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Contraception: Counseling for females with obesity

Contraception: Counseling for females with obesity
Literature review current through: Jan 2024.
This topic last updated: Sep 14, 2023.

INTRODUCTION — Use of safe and effective contraception is essential for preventing unintended pregnancy in women of all body sizes. When counseling women with obesity about contraception, it is important to consider how obesity may affect the safety and efficacy of various contraceptive methods. All contraceptive methods, including the intrauterine devices, etonogestrel implant, and combined hormonal contraceptives, are appropriate for use in women with obesity.

For the purposes of this topic, "woman" refers to any patient who has female reproductive organs and the potential to be pregnant. Clinicians should also consider the contraceptive needs of transgender men and gender nonbinary persons. This topic will address the effects of obesity on contraceptive selection, safety, efficacy, and use. Related topics on fertility and pregnancy in women with obesity are reviewed separately.

(See "Obesity in pregnancy: Complications and maternal management".)

(See "Fertility and pregnancy after bariatric surgery".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

FACTORS TO CONSIDER

Population need for contraception — Although obesity can affect fecundity, the vast majority of women with obesity ovulate regularly and are fertile. There is no evidence that obesity affects contraceptive adherence/compliance [1] or frequency of sexual intercourse [2]. Despite the need for contraception, a national survey in the United States noted that sexually active women of reproductive age with obesity were significantly less likely to use contraception than women of normal weight [3]. It was unclear whether the disparity was due to patient, provider, and/or systems issues. In addition, because contraceptive clinical trials initially excluded overweight or obese women, evidence regarding contraceptive effectiveness and safety for this population is limited [4,5]. However, any risk associated with a contraceptive method needs to be balanced with the risks from unintended pregnancy, particularly for women with obesity. (See "Obesity in pregnancy: Complications and maternal management".)

Pharmacokinetic alterations of obesity — Obesity increases metabolic rate, clearance of hepatically metabolized drugs, circulating blood volume, and absorption of contraceptive steroids by adipose tissue. As a result of these changes, women with obesity may take longer to achieve a therapeutic level of contraceptive hormones when starting oral hormonal contraceptives, or after the hormone-free interval, compared with normal-weight women [6,7]. As a result of these findings, concerns have been raised that changes in serum drug levels in women with obesity may increase the risk for contraceptive failure, but data are limited and inconsistent [4,6-13]. (See 'Efficacy' below and 'Contraceptive patch' below.)

OUR APPROACH — Our approach to contraceptive counseling does not vary based on weight/body mass index (BMI, kg/m2) unless the patient has additional comorbidities. In our practice, we review all contraceptive methods with all patients no matter their weight/BMI (figure 1). We do inform the patient that obesity does increase the baseline risk for deep venous thrombosis and, depending on age and other comorbidities, that methods that contain estrogen may not be the safest choice. Factors that are considered in contraceptive selection include patient preferences, efficacy, side effects, duration of action, and noncontraceptive benefits, among others. Details on how to approach contraceptive counseling and method selection are presented elsewhere. (See "Contraception: Counseling and selection".)

While the woman ultimately determines her contraceptive choice, we take the following approach to counseling women with obesity:

For women who desire permanent sterilization, we review the options of both female and male sterilization procedures. We discuss that male vasectomy is associated with fewer risks and complications as it is an outpatient procedure performed on external anatomy under local anesthesia. By contrast, female fallopian tube ligation or excision requires intra-abdominal surgery, typically with laparoscopy, under general anesthesia. Women of higher weight/BMI can have an increased risk of adverse events with surgery, including postoperative infection. Long-acting reversible methods, like intrauterine devices (IUDs) and implants, should also always be discussed with a woman considering a permanent method, as these methods provide the same level of protection. (See 'Surgical sterilization' below and 'Most effective reversible methods' below.)

For a woman who desires reversible contraception, we ask if she has identified a method that she is interested in and what she wants out of a method (efficacy, safety, noncontraceptive benefits, concerns about side effects). We review the advantages and disadvantages of the method she has identified but then also inform her of other methods that might meet her needs. We also take some time to review the most effective reversible methods like IUDs and the etonogestrel implant (figure 1). As these methods are not estrogen-containing and do not rely on compliance, they are extremely safe and effective for women with obesity or other comorbidities. Progestin-containing methods like the levonorgestrel (LNG) IUD or the etonogestrel implant can be protective of the endometrium and thus reduce the risk of endometrial hyperplasia, a concern in women of higher weight. However, IUD insertion can be challenging, particularly for women with class III obesity (≥40 kg/m2) or higher. (See 'Intrauterine contraception' below.)

