Contraception counseling for obese women
- Alison Edelman, MD, MPH
Alison Edelman, MD, MPH
- Director of the Family Planning Fellowship
- Department of Obstetrics and Gynecology
- Oregon Health and Science University
- Bliss Kaneshiro, MD, MPH
Bliss Kaneshiro, MD, MPH
- Associate Professor
- Co-Director of the Family Planning Fellowship
- Department of Obstetrics and Gynecology
- University of Hawaii, John A Burns School of Medicine
Use of safe and effective contraception is essential for preventing unintended pregnancy. Despite the need for contraception, a national survey in the United States noted that sexually active obese women of reproductive age were significantly less likely to use contraception than women of normal weight . It was unclear whether the disparity was due to patient, provider, and/or systems issues.
When counseling obese women about contraception, it is important to consider how obesity may affect the safety and efficacy of various contraceptive methods. Because contraceptive clinical trials excluded overweight or obese women until recently, evidence regarding contraceptive effectiveness and safety for this population is limited [2,3]. This topic will address the effects of obesity on contraceptive efficacy, as well as the effects of contraceptives on weight gain. Fertility and pregnancy issues in obese women are reviewed separately. (See "The impact of obesity on female fertility and pregnancy".)
CHOOSING A CONTRACEPTIVE METHOD
Many factors need to be considered in choosing a contraceptive method (see "Contraceptive counseling and selection"). For obese women who want to maximize safety and efficacy, we suggest a copper- or levonorgestrel-releasing intrauterine device (IUD). Intrauterine contraception has a very low rate of failure (compared with barrier methods), is not associated with weight gain (compared with depot medroxyprogesterone acetate [DMPA]), and does not expose the woman to potential risks associated with estrogen-containing contraceptives. Visualizing the cervix and determining the size and direction of the uterus can be challenging in severely obese women during insertion of the device. Optimizing equipment by selecting a large speculum or removing the tip of a condom and placing it over the blades of the speculum can help with exposure . Ultrasound may be helpful to guide insertion. (See "Intrauterine contraceptive device: Insertion and removal".)
For women who do not want to use intrauterine contraception, the potentially higher failure rates associated with oral contraceptives, the patch, and ring need to be balanced with the potentially high user failure rates associated with barrier methods. Contraception failure rates among obese oral contraceptive users are probably lower than in obese women using barrier methods, but women who choose to use oral contraceptive pills, the patch, or ring should consider using condoms as well to decrease pregnancy risk and the risk of acquiring sexually transmitted infections, if applicable. In our opinion, the decision to use the pill, patch or ring should be based on the mode of hormonal delivery that the patient feels fits with her lifestyle. For all women who want to use a pill, we start with a pill containing 20 to 30 mcg of ethinyl estradiol. Although insufficient evidence exists to recommend a specific estrogen dose or use of a higher rather than a lower dose oral contraceptive pill, most pharmacokinetic studies in obese women used a pill containing 20 mcg ethinyl estradiol. We do not start any women on a pill with more than 35 mcg of ethinyl estradiol. If obese women are satisfied with a particular pill formulation, we do not switch them to a different pill unless they develop contraindications to estrogen use, in which case we discuss non-estrogen contraceptive options. Although it is tempting to simply double the dose of oral contraceptive used by obese women to achieve higher serum levels, alterations in the pharmacokinetics of steroid hormones based on weight and resulting end-organ suppression (prevention of ovulation) do not have linear relationships. Furthermore, doubling the dose could increase side effects and risks, so this is not recommended.
Because obese women, especially those with comorbidities, are at higher risk of pregnancy-related complications, avoidance of unintended pregnancy is especially important. In addition, obesity is a risk factor for endometrial hyperplasia and endometrial cancer. Both types of IUD  and hormonal contraceptives provide endometrial protection and have been associated with a decrease in this risk. (See "Endometrial carcinoma: Epidemiology and risk factors", section on 'Hormonal contraceptives'.)
