLE. (Continued) Summary of classifications for hormonal contraceptive methods and intrauterine devices*

        Condition

        COC/P/R

        POP

        DMPA

        Implants

        LNG-IUD

        Cu-IUD

        Obesity

        a. ≥30 kg/m2 BMI

        2

        1

        1

        1

        1

        1

        b. Menarche to <18 yrs and ≥30 kg/m2 BMI

        2

        1

        2

        1

        1

        1

        History of bariatric surgery§

        a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy)

        1

        1

        1

        1

        1

        1

        b. Malabsorptive procedures: decrease absorption of nutrients and calories by shortening the functional length of the small intestine (Roux-en-Y gastric bypass, biliopancreatic diversion)

        COCs: 3 P/R: 1

        3

        1

        1

        1

        1

        Cardiovascular Disease

        Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)

        3/4?

        2?

        3?

        2?

        2

        1

        Hypertension

        a. Adequately controlled hypertension

        3?

        1?

        2?

        1?

        1

        1

        b. Elevated blood pressure levels (properly taken measurements)

        i. Systolic 140--159 mm Hg or diastolic 90--99 mm Hg

        3

        1

        2

        1

        1

        1

        ii. Systolic ≥160 mm Hg or diastolic ≥100 mm Hg§

        4

        2

        3

        2

        2

        1

        c. Vascular disease

        4

        2

        3

        2

        2

        1

        History of high blood pressure during pregnancy (where current blood pressure is measurable and normal)

        2

        1

        1

        1

        1

        1

        Deep venous thrombosis (DVT)/ pulmonary embolism (PE)

        a. History of DVT/PE, not on anticoagulant therapy

        i. Higher risk for recurrent DVT/PE (≥1 risk factors)

        4

        2

        2

        2

        2

        1

        ? History of estrogen-associated DVT/PE

        ? Pregnancy-associated DVT/PE

        ? Idiopathic DVT/PE

        ? Known thrombophilia, including antiphospholipid syndrome

        ? Active cancer (metastatic, on therapy, or within 6 mos after clinical remission), excluding non-melanoma skin cancer

        ? History of recurrent DVT/PE

        ii. Lower risk for recurrent DVT/PE (no risk factors)

        3

        2

        2

        2

        2

        1

        b. Acute DVT/PE

        4

        2

        2

        2

        2

        2

        c. DVT/PE and established on anticoagulant therapy for at least 3 mos

        i. Higher risk for recurrent DVT/PE (≥1 risk factors)

        4?

        2

        2

        2

        2

        2

        ? Known thrombophilia, including antiphospholipid syndrome

        ? Active cancer (metastatic, on therapy, or within 6 mos after clinical remission), excluding non-melanoma skin cancer

        ? History of recurrent DVT/PE

        ii. Lower risk for recurrent DVT/PE (no risk factors)

        3?

        2

        2

        2

        2

        2

        TABLE. (Continued) Summary of classifications for hormonal contraceptive methods and intrauterine devices*

        Condition

        COC/P/R

        POP

        DMPA

        Implants

        LNG-IUD

        Cu-IUD

        d. Family history (first-degree relatives)

        2

        1

        1

        1

        1

        1

        e. Major surgery

        i. With prolonged immobilization

        4

        2

        2

        2

        2

        1

        ii. Without prolonged immobilization

        2

        1

        1

        1

        1

        1

        f. Minor surgery without immobilization

        1

        1

        1

        1

        1

        1

        Known thrombogenic mutations§ (e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)

        4?

        2?

        2?

        2?

        2?

        1?

        Superficial venous thrombosis

        a. Varicose veins

        1

        1

        1

        1

        1

        1

        b. Superficial thrombophlebitis

        2

        1

        1

        1

        1

        1

        Current and history of ischemic heart disease§

        Initiation

        Continuation

        Initiation

        Continuation

        Initiation

        Continuation

        4

        2

        3

        3

        2

        3

        2

        3

        1

        Stroke§ (history of cerebrovascular accident)

        Initiation

        Continuation

        Initiation

        Continuation

        4

        2

        3

        3

        2

        3

        2

        1

        Known hyperlipidemias

        2/3?

        2?

        2?

        2?

        2?

        1?

