Contraception by Medical Condition: Using the US MEC on the FNP Exam
The CDC US MEC 2024 rates each method from category 1 (no restriction) to category 4 (unacceptable health risk) for each medical condition, and most exam items test the conditions that make combined hormonal contraception category 4. These include migraine with aura, age 35 or older smoking 15 or more cigarettes a day, blood pressure of 160/100 or higher or vascular disease, prior VTE at higher risk of recurrence, known thrombophilia, current breast cancer, the first 21 days postpartum, and sickle cell disease. The copper IUD is category 1 or 2 for nearly every one of these and is the default safe answer.
The US Medical Eligibility Criteria for Contraceptive Use (US MEC 2024) answers one question for each patient: given this medical condition, how safe is each method? Every method gets a category from 1 (no restriction) to 4 (unacceptable health risk). On the FNP exam the heavy hitters are the conditions that make estrogen-containing methods category 4, because those are where a provider can cause a stroke, myocardial infarction or venous thromboembolism (VTE) by writing a combined pill. The companion document, US SPR 2024 (Selected Practice Recommendations), covers the "how": when to start, what backup is needed, which examinations are required and what to do about missed pills.
The four categories
| Category | Meaning | Practical reading |
|---|---|---|
| 1 | No restriction for use | Use the method |
| 2 | Advantages generally outweigh theoretical or proven risks | Use the method; some follow-up may be needed |
| 3 | Theoretical or proven risks usually outweigh the advantages | Generally do not use unless other methods are unavailable or unacceptable |
| 4 | Unacceptable health risk | Do not use |
The chart lists six methods: copper IUD (Cu-IUD), levonorgestrel IUD (LNG-IUD), implant, depot medroxyprogesterone acetate (DMPA), progestin-only pill (POP) and combined hormonal contraception (CHC: pill, patch and ring). For IUDs, some conditions have separate ratings for initiation (I) and continuation (C), which matters for infections and cancers found while an IUD is already in place.
Assessment before choosing a method
The history the provider needs is the MEC checklist: age and smoking (cigarettes per day), blood pressure, migraine and whether it has aura, personal or family history of VTE and any known thrombophilia, cardiovascular disease and stroke, diabetes and its complications, breast and gynecologic cancer history, liver disease, lupus and antiphospholipid antibodies, sickle cell disease, bariatric surgery type, current medications (especially enzyme-inducing anticonvulsants and rifampin), postpartum status and breastfeeding, and current STI or pelvic infection.
US SPR 2024 limits the examination to what changes safety. Blood pressure is required before CHC. A bimanual examination and cervical inspection are required before IUD placement. Nothing else is required: no Pap test, no routine STI testing before hormonal methods, no lipid or glucose testing. For IUDs, STI screening follows routine screening guidelines and placement should not be delayed while results are pending.
Combined hormonal contraception: the category 3 and 4 list
| Condition (US MEC 2024) | CHC | Safer alternatives |
|---|---|---|
| Age 35 or older, smoking 15 or more cigarettes a day | 4 | All progestin-only methods and IUDs are 1 |
| Age 35 or older, smoking fewer than 15 a day | 3 | Same |
| Age under 35, smoker | 2 | |
| Hypertension, adequately controlled | 3 | DMPA 2; others 1 |
| Systolic 140 to 159 or diastolic 90 to 99 | 3 | DMPA 2; others 1 |
| Systolic 160 or higher or diastolic 100 or higher | 4 | Cu-IUD 1; LNG-IUD, implant, POP 2; DMPA 3 |
| Vascular disease | 4 | Same as severe hypertension |
| Migraine without aura (including menstrual migraine) | 2 | |
| Migraine with aura | 4 | All other methods 1 |
| History of DVT or PE, not on anticoagulation, higher risk of recurrence | 4 | Cu-IUD 1; LNG-IUD, implant, POP 2; DMPA 3 |
