ia_gov_sa · guide · processed · 22 chunks
Classificatjon of Contraception
Long Acting Revtable (IARC)
Permanent
Intrauterine Contraception (IUC)
•Copper-Bearing Intrauterine Device (Cu-IUD)
•Levonorgestrel Intrauterine System (LNG-IUS)
Progestogen-only
Contraception (POC)
•Progestogen only implant
•Progestogen only injectable
•Progestogen only pill
Combined Hormonal Contraception (CHC)
•Combined oral contraception
•Combined transdermal patches
•Combined Vaginal rings
Emergency Contraception (EC)
•COC
•Copper-Bearing IUD
•Oral EM
•Oral Progesterone-Only
•Ulipristal Acetate (UPA)
Barrier Method
•Condom, diaphragm
•Coitus interruptus
Vasectomy
Tubal Ligation
Contraception Clinical Practice Guidelines
How to choose a contraception method
■History: (family, sexual, cervical smears, social, medications, previous contraception)
■Check: BP, Weight and BMI
■Exclude: STI, pregnancy if appropriate
■Determine patient's preferences for contraception
■Promote barrier methods in addition for protection against STI
■Exclude contraindications to chosen method using the USMEC
Offer LARC as 1st Line option
Offer Combined Hormonal Contraception(CHC):
■ If LARCS is inappropriate
■ Not breast feeding
■ No estrogen contraindications (DVT, BMI, HTN, Migraine with aura, smoking, CVD, history of breast or cervical cancer)
USMEC 1-2
Offer progesterone only pill if CHC inappropriate
Offer other options if POC inappropriate
U.S. Medical Eligibility Criteria for Contraceptive Use
1. No restriction (method can be used)
2. Advantages generally outweigh theoretical or proven risks
3. Theoretical or proven risks usually outweigh the advantages
4. Unacceptable health risk (method not to be used)
How to Choose Contraceptives
Contraception counselling
Assess medical eligibility for CHC
USMEC 1 or single USMEC 2
\(1^{ST}\) Line
Route : oral
Preparation : Monophasic Standard Strength
OR Monophasic low Strength if CVD risk
Explain
- Directions for use
- Benefits & Risks
- Side effects & cautions
- Missed pill rule, compliance
- Sick day rule
- Red flags
\(2^{\mathrm{nd}}\) line
- Estrogen excess: Monophasic low Strength
Preparations or Monophasic Low Strength
Preparations with \( 3^{rd} \) generation progestogens
•Progesterone excess : Monophasic Standard
Strength with 3rd generation progesterone
•Acne/hirsutism: COC with progestogen that
has minimal androgenic effect; desogestrel,
gestodene, or norgestimate
•Poor cycle control: higher estrogen
strength, change progesterone
Follow up 3 months then annually
•Medical eligibility
•Satisfaction & adherence
- Drug interactions
- Consideration of alternative contraception
- Blood pressure
Intrauterine Contraception ( IUC)
<table><tr><td></td><td>Copper-Bearing Intrauterine Device (Cu-IUD)</td><td>Levonorgestrel Intrauterine System (LNG-IUS)</td></tr><tr><td>Example</td><td>1st Line (10-year license): Copper T380 A®2nd Line (5-year license): Copper T380®, 7 MED 380, Nova T380</td><td>1st Line (5- year license): Mirena®</td></tr><tr><td>Indication</td><td>Contraception</td><td>Contraception, menorrhagia(Mirena® preferred), part of HRT Effective for 4 y</td></tr><tr><td>Timing of insertion</td><td>Anytime, best of to avoid heavy days of the period. Best fitted after end of period & before calculated time of implantation . Post delivery 4-6 weeks</td><td>Insert within 7 days of onset of menstruation OR Anytime if reasonably certain women is not pregnant OR Anytime if replacement OR At least 4 weeks post delivery</td></tr><tr><td>Back up contraception requirements</td><td>Initiation: none needed Switching : none neededReplacement: noneRemoval: : removal after day 3 of the menstrual cycle another method of contraception should be used for at least 7 days after removal if had intercourse</td><td>Initiation: 7 days; only needed if > 7 days after starting menstruationSwitching: 7 days; only needed if > 7 days after starting menstruationReplacement: 7 days contraception prior to removal Removal: 7 days of contraception after removal</td></tr><tr><td colspan="3">Examination & monitoring requirements: Gynecological examination before insertion, 6-8 weeks after then annually</td></tr><tr><td>Side effects & counselling</td><td>Device related : slight increase risk of ectopic pregnancy & pelvic infection ( risk increased mainly in first 20 days), uterine injury, epilepsy ( risk of fits on insertion), hemorrhage on insertion, very small risk of uterine perforation ( ladies must be taught how to check threads and report s & s of perforation promptly). Menstrual cycles : can cause menstrual irregularities, mainly heavy periods</td><td>Device related : same as Cu-IUD Menstrual cycles : irregular, prolonged or infrequent menstrual bleeding in first 3-6 m ( may persist in some patients) Progestogen side effects usually resolve in few months( breast abnormalities, depression, hirsutism, decreased libido, nervousness, ovarian cyst, weight loss. Uncommon ( alopecia, edema)</td></tr><tr><td rowspan="2">Contraindications</td><td colspan="2">USMEC4: Distorted uterine cavity ,Cervical cancer awaiting treatment ( initiation), Endometrial cancer( initiation) , Gestational trophoblastic disease (Persistently elevated β-hCG levels or malignant disease), Immediately post-septic abortion , Current Pelvic inflammatory disease ( initiation), Puerperal sepsis ,Pregnancy , Current purulent cervicitis or chlamydial infection or gonorrhea ( initiation ), Pelvic TB ( initiation)</td></tr><tr><td>USMEC 3 Gestational trophoblastic disease(Decreasing or undetectable β-hCG levels), AIDS or on Antiretroviral therapy ( initiation), Complicated Solid organ transplantation, Severe thrombocytopenia ( initiation),Pelvic TB ( continuation ),Unexplained vaginal bleeding</td><td>USMEC 3: same as Cu-IUD besides , Current and history of IHD (continuation), Hepatocellular adenoma, Malignant liver tumors, Positive (or unknown) antiphospholipid antibodies, Unexplained vaginal bleeding</td></tr></table>
