The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1-66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Objectives: We sought to assess whether, among women with liver disease, there is an increased risk of adverse health effects with the use of hormonal contraception (HC). Study design: We conducted a systematic review of six databases from database inception through December 13, 2022. We searched for articles that examined changes in liver lesions and acute and chronic liver disease with the use of HC or after discontinuation of HC. We assessed the risk of bias for each study and certainty of evidence for all outcomes. Results: Thirteen articles met inclusion criteria, one with low risk of bias and the others with high risk of bias: three studies (four articles) were of women with focal nodular hyperplasia (FNH), five studies were of hepatocellular adenoma (HCA), and four studies were of acute or chronic hepatitis. The size and/or number of FNH lesions were generally not influenced by HC use. HCA progression was generally higher among current combined oral contraception (COC) users than those who discontinued, and lesions were stable or regressed in most women who discontinued COC or used progestin-only contraception. Studies found that viral hepatitis generally did not progress or increase in severity with the use of COC. Conclusion: Overall, a limited body of evidence suggested changes in FNH lesions were independent of hormonal contraceptive use. Estrogen-containing contraceptive method use was associated with HCA lesion progression; lesions generally remained stable with progestin-only contraceptive use. COC use did not increase progression or severity of disease among those with viral hepatitis. The certainty of evidence for all outcomes was very low. Implications: Liver conditions such as liver lesions, viral hepatitis, and cirrhosis are increasingly common in women of reproductive age. Information in this review can be used by health care providers when counseling women with liver disease about the safe use of contraception. (c) 2025 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

OBJECTIVES:To systematically review evidence on the safety and effectiveness of contraceptive use among women with chronic kidney disease (CKD). STUDY DESIGN:We searched for articles in multiple databases from database inception through December 12, 2022, that assessed safety and effectiveness of contraceptive use among women with CKD; all study designs were included. We extracted data from included articles; for studies that were not case series or case reports, we assessed risk of bias and determined certainty of evidence for each outcome. RESULTS:Eight articles, including 5 case reports, met inclusion criteria. All articles assessed safety outcomes associated with contraceptive use among women with CKD; none examined contraceptive effectiveness. Risk of bias for three studies (not including case reports) ranged from moderate to high and varied by outcome. One prospective cohort study observed no increased risk of hypertension or end stage renal disease among oral contraceptive (type unknown) users compared with non-users, while a non-randomized trial observed no changes in blood pressure over 21 days among 5 peritoneal dialysis patients using combined oral contraceptives. Another non-randomized trial examined hyperkalemia risk among drospirenone progestin-only pill users; hyperkalemia did not develop in participants with normal, mild, or moderate renal impairment. Four case reports described adverse events among intrauterine device (IUD) users, and one case report described decreased bleeding with levonorgestrel IUD use. CONCLUSION:Despite several theoretical concerns (e.g., worsening kidney disease, worsening hypertension, and thrombosis) about the safety of contraception among women with CKD, data are limited, and the certainty of existing evidence is very low. IMPLICATIONS:Health care providers can use the information in this review when counseling women with CKD about contraceptive decision-making. More research is needed to better understand the safety and effectiveness of the full range of available contraceptive methods among women with CKD.