| History of DVT or PE, not on anticoagulation, lower risk of recurrence | 3 | Cu-IUD 1; others 2 |
| Current or past DVT or PE on therapeutic anticoagulation | 3 | Cu-IUD and progestin methods 2 |
| Known thrombogenic mutation (thrombophilia) | 4 | Cu-IUD 1; DMPA 3; others 2 |
| Family history of DVT in a first-degree relative | 2 | |
| Major surgery with prolonged immobilization | 4 | DMPA 2; others 1 |
| Ischemic heart disease or history of stroke | 4 | Cu-IUD 1; DMPA 3 |
| Complicated valvular heart disease | 4 | DMPA 2; others 1 |
| Diabetes with nephropathy, retinopathy, neuropathy, other vascular disease or more than 20 years duration | 3 or 4 | DMPA 3; others 1 to 2 |
| Multiple cardiovascular risk factors | 3 or 4 | DMPA 3 |
| Systemic lupus with positive or unknown antiphospholipid antibodies | 4 | Cu-IUD 1; DMPA 3; LNG-IUD, implant, POP 2 |
| Sickle cell disease | 4 | LNG-IUD, implant, POP 1; Cu-IUD 2; DMPA 2 or 3 |
| Current breast cancer | 4 | Cu-IUD 1; all hormonal methods 4 |
| Breast cancer, past, no evidence of disease for 5 years | 3 | Cu-IUD 1; all hormonal methods 3 |
| Decompensated cirrhosis | 4 | Cu-IUD 1; DMPA 3; others 2 |
| Hepatocellular adenoma or hepatocellular carcinoma | 4 | Cu-IUD 1 |
| Peripartum cardiomyopathy, normal or mildly impaired function, under 6 months | 4 | Implant, POP 1 |
| Obesity (BMI 30 or higher) | 2 | All others 1; DMPA 2 if under 18 years |
Two updates from 2024 are worth flagging because older review books disagree. Sickle cell disease is now category 4 for CHC. Migraine without aura is category 2 for CHC regardless of age.
Progestin-only and IUD-specific restrictions
Progestin-only methods are rarely category 4, but some conditions still matter:
- Current breast cancer: every hormonal method, including the LNG-IUD, is category 4. Only the Cu-IUD is category 1.
- DMPA carries more vascular restrictions than the other progestin methods: category 3 for severe hypertension, vascular disease, ischemic heart disease, stroke, thrombophilia, diabetes with complications and lupus with antiphospholipid antibodies, and it lowers bone mineral density.
- IUD initiation is category 4 with current pelvic inflammatory disease, current purulent cervicitis, chlamydia or gonorrhea, unexplained vaginal bleeding suspicious for a serious condition before evaluation, cervical cancer awaiting treatment, endometrial cancer, a distorted uterine cavity, pregnancy, and postpartum or postabortion sepsis. For PID and STIs found with an IUD already in place, continuation is category 2: treat the infection and leave the IUD.
- Nulliparity and age from menarche to under 20 years are category 2 for IUDs, so neither is a reason to refuse one.
- Malabsorptive bariatric surgery: POP and combined oral contraceptives are category 3 because of reduced absorption; the patch and ring are category 1.
Postpartum and breastfeeding timing
| Time since delivery | CHC, not breastfeeding | CHC, breastfeeding | Progestin-only (implant, POP) |
|---|---|---|---|
| Under 21 days | 4 | 4 | 1 if not breastfeeding; 2 if breastfeeding |
| 21 to 42 days, with other VTE risk factors | 3 | 3 | 1 to 2 |
| 21 to 29 days, no other VTE risk factors | 2 | 3 | 1 to 2 |
| 30 to 42 days, no other VTE risk factors | 2 | 2 | 1 |
| More than 42 days | 1 | 2 | 1 |
Postpartum IUD placement within 10 minutes of placental delivery, or from 10 minutes to under 4 weeks, is category 2; from 4 weeks it is category 1. DMPA is category 2 in the first 21 days postpartum.
Drug interactions
Enzyme-inducing anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine) and rifampin or rifabutin make CHC and POP category 3 and the implant category 2, because they reduce contraceptive hormone levels. DMPA and both IUDs remain category 1. Lamotrigine is a reverse interaction: CHC is category 3 because estrogen lowers lamotrigine levels and can cause loss of seizure control. Broad-spectrum antibiotics, antifungals and SSRIs are category 1 with every method.
