CEU Statement: Weight and contraception
April 2017
Introduction
The true impact of contraception on weight gain is difficult to establish due to multiple confounding factors.
Yet many women and clinicians believe that it is a common side effect of use. This misconception can
deter women from initiating particular contraceptive methods or lead to discontinuation. It is important that
clinicians have a clear understanding of the relationship between contraception and weight in order to
support women in choosing the most appropriate methods of contraception.
The available literature makes it difficult to determine if and how contraception can affect weight. Weight
gain is rarely a primary outcome measure in studies on contraception, there is a lack of consensus on what
constitutes excessive weight gain and individual women have their own opinions on what constitutes
“unacceptable” weight. Furthermore, gaining weight is developmentally normal during adolescence and
many adult women gain weight over time.1
Clinicians should not only be familiar with the effects of contraception on weight, but also the effect of
weight on eligibility for contraceptive use. Links between obesity and adverse health issues such as
cardiovascular disease and metabolic disorders are well established2 and significant when considering
certain types of contraception. When discussing contraceptive options with a woman who is overweight or
obese, clinicians must relay the potential weight-related risks (e.g. venous thromboembolism,
hypertension) relevant to individual contraceptive methods in addition to any theoretical risk of weight gain
from method use.
Intrauterine Contraception
Contraception affecting weight
The 2015 FSRH guideline Intrauterine Contraception states that, “[w]eight gain has been observed with use
of intrauterine contraception (IUC). There is no significant difference between hormonal and non-hormonal
intrauterine methods and evidence to support a causal association is lacking.”3 Furthermore, there is no
known biological mechanism for weight gain with a copper intrauterine device (Cu-IUD), suggesting that
any weight gain with IUC use is likely related to confounding factors such as increasing age or lifestyle
factors.3
Review of the available literature confirms that studies examining hormonal and non-hormonal IUC have
described weight gain in participants.4-7 A 2016 Cochrane review4 examining the effect of progestogen-only
contraception on weight included four studies evaluating levonorgestrel intrauterine systems (LNG-IUS).7-10
These low- to moderate-quality studies compared LNG-IUS users with either Cu-IUD users or non-users.
Two studies found no difference in body composition between cases and controls8,9 while two studies found
an increase in fat mass and a decrease in lean body mass for LNG-IUS users.7,10 Both studies that
identified differences in body weight between women using LNG-IUS or no hormonal contraception had
statistically insignificant findings when determining overall weight change over a period of 12 months.7,10
Weight affecting contraception
The mechanisms of action of IUC are based on local effects; therefore, a woman’s weight does not affect
the contraceptive efficacy of Cu-IUDs or LNG-IUS.11-13
In summary, there is no evidence suggesting a causal association between IUC use and weight
gain or weight and IUC effectiveness.
Progestogen-only Implants
Contraception affecting weight
The 2014 FSRH guideline Progestogen-only Implants states that while some women experience weight
gain with progestogen-only implants (IMP), there is no evidence of a causal association.14
The 2016 Cochrane review4 identified five studies evaluating women using IMP, one of which included an
etonogestrel IMP, the only type currently available on the UK market (Nexplanon®). This prospective
cohort study8 examined weight change over twelve months for women using an IMP versus women using a
Cu-IUD. When adjusted for age and race, the IMP was not significantly associated with weight change
compared with the Cu-IUD (mean change 1.37 kg, confidence interval [CI] −0.16-2.91). The other four
studies15-18 examined a levonorgestrel IMP (Norplant) and found no weight difference between IMP users
and women using alternative contraception. Two of the studies15,18 found slight increases in body weight
(0.45-1.1 kg) for Norplant users compared with non-hormonal users, but both studies were deemed very
low quality and one had non-significant findings (CI 0.36-1.84).18
A 2016 randomised control trial looking at short-term effects of a levonorgestrel IMP found no significant
changes in body composition over three months between the 208 women who used the implant and the
206 women who did not. However, more women using the IMP perceived weight gain than controls.19
Weight affecting contraception
Pharmacokinetic studies have demonstrated an inverse relationship between body weight and etonogestrel
serum levels, raising concern that the IMP may be less effective in heavier women in the third year of
use.14 The manufacturer of Nexplanon advises that “heavier” women may experience reduced
contraceptive efficacy in the third year, however does not specify what weight range they consider
“heavy.”20 The FSRH therefore advises that women are made aware of the manufacturer’s advice to
replace the device early, but that there is no direct evidence that early replacement is required.14
Progestogen-only Implants recommends that “[n]o increased risk of pregnancy has been demonstrated in
women weighing up to 149 kg. However, because of the inverse relationship between weight and serum
etonogestrel levels, a reduction in the duration of contraceptive efficacy cannot be completely excluded.”14
Obesity is UKMEC category 1 for IMP use, meaning there is no restriction for use of the method.21
In summary, there is no evidence suggesting a causal association between IMP use and weight
gain. There is a theoretical potential reduction in the duration of contraceptive efficacy of IMP for
women who weigh ≥150 kg.
Progestogen-only Injectable
Contraception affecting weight
The progestogen-only injectable, depot medroxyprogesterone acetate (DMPA), is associated with weight
gain and many women discontinue the method due to this side effect.22 In the three studies of the 2016
Cochrane review4 that compared DMPA use to non-hormonal contraception, one very low quality study23
found no difference in weight gain among participants while the two low quality studies9,24 found significant
weight changes. A retrospective 2010 cohort study24 determined that women using DMPA gained 3.17 kg
(CI 2.51-3.83) after three years of use compared with non-users and a 2015 study9 found that DMPA users
gained 6.5 kg over 10 years compared with Cu-IUD users gaining 4.9 kg.
