Medical eligibility criteria type 4 for Contraceptions like cocp,DMPA,jadella,LNG-IUS and copper iucd
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WHO/CDC Medical Eligibility Criteria (MEC) — Category 4 Conditions
Category 4 = Unacceptable health risk — method MUST NOT be used.
The MEC system (WHO and its CDC US adaptation) classifies conditions into 4 categories for each contraceptive method. Category 4 conditions are absolute contraindications.
🔴 COCP (Combined Oral Contraceptive Pill) — Category 4
All combined hormonal contraception (CHC) — pills, patch, ring — share the same Category 4 conditions:
| Condition | Notes |
|---|---|
| Postpartum < 21 days | Risk of VTE is highest in the early puerperium |
| Smoker aged ≥35, ≥15 cigarettes/day | < 15 cigs/day is Cat 3 |
| Active DVT / Pulmonary Embolism | Acute or recurrent with high recurrence risk (Cat 4); lower risk = Cat 3 |
| Known thrombogenic mutations | Factor V Leiden, prothrombin gene mutation, protein C/S/antithrombin deficiencies |
| Peripartum cardiomyopathy | |
| Ischaemic heart disease (current) | |
| Stroke (history of cerebrovascular disease) | |
| Migraine with aura | Any age — absolute contraindication |
| Hypertension with vascular disease / BP ≥160/100 | Severe or with end-organ damage = Cat 4; mild-moderate = Cat 3 |
| Diabetes with nephropathy, retinopathy, neuropathy, or vascular disease | |
| Diabetes > 20 years' duration | |
| SLE with positive antiphospholipid antibodies | |
| Current breast cancer | |
| Severe (decompensated) cirrhosis | |
| Liver tumours | Hepatocellular adenoma or hepatoma/hepatocellular carcinoma |
| Complicated solid organ transplant | e.g. graft failure, rejection, cardiac transplant complications |
| Bariatric surgery (malabsorptive type) | Pills only — impaired absorption; Cat 3 for patch/ring |
| Drug interactions reducing efficacy | Rifampicin, certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine) |
— Goldman-Cecil Medicine, Table 220-3
🟠 DMPA (Depot Medroxyprogesterone Acetate — Depo-Provera) — Category 4
DMPA is a progestin-only injectable. It has fewer Category 4 conditions than the COCP, but some unique ones:
| Condition | Notes |
|---|---|
| Current breast cancer | All progestin-only methods |
| SLE with positive antiphospholipid antibodies | |
| Severe (decompensated) cirrhosis | |
| Liver tumours (hepatocellular adenoma/hepatoma) |
Important Cat 3 for DMPA (risks outweigh benefits — not Cat 4 but worth noting):
- Hypertension, ischaemic heart disease, stroke, diabetes with vascular complications — these are Category 3 for DMPA (unlike COCP where they are Cat 4)
- DMPA does not cause VTE (no oestrogen), so DVT/PE is not a contraindication
— Goldman-Cecil Medicine, Table 220-3
🟠 Jadelle (Levonorgestrel Implant) — Category 4
Jadelle contains levonorgestrel (progestin only), so it shares the same category framework as other progestin-only methods. The WHO MEC Category 4 conditions for implants mirror those of progestin-only pills:
| Condition | Notes |
|---|---|
| Current breast cancer | |
| SLE with positive antiphospholipid antibodies | |
| Severe (decompensated) cirrhosis | |
| Hepatocellular adenoma or hepatoma |
Notably, thrombosis, migraine with aura, hypertension, and cardiovascular disease are generally Category 2–3 (not Cat 4) for progestin-only implants because of the absence of oestrogen.
🟣 LNG-IUS (Levonorgestrel Intrauterine System — e.g. Mirena) — Category 4
The LNG-IUS has two sets of Category 4 conditions: those shared with all IUDs, plus LNG-specific ones.