For women who decline the IUDs and implant, we next review the various hormonal contraceptive methods, which include depot medroxyprogesterone acetate (DMPA), estrogen-progestin combined hormonal contraceptives (oral pill, transdermal patch, and vaginal ring), and progestin-only pills. These methods are considered as having moderate efficacy (figure 1). The most important factor in maintaining the effectiveness of these methods is consistent use; body weight may play a small role in failure if adherence is poor [5,14].

For women who desire a longer-acting reversible hormonal contraceptive, DMPA is injected every 12 weeks. DMPA use can be associated with weight gain in adolescent women. (See 'Depot medroxyprogesterone acetate' below.)

For women who desire combined estrogen-containing contraceptives and have no contraindications to estrogen use, the decision to use the pill, transdermal patch, or vaginal ring should be based on the mode of hormonal delivery that the patient feels fits with her lifestyle. (See 'Combined estrogen-progestin contraceptives' below.)

For women who prefer to avoid the above hormonal methods or who have contraindications to estrogen exposure but do not wish to use DMPA, progestin-only pills (POPs) are the next option. Although the available evidence is limited, POPs do not appear to be less effective or associated with weight gain in women with obesity [15]. However, these products require consistent use to maintain efficacy. (See 'Progestin-only pills' below.)

Pericoital contraceptives are available for women who desire contraception only at the time of vaginal intercourse. These methods include the single-size diaphragm, cervical cap, spermicidal sponge, and spermicide. While these methods are unlikely to be impacted by body weight, supporting data are sparse. They are also less effective forms of contraception and require both user skill and motivation (figure 1). (See 'Pericoital contraceptive methods' below.)

Barrier contraceptives include male and female condoms. These can be used by any patient, but the efficacy is lower compared with the above methods (figure 1). However, these methods can be combined with any of the above methods as a secondary (ie, backup) contraceptive to increase contraceptive efficacy or to provide protection from sexually transmitted infections. (See 'Barrier methods' below.)

The evidence for our approach is reviewed below.

COUNSELING POINTS

Safety

Coexistent medical issues — As women with obesity, especially those with comorbidities, are at higher risk of pregnancy-related complications, avoidance of unintended pregnancy is particularly important. In general, healthy women with obesity can safely use any contraceptive method following appropriate method-specific counseling regarding potential risks and benefits. Country-specific and world health guidelines exist to guide contraceptive selection for women who also have specific medical conditions or states (ie, lactation). These guidelines are generally similar; clinicians should use the one from their country or the one that best matches their patient population. When choosing contraception, the specific risks of the method relative to any underlying medical disorders must also be balanced against the risks of unintended pregnancy.

World Health Organization (WHO) – Medical Eligibility Criteria (MEC) for contraceptive use

US Centers for Disease Control and Prevention (CDC) – CDC MEC and summary table

Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists – United Kingdom MEC

Risk of thromboembolism — Obesity increases the risks of cardiovascular disease, stroke, and thromboembolism (see "Overweight and obesity in adults: Health consequences", section on 'Cardiovascular'). The risk of these problems is further elevated by independent characteristics such as increasing age and smoking. Thus, contraceptive selection for women with obesity must account for the biologic impact of obesity on thromboembolic risk, medical comorbidities, and other risk factors, especially when considering estrogen-containing contraceptives that also increase the risk of thromboembolism.

No increased risk – For women with obesity who wish to avoid any increased risk of thromboembolism, reversible contraceptive options include the copper intrauterine device (IUD), pericoital contraceptives, and barrier contraceptives. Surgical sterilization does not increase the risk of thrombosis in any patient population.

Small absolute increased risk – All progestin-only contraceptives are available for unrestricted use in otherwise healthy women with obesity [15-18]. Although there are somewhat conflicting data regarding the risk of thromboembolism with the etonogestrel implant and depot medroxyprogesterone acetate (DMPA), any increased risk attributable to the hormone itself appears to be small. Similar findings have been reported for progestin-only oral pills [19].

(See "Contraception: Etonogestrel implant", section on 'Risk of thromboembolic event'.)