The FSRH guideline Progestogen-only Injectable Contraception advises that higher initial BMI is predictive
of weight gain with DMPA use in adolescents (aged <18 years) but that association has not been observed
in adult women.22 It also advises that women who gain more than 5% of their baseline body weight in the
first 6 months of DMPA use are likely to experience continued weight gain.
Weight affecting contraception
There is currently limited evidence regarding the effect of weight on DMPA efficacy. One study25 examining
two clinical trials of subcutaneous DMPA (DMPA-SC) included women with BMIs ranging from 14.7-57.7
and recorded no pregnancies during the one-year study duration. A 26-week prospective study26 of
15 women found that DMPA levels were lower in women with BMI ≥30, especially those with BMI ≥40,
although high enough to successfully suppress ovulation. In one extremely obese woman, levels dipped
below the therapeutic level for the first two months of treatment and then rose.
In summary, DMPA appears to be associated with weight gain, particularly in women under 18 with
a BMI ≥30. There is no evidence suggesting a causal association between weight and DMPA
effectiveness, although data are limited for women with a BMI >40.
Progestogen-only Pill
Contraception affecting weight
Weight gain has been reported with POP use27 yet the evidence shows no causal association. The 2016
Cochrane review4 identified one, non-randomised study10 examining body composition changes for women
using a desogestrel POP compared with women not using hormones. After one year, mean weight and BMI
did not change significantly but the 42 women in the POP group gained an average of 2.8% (± 3.5%) fat
mass compared with the 26 controls, who experienced no change. This low-quality study is the only
evidence currently available comparing weight gain between POP users and non-users.
Weight affecting contraception
The currently available evidence has not shown reduced POP efficacy in women with higher weight and/or
BMI. Manufacturers of POP do not advise increased dosages for women who are overweight or obese.27
In summary, there is no evidence suggesting a causal association between POP use and weight
gain or weight and POP effectiveness.
Combined Hormonal Contraception
Contraception affecting weight
A Cochrane review28 from 2014 found insufficient evidence to determine the effects of combined hormonal
contraception (CHC) on weight. In the four identified trials that compared CHC use with a placebo, there
were no statistically significant differences in weight or body composition between users and non-users.28
The findings from these four studies are limited; one study29 was conducted over 40 years ago and used
high-dose COC no longer in use and the remaining three studies30-32 used only one formulation of CHC
each. The findings therefore cannot be applied to the entire range of available CHC options on the market
today.
Weight affecting contraception
A 2017 systematic review33 of the effectiveness of hormonal contraceptives in women who were overweight
or obese included fourteen studies examining COC use and two studies examining combined patch use.
One pooled analysis34 of seven studies looking at five different CHC formulations found that women with a
BMI ≥30 had a slightly increased risk of contraceptive failure than women with BMI <30 (adjusted hazard
ratio 1.44; 95% CI: 1.06–1.95). The other pooled analysis35 in the review found no association between
BMI and contraceptive failure but used a progestogen not currently used in CHC in the UK (chlormadinone
acetate). The remaining studies in the review found mixed results, although any significant contraceptive
failure assessed for women with higher BMI was low (odds/risk ratios 1.6-2.2).36 The authors noted that the
evidence is limited to fair and poor quality studies.
A 2016 Cochrane review13 had similar findings. Two out of five COC studies found an association between
BMI and pregnancy rates, although the associations were in opposite directions.
The Summary of Product Characteristics for the combined patch specifies that contraceptive efficacy may
be decreased in women weighing ≥90 kg, therefore additional precautions or an alternative method should
be advised.37,38
In summary, there is no evidence suggesting a causal association between CHC use and weight
gain or weight and CHC effectiveness. However, women weighing ≥90 kg should consider options
other than the combined contraceptive patch.
Conclusion
There is currently no conclusive evidence demonstrating a causative effect of contraception on weight
gain.4,26 There is, however, evidence that DMPA is associated with weight gain, particularly in women
under 18 years with a BMI ≥30.22,24 There is no evidence that higher weight compromises contraceptive
efficacy, with theoretical exceptions in the IMP and combined patch for women weighing ≥150 kg and
≥90 kg, respectively.
Women should be informed about what the current evidence does and does not show regarding this topic.
Discussions about potential weight gain that include advice on confounding lifestyle factors could reduce
contraception discontinuation due to assumptions that weight gained during treatment was definitively and
solely caused by contraception. Clinicians should always refer to the UKMEC when determining whether a
woman is eligible for a particular method of contraception, including women who are overweight or obese.
References
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Acknowledgements
This guidance was developed on behalf of the CEU by Dr Janine Simpson, Specialty Trainee in Community
Sexual and Reproductive Health, and Valerie Warner, CEU Researcher.
The Clinical Effectiveness Unit (CEU) was formed to support the Clinical Effectiveness Committee of the
Faculty of Sexual and Reproductive Healthcare (FSRH), the largest UK professional membership
organization working at the heart of sexual and reproductive healthcare. The CEU promotes evidence
based clinical practice and it is fully funded by the FSRH through membership fees. It is based in Edinburgh
and it provides a member’s enquiry service, evidence based guidance, new SRH product reviews and
clinical audit/research. Find out more here.