        Valvular heart disease

        a. Uncomplicated

        2

        1

        1

        1

        1

        1

        b. Complicated§ (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)

        4

        1

        1

        1

        1

        1

        Peripartum cardiomyopathy§

        a. Normal or mildly impaired cardiac function (New York Heart Association Functional Class I or II: patients with no limitation of activities or patients with slight, mild limitation of activity) (1)

        i. <6 mos

        4

        1

        1

        1

        2

        2

        ii. ≥6 mos

        3

        1

        1

        1

        2

        2

        b. Moderately or severely impaired cardiac function (New York Heart Association Functional Class III or IV: patients with marked limitation of activity or patients who should be at complete rest) (1)

        4

        2

        2

        2

        2

        2

        Rheumatic Diseases

        Systemic lupus erythematosus§

        Initiation

        Continuation

        Initiation

        Continuation

        a. Positive (or unknown) antiphospholipid antibodies

        4

        3

        3

        3

        3

        3

        1

        1

        b. Severe thrombocytopenia

        2

        2

        3

        2

        2

        2?

        3?

        2?

        c. Immunosuppressive treatment

        2

        2

        2

        2

        2

        2

        2

        1

        d. None of the above

        2

        2

        2

        2

        2

        2

        1

        1

        Rheumatoid arthritis

        Initiation

        Continuation

        Initiation

        Continuation

        a. On immunosuppressive therapy

        2

        1

        2/3?

        1

        2

        1

        2

        1

        b. Not on immunosuppressive therapy

        2

        1

        2

        1

        1

        1

        Neurologic Conditions

        Headaches

        Initiation

        Continuation

        Initiation

        Continuation

        Initiation

        Continuation

        Initiation

        Continuation

        Initiation

        Continuation

        a. Non-migrainous (mild or severe)

        1?

        2?

        1?

        1?

        1?

        1?

        1?

        1?

        1?

        1?

        1?

        b. Migraine

        i. Without aura

        ? Age <35 yrs

        2?

        3?

        1?

        2?

        2?

        2?

        2?

        2?

        2?

        2?

        1?

        ? Age ≥35 yrs

        3?

        4?

        1?

        2?

        2?

        2?

        2?

        2?

        2?

        2?

        1?

        ii. With aura (at any age)

        4?

        4?

        2?

        3?

        2?

        3?

        2?

        3?

        2?

        3?

        1?

        Epilepsy§

        1?

        1?

        1?

        1?

        1

        1

        If on treatment, see Drug Interactions section below

        TABLE. (Continued) Summary of classifications for hormonal contraceptive methods and intrauterine devices*

        Condition

        COC/P/R

        POP

        DMPA

        Implants

        LNG-IUD

        Cu-IUD

        Depressive Disorders

        Depressive disorders

        1?

        1?

        1?

        1?

        1?

        1?

        Reproductive Tract Infections and Disorders

        Vaginal bleeding patterns

        Initiation

        Continuation

        a. Irregular pattern without heavy bleeding

        1

        2

        2

        2

        1

        1

        1

        b. Heavy or prolonged bleeding (includes regular and irregular patterns)

        1?

        2?

        2?

        2?

        1?

        2?

        2?

        Unexplained vaginal bleeding (suspicious for serious condition)

        Initiation

        Continuation

        Initiation

        Continuation

        Before evaluation

        2?

        2?

        3?

        3?

        4?

        2?

        4?

        2?

        Endometriosis

        1

        1

        1

        1

        1

        2

        Benign ovarian tumors (including cysts)

        1

        1

        1

        1

        1

        1

        Severe dysmenorrhea

        1

        1

        1

        1

        1

        2

        Gestational trophoblastic disease

        a. Decreasing or undetectable ?-hCG levels

        1

        1

        1

        1

        3

        3

        b. Persistently elevated ?-hCG levels or malignant disease§

        1

        1

        1

        1

        4

        4

        Cervical ectropion

        1

        1

        1

        1

        1

        1

        Cervical intraepithelial neoplasia

        2

        1

        2

        2

        2

        1

        Cervical cancer (awaiting treatment)

        Initiation

        Continuation

        Initiation

        Continuation

        2

        1

        2

        2

        4

        2

        4

        2

        Breast disease

        a. Undiagnosed mass

        2?

        2?

        2?

        2?