(See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Cardiovascular and thromboembolic risk'.)

Confirmed increased risk – For combined estrogen-progestin hormonal contraceptives (CHC; ie, oral pill, transdermal patch, and vaginal ring), both hormonal components can impact the thrombosis risk, but the greater risk comes from the estrogen component. While the relative risk of thromboembolism is increased with CHC use [20], the absolute risk is still considered acceptable for otherwise healthy women with obesity (ie, "the advantages of using the method generally outweigh the theoretical or proven risks") [16,18]. The risk of venous thromboembolism (VTE) in obese women who use CHCs is less than the VTE risk associated with obesity and pregnancy or the postpartum period [21,22]. Although there are conflicting data on the risk of acute myocardial infarction and stroke in women with obesity who use CHCs, the absolute risk appears to be low [23,24].

While the WHO and the CDC do not provide age limits for CHC use in healthy women with obesity, the United Kingdom MEC advise against CHC use in women with a body mass index (BMI) ≥35 kg/m2 [15-18]. In our practice, we offer estrogen-progestin contraceptives to women with obesity, including those older than 35 years of age, as long as they do not have other medical contraindications to use of these drugs and are nonsmokers (for women age >35 years). (See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Cardiovascular effects'.)

Efficacy — Although studies are limited, there is no evidence that any method of contraception is significantly less effective in women with obesity [5,14,15,25]. Thus, women with obesity can be offered all contraceptive methods that are compatible with their other medical conditions; specific discussions by contraceptive method are presented below. Previously, concerns have been raised that the efficacy of oral contraceptives is suboptimal in this population. However, it is important to remember that the overall rate of contraceptive failure is related to several factors, including the inherent effectiveness of the method, adherence and compliance with the method, fecundity of the population, and sexual behavior (eg, rare versus frequent sexual intercourse). Concerns have also been raised that serum drug levels in women with obesity may be insufficient to maintain contraceptive effects, but data are limited and inconsistent [4,6-13]. If contraceptive efficacy is reduced, the magnitude of effect is likely to be small as pharmacokinetic studies have estimated that body weight accounts for only 10 to 20 percent of the variability in hormone levels, which is consistent with normal variability in steroid levels among individuals.

Weight gain — Weight gain is a concern for many women, particularly women who are already overweight or obese. Fear of weight gain is often cited as a reason women do not initiate or continue hormonal contraception [26]. There is good evidence that use of CHCs, progestin-only pills, intrauterine contraception, and contraceptive implants is not associated with substantial weight gain or discontinuation of a contraceptive due to weight gain [27-31]. Although randomized trials have not reported significant weight gain in DMPA users [32,33], observational studies have reported that overweight and obese adolescents gain more weight when using this method than when using oral contraceptives or no contraception [34-37]. A study in adult women found that normal and overweight women gained weight with DMPA use, whereas women with obesity did not [38]. Based on these data, several guidelines label the use of DMPA in adolescent women (<18 years) as category 2, or as "advantages generally outweigh theoretical or proven risks") [16-18]. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Weight changes'.)

Noncontraceptive benefits — 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 [39]. (See "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Use of hormonal contraception'.)

CONTRACEPTIVE OPTIONS — Women who are obese and desire contraception should be offered the full range of contraceptive options that are compatible with any other medical comorbidities [5,14].

Surgical sterilization — Fallopian tube ligation or excision provide effective contraception, but both processes are associated with longer operating times and more anesthetic and surgical complications in women with obesity compared with women who are not obese [40-43]. If acceptable, male sterilization (ie, vasectomy) avoids the risks of intra-abdominal surgery and general anesthesia.

(See "Overview of female permanent contraception".)

(See "Vasectomy".)

Most effective reversible methods — Intrauterine devices (IUDs) and progestin-only implants are the most effective reversible contraceptive methods (figure 1).

Intrauterine contraception — IUDs are a preferred contraceptive option for women with obesity who have no contraindications to use of this method and are accepting of it. Both the copper and levonorgestrel (LNG)-releasing IUDs are highly effective regardless of weight [14-16,18]. The LNG-releasing IUDs have the added benefit of treating abnormal uterine bleeding and endometrial hyperplasia, if present [14,44]. (See "Intrauterine contraception: Candidates and device selection".)