Category 4 — For ALL IUDs (including LNG-IUS)
| Condition |
|---|
| Pregnancy (or suspected pregnancy) |
| Congenital or acquired uterine cavity distortion — large fibroids, bicornuate uterus, cavity < 6 cm or > 9 cm axial length |
| Immediate post-septic abortion or puerperal sepsis |
| Postpartum endometritis or infected abortion within past 3 months |
| Current or recent STI (within 3 months) |
| Current or recent PID (within 3 months) |
| Known pelvic tuberculosis |
| Unexplained genital bleeding |
| Known or suspected uterine/cervical neoplasia (awaiting treatment) |
| Malignant gestational trophoblastic disease |
| Ovarian cancer (contraindication to insertion) |
Category 4 — LNG-IUS Specific (Category 1 for copper IUD)
| Condition | Note |
|---|---|
| Current breast cancer | All progestin-containing methods |
| Active viral hepatitis | Cat 1 for copper IUD |
| Active liver disease — severe decompensated cirrhosis, liver adenoma, hepatoma | Cat 1 for copper IUD |
| Current DVT/PE | Cat 1 for copper IUD |
| History of breast cancer, disease-free < 5 years | Cat 3 after 5 years disease-free |
| Migraine with focal neurological symptoms | Cat 1 for copper IUD |
— Pfenninger & Fowler's Procedures for Primary Care, pp. 1013–1014
🔵 Copper IUD (Cu-IUD) — Category 4
The copper IUD is non-hormonal, so it does not share the hormonal contraindications above. Its Category 4 conditions relate entirely to uterine/pelvic factors:
| Condition |
|---|
| Pregnancy |
| Congenital or acquired uterine cavity distortion |
| Immediate post-septic abortion or puerperal sepsis |
| Postpartum endometritis or infected abortion within past 3 months |
| Current or recent STI (within 3 months) |
| Current or recent PID (within 3 months) |
| Known pelvic tuberculosis |
| Unexplained genital bleeding |
| Known or suspected uterine/cervical neoplasia (awaiting treatment) |
| Malignant gestational trophoblastic disease |
| Ovarian cancer (contraindication to insertion) |
The copper IUD has no hormonal contraindications — thrombosis, liver disease, breast cancer, migraines, and cardiovascular conditions are generally Category 1 (no restriction) for the Cu-IUD.
Quick Comparison Table
| Condition | COCP | DMPA | Jadelle | LNG-IUS | Cu-IUD |
|---|---|---|---|---|---|
| Current breast cancer | 4 | 4 | 4 | 4 | 1 |
| Migraine with aura | 4 | 2 | 2 | 3 | 1 |
| DVT / PE (acute) | 4 | 2 | 2 | 2 | 1 |
| Thrombogenic mutations | 4 | 2 | 2 | 2 | 1 |
| Decompensated cirrhosis | 4 | 4 | 4 | 4 | 1 |
| Liver tumours (adenoma/HCC) | 4 | 4 | 4 | 4 | 1 |
| Hypertension (severe / vascular) | 4 | 3 | 2 | 2 | 1 |
| Ischaemic heart disease | 4 | 3 | 2 | 2 | 1 |
| Stroke | 4 | 3 | 2 | 2 | 1 |
| Uterine cavity distortion | — | — | — | 4 | 4 |
| Pregnancy | — | — | — | 4 | 4 |
| Active PID / STI (< 3 months) | — | — | — | 4 | 4 |
| Post-septic abortion / puerperal sepsis | — | — | — | 4 | 4 |
| Pelvic TB | — | — | — | 4 | 4 |
| Unexplained genital bleeding | — | — | — | 4 | 4 |
| Uterine/cervical neoplasia | — | — | — | 4 | 4 |
| Postpartum < 21 days | 4 | 2 | 2 | varies | varies |
| Smoker ≥35 yrs, ≥15 cigs/day | 4 | 2 | 1 | 1 | 1 |
| SLE + antiphospholipid Ab | 4 | 4 | 4 | 3 | 1 |
Sources: Goldman-Cecil Medicine International Edition (Table 220-3); Pfenninger & Fowler's Procedures for Primary Care (pp. 1013–1014); Berek & Novak's Gynecology — WHO/CDC Medical Eligibility Criteria framework.
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