OBJECTIVES:To systematically review literature on whether hormonal contraception following ulipristal acetate (UPA) for emergency contraception decreases the effectiveness of either drug. STUDY DESIGN:We searched multiple databases through December 2022 for studies assessing the interaction between UPA and hormonal contraception. The primary outcome was contraceptive effectiveness, measured by pregnancy rates or proxy measures (e.g., ovarian activity). We extracted and summarized findings from identified studies, assessed risk of bias for each study, and determined certainty of evidence for all outcomes. RESULTS:Four studies met inclusion criteria; all had low risk of bias. Two studies assessed whether UPA use affected the ability of oral contraceptives (OCs) to inhibit ovulation; no differences were observed in ovarian activity when starting OCs 1 day after UPA compared with starting OCs 1 day after placebo. Two studies assessed whether OC use affected the ability of UPA to delay ovulation; both studies observed higher proportions of ovulation when UPA was followed by OC use versus delayed or no OC use. One study assessed ovulation risk when UPA was taken after missed OCs, followed by immediate versus delayed OC resumption; no ovulations occurred within the first 5 days after UPA administration in either group, but there was greater risk of ovulation beyond 5 days with delayed versus immediate OC resumption. CONCLUSIONS:While there is no evidence that UPA affects the ability of hormonal contraception to inhibit ovulation, hormonal contraception use immediately or soon after UPA may decrease UPA's ability to delay ovulation. The certainty of evidence ranged from moderate to very low. IMPLICATIONS:If a patient desires hormonal contraception after UPA, an interaction can be avoided by delaying initiation or resumption of hormonal contraception. The risk of pregnancy due to decreased UPA effectiveness with immediate hormonal contraception should be balanced against the risk of subsequent pregnancy due to delay or non-start of hormonal contraception.

OBJECTIVE:To update a previous systematic review on contraceptive safety and effectiveness among women with solid organ transplants. STUDY DESIGN:We searched multiple databases from inception through December 7, 2022, for studies of any design that examined contraceptive safety and effectiveness for any contraceptive method among women with solid organ transplants. We extracted data from included articles; for studies that were not case series/reports, we assessed risk of bias and determined certainty of evidence. RESULTS:Twenty-six articles satisfied inclusion criteria, 11 cohort studies and 15 case series/reports. Among the 11 cohort studies, most had moderate or high risk of bias. For levonorgestrel intrauterine devices (LNG-IUDs), four non-comparative cohort studies of women with transplants (total n = 55) observed no pregnancies and no pelvic infections. One comparative cohort study (n = 16) suggested similar LNG-IUD effectiveness between women with and without transplants, based on uterine histologic and inflammatory markers. Another comparative cohort study found no unwanted pregnancies among 178 IUD users (type unspecified) with kidney transplants. For non-IUD hormonal contraception, one comparative cohort study (n = 48) found no differences in transplant-related safety outcomes or pregnancy rates for etonogestrel implant use compared with no hormonal contraception; another (n = 126 with kidney transplant) observed fewer unwanted pregnancies among oral contraceptive users (11.8%) compared with non-users (59.8%). Four non-comparative cohort studies of combined hormonal contraception users (total n = 76) observed no clinically meaningful safety outcomes and no pregnancies. CONCLUSIONS:Very low certainty evidence does not suggest adverse safety or effectiveness outcomes among LNG-IUD and non-IUD hormonal contraception users with solid organ transplant. IMPLICATIONS:While limited, this evidence can be used by health care providers and women with solid organ transplants in counseling and shared decision-making about contraception. Further studies are needed to address concerns about contraceptive use among women with transplants, such as the risk of thrombosis and other cardiovascular risks with hormonal contraceptive use.

OBJECTIVES:To systematically review evidence on whether medications with smooth muscle relaxant properties improve patient and provider outcomes for intrauterine device (IUD) placement. STUDY DESIGN:We searched multiple databases through August 2022 for randomized clinical trials assessing smooth muscle relaxants for IUD placement. Primary outcomes were pain experienced with IUD placement, provider ease of placement, need for adjunctive placement measures, placement success, patient satisfaction with procedure, medication side effects occurring before clinic discharge, and adverse events occurring before clinic discharge. We extracted data from included articles, assessed risk of bias for each trial, narratively summarized results, and determined certainty of evidence for all outcomes. RESULTS:Five placebo-controlled trials met inclusion criteria; four trials had low risk of bias and one had moderate risk. Two trials of topical nitroprusside gel or nitroglycerin ointment found no differences in patient pain, provider ease of placement, patient satisfaction, placement success, side effects, or adverse events. One trial suggested that drotaverine plus mefenamic acid reduced patient pain but did not improve placement success. Two trials suggested that isonicotinic acid hydrazide reduced patient pain, improved provider ease of placement and patient satisfaction, reduced need for analgesia and for cervical dilation (in one trial) and did not increase side effects; neither trial reported improved placement success. CONCLUSIONS:Evidence on smooth muscle relaxants for IUD placement remains sparse with inconsistent findings across specific medications. Certainty of evidence for all outcomes was low for topical nitroprusside gel and nitroglycerin ointment, very low for drotaverine plus mefenamic acid, and mostly high for isonicotinic acid hydrazide. IMPLICATIONS:Before IUD placement, healthcare providers can counsel patients on the potential for pain during placement and options for pain management. However, more evidence is needed on specific smooth muscle relaxants to determine their effectiveness as an intervention for IUD placement.