Starting, switching and backup: US SPR 2024
Any method can be started on any day if the provider is reasonably certain the patient is not pregnant. That is true when the patient has no symptoms of pregnancy and meets one of these criteria: within 7 days of the start of normal menses, no intercourse since the start of the last normal menses, correct and consistent use of a reliable method, within 7 days of a spontaneous or induced abortion, within 4 weeks postpartum, or fully or nearly fully breastfeeding, amenorrheic and under 6 months postpartum.
| Method | No backup needed if started | Otherwise |
|---|---|---|
| Cu-IUD | Any time | No backup needed; also emergency contraception within 5 days |
| LNG-IUD | Within 7 days of the start of menses | Backup or abstinence for 7 days |
| Implant | Within 5 days of the start of menses | Backup for 7 days |
| DMPA | Within 7 days of the start of menses | Backup for 7 days |
| CHC | Within 5 days of the start of menses | Backup for 7 days |
| POP (norethindrone or norgestrel) | Within 5 days of the start of menses | Backup for 2 days |
| POP (drospirenone) | First day of menses | Backup for 7 days |
Missed pills and late injections
- Combined pill, one late or missed pill (under 48 hours since a pill should have been taken): take it as soon as possible, continue the pack, even if two pills are taken in one day; no backup is needed.
- Combined pill, two or more consecutive missed pills (48 hours or more): take the most recent missed pill now, discard the others, continue the pack and use backup until hormonal pills have been taken for 7 consecutive days. If the pills were missed in the last week of active pills, skip the hormone-free interval and start a new pack. If pills were missed in the first week and there was unprotected intercourse in the previous 5 days, consider emergency contraception.
- Norethindrone or norgestrel POP more than 3 hours late: take a pill as soon as possible, continue daily and use backup for 2 days; consider emergency contraception after recent unprotected intercourse.
- DMPA: repeat every 3 months (13 weeks); up to 15 weeks from the last injection needs no backup. Later than that, give it if reasonably certain not pregnant and advise 7 days of backup.
Emergency contraception
The options are the Cu-IUD within 5 days (the most effective), ulipristal acetate 30 mg once, or levonorgestrel 1.5 mg once, each as soon as possible within 5 days. After ulipristal, wait 5 days before starting a hormonal method (with backup until the method takes effect), because progestin can reduce ulipristal's effect. After levonorgestrel, a hormonal method can begin immediately.
Follow-up and bleeding problems
US SPR advises no routine follow-up visit for most methods; patients return for problems or a desire to change. Recheck blood pressure on CHC at follow-up. For bothersome bleeding on an implant, options include NSAIDs for 5 to 7 days tranexamic acid for 5 days, or short-term hormonal treatment such as a combined pill with 20 to 30 mcg ethinyl estradiol or estrogen if medically eligible. Check for pregnancy, STI and structural causes when bleeding changes or persists. Remove an IUD and reevaluate if pregnancy occurs with it in place, or if the strings are missing and the device cannot be confirmed by ultrasound.
Patient education
- No hormonal method or IUD protects against STIs; use condoms for that.
- CHC: report severe headache, new aura, chest pain, leg swelling or sudden breathlessness right away.
- DMPA: irregular bleeding and later amenorrhea are expected; return to fertility can be delayed for months; weight gain and bone density loss are possible.
- Implant and LNG-IUD: unscheduled bleeding is common in the first months and is not harmful.
- Keep emergency contraception on hand or know how to get it.
How the exam tests this
- Migraine with versus without aura: a woman with visual aura before headaches should never get a combined pill, even at age 22.
- Smoking numbers: age 35 and 15 cigarettes a day mark category 4; a 30-year-old smoker is category 2.
- "Safest choice" questions: the Cu-IUD is category 1 or 2 for nearly every cardiovascular, thrombotic and breast cancer condition.
- Breast cancer: the LNG-IUD is hormonal and is category 4 with current disease.
- Postpartum: a combined pill at the 2-week postpartum visit is category 4 for everyone.
- Exam requirements: the correct answer for starting a pill in a 19-year-old is a blood pressure, not a pelvic examination or Pap test.
