What are the guidelines for contraception in patients with obesity?

From the Guidelines

Women with obesity can safely use most contraceptive methods, including hormonal options, and the choice of birth control should be based on individual health factors and medical history. According to the U.S. Selected Practice Recommendations for Contraceptive Use, 2024 1, weight measurement is not needed to determine medical eligibility for any methods of contraception, as all methods can be used or generally can be used among patients with obesity. The guidelines recommend that combined hormonal contraceptives, progestin-only methods, and intrauterine devices can be used by women with obesity, but the effectiveness of combined hormonal methods may be slightly reduced.

When considering birth control options, women with obesity should discuss their individual health factors, such as hypertension or diabetes, with their healthcare provider to determine the best choice. The guidelines suggest that the benefits of starting the implant, DMPA, CHC, and POP likely exceed any risk, even if the provider is uncertain whether the patient might be pregnant 1.

Key points to consider when selecting birth control for women with obesity include:

• Combined hormonal contraceptives are generally safe but may have slightly reduced effectiveness
• Progestin-only methods, such as the mini-pill, implants, and hormonal IUDs, are excellent choices as their effectiveness is not impacted by body weight
• Barrier methods like condoms remain equally effective regardless of weight
• The slight increased risk of venous thromboembolism with combined hormonal methods should be considered, but for most women with obesity, the benefits of effective contraception outweigh these risks when no other contraindications exist.

From the FDA Drug Label

The risk of morbidity and mortality increases significantly in the presence of other underlying risk factors such as hypertension, hyperlipidemias, obesity, and diabetes. Oral contraceptives may compound the effects of well-known risk factors, such as hypertension, diabetes, hyperlipidemias, age and obesity

The use of oral contraceptives in women with obesity may increase the risk of serious conditions, including myocardial infarction, thromboembolism, stroke, and other vascular problems.

• Obesity is considered a risk factor that may be compounded by the use of oral contraceptives, increasing the risk of cardiovascular disease.
• Women with obesity should be cautious when using oral contraceptives, as the risk of morbidity and mortality increases significantly in the presence of this underlying risk factor 2, 2.

From the Research

Obesity Guidelines and Birth Control

• Obesity has reached epidemic proportions around the world, and its impact on the effectiveness of hormonal contraceptives is a significant concern 3, 4, 5, 6.
• Studies have shown that the efficacy of hormonal contraceptives may be affected by metabolic changes in obesity or greater body mass or body fat 3, 4, 6.
• However, the evidence generally does not indicate an association between higher BMI or weight and effectiveness of hormonal contraceptives, except for oral emergency contraception and the patch 4, 5.
• Long-acting, reversible contraceptive methods offer superior effectiveness, minimal risk, and numerous noncontraceptive benefits across body mass index groups 5.
• The use of combined oral contraceptives (COCs) in obese women may increase the risk of venous thromboembolism, and progestin-only products are considered a safer alternative 7.

Key Findings

• A study published in 2010 found that overweight or obese women had a higher pregnancy risk compared to those with lower weight or BMI when using certain hormonal contraceptives, such as the skin patch and vaginal ring 3.
• A 2016 review found that the evidence generally did not indicate an association between higher BMI or weight and effectiveness of hormonal contraceptives, but the quality of evidence was considered low 4.
• A 2018 review emphasized the importance of considering the benefits, adverse effects, and risk factors associated with contraceptive methods in obese women, and recommended long-acting, reversible contraceptive methods as a superior option 5.
• A 2022 narrative review highlighted the synergistic effect of obesity and contraceptive use on cardiovascular risk, and recommended progestin-only products as a safer alternative to COCs in patients with overweight or obesity 7.

Implications for Practice

• Healthcare providers should consider the potential impact of obesity on the effectiveness of hormonal contraceptives when counseling patients 3, 4, 5, 6.
• Obese women should be advised to use long-acting, reversible contraceptive methods, which offer superior effectiveness and minimal risk 5.
• The use of COCs in obese women should be avoided due to the increased risk of venous thromboembolism, and progestin-only products should be considered as a safer alternative 7.