A prospective cohort study reported no statistically significant difference in the contraceptive failure rate during the first two to three years of use among IUD users (copper-releasing or LNG-releasing [LNG 52, 20 mcg/day release, total LNG content 52 mg]) who were of normal body mass index (BMI; n = 1584), overweight BMI (n = 1149), or obese BMI (n = 1467): the overall failure rate of less than 1 pregnancy per 100 woman-years did not vary by BMI [45]. The initial efficacy trial of a subsequent lower-dose LNG-releasing IUD (LNG 14; 14 mcg/day release, total LNG content 13.5 mg) included women 38 to 155 kg (mean 68.7 kg) and BMI 16 to 55 kg/m2 (mean 25.3 kg/m2) and did not report lower efficacy for obese study participants.

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 [4]. Ultrasound may be helpful to guide insertion. (See "Intrauterine contraception: Insertion and removal".)

Contraceptive implant — The LNG and etonogestrel (ENG) contraceptive implants appear to be highly effective in overweight and obese women, although possibly less effective compared with women who weigh less [5]. In a three-year trial of nearly 1000 women randomly assigned to receive the LNG implant, three pregnancies occurred, all in women weighing ≥70 kg at conception, for a cumulative pregnancy rate of 0.4 per 100 woman-years for all LNG users [46]. For nearly 1000 women randomly assigned to the ENG implant, there were no pregnancies in women ≥70 kg compared with three pregnancies in women <70 kg at conception. Because of the small total number of pregnancies in the study and the relatively small number of women ≥70 kg (fewer than 20 percent of subjects), it is unclear whether weight ≥70 kg affects contraceptive implant efficacy and whether there is a true difference in efficacy between LNG and ENG implants at weights ≥70 kg. The trial data are consistent with pharmacologic studies that report plasma hormone concentrations for both ENG and LNG remain above the contraceptive threshold for the approved duration of the device in women with obesity, although these levels may be lower compared with nonobese women [47-49]. It is likely that there is no large difference in contraceptive implant efficacy between women ≥70 kg and those <70 kg. Extending the use of the implant from three to five years has not been sufficiently studied in a population of women weighing over 70 kg; thus, we would not advise extended use of the implant in this population [50]. (See "Contraception: Etonogestrel implant".)

Moderately effective reversible methods — Moderately effective reversible contraceptive methods include the combined estrogen-progestin and progestin-only options (figure 1). These methods are generally considered to be as effective in women with obesity compared with normal-weight women, although conflicting data exist [5]. However, use of contraception, even if somewhat less effective, will prevent more pregnancies than no contraception and is always less risky to women with obesity compared with pregnancy [5,51].

Depot medroxyprogesterone acetate — Depot medroxyprogesterone acetate (DMPA) is available as a 150 mg intramuscular injection ("DMPA") and as a 104 mg subcuticular injection ("DMPA-SC"). Both provide effective contraception for obese women [14].

DMPA – A multinational study including 846 women receiving DMPA for one year reported a 12-month pregnancy rate of 0.7±0.4 percent with no impact of body weight [52].

DMPA-SC – A study of the contraceptive efficacy of DMPA-SC that included substantial numbers of overweight women and women with obesity reported no pregnancies in 16,023 woman-cycles of use [53]. In addition, a study of the pharmacokinetics of DMPA-SC in class I, II, and III women with obesity versus women with normal BMI reported that median medroxyprogesterone levels remained above the level needed to prevent ovulation, although estradiol levels fluctuated more in women with obesity than normal controls [54].

Women who are acceptable candidates for progestin-only contraception can use either formulation. Neither product is associated with additional weight gain in adult women with obesity, although there are conflicting data for younger women with obesity (less than age 18 years) [5,34,37,55,56]. For all women younger than age 18, DMPA use is labeled as category 2 (ie, the advantages of using the method generally outweigh the theoretical or proven risks) because of potential concern for long-term reductions in bone mineral density, although supporting data are limited [16-18]. Of note, the persistence of ovulation suppression following discontinuation of DMPA is related to weight: women with lower body weights conceive sooner than women with higher body weights after stopping the drug. (See "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration", section on 'Return to fertility after discontinuation'.)

DMPA is designed to be an intramuscular injection. In some women, a longer needle or deltoid injection may be necessary to reach the muscle layer [15]. DMPA-SC does not require any changes in administration for women with obesity.