Progesterone-only contraception (POC)
<table><tr><td></td><td>Subdermal implants</td><td>Injection</td><td>Progestin-only pill (POP)</td></tr><tr><td>Route</td><td>•Nexplanon(Etonogestrel) (3-year license)</td><td>(Medroxyprogesterone): 12 Weekly SC or deep IM Injection: Depo-provera®, Sayana press®</td><td>•Desogestrol 75mg (Cerazette®)</td></tr><tr><td>Indication</td><td>Long term revisable Contraception</td><td>Long term revisable Contraception.Norethisterone injections can be used IM for short term contraception (8 weeks)</td><td>Contraception. Norethisterone (endometriosis, to arrest bleeding in DUB & menorrhagia, dysmenorrhea, postponement of menstruation,</td></tr><tr><td>Timing : when to start? How to take?</td><td>Insert within 5 days of onset of menstruation or after \( 1^{st} \) trimester miscarriage OR Anytime if reasonably certain women is not pregnant OR Anytime if replacement OR 21-28 days post delivery or \( 2^{nd} \) trimester miscarriage</td><td>Inject within 5 days of onset of menstruation OR within 5 days postpartum every 150mg every 12 weeks deep IM or 104 mg every 13 weeks SC (abdomen or anterior thigh). Ca+ Vit d co prescription advised. After 2 years review annually</td><td>Start on day 1 of cycle, take at same time every day. If admiration is delayed for 3 hours or more for Norethisterone or 12 hours or more for Desogestrol should be regarded as missed pill.</td></tr><tr><td>Breast Feeding</td><td>Delay until 4 weeks postpartum</td><td>Delay until 6 weeks postpartum</td><td>POP don’t affect breast feeding</td></tr><tr><td>Back up contraception requirements</td><td>Initiation: 7 days; only needed if >5 days after starting menstruation Switching : 7 days; only needed if >5 days after starting menstruation Replacement: none Removal: should be removed within 3 yrs</td><td>Initiation: 7 days; only needed if >7 days after starting menstruation Switching: 7 days; only needed if >7 days after starting menstruation Replacement: none</td><td>Initiation: 2 days; only needed if >5 days after starting menstruation Switching : 2 days; only needed if >5 days after starting menstruation</td></tr><tr><td>Progestogen side effects</td><td colspan="3">Common: menstrual cycle irregularities, breast abnormalities, alopecia, depression, hirsutism, dizziness, decreased libido, nervousness, ovarian cyst, weight changes, fluid retention, mood alteration, flatulence, insomnia, Uncommon: embolism & thrombosis, vulvovaginal infections.</td></tr><tr><td>Specific side effects</td><td>Migration of implant, neurovascular injury, angioedema</td><td>Hypertension, vertigo, osteoporosis ( no monitoring is required, lipodystrophy</td><td>Desogestrol: contact lens intolerance, erythema nodosum</td></tr><tr><td>Contraindications</td><td colspan="3">USMEC4 ALL Current breast cancer, Acute porphyriasUSMEC 3 ALL Breast cancer (past and no evidence of current disease for 5 yrs), Headache with aura(continuation), Severe Cirrhosis, Current and history of IHD (continuation), Hepatocellular adenoma, Malignant liver tumors, History of CVA (continuation), SLE with Positive (or unknown) antiphospholipid antibodies, USMEC 3 Injection same as all , besides DM with ( Nephropathy/retinopathy/neuropathy ) or >20 years' duration) or with vascular disease., Hypertension ( systolic ≥160 or diastolic ≥100) or with vascular disease, Current and history of IHD ( initiation ), Multiple risk factors for arterial cardiovascular disease such as age, smoking, diabetes and hypertension), RA on On immunosuppressive therapy, History of CVA ( initiation), Severe thrombocytopenia ( initiation ), Unexplained vaginal bleeding USMEC 3 POP same as all, besides History of bariatric surgery ( Malabsorptive procedures), certain antiretroviral therapy (Ritonavir-boosted protease inhibitors), Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine), certain antimicrobial therapy ( Rifampicin or rifabutin )</td></tr><tr><td>Missed pill / late administration</td><td>rule out pregnancy and use additional contraception for 7 days.</td><td>If interval between dose is greater than 12 w & 5 days in IM administration or 13 w & 5 days in SC rule out pregnancy and use additional contraception for 7 days.</td><td>Take missed pill ASAP and take next pill at usual time. Additional contraceptive (condoms or abstain) for 2 days. EC if unprotected SI occurred within 48 hours of restarting the POP.</td></tr></table>
Combined Hormonal Contraception (CHC)
<table><tr><td>Route</td><td>•Oral (COCs): 1st Line is oral admiration, other routes Not a cost effective option, consider only if compliance issues with oral CHC and LARC unsuitable•Transdermal patches (CTP):apply on day 1, changed on day 8 and 15 then 7 day patch free period•Vaginal rings (CVR):1 ring inserted on day 1 of cycle for 3 weeks, followed by 7-day ring free</td></tr><tr><td>Preparations</td><td>Monophasic : COCs containing a fixed amount of an estrogen & progestogen in each active tablet are termed ‘monophasic’Multiphasic: COCs with varying amounts of the two hormones are termed ‘multiphasic’.COCs: usually contain ethinylestradiol (range from 20–40 micrograms) as the estrogen component; mestranol and estradiol are also used. levonorgestrel or norethisterone are the usual progesterone component. Desogestrol, drospirenone, dienogest, 3rdgeneration (gestodene, Norgestimate) are also used</td></tr><tr><td>Preparation choice</td><td>1st line: Monophasic COCs containing ≤ 30 micrograms ethinylestradiol in combination with levonorgestrel or norethisterone (to minimize cardiovascular risk)Monophasic standard strength:Marvelon®, Microgynon®Monophasic low strength: Loestrin®Multiphasic: Logynon®, Synphase®, not available in KSA</td></tr><tr><td>Regimen</td><td>Traditionally: 21 day with a monthly withdrawal bleed during the 7 day hormone free interval (HFI)Tailored CHC regimens can only be used with monophasic CHC containing (unlicensed use); Shortened HFI: 21 days of continuous use followed by a 4 day HFI; Extended use (tricycling): 9 weeks of continuous use followed by a 4 or 7 day HFI; Flexible extended use: continuous use for 21 days or more followed by a 4 day HFI when breakthrough bleeding occurs; Continuous use: continuous CHC use with no HFI.Benefits of tailored regimens : less heavy or painful withdrawal bleeds, headaches, mood changes, and decreased risk of incorrect use</td></tr><tr><td>Indications</td><td>Menstrual symptoms, contraception</td></tr><tr><td>Side effects</td><td>Estrogen related: Nausea, bloating, breast tenderness, vaginal discharge without infection, fluid retentionProgesterone related: (acne, headache, depression, breast symptoms, breakthrough bleeding , weight gain ). Uncommon Alopecia; hypertension Rare Venous thromboembolismBreast cancer: small increase in the risk of having breast cancer diagnosed in women taking the COCs; this relative risk may be due to an earlier diagnosis. The most important factor for diagnosing breast cancer appears to be the age at which the contraceptive is stopped rather than the duration of use; any increase in the rate of diagnosis diminishes gradually during the 10 years after stopping and disappears by 10 years.Cervical cancer: Use of for 5 years or longer is associated with a small increased risk of cervical cancer; the risk diminishes after stopping and disappears by about 10 years</td></tr><tr><td>Contraindications</td><td>USMEC4 Current & breast cancer, Acute porphyrias, Severe Cirrhosis, acute DVT, history of DVT with high risk for recurrence, major surgery with prolonged immobilization, migraine with aura or without if age≥ 35, DM with (Nephropathy/retinopathy/neuropathy ) or >20 years' duration) or with vascular disease, Hypertension ( systolic ≥160 or diastolic ≥100) or with vascular disease, Hepatocellular adenoma, Malignant liver tumors, Peripartum cardiomyopathy, Postpartum : <21 days, smoking Age ≥35 , <15 cigarettes/day , Solid organ transplantation: complicated, History of CVA, SLE with positive ( or unknown) antiphospholipid antibodies, Thrombogenic mutations , complicated Valvular heart disease, acute or flare up of viral hepatitis.USMEC 3 Breast cancer (past and no evidence of current disease for 5 yrs), breast feeding <1 month postpartum, history of DVT with low risk of recurrence, Gallbladder disease: current or medically treated, migraine without aura(continuation age< 35 ) ( initiation age≥ 35),hyperlipidemia, history of cholestasis post COC use, Hypertension: adequately controlled or systolic 140-159 or diastolic 90-99, inflammatory Bowel disease, postpartum 21-41 days with risk factors for VTE, smoking Age ≥35 , <15 cigarettes/day ,Anticonvulsants : (phenytoin, carbamazepine, barbiturates, primidone, topiramate, coxcarbazepine, Lamotrigine Antimicrobial: rifampicin or rifabutin</td></tr><tr><td>Surgery</td><td>Discontinue COCs at least 4 weeks prior to major elective surgery,surgery to the legs or pelvis, or that involves prolonged immobilisation of a lower limb. An alternative contraception should be used to prevent unintentional pregnancy, and CHC may be recommenced 2 weeks after full remobilisation</td></tr></table>
<table><tr><td colspan="2">Combined Hormonal Contraception (CHC)</td></tr><tr><td>Health care benefits</td><td>Reduced risk of ovarian, endometrial and colorectal cancer, Predictable bleeding patterns, Reduced dysmenorrhoea and menorrhagia, Management of symptoms of PCOS, endometriosis and premenstrual syndrome, Improvement of acne, Reduced menopausal symptoms, Maintaining bone mineral density in perimenopausal females under the age of 50 years</td></tr><tr><td>Efficacy</td><td>User-dependant ; if used perfectly (i.e. correctly and consistently) failure rate is less than 1%•Certain factors such as the weight, malabsorption (COC only), and drug interactions may contribute to contraceptive failure</td></tr><tr><td>Starting , switching & back up contraception requirements</td><td>•Start in the first 5 days OR anytime if reasonably certain woman is not pregnant starting on day 6 of cycle or later, additional precautions (barrier methods) necessary during first 7 days.•Changing to COC containing different progestogen: If previous contraceptive used correctly start the first active tablet of new brand immediately•Changing from progestogen-only tablet: If previous contraceptive used correctly, or pregnancy can reasonably be excluded, start new brand immediately, additional precautions (barrier methods) necessary for first 7 days•After childbirth (not breast-feeding) : 3 weeks in the absence of additional risk factors for thromboembolism, or 6 weeks after childbirth in the presence of additional risk factors for thromboembolism additional precautions (barrier methods) necessary for first 7 days•After abortion, miscarriage, ectopic pregnancy or gestational trophoblastic disease: additional contraceptive precautions (barrier methods) required for 7 days if started after day 5 following treatment</td></tr><tr><td>Breast feeding</td><td>Avoid until weaning or after 6 weeks</td></tr><tr><td rowspan="2">Missed pill Sick day rule</td><td>If ONE pill has been missed (48 – 72 hours since last pill in current packet or 24- 48 hours late starting first pill in new pack)</td><td>IF TWO or MORE pills have been missed (>72 since last pill in current packet or >48 hours late starting first pill in new packet)</td></tr><tr><td>Continuing contraceptive cover•The missed pill should be taken as soon as it is remembered•The remaining pills should be continued at the usual time</td><td>Continuing contraceptive cover•The most recent pill missed should be taken as soon as possible. – if vomiting or diarrhea, take the next pill as soon as tolerated•The remaining pills should be continued at the usual time.