- Chuang CH, Chase GA, Bensyl DM, Weisman CS. Contraceptive use by diabetic and obese women. Womens Health Issues 2005; 15:167.
- Grimes DA, Shields WC. Family planning for obese women: challenges and opportunities. Contraception 2005; 72:1.
- Lopez LM, Bernholc A, Chen M, et al. Hormonal contraceptives for contraception in overweight or obese women. Cochrane Database Syst Rev 2016; 8:CD008452.
- Curtis KM, Marchbanks PA, Peterson HB. Neoplasia with use of intrauterine devices. Contraception 2007; 75:S60.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
- Abdollahi M, Cushman M, Rosendaal FR. Obesity: risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use. Thromb Haemost 2003; 89:493.
- Effect of different progestagens in low oestrogen oral contraceptives on venous thromboembolic disease. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet 1995; 346:1582.
- Lidegaard Ø, Edström B, Kreiner S. Oral contraceptives and venous thromboembolism: a five-year national case-control study. Contraception 2002; 65:187.
- Medical Eligibility Criteria for Contraceptive Use (UK MEC 2005/2006), Faculty of Family Planning and Reproductive Health Care, London (2006).
- Trussell J, Guthrie KA, Schwarz EB. Much ado about little: obesity, combined hormonal contraceptive use and venous thrombosis. Contraception 2008; 77:143.
- Society of Family Planning, Higginbotham S. Contraceptive considerations in obese women: release date 1 September 2009, SFP Guideline 20091. Contraception 2009; 80:583.
- Edelman AB, Carlson NE, Cherala G, et al. Impact of obesity on oral contraceptive pharmacokinetics and hypothalamic-pituitary-ovarian activity. Contraception 2009; 80:119.
- Westhoff CL, Torgal AH, Mayeda ER, et al. Pharmacokinetics of a combined oral contraceptive in obese and normal-weight women. Contraception 2010; 81:474.
- Edelman AB, Cherala G, Munar MY, et al. Prolonged monitoring of ethinyl estradiol and levonorgestrel levels confirms an altered pharmacokinetic profile in obese oral contraceptives users. Contraception 2013; 87:220.
- Speerhas R. Drug metabolism in malnutrition and obesity: clinical concerns. Cleve Clin J Med 1995; 62:73.
- Ravussin E, Burnand B, Schutz Y, Jéquier E. Twenty-four-hour energy expenditure and resting metabolic rate in obese, moderately obese, and control subjects. Am J Clin Nutr 1982; 35:566.
- Stadel BV, Sternthal PM, Schlesselman JJ, et al. Variation of ethinylestradiol blood levels among healthy women using oral contraceptives. Fertil Steril 1980; 33:257.
- Fishman J, Boyar RM, Hellman L. Influence of body weight on estradiol metabolism in young women. J Clin Endocrinol Metab 1975; 41:989.
- Westhoff CL, Torgal AH, Mayeda ER, et al. Ovarian suppression in normal-weight and obese women during oral contraceptive use: a randomized controlled trial. Obstet Gynecol 2010; 116:275.
- Kaneshiro B, Jensen JT, Carlson NE, et al. Body mass index and sexual behavior. Obstet Gynecol 2008; 112:586.
- Xu H, Wade JA, Peipert JF, et al. Contraceptive failure rates of etonogestrel subdermal implants in overweight and obese women. Obstet Gynecol 2012; 120:21.
- Bahamondes L, Brache V, Meirik O, et al. A 3-year multicentre randomized controlled trial of etonogestrel- and levonorgestrel-releasing contraceptive implants, with non-randomized matched copper-intrauterine device controls. Hum Reprod 2015; 30:2527.
- Mornar S, Chan LN, Mistretta S, et al. Pharmacokinetics of the etonogestrel contraceptive implant in obese women. Am J Obstet Gynecol 2012; 207:110.e1.
