The Centers for Disease Control and Prevention (CDC) has released the "U.S. Selected Practice Recommendations for Contraceptive Use, 2024" (2024 U.S. SPR), providing updated guidance for health care providers on the safe and effective use of contraceptive methods.

The 2024 U.S. SPR serves as a companion document to the "U.S. Medical Eligibility Criteria for Contraceptive Use, 2024," which provides guidance on the safety of contraceptive methods for patients with various medical conditions and characteristics. Together, these evidence-based recommendations support health care providers in delivering high-quality, equitable contraceptive care.

The recommendations, based on a review of scientific evidence and expert input, aim to remove unnecessary medical barriers and support patient-centered contraceptive counseling and services.

Key updates in the 2024 U.S. SPR, which was published in Morbidity and Mortality Weekly Report, include:

• Updated recommendations for the provision of medications for intrauterine device (IUD) placement and management of bleeding irregularities during implant use.
• New recommendations for testosterone use and risk for pregnancy, and self-administration of injectable contraception.

Medications for IUD Placement

• Misoprostol is not recommended for routine use but may be useful in selected circumstances (eg, patients with a recent failed placement).
• Lidocaine (paracervical block or topical) may be useful for reducing patient pain.

Bleeding Irregularities During Implant Use

If the patient wants treatment, options may include:

• Treatments that might improve bleeding during use, but are likely to result in recurrence after cessation (eg, hormonal treatment, antifibrinolytic agents).
• Treatments that might improve bleeding during use with effects persisting after cessation (eg, nonsteroidal anti-inflammatory drugs or selective estrogen receptor modulators).

Bleeding Irregularities During Levonorgestrel IUD Use

• A systematic review found no differences between treatment and placebo groups in bleeding or spotting over 90 days for tranexamic acid, mefenamic acid, and ulipristal acetate in managing bleeding irregularities with 52-mg levonorgestrel IUDs (certainty of evidence: moderate to high for randomized clinical trials).

Testosterone Use and Pregnancy Risk

• The guidance urges practitioners to counsel that testosterone use might not prevent pregnancy among transgender, gender-diverse, and nonbinary persons with a uterus, and to offer contraceptive counseling and services to those at risk for and not desiring pregnancy.
• One noncomparative study of 16 continuing and 6 new testosterone users found that 5% ovulated using a urinary pregnanediol-3-glucuronide threshold of >5 μg/mL for 3 days, while 36% ovulated using a threshold of >3 μg/mL for 2 days (certainty of evidence: very low).

Self-Administration of Injectable Contraception

• Self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) should be made available as an additional approach to deliver injectable contraception.
• A systematic review and meta-analysis of three randomized clinical trials and three prospective cohort studies found higher continuation rates with self-administered DMPA-SC compared to provider-administered DMPA-SC or DMPA-IM (pooled risk ratio [RR] = 1.27, 95% confidence interval [CI] = 1.16-1.39 for randomized clinical trials; pooled RR = 1.18, 95% CI = 1.10-1.26 for cohort studies); low pregnancy rates that did not differ between self-administered and provider-administered groups (four studies); and higher rates of injection-site reactions with self-administered DMPA-SC in two studies, while two studies found no differences (certainty of evidence: moderate for randomized clinical trials, very low for observational studies).

Contraceptive Decision-Making

• The 2024 U.S. SPR emphasizes the paramount importance of personal autonomy in contraceptive decision-making, particularly in light of historical and ongoing contraceptive coercion and reproductive mistreatment in the United States.
• A person-centered approach prioritizes individual preferences and reproductive autonomy, respects the person as the main decision-maker, and includes respecting the decision not to use contraception or to discontinue use.

Methods

The CDC monitored the literature for new evidence relevant to the recommendations through the World Health Organization (WHO)/CDC Continuous Identification of Research Evidence (CIRE) system. Systematic reviews were conducted for each topic considered for update. The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of evidence.

In January 2023, the CDC held a meeting with 40 invited experts to review the scientific evidence and provide individual perspectives on updating the recommendations. Patient perspectives were also gathered through listening sessions to inform the guideline development process.

The CDC uses the WHO/CDC CIRE system to ensure recommendations are based on the best available evidence and can be updated when new evidence warrants. The CDC identifies gaps in evidence for the recommendations considered, noting that new, high-quality research on contraception addressing priority gaps and including diverse populations can further strengthen the recommendations.

The updated recommendations emphasize the importance of patient autonomy in contraceptive decision-making and aim to support health care providers in delivering noncoercive, patient-centered counseling and services. The CDC will continue to monitor new evidence and update the recommendations as warranted to improve clinical practice and patient care.