- Lamotrigine: estrogen lowers seizure-drug levels; with enzyme inducers, the method fails instead.
Practice question
A 34-year-old woman requests contraception. She has migraines about twice a month, preceded by 20 minutes of zigzag lines in her vision. She smokes 5 cigarettes a day. Blood pressure is 128/80 mm Hg and BMI is 31. She wants a method she does not have to remember every day. Which method is most appropriate?
- A. Combined vaginal ring, replaced monthly.
- B. Etonogestrel implant.
- C. Combined oral contraceptive with 20 mcg ethinyl estradiol.
- D. Transdermal combined patch with counseling to stop smoking.
Answer: B. Migraine with aura makes every estrogen-containing method category 4 under US MEC 2024 because of the added ischemic stroke risk, while the implant is category 1 and requires no daily action. Option A is a combined method and is category 4 whether given as a ring, pill or patch. Option C is wrong because lowering the estrogen dose does not change the category for migraine with aura. Option D adds smoking counseling, which is appropriate, but it does not remove the aura contraindication.
Key points
- US MEC categories: 1 use, 2 generally use, 3 generally do not use, 4 do not use.
- CHC is category 4 with migraine with aura, age 35 or older and 15 or more cigarettes a day, blood pressure 160/100 or higher, vascular disease, thrombophilia, prior VTE at higher recurrence risk, current breast cancer, sickle cell disease and the first 21 days postpartum.
- The Cu-IUD is category 1 for current breast cancer and nearly every thrombotic condition; all hormonal methods, including the LNG-IUD, are category 4 with current breast cancer.
- Enzyme-inducing anticonvulsants and rifampin make CHC and POP category 3; DMPA and IUDs stay category 1.
- Only blood pressure is required before starting CHC; IUD placement requires a bimanual examination and cervical inspection.
- Backup: none for Cu-IUD, 2 days for norethindrone POP, 7 days for the other methods unless started early in the cycle; DMPA is on time up to 15 weeks.
Related NPPace guides
- Menopause Symptom Management: Who Can Have Hormone Therapy, Who Cannot and the Nonhormone Options
- Prenatal Care for the FNP Exam: Visit Schedule, Labs by Trimester and the Numbers to Know
- Well-Child Visits for the FNP Exam: Milestones by Age, Screening Schedule and Immunizations
- How to Read a Primary-Care Vignette Like a Provider: The 5-Step Method
- AANP vs ANCC: Which NP Certification Exam Should You Take?
Frequently asked questions
Common follow-up questions on Pediatrics & Women's Health (FNP).
What is the difference between US MEC category 3 and category 4?
Category 4 means the method should not be used because the health risk is unacceptable. Category 3 means risks usually outweigh benefits, so the method is generally not recommended unless more appropriate methods are unavailable or unacceptable, with careful clinical judgment and follow-up.
Can a patient with migraine take a combined pill?
Migraine without aura, including menstrual migraine, is category 2 for combined hormonal contraception in US MEC 2024, so the method can generally be used. Migraine with aura is category 4 because of the added stroke risk; progestin-only methods and IUDs remain category 1.
Which tests are needed before starting a combined pill?
Only a blood pressure measurement. US SPR 2024 does not require a pelvic examination, Pap test, STI testing or routine laboratory tests before starting hormonal contraception; weight or BMI is helpful but not required.
How late can a DMPA injection be without needing backup?
DMPA is repeated every 3 months (13 weeks) and can be given up to 2 weeks late, meaning up to 15 weeks from the last injection, without additional protection. Beyond 15 weeks, give it if the patient is reasonably certain not to be pregnant and advise backup for 7 days.
Sources and references
- Nguyen AT, Curtis KM, Tepper NK, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recommendations and Reports. 2024. https://www.cdc.gov/mmwr/volumes/73/rr/rr7304a1.htm
- Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use. CDC. 2024. https://stacks.cdc.gov/view/cdc/251903
- Curtis KM, Nguyen AT, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recommendations and Reports. 2024. https://www.cdc.gov/mmwr/volumes/73/rr/rr7303a1.htm
- Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), provider resources. CDC. 2024. https://www.cdc.gov/contraception/hcp/usmec/
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