- Sivin I, Wan L, Ranta S, et al. Levonorgestrel concentrations during 7 years of continuous use of Jadelle contraceptive implants. Contraception 2001; 64:43.
- Morrell KM, Cremers S, Westhoff CL, Davis AR. Relationship between etonogestrel level and BMI in women using the contraceptive implant for more than 1 year. Contraception 2016; 93:263.
- Jain J, Jakimiuk AJ, Bode FR, et al. Contraceptive efficacy and safety of DMPA-SC. Contraception 2004; 70:269.
- Segall-Gutierrez P, Taylor D, Liu X, et al. Follicular development and ovulation in extremely obese women receiving depo-medroxyprogesterone acetate subcutaneously. Contraception 2010; 81:487.
- Dinger J, Minh TD, Buttmann N, Bardenheuer K. Effectiveness of oral contraceptive pills in a large U.S. cohort comparing progestogen and regimen. Obstet Gynecol 2011; 117:33.
- Holt VL, Cushing-Haugen KL, Daling JR. Body weight and risk of oral contraceptive failure. Obstet Gynecol 2002; 99:820.
- Holt VL, Scholes D, Wicklund KG, et al. Body mass index, weight, and oral contraceptive failure risk. Obstet Gynecol 2005; 105:46.
- Brunner Huber LR, Hogue CJ. The association between body weight, unintended pregnancy resulting in a livebirth, and contraception at the time of conception. Matern Child Health J 2005; 9:413.
- Vessey M. Oral contraceptive failures and body weight: findings in a large cohort study. J Fam Plann Reprod Health Care 2001; 27:90.
- Brunner Huber LR, Toth JL. Obesity and oral contraceptive failure: findings from the 2002 National Survey of Family Growth. Am J Epidemiol 2007; 166:1306.
- Burkman RT, Fisher AC, Wan GJ, et al. Association between efficacy and body weight or body mass index for two low-dose oral contraceptives. Contraception 2009; 79:424.
- McNicholas C, Zhao Q, Secura G, et al. Contraceptive failures in overweight and obese combined hormonal contraceptive users. Obstet Gynecol 2013; 121:585.
- Kaneshiro B, Edelman A, Carlson N, et al. The relationship between body mass index and unintended pregnancy: results from the 2002 National Survey of Family Growth. Contraception 2008; 77:234.
- Zieman M, Guillebaud J, Weisberg E, et al. Contraceptive efficacy and cycle control with the Ortho Evra/Evra transdermal system: the analysis of pooled data. Fertil Steril 2002; 77:S13.
- Edelman A, Cherala G, Lim JY, Jensen JT. Contraceptive failures in overweight and obese combined hormonal contraceptive users. Obstet Gynecol 2013; 122:158.
- Westhoff CL, Torgal AH, Mayeda ER, et al. Pharmacokinetics and ovarian suppression during use of a contraceptive vaginal ring in normal-weight and obese women. Am J Obstet Gynecol 2012; 207:39.e1.
- Dragoman M, Petrie K, Torgal A, et al. Contraceptive vaginal ring effectiveness is maintained during 6 weeks of use: a prospective study of normal BMI and obese women. Contraception 2013; 87:432.
- Chi IC, Wilkens L. Interval tubal sterilization in obese women--an assessment of risks. Am J Obstet Gynecol 1985; 152:292.
- Chi IC, Wilkens LR, Reid SE. Prolonged hospital stay after laparoscopic sterilization. IPPF Med Bull 1984; 18:3.
- Chi I, Mumford SD, Laufe LE. Technical failures in tubal ring sterilization: Incidence, perceived reasons, outcome, and risk factors. Am J Obstet Gynecol 1980; 138:307.
- Jamieson DJ, Hillis SD, Duerr A, et al. Complications of interval laparoscopic tubal sterilization: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol 2000; 96:997.
- Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation. Contraception 1995; 51:283.