•Condoms should be used or sex avoided until seven consecutive activity pills have been taken. This advice may be over-cautious in the second and third weeks, but the advice is a back-up in the event that further pills are missed.</td></tr><tr><td rowspan="2"></td><td rowspan="2">Minimising the risk of pregnancyEC is not usually required but may need to be considered if pills have been missed earlier in the packet or in the last week of the previous packet</td><td>Minimising the risk of pregnancy•If pills are missed in the 1stweek (Pills 1-7): EC should be considered if unprotected sex occurred in the pill-free interval or in the first week of pill taking•If pills are missed in the second week (pills 8-14): No indication for EC if pills in the preceding 7 days have been taken consistently and correctly, provided the pills thereafter are taken correctly and additional contraceptive precautions used•If pills are missed in the third week (pills 15-21): OMIT THE PILL-FREE INTERVAL by finishing the pills in the current pack (or discarding any placebo tablets) and starting a new pack the next day</td></tr><tr><td>•If side effect for current COC switch to COC with progestogen that has minimal androgenic effect; desogestrel, gestodene, or norgestimate (Marvelon®)•If severe acne unresponsive to topical therapy and oral antibiotics: Co-Cyprindiol 2000/35 tabs (Not licensed solely for contraception).Higher VTE risk: Discontinue 3-4 cycles after acne has resolved. Continuation of treatment with co-cyprindiol should be under a specialist. Higher risk of meningioma</td></tr></table>
Contraception in special situations
<table><tr><td>Condition</td><td>Options</td><td>Remarks</td></tr><tr><td>Age</td><td>POP, progesterone implants and LNG-IUD are safer options in older women with high CVD risk</td><td>Healthy , non-smoking women without specific risk factors for cardiovascular disease can continue use till age of 50-55</td></tr><tr><td>Postpartum</td><td>POP can be use immediately after delivery USMEC 1 COC can be used 4-6 weeks after delivery</td><td>IUDs can be placed at anytime postpartum, although there may be an increased risk of expulsion if placed less than 4 weeks from delivery.</td></tr><tr><td>Breast feeding</td><td>POC</td><td>Exclusively breast-feeding mom , with amenorrhea , meet criteria of LAM method of contraception</td></tr><tr><td>Trophoblastic disease</td><td>Any</td><td>Trophoblastic disease treated with suction curettage and falling or undetectable HCG – Any hormonal method of contraception is considered appropriate</td></tr><tr><td>Obesity</td><td>POP and LNG-IUD is considered safer option in women with obesity and older then 35yrs CHC is rated as USMEC 2 for women with obesity</td><td>Surgery compromising the absorption of oral medication like Rouxen-Y gastric bypass or biliopancreatic diversion –should not use oral contraception USMEC3</td></tr><tr><td>Migraine</td><td>No restriction in use of progesterone only methods in patient with migraine with or without aura USMEC1</td><td>CHC can be used in women with migraine without aura and no other risk factor for stroke USMEC2</td></tr><tr><td>Diabetes</td><td>POP, LNG-IUD and subdermal implants are suitable options</td><td>Uncomplicated Insulin and non-insulin dependent diabetics-hormonal methods of contraception are USMEC2DMPA is also USMEC 3 in such patient as of increase lipoprotein profile</td></tr><tr><td>Hypertension</td><td>BP below 140/90- any contraceptive method can be used</td><td>Women on antihypertensive medication progesterone only or non hormonal methods are recommendedDMPA is also USMEC 3 in such patient as of increase lipoprotein profile</td></tr><tr><td>Mood Disorders</td><td>Women with depressive disorders can use all methods of hormonal contraception</td><td>CHC does not modify the metabolism and effectiveness of SSRI and SNRI</td></tr><tr><td>Drug interaction</td><td>Women taking Rifampin and liver enzyme inducing antiepileptic and antiretroviral medication that interfere with contraceptive efficacy can use DMPA and LNG-IUD</td><td>COC and POP are not recommended because of increased contraceptive failure (USMEC 3)All other broad-spectrum antibiotics, antifungal and antiparasitic do not interfere with OC efficacy</td></tr><tr><td>Epilepsy</td><td>Avoid oral routes with certain anticonvulsants</td><td>Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)</td></tr></table>
Approaching Menopause
Choice of Contraception: Methods that can be used without restriction
Barrier methods
■ Copper intra-uterine devices (IUD)
■ Levonorgesterel releasing Intrauterine system (IUS)
■ Progesterone only pill, progesterone only implant
■ Progesterone only injections can be used until age of 50
■ Combined hormonal contraception is not contraindicated by age alone but factors like smoking and migraine history must be considered. If suitable, a pill containing 20 mcg of ethinylestradiol is a reasonable first choice.
Non-contraceptive Benefits can influence the choice of contraceptive:
■ Vasomotor symptoms (hot flushes): combined hormonal contraception may reduce symptoms.
■ Osteoporosis: Combined hormonal contraception may increase bone mineral density. Depot medoxyprogesterone acetate can reduce BMD.
