Medical eligibility criteria for contraceptive use, 6th edition

What this guideline says

GMJ summary

This sixth edition of the WHO Medical Eligibility Criteria (MEC) provides evidence-based recommendations for safe use of contraceptive methods by women with various medical conditions and physiological characteristics. It employs a four-category classification system (1–4) indicating whether a method can be used without restriction, generally can be used, is usually not recommended, or represents an unacceptable health risk.

The guideline covers combined hormonal contraceptives (COCs ≤35 µg ethinyl estradiol, patch, vaginal ring, injectables), progestogen-only methods (pills, DMPA/NET-EN injectables, LNG/ETG implants), intrauterine devices (copper and levonorgestrel-releasing), emergency contraception, barrier methods, fertility-awareness-based methods, lactational amenorrhoea, and sterilization. Significant updates in this edition include revised recommendations for hormonal contraception during breastfeeding, use among women on antiretroviral therapy or HIV pre-exposure prophylaxis, and repeated emergency contraceptive pill use.

The MEC is intended for national policy-makers and programme managers to adapt into country-specific guidelines, not for direct clinical application. It emphasizes that contraceptive choice must respect human rights, informed consent, and individual preferences, and that multiple risk factors may compound to change eligibility. The recommendations are based on systematic reviews using GRADE methodology, with the quality of evidence for most conditions rated as low or very low.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Women < 6 weeks postpartum who are breastfeeding can generally use progestogen-only pills, LNG/ETG implants, and DMPA/NET-EN injectables (Category 2); at ≥ 6 weeks postpartum these become Category 1
2. Women on efavirenz-containing ART can generally use CHCs, POPs, NET-EN and implants (Category 2); DMPA is Category 1 with efavirenz
3. Women using HIV PrEP (tenofovir-emtricitabine, dapivirine ring, or cabotegravir) can use all hormonal contraceptives without restriction (Category 1)
4. Emergency contraceptive pills (COCs, levonorgestrel, or ulipristal acetate) can be used more than once in a menstrual cycle without restriction (Category 1)
5. Women with hypertension (systolic 140–159 or diastolic 90–99 mm Hg) should generally not use CHCs (Category 3); systolic ≥160 or diastolic ≥100 mm Hg is Category 4
6. COC users who smoke ≥15 cigarettes/day and are ≥35 years old face unacceptable cardiovascular risk (Category 4); those smoking <15 cigarettes/day are Category 3
7. Breastfeeding women < 48 hours postpartum can use Cu-IUD without restriction (Category 1) but LNG-IUD is Category 2; insertion at ≥48 hours to <4 weeks is Category 3 for both IUDs
8. Women with history of venous thromboembolism, current ischaemic heart disease, stroke, or migraine with aura at any age should not use CHCs (Category 4)

MEC categories for contraceptive eligibility

Table extracted from the guideline

Source: World Health Organization, Medical eligibility criteria for contraceptive use, 6th edition. Reproduced in summary form.

What changed in this edition

Versus the previous edition

• Recommendations for progestogen-only contraceptive use among breastfeeding women: < 6 weeks postpartum changed from Category 3 to Category 2 for POPs, implants and POIs
• Recommendations for IUD use among breastfeeding women: LNG-IUD < 48 hours postpartum changed from Category 1 to Category 2
• New recommendations added for HIV pre-exposure prophylaxis (PrEP) including tenofovir-emtricitabine, dapivirine ring, and cabotegravir – all Category 1 for hormonal contraceptives
• Antiretroviral therapy recommendations updated with specific guidance for NRTIs, NNRTIs (including efavirenz Category 2 for most hormonal methods except DMPA Category 1), protease inhibitors, and integrase inhibitors (raltegravir, dolutegravir)
• Emergency contraceptive pill use more than once in a menstrual cycle classified as Category 1 for COCs, levonorgestrel and ulipristal acetate
• CYP3A4 inducers including anticonvulsants now listed as Category 1 for emergency contraceptive pills (previously unspecified)

From the guideline

Verbatim

“Women using PrEP can use all hormonal contraceptive methods without restriction (MEC Category 1).”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

Related on GMJ

Interconnected resources

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