RATIONALE:Identifying effective approaches to reduce pain and improve providers' ease of intrauterine device (IUD) placement may reduce barriers to IUD access and use. The cervical softening and dilation effects of misoprostol might make IUD placement less painful for women and technically easier for providers. However, evidence suggests that misoprostol does not improve many outcomes and may only be helpful for some patients (e.g. those with a recent failed IUD placement). OBJECTIVES:To examine the effect of misoprostol for routine IUD placement on patient and provider outcomes compared to placebo or no treatment. SEARCH METHODS:In November 2021 we searched CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ClinicalTrials.gov. We conducted update searches in July 2022 and September 2024. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) in July 2025. ELIGIBILITY CRITERIA:We included randomized controlled trials (RCTs) of women undergoing interval IUD placement (i.e. placement outside the postabortion or postpartum period) that compared misoprostol to placebo or no treatment. We included trials that examined the placement of currently available levonorgestrel (LNG)-releasing IUDs, or any copper T IUD, for women of any age, of any parity, and for any indication. OUTCOMES:Our core critical and important outcomes were pain (during tenaculum placement, during IUD placement, and after IUD placement before clinic discharge); providers' ease of placement; need for cervical dilation; placement success; patient satisfaction; misoprostol side effects (preplacement abdominal pain or cramping, and diarrhea); and adverse events (vasovagal reaction). RISK OF BIAS:We used the Risk of Bias 2 tool (RoB 2) to assess the risk of bias for outcomes. SYNTHESIS METHODS:We synthesized results for each outcome using meta-analysis. We calculated mean differences (MD) for continuous outcomes using inverse variance estimation and random-effects models. We calculated risk ratios (RR) for dichotomous outcomes using Mantel-Haenszel estimation and random-effects models. We used GRADE to assess the certainty of evidence for each outcome. INCLUDED STUDIES:We included 14 RCTs with a total of 1972 women. The trials were conducted in North America, South America, Europe and Africa, and were published between 2007 and 2022. SYNTHESIS OF RESULTS:The results below summarize the effect of misoprostol on outcomes compared to placebo or no treatment. Pain: misoprostol results in little to no difference in pain during tenaculum placement (MD -0.73, 95% confidence interval [CI] -1.19 to -0.28; 3 RCTs, 261 women; high-certainty evidence) and after IUD placement before clinic discharge (MD -0.01, 95% CI -0.45 to 0.43; 5 RCTs, 448 women; high-certainty evidence). Misoprostol may result in little to no difference in pain during IUD placement (MD -0.47, 95% CI -1.23 to 0.29; 7 RCTs, 766 women; low-certainty evidence). Providers' ease of placement: misoprostol may result in little to no difference in a clinically meaningful effect on ease of IUD placement for providers (MD -0.89, 95% CI -1.55 to -0.22; 8 RCTs, 848 women; low-certainty evidence). Need for cervical dilation: misoprostol may result in little to no difference in need for cervical dilation for women without a recent failed placement attempt (RR 0.84, 95% CI 0.38 to 1.85; 6 RCTs, 562 women; low-certainty evidence). Misoprostol probably results in little to no difference in need for cervical dilation for women with a recent failed placement attempt (RR 0.88, 95% CI 0.56 to 1.36; 1 RCT, 90 women; moderate-certainty evidence). Placement success: misoprostol probably results in little to no difference in placement success for women without a recent failed placement attempt (RR 1.01, 95% CI 0.98 to 1.04; 12 RCTs, 1579 women; moderate-certainty evidence) but probably results in a slight increase in placement success for women with a recent failed placement attempt (RR 1.41, 95% CI 1.09 to 1.83; 1 RCT, 90 women; moderate-certainty evidence). Patient satisfaction: misoprostol may increase women's satisfaction with the IUD placement procedure, but the evidence is very uncertain (MD 2.00, 95% CI -0.05 to 4.06; 2 RCTs, 226 women; very low-certainty evidence) Misoprostol side effects before clinic discharge: misoprostol probably results in an increase in preplacement abdominal pain or cramping (RR 2.14, 95% CI 1.42 to 3.23; 7 RCTs, 781 women; moderate-certainty evidence)and probably results in a slight increase in diarrhea (RR 1.76, 95% CI 1.01 to 3.06; 9 RCTs, 940 women; moderate-certainty evidence). Adverse events before clinic discharge: misoprostol may result in little to no difference in vasovagal reaction (RR 0.94, 95% CI 0.37 to 2.37; 6 RCTs [3 RCTs had 0 events], 780 women; low-certainty evidence). We downgraded the evidence due to serious concerns about inconsistency and serious or very serious concerns about imprecision. AUTHORS' CONCLUSIONS:Evidence from RCTs of women seeking routine IUD placement suggests that receiving misoprostol compared to placebo or no treatment makes little to no difference to pain during tenaculum placement or after IUD placement; and may make little to no difference to pain during IUD placement. Misoprostol may make little to no difference to reduced vasovagal reaction, improved providers' ease of placement, or reduced need for cervical dilation; and probably makes little to no difference to placement success, except for women with a recent failed IUD placement attempt, where misoprostol probably leads to a clinically meaningful increase in placement success. Misoprostol use probably leads to clinically important increases in harms, specifically preplacement abdominal pain or cramping and diarrhea. Misoprostol may increase patient satisfaction with the IUD placement procedure, but the evidence is very uncertain. The number of available RCTs did not support examining effect modifiers such as prior vaginal delivery status, misoprostol dose, or IUD type. FUNDING:This review was supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention (CDC) administered by the Oak Ridge Institute for Science and Education. REGISTRATION:Protocol (2022): doi.org/10.1002/14651858.CD015584.