■ Menstrual pain, bleeding, and irregularity: combined hormonal contraception may reduce symptoms. Progestogen-only methods may reduce pain
■ Heavy menstrual bleeding: The LNG-IUS reduces menstrual bleeding and can cause amenorrhoea.
Advise Women that Hormone Replacement Therapy does not provide contraception
Stopping Contraception
If using a non-hormonal method of contraception: Continue until:
■ 1y of amenorrhoea >50 years of age Or 2 years of amenorrhoea <50 years of age
■ If a women continues to menstruate >55 years, advise contraception use until 1 year of amenorrhoea has passed.
If using a hormonal method of contraception:
If woman wishes to stop contraception aged <50 years: advise to switch to a non-hormonal method and wait until 2 years of amenorrhoea (3 years if switching from progestogen only injections)
Combined hormonal contraception and progestogen only injections
- Continue until aged 50, then switch to a non-hormonal method OR switch to one of the following: POP, Progestogen only implant or LNG-IUS
■ Follow advice for chosen method
POP, Progestogen only implant or LNG-IUS
■ Continue until aged 55
■ if woman still not amenorrhoeic at the age of 55 continue until 1 year of amenorrhoea
- If amenorrhoeic and aged > 50, arrange confirmation of menopause (two FSH readings taken 6 weeks apart and results of both tests are >30) and continue contraception for another year
Emergency Contraception
<table><tr><td>METHOD</td><td>DOSAGE</td><td>TIMING OF USE AFTER UPSI</td></tr><tr><td>Combined oral contraceptive</td><td>100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel; two doses taken 12 hours apart4 Pills stat and 4 pills 12 h later</td><td>5 days</td></tr><tr><td>Levonorgestrel, split dose</td><td>0.75 mg; two doses taken at the same time or 12 hours apart</td><td>3 days</td></tr><tr><td>Levonorgestrel, single dose</td><td>1.5 mg, single dose</td><td>3 days</td></tr><tr><td>Ulipristal (Ella)</td><td>30 mg, single dose</td><td>5days</td></tr><tr><td>Cu-IUD</td><td>Single device, can be left for long term contraception</td><td>5 days</td></tr></table>
References
US Medical Eligibility Criteria (US MEC) for Contraceptive Use 2020 The American College of Obstetricians & Gynecologists
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use
<table><tr><td>Condition</td><td>Sub-Condition</td><td>CHC</td><td>POP</td><td>Injection</td><td>Implant</td><td>LNG-IFUD</td><td>Cu-IUD</td></tr><tr><td></td><td></td><td>I</td><td>C</td><td>I</td><td>C</td><td>I</td><td>I</td></tr><tr><td>Age</td><td></td><td>Menarche to <40-1 ≥40-2</td><td>Menarche to <18-1 ≥45-2</td><td>Menarche to <18-2 ≥45-2</td><td>Menarche to <18-1 ≥45-2</td><td>Menarche to <20-2 ≥20-1</td><td>Menarche to <20-2 ≥20-1</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Anatomic abnormalities</td><td>a) Distorted uterine cavity</td><td></td><td></td><td></td><td>4</td><td>4</td><td></td></tr><tr><td></td><td>b) Other abnormalities</td><td></td><td></td><td></td><td>2</td><td>2</td><td></td></tr><tr><td>Anemias</td><td>a) Thalassemia</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>2</td></tr><tr><td></td><td>b) Sickle cell disease‡</td><td>2</td><td>1</td><td>1</td><td>1</td><td>1</td><td>2</td></tr><tr><td></td><td>c) Iron-deficiency anemia</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>2</td></tr><tr><td>Benign ovarian tumors</td><td>(including cysts)</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>Breast disease</td><td>a) Undiagnosed mass</td><td>2*</td><td>2*</td><td>2*</td><td>2*</td><td>2</td><td>1</td></tr><tr><td></td><td>b) Benign breast disease</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td></td><td>c) Family history of cancer</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td></td><td>d) Breast cancer‡</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>i) Current</td><td>4</td><td>4</td><td>4</td><td>4</td><td>1</td><td>1</td></tr><tr><td></td><td>ii) past and no evidence of current disease for 5 years</td><td>3</td><td>3</td><td>3</td><td>3</td><td>1</td><td></td></tr><tr><td>Breastfeeding(see also Postpartum)</td><td>a) <1 month postpartum</td><td>3*</td><td>2*</td><td>2*</td><td>2*</td><td></td><td></td></tr><tr><td></td><td>b) 1 month or more postpartum</td><td>2*</td><td>1*</td><td>1*</td><td>1*</td><td></td><td></td></tr><tr><td>Cervical cancer</td><td>Awaiting treatment</td><td>2</td><td>1</td><td>2</td><td>2</td><td>4</td><td>2</td></tr><tr><td>Cervical ectropion</td><td></td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td></td></tr><tr><td>Cervical intraepithelial neoplasia</td><td></td><td>2</td><td>1</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td>Cirrhosis</td><td>a) Mild (compensated)</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td></td></tr><tr><td></td><td>b) Severe‡ (decompensated)</td><td>4</td><td>3</td><td>3</td><td>3</td><td>3</td><td>1</td></tr><tr><td rowspan="9">Deep venous thrombosis (DVT)/Pulmonary embolism (PE)</td><td>a) History of DVT/PE, not on anticoagulant therapy</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>i) higher risk for recurrent DVT/PE</td><td>4</td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td>ii) lower risk for recurrent DVT/PE</td><td>3</td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td>ii) acute