Combined estrogen-progestin contraceptives — Women with obesity who have no additional contraindications to estrogen exposure can safely use combined estrogen-progestin contraceptives. The choice of which combined method is related to patient preferences, such as need for daily pill consumption and route of application. Specific information on each of these methods is reviewed in detail elsewhere:

(See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use".)

(See "Contraception: Transdermal contraceptive patches".)

(See "Contraception: Hormonal contraceptive vaginal rings".)

Oral contraceptives — The available literature suggests that oral contraceptives are generally effective at pregnancy prevention in women with obesity but may be less forgiving of imperfect use because of altered steroid hormone pharmacokinetics in this group compared with normal-weight users [5-8,57-61]. (See 'Pharmacokinetic alterations of obesity' above.)

We start all women who desire oral contraceptive pills on products containing 20 to 30 mcg of ethinyl estradiol, regardless of the woman's body weight or BMI. Although insufficient evidence exists to recommend a specific estrogen dose or use of a higher-dose rather than a lower-dose oral contraceptive pill, most pharmacokinetic studies in women with obesity used a pill containing 20 mcg ethinyl estradiol and demonstrated ovulation suppression [7,8,13]. We do not start any women on a pill with more than 35 mcg of ethinyl estradiol because of the increased risk of thromboembolism. As women with obesity require more time to achieve steady state levels, these women may benefit from extended-cycle or 24/4 regimens compared with traditional 21/7 regimens [5-8,57-59]. Because 24/4 regimens overall provide higher contraceptive efficacy than 21/7 regimens, we advise 24/4 dosing in all women who desire oral contraceptive pills, regardless of body weight.

While the data on the impact of obesity on combined oral contraceptive efficacy are mixed, the absolute increased risk of pregnancy appears to be small [60]. In a study including a cohort of more than 55,000 United States women, oral contraceptive pill failure was slightly higher for women with BMI ≥35 kg/m2 compared with women with BMI <35 (adjusted hazard ratio 1.5, 95% CI 1.3-1.8) [62]. Other epidemiologic studies have reported inconsistent results, with several studies demonstrating a higher risk of pregnancy in obese oral contraceptive pill users [63-65] and others finding no significant association for either combined oral contraceptives or progestin-only pills [66-70].

The use of oral contraceptives in women with obesity with polycystic ovary syndrome is reviewed separately. (See "Treatment of polycystic ovary syndrome in adults".)

Contraceptive ring — In the absence of data to suggest otherwise, we counsel both obese and normal-weight women similarly regarding contraceptive ring efficacy. The use of contraception prevents more pregnancies than no use of contraception, and adherence/compliance is the biggest issue with effectiveness even if a difference exists regarding BMI.

All large trials assessing the effectiveness of the estrogen-progestin vaginal rings (sample names NuvaRing, Annovera) have been conducted in nonobese women [71,72]. While a systematic review reported similar efficacy for obese and normal-weight women using any combined hormonal contraception, the study was unable to separate the data for pill, ring, and patch users [5]. A study of 128 pregnancies that resulted from a combined group of pill, patch, or ring users concluded three-year failure rates among women using these methods were not different across BMI categories [69]. However, the methodology used and the possible effect of noncompliance may have masked the actual effect of BMI on contraceptive failure [73].

A small pharmacokinetic study in etonogestrel/ethinyl estradiol ring users reported that follicular development was minimal in both obese and normal BMI women [74]. Another small study noted hormone levels remained in the therapeutic range up to 35 days after ring insertion in both obese and normal BMI ring users [75]. Although reassuring, these studies were conducted over only one cycle in small groups of women and immediately following a cycle of oral contraceptive pill use; thus, efficacy could not be determined. The initial approval studies for the segesterone/ethinyl estradiol ring did not include women with BMIs above 29 kg/m2 [72].

Contraceptive patch — The use of transdermal contraception by patients with obesity varies by the patch type. Detailed discussions of contraceptive patch types and efficacy are presented in detail separately. (See "Contraception: Transdermal contraceptive patches", section on 'Patch types' and "Contraception: Transdermal contraceptive patches", section on 'Efficacy'.)