OBJECTIVES:In August 2024, the U.S. Centers for Disease Control and Prevention updated U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC), which provides recommendations for safe use of contraception for women with certain characteristics and medical conditions. This paper provides a summary of the evidence and context for new and updated U.S. MEC recommendations. STUDY DESIGN:The 2024 U.S. MEC was updated through a rigorous, multi-year process of determining priorities that would have high impact on clinical care, conducting systematic reviews of the evidence, and considering perspectives of health care providers and patients on how the evidence could best support updated recommendations. RESULTS:New U.S. MEC recommendations were added for chronic kidney disease, specifically for three subconditions: current nephrotic syndrome, hemodialysis, and peritoneal dialysis. Revisions were made to several existing recommendations, such as those for sickle cell disease, anticoagulant therapy use, various thrombogenic conditions, cirrhosis, liver tumors, solid organ transplantation, and intrauterine device placement in the postpartum period. Updated recommendations include those that reflect decreased safety concerns for some medical conditions (e.g., progestin-only contraception and some liver diseases) and increased safety concerns for others (e.g., combined hormonal contraception and depot medroxyprogesterone acetate for women with sickle cell disease). Recommendations for new contraceptive methods were added. CONCLUSIONS:Evidence-based clinical guidelines can be used by health care providers to support patient-centered contraceptive counseling and services and remove unnecessary barriers to accessing and using contraception. Provider tools including a mobile app are available to help with implementation of the updated recommendations. IMPLICATIONS:Keeping U.S. MEC up-to-date is critical for supporting contraceptive decision-making and improving access to contraception and reproductive health care. This includes new research to address current evidence gaps, rigorous methodology for continuous evidence identification and synthesis, state-of-the-art methods for guideline development, and a broad range of dissemination and implementation strategies.