DVT/PE</td><td>4</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td></tr><tr><td>c) DVT/PE and established on anticoagulant therapy for at least 3 months</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>i) higher risk for recurrent DVT/PE</td><td>4*</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td></tr><tr><td>ii) lower risk for recurrent DVT/PE</td><td>3*</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td></tr><tr><td>d) Family history (first-degree relatives)</td><td>2</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>e) Major surgery</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>i) with prolonged immobilization</td><td>4</td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td>ii) without prolonged immobilization</td><td>2</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>f) Minor surgery without immobilization</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>Depressive disorders</td><td></td><td>1*</td><td>1*</td><td>1*</td><td>1*</td><td>1*</td></tr><tr><td rowspan="2">Diabetes mellitus (DM)</td><td>a) History of gestational DM only</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>b) Non-vascular disease</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>i) non-insulin dependent</td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td></td><td>ii) insulin dependent‡</td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td></td><td>c) Nephropathy/retinopathy/neuropathy‡</td><td>3/4*</td><td>2</td><td>3</td><td>2</td><td>1</td></tr><tr><td></td><td>d) Other vascular disease or diabetes of >20 years* duration‡</td><td>3/4*</td><td>2</td><td>3</td><td>2</td><td>1</td></tr><tr><td colspan="7">Condition</td></tr><tr><td>Condition</td><td>Sub-Condition</td><td>CHC</td><td>POP</td><td>Injection</td><td>Implant</td><td>LNG-IUD</td></tr><tr><td></td><td>I</td><td>C</td><td>I</td><td>C</td><td>I</td><td>C</td></tr><tr><td>Ischemic heart disease‡</td><td>Current and history of</td><td>4</td><td>2</td><td>3</td><td>2</td><td>3</td></tr><tr><td>Liver tumors</td><td>a) Benign</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>i) Focal nodular hyperplasia</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td></tr><tr><td></td><td>ii) Hepatocellular adenoma‡</td><td>4</td><td>3</td><td>3</td><td>3</td><td>3</td></tr><tr><td>b) Malignant‡</td><td>4</td><td>3</td><td>3</td><td>3</td><td>3</td><td>1</td></tr><tr><td>Malaria</td><td></td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>Multiple risk factors for arterial cardiovascular disease</td><td>(such as older age, smoking, diabetes and hypertension)</td><td>3/4*</td><td>2*</td><td>3*</td><td>2*</td><td>2</td></tr><tr><td>Obesity</td><td>a) ≥30 kg/m2 body mass index (BMI)</td><td>2</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>b) Menarche to <18 years and ≥30 kg/m2 BMI</td><td>2</td><td>1</td><td>2</td><td>1</td><td>1</td><td>1</td></tr><tr><td>Ovarian cancer‡</td><td></td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>Parity</td><td>a) Nulliparous</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>b) Parous</td><td>1</td><td>1</td><td>1</td><td>2</td><td>2</td><td>2</td></tr><tr><td>Past ectopic pregnancy</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td rowspan="4">Pelvic inflammatory disease</td><td>a) Past, (assuming no current risk factors of sexually transmitted infections [STIs])</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>i) with subsequent pregnancy</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>ii) without subsequent pregnancy</td><td>1</td><td>1</td><td>1</td><td>2</td><td>2</td></tr><tr><td>b) Current</td><td>1</td><td>1</td><td>1</td><td>4</td><td>2*</td></tr><tr><td rowspan="5">Peripartum cardiomyopathy†</td><td>a) Normal or mildly impaired cardiac function</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>i) <6 months</td><td>4</td><td>1</td><td>1</td><td>1</td><td>2</td></tr><tr><td>ii) ≥6 months</td><td>3</td><td>1</td><td>1</td><td>1</td><td>2</td></tr><tr><td>b) Moderately or severely impaired cardiac function</td><td>4</td><td>2</td><td>2</td><td>2</td><td>2</td></tr><tr><td>Postabortion</td><td>a) First trimester</td><td>1*</td><td>1</td><td>1*</td><td>1*</td></tr><tr><td rowspan="2"></td><td>b) Second trimester</td><td>1*</td><td>1</td><td>1*</td><td>1</td><td>2</td></tr><tr><td>c) Immediately post-septic abortion</td><td>1*</td><td>1</td><td>1*</td><td>1</td><td>4</td></tr><tr><td rowspan="4">Postpartum (see also Breastfeeding)</td><td>a) <21 days</td><td>4</td><td>1</td><td>1</td><td></td><td></td></tr><tr><td>b) 21 days to 42 days</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>i) with other risk factors for venous thromboembolism (VTE)</td><td>3*</td><td>1</td><td>1</td><td></td><td></td></tr><tr><td>ii) without other risk factors for VTE</td><td>2</td><td>1</td><td>1</td><td></td><td></td></tr><tr><td rowspan="3">Postpartum (in breastfeeding or non-breastfeeding women, including post-cesarean section)</td><td>a) <10 minutes after delivery of the placenta</td><td></td><td></td><td></td><td>2</td><td>1</td></tr><tr><td>b) 10 minutes after delivery of the placenta to <4 weeks</td><td></td><td></td><td></td><td>2</td><td>2</td></tr><tr><td>c) ≥4 weeks</td><td></td><td></td><td></td><td>1</td><td>1</td></tr><tr><td></td><td>d) Perperal sepsis</td><td></td><td></td><td></td><td></td><td>4</td></tr><tr><td>Pregnancy</td><td></td><td>NA*</td><td>NA*</td><td>NA*</td><td>NA*</td><td>4*</td></tr><tr><td rowspan="3">Rheumatoid arthritis</td><td>a) On immunosuppressive therapy</td><td>2</td><td>1</td><td>2/3*</td><td>1</td><td>2</td></tr><tr><td>b) Not on immunosuppressive therapy</td><td>2</td><td>1</td><td>2</td><td>1</td><td>1</td></tr><tr><td>c) Schistosomiasis</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td></td><td>b) Fibrosis of the liver†</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>Severe dysmenorrhea</td><td></td><td>1</td><td>1</td><td>1</td><td>1</td><td>2</td></tr><tr><td></td><td></td><td>1</td><td>1</td><td>1</td><td>1</td><td>2</td></tr></table>