Ethinyl estradiol and norelgestromin-containing patch – The ethinyl estradiol and norelgestromin (EE/N, sample name Xulane) patch is labeled as contraindicated for individuals with a BMI ≥30 kg/m2 [76]. A pooled analysis of three large studies examining the efficacy of the EE/N contraceptive patch reported contraceptive failure was low and uniformly distributed across the range of body weights <90 kg (198 pounds) but suggested the EE/N patch may be less effective in the subgroup of women ≥90 kg (198 lbs) [77]. In this analysis, 5 of the 15 pregnancies in EE/N patch users occurred in the 83 women (3 percent of study subjects) who weighed ≥90 kg. The small number of pregnancies in this pooled analysis made it impossible to provide a good estimate of the excess risk of contraceptive failure in individuals weighing ≥90 kg. In addition, studies of the EE/N contraceptive patch have included individuals who are as much as 35 percent above their ideal body weight, which contrasts from most oral contraceptive pill studies that excluded individuals who were more than 20 percent above ideal body weight and further complicates the understanding of patch efficacy.

Ethinyl estradiol and levonorgestrel-containing patch – The US Food and Drug Administration-approved package label states that the ethinyl estradiol and levonorgestrel (EE/LNG, sample name Twirla) patch is contraindicated in people with a BMI >30 kg/m2 because of concerns for diminished efficacy and elevated venous thromboembolism (VTE) risk [78]. Though there is a concern for diminished efficacy, available data suggest the risk of VTE with the EE/LNG patch is similar to that of other oral combined estrogen-progestin contraceptive pills [79].

Progestin-only pills — There are no studies examining the contraceptive efficacy of progestin-only pills in obese women. All women, regardless of body weight, should be informed that typical-use failure rates of oral contraceptives, including progestin-only pills, are 9 percent [80]. Therefore, women who desire more effective contraceptives should consider a different method.

Less effective reversible methods — These methods are event-based forms of contraception, which makes them more prone to user-related contraceptive failure (figure 1). There are no data that obesity specifically lowers the contraceptive efficacy of these methods.

Pericoital contraceptive methods — No studies have evaluated the efficacy of pericoital contraceptives (ie, single-size diaphragm, cervical cap, spermicidal sponge) in obese users. Theoretically, obesity should not affect the safety or efficacy of these contraceptives, but fitted diaphragms should be resized if the patient has a large change in weight. (See "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge".)

Barrier methods — Condoms (male and female) are barrier contraceptives. If a barrier method is used simultaneously with a pericoital method (eg, male condom and diaphragm, cervical cap, or vaginal spermicide), efficacy increases substantially. While less effective as contraception (figure 1), barrier methods do provide protection from sexually transmitted infections. (See "Internal (formerly female) condoms" and "External (formerly male) condoms".)

EMERGENCY CONTRACEPTION — The copper intrauterine device is the most reliable emergency contraceptive (EC) regardless of body mass index (BMI) and is not impacted by increasing BMI. However, oral drugs for EC may be less effective in overweight women and women with obesity compared with normal-weight women, particularly levonorgestrel. Data on EC use in those with obesity are reviewed in detail separately. (See "Emergency contraception", section on 'Impact of body weight'.)

CONTRACEPTION PRE- AND POST-BARIATRIC SURGERY — Women who are planning bariatric surgery and using any estrogen-containing contraceptive are advised to discontinue the contraceptive at least one month before surgery to reduce the risk of postoperative thromboembolism. An alternate method should be employed. Women using intrauterine devices (IUDs), etonogestrel implants, or progestin-only methods do not need to stop or alter their contraceptives. (See "Perioperative medication management", section on 'Oral contraceptives'.)

Postoperatively, the weight loss that accompanies bariatric surgery can enhance fecundity in women who were subfertile because of oligo-ovulation or anovulation [81-83]. Thus, these women ideally have a contraceptive plan in place prior to their surgery. (See "Fertility and pregnancy after bariatric surgery".)

Women who undergo restrictive bariatric procedures, including vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy, can safely and effectively begin or restart oral contraceptives once they are mobile [18].

Women who undergo malabsorptive procedures, such as biliopancreatic diversion, jejunoileal bypass, or Roux-en-Y bypass, may have reduced absorption of oral contraceptives, although there does not appear to be a substantial decrease in efficacy for these women [84-86]. The paucity of data makes patient counseling difficult. A 2010 systematic review of five studies reported an increased pregnancy rate in women with biliopancreatic diversion, but the total number of both patients and pregnancies was small (two pregnancies among nine oral contraceptive users) and based on one study [86]. In the same review, two pharmacokinetic studies evaluated women with jejunoileal bypass. One study reported lower plasma levels of norethisterone and levonorgestrel while the other study reported identical to elevated plasma levels of D-norgestrel; the variation in the second study correlated with the remaining ratio of jejunum and ileum left in continuity. Women with a 1:3 ratio had significantly higher plasma levels. Another study of oral desogestrel found no clinically significant changes in etonogestrel pharmacokinetics before and after Roux-en-Y gastric bypass surgery.