OBJECTIVE:Women on anticoagulant therapy are at risk for bleeding and may be at risk for recurrent thrombosis, which may be further increased with use of certain contraceptive methods. Our objective was to update a previous systematic review on safety of contraception among women on anticoagulant therapy. STUDY DESIGN:We searched multiple databases from inception through December 12, 2022 for articles on concurrent use of contraception and anticoagulant therapy. Outcomes were thromboembolism, bleeding, and drug-drug interactions. Among women on anticoagulant therapy, we compared outcomes for women using and not using contraception. We assessed risk of bias for each study, and certainty of evidence for all outcomes. RESULTS:Fourteen articles met inclusion criteria (12 were new); one had low risk of bias, three had moderate risk of bias, and 10 had high risk of bias. Anticoagulants examined included warfarin, heparin, aspirin, rivaroxaban, enoxaparin, phenindione, acenocoumarol, combined therapy, and unspecified. Four studies (two comparative and two non-comparative studies) in women using anticoagulant therapy found no evidence that use of combined or progestin-only hormonal contraceptive increased the risk of recurrent venous thromboembolism (VTE). Ten studies (four comparative and six non-comparative studies) examined uterine bleeding with use of anticoagulant therapy and generally found that bleeding was increased during use of copper intrauterine devices (IUDs) and decreased during use of levonorgestrel (LNG) IUDs. Two studies examined pharmacokinetic outcomes and found no decreases in anticoagulant levels with combined oral contraceptive exposure. CONCLUSIONS:Limited evidence suggests risk for recurrent VTE may not be increased with hormonal contraceptive use among women using anticoagulants. Bleeding among women on anticoagulant therapy might worsen with copper IUD use but might improve with LNG-IUD use. The certainty of evidence for most outcomes is very low. IMPLICATIONS:Women on anticoagulant therapy are at risk for recurrent thrombosis and bleeding, which might be further exacerbated with use of certain contraceptive methods. Additional evidence is needed on safety of concurrent use of anticoagulant medications and contraceptives.

OBJECTIVES:Evidence is limited on whether the use of progestin-only contraception (POC) is associated with the risk of thrombosis. Our objective was to update an earlier systematic review on POC and thrombosis risk. STUDY DESIGN:We searched for articles that examined risk of venous thromboembolism (VTE) (e.g., deep venous thrombosis or pulmonary embolism) or arterial thromboembolism (ATE) (e.g., myocardial infarction or stroke) among women with thrombogenic conditions or characteristics or in the general population using POC, compared with women using nonhormonal or no contraception, published during February 1, 2016 through November 30, 2022. We also included articles from a previous systematic review, with articles published through January 2016. We assessed quality for each study and certainty of evidence for all outcomes. RESULTS:Thirty-three articles met inclusion criteria; one was good quality, 20 were fair quality, and 12 were poor quality. Seven articles were newly identified, and 26 were included in the previous review. Risk of VTE, but not ATE, was generally elevated with depot medroxyprogesterone acetate (DMPA) use among women with certain thrombogenic conditions or characteristics (e.g., diabetes or postpartum) and women in the general population. Risks of VTE and ATE were generally not elevated with use of other POC, including levonorgestrel intrauterine devices, implants, or progestin-only pills. CONCLUSIONS:Evidence suggests that risk of VTE, but not ATE, is increased with DMPA use compared with nonuse among women with certain thrombogenic conditions and women in the general population. Evidence does not suggest increased risk of VTE or ATE with use of other POC. While several studies examined thrombosis risk with POC use and thrombogenic conditions or characteristics, data are limited for individual conditions or characteristics and no evidence was identified for most conditions. The certainty of evidence is low or very low for all outcomes. IMPLICATIONS:Use of DMPA might increase the risk of VTE among women with medical conditions associated with thrombosis and among women in the general population. Evidence does not suggest an increased risk of thrombosis with other POC. Further study is needed on safety of POC use by women with thrombogenic conditions.