<table><tr><td>Condition</td><td>Sub-Condition</td><td>CHC</td><td>POP</td><td>Injection</td><td>Implant</td><td>LNG-IUD</td><td>Cu-IUD</td></tr><tr><td></td><td></td><td>I</td><td>C</td><td>I</td><td>C</td><td>I</td><td>C</td></tr><tr><td>Endometrial cancer‡</td><td></td><td>1</td><td>1</td><td>1</td><td>1</td><td>4</td><td>2</td></tr><tr><td>Endometrial hyperplasia</td><td></td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>Endometriosis</td><td></td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>Epilepsy‡</td><td>(see also Drug Interactions)</td><td>1*</td><td>1*</td><td></td><td>1</td><td></td><td></td></tr><tr><td>Gallbladder disease</td><td>a) Symptomatic</td><td></td><td></td><td></td><td>1*</td><td></td><td></td></tr><tr><td></td><td>i) treated by cholecystectomy</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td></td><td>ii) medically treated</td><td>3</td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td></td><td>iii) current</td><td>3</td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td></td><td>b) Asymptomatic</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td>Gestational trophoblastic disease</td><td>a) Decreasing or undetectable B-hCG levels</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>3</td></tr><tr><td></td><td>b) Persistently elevated B-hCG levels or malignant disease‡</td><td>1</td><td>1</td><td>1</td><td>1</td><td>4</td><td>4</td></tr><tr><td>Headaches</td><td>a) Non-migrainous</td><td>1*</td><td>2*</td><td>1*</td><td>1*</td><td>1*</td><td>1*</td></tr><tr><td></td><td>b) Migraine</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>i) without aura, age <35</td><td>2*</td><td>3*</td><td>1*</td><td>2*</td><td>2*</td><td>2*</td></tr><tr><td></td><td>ii) without aura, age ≥35</td><td>3*</td><td>4*</td><td>1*</td><td>2*</td><td>2*</td><td>2*</td></tr><tr><td></td><td>iii) With aura, any age</td><td>4*</td><td>4*</td><td>2*</td><td>3*</td><td>2*</td><td>3*</td></tr><tr><td>History of bariatric surgery‡</td><td>a) Restrictive procedures</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td>1</td></tr><tr><td></td><td>b) Malingorrhea procedures</td><td>COCs: 3</td><td></td><td>1</td><td></td><td>1</td><td>1</td></tr><tr><td></td><td></td><td>P/R: 1</td><td>3</td><td></td><td>1</td><td></td><td>1</td></tr><tr><td>History of cholestasis</td><td>a) Pregnancy-related</td><td>2</td><td>1</td><td></td><td>1</td><td></td><td>1</td></tr><tr><td></td><td>b) Past COC-related</td><td>3</td><td>2</td><td></td><td>2</td><td>2</td><td>1</td></tr><tr><td>History of high blood pressure during pregnancy</td><td></td><td>2</td><td>1</td><td></td><td>1</td><td>1</td><td>1</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>History of pelvic surgery</td><td></td><td>1</td><td>1</td><td></td><td>1</td><td>1</td><td>1</td></tr><tr><td>Human immunodeficiency virus (HIV)</td><td>High risk</td><td>1</td><td>1</td><td></td><td>1*</td><td>1</td><td>2</td></tr><tr><td>AIDS (see also Drug Interactions)‡</td><td>HIV infected (see also Drug Interactions)‡</td><td>1*</td><td>1*</td><td></td><td>1*</td><td>2</td><td>2</td></tr><tr><td>Clinically well on therapy</td><td></td><td>1*</td><td>1*</td><td></td><td>1*</td><td>3</td><td>2*</td></tr><tr><td>Hyperlipidemias</td><td>2/3*</td><td>2*</td><td></td><td>2*</td><td>2*</td><td></td><td>1*</td></tr><tr><td>Hypertension</td><td>a) Adequately controlled hypertension</td><td>3*</td><td>1*</td><td></td><td>2*</td><td>1*</td><td>1</td></tr><tr><td>b) Elevated blood pressure levels (properly taken measurements)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>i) systolic 140-159 or diastolic 90-99</td><td>3</td><td>1</td><td>2</td><td></td><td>1</td><td>1</td><td>1</td></tr><tr><td>ii) systolic ≥160 or diastolic ≥100‡</td><td>4</td><td>2</td><td>3</td><td></td><td>2</td><td>2</td><td>1</td></tr><tr><td>c) Vascular disease</td><td>4</td><td>2</td><td>3</td><td></td><td>2</td><td>2</td><td>1</td></tr><tr><td>(Uncertainty colitis, Crohn's disease)</td><td>2/3*</td><td>2</td><td>2</td><td></td><td>1</td><td>1</td><td>1</td></tr><tr><td colspan="8">Abbreviations: C=contribution of contraceptive method; CHC=combined hormonal contraceptive (pill, patch, and ring); COC=combined oral contraceptive; Cu-IUD=copper-containing intrauterine device; I=Initiation of contraceptive method; LNG-IUD=levonorgestrel-releasing intrauterine device; NA=not applicable; POP=progestin-only pill; P/R=patch/ring.</td></tr><tr><td>Legend:</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>1</td><td>No restriction (method can be used)</td><td>3</td><td>Theoretical or proven risks usually outweigh the advantages</td><td></td><td></td><td></td><td></td></tr><tr><td>2</td><td>Advantages generally outweigh theoretical or proven risks</td><td>4</td><td>Unacceptable health risk (method not to be used)</td><td></td><td></td><td></td><td></td></tr></table>
