What conditions are considered category 3 when considering progestin-only pills (POP)?

Category 3 Conditions for Progestin-Only Pills

Based on the U.S. Medical Eligibility Criteria, the conditions that are Category 3 for progestin-only pills (POPs) are: seizure disorder treated with topiramate, severe cirrhosis (decompensated), and hepatocellular adenoma. 1

Specific Category 3 Conditions for POPs

From your list, the following are Category 3:

• Seizure disorder treated with topiramate - Category 3 1
• Severe cirrhosis (decompensated/impaired liver function) - Category 3 1

The following are NOT Category 3:

• Iron deficiency anemia - Category 1 (no restriction) 1
• Hypothyroid - Category 1 (no restriction) 1

Rationale for Category 3 Classifications

Enzyme-Inducing Anticonvulsants (Including Topiramate)

Topiramate and other enzyme-inducing anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, oxcarbazepine) are classified as Category 3 for POPs because they reduce contraceptive effectiveness through hepatic enzyme induction. 1 The interaction is not harmful to the woman, but it significantly decreases the efficacy of POPs by increasing their metabolism. 1, 2, 3

The guideline explicitly states that use of other contraceptives should be encouraged for women on long-term enzyme-inducing anticonvulsants, and whether increasing the hormone dose of POPs alleviates this concern remains unclear. 1 DMPA is preferred in this population (Category 1) because its effectiveness is not decreased by enzyme-inducing anticonvulsants. 1

Decompensated Cirrhosis

Severe cirrhosis with impaired liver function (decompensated) is Category 3 for POPs due to concerns about hepatic metabolism and the inability to adequately process hormonal contraceptives. 1 In contrast, compensated cirrhosis with normal liver function is Category 1. 1 The distinction is critical: decompensated cirrhosis represents significant hepatic dysfunction where the theoretical risks of progestin metabolism outweigh the benefits. 1

Why Other Conditions Are Not Category 3

Iron deficiency anemia carries no restrictions (Category 1) for POP use because progestin-only methods do not adversely affect anemia and may actually reduce menstrual blood loss. 1

Hypothyroid is Category 1 for all contraceptive methods including POPs, as thyroid disorders do not interact with or contraindicate progestin-only contraception. 1

Additional Category 3 Conditions Not Listed

Other Category 3 conditions for POPs include:

• Hepatocellular adenoma - Category 3 1
• Malignant liver tumors (hepatoma) - Category 3 1
• Rifampicin or rifabutin therapy - Category 3 (similar mechanism to enzyme-inducing anticonvulsants) 1
• Systemic lupus erythematosus with positive or unknown antiphospholipid antibodies - Category 3 1
• Past breast cancer with no evidence of disease for 5 years - Category 3 1