OBJECTIVES:To systematically review literature on management of bleeding irregularities during contraceptive implant use. STUDY DESIGN:We searched multiple databases through November 2022 for randomized clinical trials assessing treatment of bleeding irregularities during implant use. Primary outcomes were changes in bleeding irregularities during and after treatment and patient satisfaction. We extracted data and assessed risk of bias for each included study, narratively summarized results, and determined certainty of evidence for primary outcomes. RESULTS:Twenty-one articles met inclusion criteria. Risk of bias ranged from high to low. Trials examining some non-steroidal anti-inflammatory drugs (celecoxib and mefenamic acid), tamoxifen, and ulipristal acetate (UPA) generally showed improved bleeding patterns during and after treatment compared with placebo, while ibuprofen trials showed no improvements during treatment and inconsistent results after treatment. Trials of tranexamic acid, some hormonal treatments [oral ethinyl estradiol (EE; 50 mcg), combined oral contraceptives], and mifepristone with EE or doxycycline showed improved bleeding patterns only during treatment. Mifepristone alone, doxycycline alone or with EE, oral EE (20 mcg), transdermal estradiol patch, oral levonorgestrel, aspirin, and vitamin E were not consistently effective during or after treatment. Six trials measured patient satisfaction and found improved satisfaction with bleeding patterns for tamoxifen and UPA, and improved satisfaction with treatment for celecoxib, tamoxifen, and mifepristone. CONCLUSIONS:Across the different interventions assessed, certainty of evidence ranged from high to very low. The evidence summarized in this systematic review can help providers counsel patients about interventions to improve bleeding irregularities with contraceptive implant use, depending on patient preferences and goals. IMPLICATIONS:Patients experiencing bothersome bleeding irregularities during contraceptive implant use may be offered different options to manage bleeding and improve their satisfaction. More data are needed on the effectiveness of specific interventions (drugs, regimens, and repeat dosing) and patient satisfaction outcomes.

The US Centers for Disease Control and Prevention publishes evidence-based contraception guidelines to assist healthcare providers when counseling patients about safe and effective contraceptive use. The US Medical Eligibility Criteria for Contraceptive Use (US MEC) and the US Selected Practice Recommendations for Contraceptive Use (US SPR) have been updated on a regular basis, with the most recent full update published in 2024. This paper provides an overview of research gaps identified throughout the update process and discusses in further depth evidence gaps on several topics, including risk of thrombosis with hormonal contraception, medications for intrauterine device placement, and bleeding irregularities during implant use. Expanded study on these research gaps is needed to bolster guidelines and to improve safe and effective delivery of contraception.

OBJECTIVES:Thrombophilia is associated with an elevated risk of thrombosis, which may be further elevated with the use of hormonal contraception. Our objective was to update a previously published systematic review on thrombosis risk with the use of hormonal contraception among women with thrombophilia. STUDY DESIGN:We conducted a systematic review of five databases from database inception through December 8, 2022. We searched for articles that examined risk of venous thromboembolism (VTE) or arterial thromboembolism (ATE) in women with thrombophilia using hormonal contraception compared with women using nonhormonal or no contraception. We assessed the risk of bias for each study and certainty of evidence for all outcomes. RESULTS:Eighteen articles met inclusion criteria; four had moderate risk of bias and 14 had high risk of bias. Odds of VTE in women with factor V Leiden (FVL) mutation or prothrombin (PT) gene mutation were elevated in combined oral contraception (COC) users vs nonusers. Odds of VTE were elevated in COC users with FVL mutation, PT gene mutation, both FVL and PT mutations, antithrombin deficiency, or protein C deficiency compared with nonusers without the mutation. Odds of stroke were elevated in COC users with FVL mutation compared with nonusers without the mutation. Evidence was mixed on whether risk was elevated in women with protein S deficiency using COC compared with nonuse. One study found elevated odds of VTE in women with FVL mutation but not women with PT gene mutation using progestin-only contraception (POC), compared with nonusers without the mutation. CONCLUSIONS:Overall, studies found elevated odds of VTE and ATE in women with thrombophilia using COC compared with nonusers without thrombophilia. The certainty of evidence for all outcomes is low. Evidence is also limited by small numbers of women and minimal evidence on the use of patch, ring, or progestin-only contraception and is insufficient to assess differential risk by all thrombophilia types. IMPLICATIONS:Use of estrogen-containing hormonal contraception might further elevate the risk of thrombosis among women with thrombophilia. Further study is needed on safety of POC use in women with thrombophilia.