- Funk S, Miller MM, Mishell DR Jr, et al. Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel. Contraception 2005; 71:319.
- Goldzieher JW, Moses LE, Averkin E, et al. A placebo-controlled double-blind crossover investigation of the side effects attributed to oral contraceptives. Fertil Steril 1971; 22:609.
- Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev 2014; :CD003987.
- Coney P, Washenik K, Langley RG, et al. Weight change and adverse event incidence with a low-dose oral contraceptive: two randomized, placebo-controlled trials. Contraception 2001; 63:297.
- Edelman A, Jensen JT, Bulechowsky M, Cameron J. Combined oral contraceptives and body weight: do oral contraceptives cause weight gain? A primate model. Hum Reprod 2011; 26:330.
- Kaunitz AM. Injectable depot medroxyprogesterone acetate contraception: an update for U.S. clinicians. Int J Fertil Womens Med 1998; 43:73.
- Pelkman CL, Chow M, Heinbach RA, Rolls BJ. Short-term effects of a progestational contraceptive drug on food intake, resting energy expenditure, and body weight in young women. Am J Clin Nutr 2001; 73:19.
- Bonny AE, Ziegler J, Harvey R, et al. Weight gain in obese and nonobese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no hormonal contraceptive method. Arch Pediatr Adolesc Med 2006; 160:40.
- Clark MK, Dillon JS, Sowers M, Nichols S. Weight, fat mass, and central distribution of fat increase when women use depot-medroxyprogesterone acetate for contraception. Int J Obes (Lond) 2005; 29:1252.
- Bonny AE, Britto MT, Huang B, et al. Weight gain, adiposity, and eating behaviors among adolescent females on depot medroxyprogesterone acetate (DMPA). J Pediatr Adolesc Gynecol 2004; 17:109.
- Mangan SA, Larsen PG, Hudson S. Overweight teens at increased risk for weight gain while using depot medroxyprogesterone acetate. J Pediatr Adolesc Gynecol 2002; 15:79.
- Pantoja M, Medeiros T, Baccarin MC, et al. Variations in body mass index of users of depot-medroxyprogesterone acetate as a contraceptive. Contraception 2010; 81:107.
- Merhi ZO. Impact of bariatric surgery on female reproduction. Fertil Steril 2009; 92:1501.
- Gosman, GG. Reproductive health of women electing bariatric surgery. Fertil Steril 2009; :. [Epub ahead of print].
- Teitelman M, Grotegut CA, Williams NN, Lewis JD. The impact of bariatric surgery on menstrual patterns. Obes Surg 2006; 16:1457.
- Gerrits EG, Ceulemans R, van Hee R, et al. Contraceptive treatment after biliopancreatic diversion needs consensus. Obes Surg 2003; 13:378.
- Victor A, Odlind V, Kral JG. Oral contraceptive absorption and sex hormone binding globulins in obese women: effects of jejunoileal bypass. Gastroenterol Clin North Am 1987; 16:483.
- American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009; 113:1405.
- Ciangura C, Corigliano N, Basdevant A, et al. Etonorgestrel concentrations in morbidly obese women following Roux-en-Y gastric bypass surgery: three case reports. Contraception 2011; 84:649.
- Hillman JB, Miller RJ, Inge TH. Menstrual concerns and intrauterine contraception among adolescent bariatric surgery patients. J Womens Health (Larchmt) 2011; 20:533.
- CHOOSING A CONTRACEPTIVE METHOD
- Most effective reversible methods
- - Intrauterine contraception
- - Contraceptive implant
- - Depot medroxyprogesterone acetate
- Less effective reversible methods
- - Oral contraceptives
- - Contraceptive patch
- - Contraceptive ring
- - Barrier methods
- Surgical sterilization
- WEIGHT GAIN
- CONTRACEPTION PRE- AND POST-BARIATRIC SURGERY
- EMERGENCY CONTRACEPTION
- SUMMARY AND RECOMMENDATIONS