Contraception counselling
Patient-centred choice of a method for a person who can become pregnant
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Family MedicineManagement
Contraception Selection & Counseling (CDC US-MEC)
Contraception Selection & Counseling (CDC US-MEC): Contraception counselling → Assess patient preferences → If unprotected sex in the last 5 days: emerg...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Assess patient preferences
Key questions to ask
- Wish for future pregnancy, and when
- Importance of effectiveness, convenience and bleeding pattern
- Hormonal or non-hormonal preference
- How often the patient can take or renew a method
- STI risk: condoms add STI protection to any method
- Confidentiality and safety concerns
03Action If unprotected sex in the last 5 days: emergency contraception
Ask at every visit. Copper IUD is most effective. Enzyme inducer and no IUD: levonorgestrel 3 mg, not ulipristal. After ulipristal, wait 5 days before any hormonal method.
- Copper IUD within 5 days: most effective; can stay as ongoing contraception
- Ulipristal 30 mg orally, single dose, within 120 h; more effective than levonorgestrel at 3-5 days
- Levonorgestrel 1.5 mg orally, single dose, as soon as possible (label 72 h; some effect to 5 days)
- Enzyme (CYP3A4) inducer in the last 4 weeks: copper IUD; if declined, levonorgestrel 3 mg (2 x 1.5 mg) single dose; ulipristal not advised
- BMI 30 or more: pills may be less effective; copper IUD is best; ulipristal may work better than levonorgestrel
- After ulipristal: start hormonal contraception no sooner than 5 days later; condoms or abstain until 7 days after starting
- After levonorgestrel: start any method now; condoms or abstain for 7 days
- Pregnancy test if no bleed within 3 weeks
04Action Be reasonably certain the patient is not pregnant
No symptoms or signs of pregnancy and any one of these (US-SPR Box 3)
- 7 days or less since the start of normal menses
- No sex since the start of the last normal menses
- Correct and consistent use of a reliable method
- 7 days or less after abortion or miscarriage; or within 4 weeks postpartum
- Under 6 months postpartum, fully or nearly fully breastfeeding and amenorrhoeic
- Not certain: delay IUD (a copper IUD for emergency contraception within 5 days is the exception); other methods can start now, with a pregnancy test in 2-4 weeks
05Action Medical history, medicines and BP
Screen for US-MEC category 3 and 4 conditions before choosing a method
- Measure BP before starting combined hormonal contraception (CHC)
- Migraine type, smoking and age, VTE history, heart disease, stroke, diabetes complications
- Postpartum weeks and breastfeeding; breast or liver disease; SLE
- Medicines: enzyme inducers, lamotrigine, antiretrovirals
- Malabsorptive bariatric surgery (e.g. Roux-en-Y bypass): oral pills US-MEC 3
- Pelvic symptoms, unexplained bleeding and STI risk if an IUD is an option
06Warning No estrogen (CHC) if any of these (US-MEC 4)
Combined pill, patch or ring. Offer a progestogen-only method or a copper IUD, checking its own category.
- Migraine with aura; age 35 or over and smoking 15 or more cigarettes a day
- BP 160/100 mmHg or higher; vascular disease; ischaemic heart disease; stroke; complicated valvular heart disease; peripartum cardiomyopathy (under 6 months, or moderate or severe)
- Past DVT or PE with higher recurrence risk and not on therapeutic anticoagulation; known thrombophilia; major surgery with prolonged immobilisation; SLE with positive or unknown antiphospholipid antibodies
07Warning Also no CHC (US-MEC 4): under 21 days postpartum; liver, sickle cell, kidney
CHC usually not advised (US-MEC 3 or 3/4): any hypertension, even if controlled; age 35 or over and smoking under 15 a day; breastfeeding 21-29 days postpartum; 21-42 days postpartum with VTE risk factors; DVT or PE on therapeutic anticoagulation or with lower recurrence risk; superficial venous thrombosis; diabetes with vascular complications or for more than 20 years; multiple cardiovascular risk factors; acute viral hepatitis. Australia and UK (UKMEC): BMI 35 or more is also category 3.
- Under 21 days postpartum, breastfeeding or not
- Decompensated cirrhosis; hepatocellular adenoma or liver cancer; sickle cell disease
- Nephrotic syndrome or dialysis; solid organ transplant with graft failure
08Warning Current breast cancer: no hormonal method (US-MEC 4). Check interacting drugs.
Copper IUD is US-MEC 1. Past breast cancer with no disease for 5 years: hormonal methods US-MEC 3. Liver cancer: all progestogen methods US-MEC 3. Unexplained vaginal bleeding before evaluation: implant and DMPA US-MEC 3.
- Enzyme inducers (carbamazepine, phenytoin, barbiturates, primidone, topiramate, oxcarbazepine, rifampicin, rifabutin): CHC and POP US-MEC 3; implant 2; DMPA and IUDs 1
- Lamotrigine: CHC US-MEC 3 (CHC lowers lamotrigine levels; seizure risk)
- DMPA US-MEC 3: BP 160/100 mmHg or higher or vascular disease; ischaemic heart disease; stroke; multiple cardiovascular risk factors; higher-risk DVT or PE, or thrombophilia; diabetes with vascular disease or for more than 20 years; SLE with positive antiphospholipid antibodies; nephrotic syndrome or dialysis; moderate or severe peripartum cardiomyopathy; decompensated cirrhosis, liver adenoma or cancer
09Warning Do not place an IUD if any of these (US-MEC 4)
Also US-MEC 4: gestational trophoblastic disease with persistently raised hCG or malignancy and intrauterine disease. Offer another method now; place the IUD when the condition is treated or excluded.