The Zika Contraception Access Network (Z-CAN) provided access to high-quality client-centered contraceptive services across Puerto Rico during the 2016-2017 Zika virus outbreak. We sent online surveys during May 2017-August 2020 to a subset of Z-CAN patients at 6, 24, and 36 months after program enrollment (response rates: 55-60 percent). We described contraceptive method continuation, method satisfaction, and method switching, and we identified characteristics associated with discontinuation using multivariable logistic regression. Across all contraceptive methods, continuation was 82.5 percent, 64.2 percent, and 49.9 percent at 6, 24, and 36 months, respectively. Among continuing users, method satisfaction was approximately ≥90 percent. Characteristics associated with decreased likelihood of discontinuation included: using an intrauterine device or implant compared with a nonlong-acting reversible contraceptive method (shot, pills, ring, patch, or condoms alone); wanting to prevent pregnancy at follow-up; and receiving as their baseline method the same method primarily used before Z-CAN. Other associated characteristics included: receiving the method they were most interested in postcounseling (6 and 24 months) and being very satisfied with Z-CAN services at the initial visit (6 months). Among those wanting to prevent pregnancy at follow-up, about half reported switching to another method. Ongoing access to contraceptive services is essential for promoting reproductive autonomy, including supporting patients with continued use, method switching, or discontinuation.

Problem/Condition: CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and the number of abortion-related deaths in the United States. Period Covered: 2022. Description of System: Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2022, a total of 48 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 47 reporting areas provided data each year during 2013-2022. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2021 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS). Results: For 2022, a total of 613,383 abortions were reported to CDC from 48 reporting areas. Among 47 reporting areas with data each year during 2013-2022, in 2022, a total of 609,360 abortions were reported, the abortion rate was 11.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 199 abortions per 1,000 live births. From 2021 to 2022, the total number of abortions decreased 2% (from 622,108 total abortions), the abortion rate decreased 3% (from 11.6 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 2% (from 204 abortions per 1,000 live births). From 2013 to 2022, the total number of reported abortions decreased 5% (from 640,154), the abortion rate decreased 10% (from 12.4 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 1% (from 198 abortions per 1,000 live births). In 2022, women in their 20s accounted for more than half of abortions (56.5%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (28.3% and 28.2%, respectively) and had the highest abortion rates (18.1 and 18.7 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged >= 40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.5 abortions per 1,000 women aged <15 and >= 40 years, respectively). However, abortion ratios were highest among adolescents (aged 519 years) and lowest among women aged 30-39 years. From 2021 to 2022, abortion rates decreased among women aged >= 20 years and did not change among adolescents (aged 519 years). Abortion rates decreased from 2013 to 2022 among all age groups, except women aged 30-34 years for whom it increased. The decrease in the abortion rate from 2013 to 2022 was highest among adolescents compared with other age groups. From 2021 to 2022, abortion ratios increased for adolescents and decreased among women aged >= 20 years. From 2013 to 2022, abortion ratios increased among adolescents and women aged 20-34 years and decreased among women aged >= 35 years. In 2022, the majority (78.6%) of abortions were performed at 59 weeks' gestation, and nearly all (92.8%) were performed at 513 weeks' gestation. During 2013-2022, the percentage of abortions performed at >13 weeks' gestation remained low (58.7%). In 2022, the highest percentage of abortions were performed by early medication abortion at 59 weeks' gestation (53.3%), followed by surgical abortion at 513 weeks' gestation (35.5%), surgical abortion at >13 weeks' gestation (6.9%), and medication abortion at >9 weeks' gestation (4.3%); all other methods were uncommon (<0.1%). Among those that were eligible (59 weeks' gestation), 70.2% of abortions were early medication abortions. In 2021, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, five women died as a result of complications from legal induced abortions. Interpretation: Among the 47 areas that reported data continuously during 2013-2022, overall decreases were observed over this time in the number and rate of reported abortions and an increase was observed in the abortion ratio; in addition, from 2021 to 2022, decreases of 2%-3% were observed across all measures.

