Weight Changes and hormonal contraceptives

March 19, 2024

People gain weight as they age regardless of contraceptive use because their body metabolism changes and therefore weight increases if they make no compensatory changes in nutrition and activity. Key events over the reproductive lifespan, including puberty, pregnancy, and menopause, can have significant effects on metabolism and weight. Early identification of weight gain allows for timely discussion about changes in nutrition, activity, or contraceptive method, write Megan Lawley, MD, MPH, and Carrie Cwiak, MD, MPH, in the new edition of Contraceptive Technology (CT). [1] Alternatively, lack of significant weight change may be reassuring to patients.

A patient’s perception of their weight change may not correlate with measured changes, or lack thereof, but that does not mean that clinicians should dismiss their perception. Most importantly, providers must listen to patients concerns, briefly review the medical evidence about weight change and use of contraceptive methods, and assist them in weighing the pros and cons of changing methods.

Progestin-only methods and weight changes

Injectables: Aside from unpredictable bleeding, weight gain is the most commonly reported side effect among DMPA users and is a commonly cited reason for discontinuation. Early clinical trials of DMPA relied on self-reported weight changes or discontinuation due to the same, which do not necessarily correlate with actual changes in weight with contraceptive use or differential changes among methods. [2]

In a 2016 review of clinical trials that measured weight changes in DMPA users, 15 studies noted no significant differences in mean weight gain or percentage change in body composition associated with DMPA use in comparison to other hormonal or nonhormonal methods write Lawley and Carrie Cwiak. Only three studies found a differential effect. Among them, two retrospective trials compared DMPA to copper intrauterine device (IUD) users: one study found that mean weight gain was higher for DMPA users at 1 year (mean difference 2.28 kg), 2 years (MD 2.71 kg), and 3 years of use (MD 3.17 kg), among normal weight and overweight, but not obese, users; the other study found that mean weight gain was higher for DMPA users at 1 year (1.3 vs 0.2 kg), 4 years (3.5 vs 1.9 kg), and 10 years of use (6.6 vs 4.9 kg).[2] Bonny et al. compared DMPA use to no hormonal contraceptive use in a small study of 26 adolescents and reported a significant increase in total body fat percentage (11%) and decrease in lean body mass percentage (–4%) at 6 months, though weight gain was not reported.[4] It should be noted that all but one of the 18 trials were considered very low to low in quality.[2] Given that DMPA is the only method that shows an association with weight gain and that weight gain is the most common reason people discontinue it, proactive and informative counseling about weight changes attributable to DMPA use and patient concerns is particularly relevant.

While the mean weight gain attributable to DMPA use may be of negligible or low magnitude for most users, some patients may be more likely to gain significant weight over time with DMPA use. One study of adult DMPA users suggests that a 5% weight change in the first 6 months of use was predictive of more progressive weight gain such that mean weight change was significantly higher (7.03 kg) by 36 months of use in those who experienced early weight gain. Other predictors included nonobese body mass index (BMI) and self-reported increase in appetite.[3] A study of adolescent DMPA users similarly found that DMPA users with a 5% weight change in the first 6 months had a higher mean BMI change (7.6 vs. 2.3) by 18 months of use compared to those who did not have an early weight change.[4] The high loss-to-follow-up rate in both studies limits the generalizability of these findings. Yet, it is reasonable to monitor weight and BMI changes over time in DMPA users to assist in counseling those who are concerned about weight gain.

IUDs: Although up to 10% of individuals will report concerns that their weight has increased after placement of an LNG IUD,[5] mean weight change at 1 year for LNG IUD users is 1 kg, which is less than seen with the use of subdermal or injectable contraception.[6]

Implants: Comparative trials have demonstrated that implant users did not have any differences in weight gain or body composition changes compared with copper IUD users.[7,8] The ability of postpartum users with BMI > 25 kg/m2 to lose weight by 6 months was also not statistically different from postpartum patients who used nonhormonal contraceptive methods.[9]

Progestin-only pills (POPs): A Cochrane review identified two comparative trials of POP effects on weight. One trial showed no significant weight change after 6 months of use of either a norethisterone or levonorgestrel POP. Another study of perimenopausal women that compared desogestrel POP to control showed no change in weight or body mass index after 12 months, with the desogestrel group showing a greater increase in fat mass.[10] No significant weight, heart rate, or blood pressure changes were observed with drospirenone POP in Phase III clinical trials.[11]

Combined hormonal contraceptive methods and weight changes

In clinical trials, women who use combined hormonal contraceptives (CHC)s do not typically gain more weight than they normally do in the same time interval without CHCs, write Shaalini Ramanadhan, MD, MCR, and Alison Edelman, MD, MPH, in the 22nd edition of Contraceptive Technology.[12] A Cochrane review confirmed that available evidence is insufficient to determine the effect of combination contraceptives on weight but concluded that no large effect was evident.[13] The hypothesized mechanisms for CHC-related weight gain include changes to the renin-angiotensin-aldosterone system causing fluid retention and hypertrophy of adipose tissue. But as no clear clinical evidence has been found, it is unlikely that any of these mechanisms cause significant problems.

COCs: Randomized clinical trials have demonstrated that, on average, patients do not experience more weight gain with low-dose COCs than with placebo or no intervention.[12,14,15] In a prospective trial of women using triphasic COCs with daily weight measurements for 4 months, no changes in mean weight fluctuations were noted during the cycle.[16] A 9-year study showed that COC use by adolescents was not associated with either weight gain or increased body fat.[17]

Rings: Rings have no significant impact on weight gain. In clinical studies, women are as likely to lose weight as to gain it when using the ring for a year.[18,19] A recent randomized review noted no large effect on weight among ring users, though the authors noted that available data were limited.[20]

Patches: Patches have no significant impact on weight gain. In a randomized placebo-controlled trial, the contraceptive patch was not associated with weight gain. In a pooled analysis of the clinical trials, the mean change in body weight from baseline to the end of treatment was an increase of 0.3 kg, and 79% of participants remained within 5% of their baseline weight.[21]

Acknowledgements: Additional CT authors whose work appears here are Melissa Chen, MD, MPH, and Melissa Matulich, MD, MAS (implants); Nicole Economou, MD, MPH, Biftu Mengesha, MD, MAS, and Eleanor Bimla Schwarz, MD, MS (IUDs); Charita Roque, MD, MPH, and Anne Burke MD, MPH (Progestin-only pills)

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