Based on the limited available data above, we take a conservative approach and advise avoiding oral contraceptive pills in women who have undergone malabsorptive procedures and suggest use of any nonoral method (ie, the vaginal ring, transdermal patch, IUDs, or progestin-only implant or injection), which is consistent with the approaches taken by the American College of Obstetricians and Gynecologists and the US Centers for Disease Control and Prevention, [14,16,87,88]. The United Kingdom Medical Eligibility Criteria do not place a restriction based on surgery type but instead advise avoiding all combined hormonal contraceptives in women who have had bariatric surgery but still have a body mass index of 35 or greater [17]. The World Health Organization does not list bariatric surgery as a medical factor but advises that combined hormonal contraceptives not be used in women undergoing major surgery with prolonged immobilization [18].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception" and "Society guideline links: Obesity in adults".)

SUMMARY AND RECOMMENDATIONS

Fertility – Although obesity can affect fecundity, the vast majority of women with obesity ovulate regularly and are fertile. There is no evidence that obesity affects contraceptive adherence/compliance or frequency of sexual intercourse. (See 'Population need for contraception' above.)

Metabolic impact on hormonal contraceptives – Obesity increases metabolic rate, clearance of hepatically metabolized drugs, circulating blood volume, and absorption of contraceptive steroids by adipose tissue. As a result of these changes, women with obesity take twice as long to achieve therapeutic steady-state levels of contraceptive hormones. (See 'Pharmacokinetic alterations of obesity' above.)

Contraceptive counseling – In our practice, we review all contraceptive methods with all patients. Factors that are considered in contraceptive selection include patient preferences, side effects, duration of action, noncontraceptive benefits, and efficacy (figure 1), among others. Details on how to approach contraceptive counseling and method selection are presented elsewhere. (See 'Our approach' above.)

Contraceptive selection – In general, healthy individuals with obesity can safely use any contraceptive method following appropriate method-specific counseling regarding potential risks and benefits. Individual countries and the World Health Organization have published Medical Eligibility Criteria to guide contraceptive selection in women with medical issues. When choosing contraception, the specific risks of the method relative to any underlying medical disorders must also be balanced against the risks of unintended pregnancy in this group. (See 'Coexistent medical issues' above.)

Long-acting reversible contraceptives – Regardless of body weight, intrauterine devices (IUDs, either copper or levonorgestrel-releasing) and implants (etonogestrel) are the most effective contraceptive methods (figure 1). These methods are not associated with weight gain (compared with depot medroxyprogesterone acetate [DMPA]) and do not expose the woman to potential risks associated with estrogen-containing contraceptives. (See 'Efficacy' above and 'Weight gain' above.)

Hormonal contraceptive methods – Moderately effective reversible contraceptive methods include the combined estrogen-progestin and progestin-only options (figure 1). These methods are generally considered to be as effective in women with obesity compared with normal-weight women, although conflicting data exist. However, use of hormonal contraception, even if somewhat less effective, will prevent more pregnancies than no contraception and is always less risky to women with obesity compared with pregnancy. 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 choose oral contraception, we start with a pill containing 20 to 30 mcg of ethinyl estradiol. (See 'Moderately effective reversible methods' above.)

Emergency contraception – The copper IUD is the most reliable emergency contraceptive (EC) regardless of body mass index (BMI) and is not impacted by increasing BMI. However, oral drugs for EC may be less effective in overweight women and women with obesity compared with normal-weight women, particularly levonorgestrel. (See 'Emergency contraception' above.)

Impact of bariatric surgery – Bariatric surgery procedures causing malabsorption, such as biliopancreatic diversion or jejunoileal bypass, may interfere with the absorption of oral contraceptives, thus reducing their effectiveness. If hormonal contraception is used, we advise nonoral hormonal contraceptives over oral hormonal contraceptives. (See 'Contraception pre- and post-bariatric surgery' above.)

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Topic 5470 Version 63.0

References

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