        2

        1

        b. Benign breast disease

        1

        1

        1

        1

        1

        1

        c. Family history of cancer

        1

        1

        1

        1

        1

        1

        d. Breast cancer§

        i. Current

        4

        4

        4

        4

        4

        1

        ii. Past and no evidence of current disease for 5 yrs

        3

        3

        3

        3

        3

        1

        Endometrial hyperplasia

        1

        1

        1

        1

        1

        1

        Endometrial cancer§

        Initiation

        Continuation

        Initiation

        Continuation

        1

        1

        1

        1

        4

        2

        4

        2

        Ovarian cancer§

        1

        1

        1

        1

        1

        1

        Uterine fibroids

        1

        1

        1

        1

        2

        2

        Anatomical abnormalities

        a. Distorted uterine cavity (any congenital or acquired uterine abnormality distorting the uterine cavity in a manner that is incompatible with IUD insertion)

        4

        4

        b. Other abnormalities (including cervical stenosis or cervical lacerations) not distorting the uterine cavity or interfering with IUD insertion

        2

        2

        Pelvic inflammatory disease (PID)

        a. Past PID (assuming no current risk factors of STIs)

        Initiation

        Continuation

        Initiation

        Continuation

        i. With subsequent pregnancy

        1

        1

        1

        1

        1

        1

        1

        1

        ii. Without subsequent pregnancy

        1

        1

        1

        1

        2

        2

        2

        2

        b. Current PID

        1

        1

        1

        1

        4

        2?

        4

        2?

        TABLE. (Continued) Summary of classifications for hormonal contraceptive methods and intrauterine devices*

        Condition

        COC/P/R

        POP

        DMPA

        Implants

        LNG-IUD

        Cu-IUD

        STIs

        Initiation

        Continuation

        Initiation

        Continuation

        a. Current purulent cervicitis or chlamydial infection or gonorrhea

        1

        1

        1

        1

        4

        2?

        4

        2?

        b. Other STIs (excluding HIV and hepatitis)

        1

        1

        1

        1

        2

        2

        2

        2

        c. Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)

        1

        1

        1

        1

        2

        2

        2

        2

        d. Increased risk for STIs

        1

        1

        1

        1

        2/3?

        2

        2/3?

        2

        HIV/AIDS

        Initiation

        Continuation

        Initiation

        Continuation

        High risk for HIV

        1

        1

        1

        1

        2

        2

        2

        2

        HIV infection§

        1

        1

        1

        1

        2

        2

        2

        2

        AIDS§

        1?

        1?

        1?

        1?

        3

        2?

        3

        2?

        Clinically well on ARV therapy

        If on treatment, see Drug Interactions section below

        2

        2

        2

        2

        Other Infections

        Schistosomiasis

        a. Uncomplicated

        1

        1

        1

        1

        1

        1

        b. Fibrosis of the liver (if severe, see Cirrhosis)§

        1

        1

        1

        1

        1

        1

        Tuberculosis§

        Initiation

        Continuation

        Initiation

        Continuation

        a. Nonpelvic

        1?

        1?

        1?

        1?

        1

        1

        1

        1

        b. Pelvic

        1?

        1?

        1?

        1?

        4

        3

        4

        3

        If on treatment, see Drug Interactions section below

        Malaria

        1

        1

        1

        1

        1

        1

        Endocrine Conditions

        Diabetes

        a. History of gestational disease

        1

        1

        1

        1

        1

        1

        b. Nonvascular disease

        i. Noninsulin-dependent

        2

        2

        2

        2

        2

        1

        ii. Insulin-dependent§

        2

        2

        2

        2

        2

        1

        c. Nephropathy/retinopathy/neuropathy§

        3/4?

        2

        3

        2

        2

        1

        d. Other vascular disease or diabetes of >20 yrs' duration§

        3/4?

        2

        3

        2

        2

        1

        Thyroid disorders

        a. Simple goiter

        1

        1

        1

        1

        1

        1

        b. Hyperthyroid

        1

        1

        1

        1

        1

        1

        c. Hypothyroid

        1

        1

        1

        1

        1

        1

        Gastrointestinal Conditions

        Inflammatory bowel disease (IBD)(ulcerative colitis, Crohn disease)

        2/3?