<table><tr><td>Condition</td><td>Sub-Condition</td><td>CHC</td><td>POP</td><td>Injection</td><td>Implant</td><td>LNG-IUD</td><td>Cu-IUD</td></tr><tr><td></td><td></td><td>I</td><td>C</td><td>I</td><td>C</td><td>I</td><td>C</td></tr><tr><td rowspan="5">Sexually Transmitted Infections (STI)</td><td>a) Current purulent cervicitis or chlamydial infections or gonorrhea</td><td>1</td><td></td><td>1</td><td></td><td>4</td><td>2*</td></tr><tr><td>b) Other STIs (excluding trichomonas vaginalis and bacteria)</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td>2</td></tr><tr><td>c) Vaginitis (including trichomonas vaginalis and bacterial vaginosis)</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td>2</td></tr><tr><td>d) Increased risk of STIs</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td>2/3*</td></tr><tr><td>Smoking</td><td>a) Age <35</td><td>2</td><td></td><td>1</td><td></td><td>1</td></tr><tr><td rowspan="2"></td><td>b) Age ≥35, <15 cigarettes/day</td><td>3</td><td></td><td>1</td><td></td><td>1</td><td>1</td></tr><tr><td>c) Age ≥35, ≥15 cigarettes/day</td><td>4</td><td></td><td>1</td><td></td><td>1</td><td>1</td></tr><tr><td rowspan="2">Solid organ transplantation‡</td><td>a) Complicated</td><td>4</td><td></td><td>2</td><td></td><td>2</td><td>3</td></tr><tr><td>b) Uncomplicated</td><td>2*</td><td></td><td>2</td><td></td><td>2</td><td>2</td></tr><tr><td>Stroke†</td><td>History of cerebrovascular accident</td><td>4</td><td>2</td><td>3</td><td></td><td>2</td><td>3</td></tr><tr><td>Superficial venous thrombosis</td><td>a) Varicose veins</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td>1</td></tr><tr><td rowspan="4">Systemic lupus erythematosus‡</td><td>a) Positive (or unknown) antiphospholipid antibodies</td><td>4</td><td></td><td>3</td><td>3</td><td>3</td><td>1</td><td>1</td></tr><tr><td>b) Severe thrombocytopenia</td><td>2</td><td></td><td>2</td><td>3</td><td>2</td><td>2*</td><td>3*</td></tr><tr><td>c) Immunosuppressive treatment</td><td>2</td><td></td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td>d) None of the above</td><td>2</td><td></td><td>2</td><td>2</td><td>2</td><td>2</td><td>1</td></tr><tr><td rowspan="2">Thrombogenic mutations‡</td><td></td><td>4*</td><td></td><td>2*</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td>2*</td><td></td><td>2*</td><td></td></tr><tr><td rowspan="2">Thyroid disorders (see also Drug Interactions)</td><td>Simple goiter/hyperthyroid/hypothyroid</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td>1</td><td>1</td></tr><tr><td></td><td>1*</td><td></td><td>1*</td><td></td><td>1*</td><td>1</td><td>1</td></tr><tr><td rowspan="2">Tuberculosis (see also Drug Interactions)</td><td>b) Pelvic</td><td>1*</td><td></td><td>1*</td><td></td><td>1*</td><td>4</td><td>3</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="2">Unexplained vaginal bleeding</td><td>(suspicious for serious condition) before evaluation</td><td>2*</td><td></td><td>2*</td><td></td><td>3*</td><td>3*</td><td>4*</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="2">Uterine fibroids</td><td></td><td></td><td>1</td><td></td><td>1</td><td></td><td>1</td><td>2</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="2">Valvular heart disease</td><td>a) Uncomplicated</td><td>2</td><td></td><td>1</td><td></td><td>1</td><td></td><td>1</td></tr><tr><td>b) Complicated*</td><td>4</td><td></td><td>1</td><td></td><td>1</td><td></td><td>1</td></tr><tr><td rowspan="2">Vaginal bleeding patterns</td><td>a) Irregular pattern without heavy bleeding</td><td>1</td><td></td><td>2</td><td></td><td>2</td><td></td><td>1</td></tr><tr><td>b) Heavy or prolonged bleeding</td><td>1*</td><td></td><td>2*</td><td></td><td>2*</td><td></td><td>2*</td></tr><tr><td rowspan="2">Viral hepatitis</td><td>a) Acute or flare</td><td>3/4*</td><td>2</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>b) Carrier/Chronic</td><td>1</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td colspan="9">Drug Interactions</td></tr><tr><td rowspan="4">Antiretroviral therapy</td><td>a) Nucleoside reverse transcriptase inhibitors</td><td>1*</td><td></td><td>1</td><td></td><td>1</td><td>2/3*</td><td>2*</td></tr><tr><td>b) Non-nucleoside reverse transcriptase inhibitors</td><td>2*</td><td>2*</td><td></td><td>1</td><td></td><td>2*</td><td>2/3*</td></tr><tr><td>c) Ritonavir-boosted protease inhibitors</td><td>3*</td><td>3*</td><td></td><td>1</td><td></td><td>2*</td><td>2/3*</td></tr><tr><td>Anticonvulsant therapy</td><td>a) Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)</td><td>3*</td><td>3*</td><td></td><td>1</td><td></td><td>2*</td></tr><tr><td rowspan="4">Antimicrobial therapy</td><td>b) Lamotrigine</td><td>3*</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>a) Broad spectrum antibiotics</td><td>1</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>b) Antifungals</td><td>1</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>c) Antiparasitics</td><td>1</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>d) Rifampicin or rifabutin therapy</td><td>3*</td><td>3*</td><td></td><td>1</td><td></td><td>2*</td><td></td><td></td></tr></table>