OBJECTIVES:To describe unmet desire for long-acting reversible contraception (LARC) after the Zika Contraception Access Network (Z-CAN) in Puerto Rico during the 2016-2017 Zika outbreak. STUDY DESIGN:Z-CAN patients completed surveys about contraception experiences over a 3-year period. RESULTS:Of 1809 respondents, 3% never used LARC but reported wanting it since their initial visit. As reasons for not getting LARC, nearly 50% indicated a provider-related reason and 25% reported cost. CONCLUSIONS:Few Z-CAN patients who never used LARC had unmet desire. Provider training in contraception guidelines and strategies to address costs can expand access to the full range of reversible contraception. IMPLICATIONS:Three years after a short-term program provided reversible contraception in Puerto Rico, few respondents had never used but wanted a long-acting reversible contraception method. Nearly half reported provider-related reasons for not receiving long-acting reversible contraception, and 25% reported cost. Provider awareness of contraceptive guidance and method availability can support client-centered care.

ObjectiveTo describe immediate postpartum long-acting reversible contraception (IPP LARC) insertion rates during delivery hospitalizations at the state level and by payor type.Study designThis is a cross sectional study of 26 states and District of Columbia (DC) using 2020 State Inpatient Database.ResultsIn 2020, IPP LARC insertion rates varied widely by states, ranging from 2.55 to 637.25 per 10,000 deliveries. Rates were higher for deliveries with Medicaid as primary expected payor than with private insurance in all states but DC.ConclusionsRates of IPP LARC insertion varied in 2020 by state and were higher for deliveries with Medicaid as primary expected payor.

The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Objective: To examine claims for reversible prescription contraceptives and chlamydia and gonorrhea testing among commercially and Medicaid-insured adolescent and young adult (AYA) females in the United States.Methods: Using IBM MarketScan Research Databases, we identified sexually active, nonpregnant AYA (15- to 24-year-old) females enrolled in 2018. We examined claims for reversible prescription contraceptives and chlamydia and gonorrhea testing, using drug names and diagnosis/procedure codes, by age-group in commercially and Medicaid-insured separately and by race/ethnicity in Medicaid-insured.Results: Among 15- to 19-year-old and 20- to 24-year-old females, 67.2% and 67.9% of commercially insured and 57.3% and 54.0% of Medicaid-insured, respectively, had claims for reversible prescription contraceptives in 2018. Across insurance types among both age-groups, the most common claim for contraceptives was prescription for combined oral contraceptives. Among Medicaid-insured 15- to 19-year-olds, claims for contraceptives ranged from 42.6% for Hispanic females to 63.4% for non-Hispanic White females; among Medicaid-insured 20- to 24-year-olds, claims ranged from 50.4% for non-Hispanic Black females to 57.0% for non-Hispanic White females. Approximately half of the commercially and Medicaid-insured females had claims for chlamydia and gonorrhea testing. Non-Hispanic Black females had the highest percentages of claims for chlamydia testing (56.3% among 15- to 19-year-olds and 61.1% among 20- to 24-year-olds) and gonorrhea testing (61.6% among 15- to 19-year-olds and 64.9% among 20- to 24-year-olds).Conclusion: Approximately, two-thirds of commercially insured and more than half of Medicaid-insured, sexually active, nonpregnant AYA females had claims for reversible prescription contraceptives. Race/ethnicity data were available for Medicaid-insured females, and there were differences in claims for contraceptives and chlamydia and gonorrhea testing by race/ethnicity. Half of the AYA females had claims for chlamydia and gonorrhea testing suggesting missed opportunities.

The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1-66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.