        2

        2

        1

        1

        1

        Gallbladder disease

        a. Symptomatic

        i. Treated by cholecystectomy

        2

        2

        2

        2

        2

        1

        ii. Medically treated

        3

        2

        2

        2

        2

        1

        iii. Current

        3

        2

        2

        2

        2

        1

        b. Asymptomatic

        2

        2

        2

        2

        2

        1

        History of cholestasis

        a. Pregnancy-related

        2

        1

        1

        1

        1

        1

        b. Past COC-related

        3

        2

        2

        2

        2

        1

        Viral hepatitis

        Initiation

        Continuation

        a. Acute or flare

        3/4?

        2

        1

        1

        1

        1

        1

        b. Carrier

        1

        1

        1

        1

        1

        1

        1

        c. Chronic

        1

        1

        1

        1

        1

        1

        1

        Cirrhosis

        a. Mild (compensated)

        1

        1

        1

        1

        1

        1

        b. Severe§ (decompensated)

        4

        3

        3

        3

        3

        1

        TABLE. (Continued) Summary of classifications for hormonal contraceptive methods and intrauterine devices*

        Condition

        COC/P/R

        POP

        DMPA

        Implants

        LNG-IUD

        Cu-IUD

        Liver tumors

        a. Benign

        i. Focal nodular hyperplasia

        2

        2

        2

        2

        2

        1

        ii. Hepatocellular adenoma§

        4

        3

        3

        3

        3

        1

        b. Malignant§ (hepatoma)

        4

        3

        3

        3

        3

        1

        Anemias

        Thalassemia

        1

        1

        1

        1

        1

        2

        Sickle cell disease§

        2

        1

        1

        1

        1

        2

        Iron-deficiency anemia

        1

        1

        1

        1

        1

        2

        Solid Organ Transplantation

        Solid organ transplantation§

        Initiation

        Continuation

        Initiation

        Continuation

        a. Complicated: graft failure (acute or chronic), rejection, cardiac allograft vasculopathy

        4

        2

        2

        2

        3

        2

        3

        2

        b. Uncomplicated

        2?

        2

        2

        2

        2

        2

        Drug Interactions

        Antiretroviral therapy (see appendix M)

        Initiation

        Continuation

        Initiation

        Continuation

        a. Nucleoside reverse transcriptase inhibitors (NRTIs)

        1?

        1

        1

        1

        2/3?

        2?

        2/3?

        2?

        b. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

        2?

        2?

        1

        2?

        2/3?

        2?

        2/3?

        2?

        c. Ritonavir-boosted protease inhibitors

        3?

        3?

        1

        2?

        2/3?

        2?

        2/3?

        2?

        Anticonvulsant therapy

        a. Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)

        3?

        3?

        1

        2?

        1

        1

        b. Lamotrigine

        3?

        1

        1

        1

        1

        1

        Antimicrobial therapy

        a. Broad-spectrum antibiotics

        1

        1

        1

        1

        1

        1

        b. Antifungals

        1

        1

        1

        1

        1

        1

        c. Antiparasitics

        1

        1

        1

        1

        1

        1

        d. Rifampicin or rifabutin therapy

        3?

        3?

        1

        2?

        1

        1

        * Abbreviations: COC = combined oral contraceptive; P = combined hormonal contraceptive patch; R = combined hormonal vaginal ring; POP = progestin-only pill; DMPA = depot medroxyprogesterone acetate; IUD = intrauterine device; LNG-IUD = levonorgestrel-releasing IUD; Cu-IUD = copper IUD; BMI = body mass index; DVT = deep venous thrombosis; PE = pulmonary embolism; hCG, = human chorionic gonadotropin; PID = pelvic inflammatory disease; STI = sexually transmitted infection; HIV = human immunodeficiency virus; AIDS = acquired immunodeficiency syndrome; NRTI = nucleoside reverse transcriptase inhibitor; NNRTI = non-nucleoside reverse transcriptase.

        ? Consult the appendix for this contraceptive method for a clarification to this classification.

        § Condition that exposes a woman to increased risk as a result of unintended pregnancy.

        Reference

        1. The Criteria Committee of the New York Heart Association. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Little, Brown & Co.; 1994.


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        14. N
        15. O
        16. P
        17. Q
        18. R
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        20. T
        21. U
        22. V
        23. W
        24. X
        25. Y
        26. Z
        27. #
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