- Pregnancy, or pregnancy not reasonably excluded
- Current PID, purulent cervicitis, chlamydia or gonorrhoea; postpartum sepsis or immediately after septic abortion
- Unexplained vaginal bleeding before evaluation; cervical or endometrial cancer awaiting treatment; distorted uterine cavity; pelvic TB
10Action Choose a method with the patient
Discuss all suitable methods, most effective first; the patient decides. Typical-use pregnancies per 100 in the first year:
- IUD or implant: fewer than 1
- DMPA injection: about 4; pill, patch or ring: about 7
- Condoms: about 13; withdrawal: about 20
11Action Option 1, IUD or implant: long-acting reversible methods
Most effective. Can place today if reasonably certain not pregnant and no US-MEC 4 condition.
- Copper IUD: no hormones; periods may be heavier or more painful; 5-10 years by device
- LNG-IUD: periods lighter or absent; 52 mg device 8 years (US and Australian labels), 19.5 mg device 5 years; check the local product label
- Etonogestrel implant (Nexplanon; Implanon NXT in Australia): 3 years; irregular bleeding common
- IUD: bimanual examination and cervical inspection before placement
- STI testing if due: do it at the visit; do not delay placement
- Implant: no pelvic examination needed
- Nulliparous or under 20: IUD US-MEC 2, implant US-MEC 1
12Action Option 2, short-acting hormonal methods
Need regular use. Apply the CHC and DMPA warnings above. Drospirenone pill: not with known hyperkalaemia.
- DMPA injection: every 13 weeks, no backup needed up to 15 weeks (US-SPR); Australian label every 12 weeks, up to 14 weeks; weight gain possible; bone density falls during use
- Combined pill: daily
- Vaginal ring: 3 weeks in, then a new ring after a 7-day break or with no break
- Patch (where available): weekly; may be less effective with BMI 30 or more or weight over 90 kg
- Progestogen-only pill: daily; missed if more than 3 h late (norethisterone or levonorgestrel/norgestrel type) or 24 h late (drospirenone)
- Drospirenone pill: not with known hyperkalaemia (US-MEC 4); consider a potassium check in chronic kidney disease
13Action Option 3, barrier and other methods
Need use with each act. Offer an advance supply of emergency contraception.
- External (male) condom: also protects against STIs
- Internal (female) condom: can be inserted before sex
- Diaphragm or cap: needs fitting; use with spermicide
- Fertility awareness methods: need training and a regular cycle
- Withdrawal: about 20 pregnancies per 100 in the first year
14Action Start the chosen method today (quick start)
IUD only if reasonably certain not pregnant. Other methods can start today even if not certain, with a pregnancy test in 2-4 weeks. No need to wait for menses.
- No backup: copper IUD; CHC, implant or norethisterone/levonorgestrel POP started within 5 days of period start; drospirenone POP on day 1; DMPA or LNG-IUD within 7 days
- Otherwise condoms or abstain for 7 days (2 days for norethisterone or levonorgestrel/norgestrel POP)
- After ulipristal emergency contraception: wait 5 days before a hormonal method
15Action Follow-up
No routine follow-up visit needed. Invite return at any time.
- Return for side effects, problems, or to change, remove or replace the method
- CHC: check BP at routine visits
- DMPA: next injection due at 13 weeks (Australian label: 12 weeks)
- At each visit: check new conditions or medicines against US-MEC
- Condoms for STI protection if at risk
Guideline Source
CDC U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (with U.S. Selected Practice Recommendations, 2024)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Summary of US-MEC 2024 only: check the full tables (UKMEC in the UK and Australia) for any condition not listed
- Postpartum, post-abortion, adolescent and perimenopausal timing are not covered in detail
- Permanent methods (tubal surgery, vasectomy) and IUD placement technique are not covered
- Failure rates are typical-use averages for the first year
Applicable Regions
USAUUKEU
AU: Australian services use UKMEC (FSRH); most categories match US-MEC; BMI 35 or more is category 3 for CHC. DMPA every 12 weeks (no backup up to 14 weeks). Mirena approved for 8 years (2024). Implanon NXT is the only implant. Drospirenone POP is Slinda. Emergency contraception pills are available from pharmacies without a prescription.
UK: Use UKMEC (FSRH, 2025 edition) and FSRH guidance.
US: CDC US-MEC 2024 and US-SPR 2024.
Version 2Next review: 2027-09-30
Next steps
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Related Resources
Frequently Asked Questions
What is the Contraception Selection & Counseling (CDC US-MEC)?
The Contraception Selection & Counseling (CDC US-MEC) is a management clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on CDC U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (with U.S. Selected Practice Recommendations, 2024).
What guideline is the Contraception Selection & Counseling (CDC US-MEC) based on?
This algorithm is based on CDC U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (with U.S. Selected Practice Recommendations, 2024) (DOI: 10.15585/mmwr.rr7304a1).
What are the limitations of the Contraception Selection & Counseling (CDC US-MEC)?
Known limitations include: Summary of US-MEC 2024 only: check the full tables (UKMEC in the UK and Australia) for any condition not listed; Postpartum, post-abortion, adolescent and perimenopausal timing are not covered in detail; Permanent methods (tubal surgery, vasectomy) and IUD placement technique are not covered; Failure rates are typical-use averages for the first year. Individual patient factors may require deviation from these recommendations.
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