What is the best contraception method for a 39-year-old individual with a Body Mass Index (BMI) of 36?

Best Contraception Method for a 39-Year-Old with BMI 36

For a 39-year-old individual with a BMI of 36, a long-acting reversible contraceptive (LARC) method, particularly the copper intrauterine device (Cu-IUD) or levonorgestrel intrauterine device (LNG-IUD), is the most effective and safest contraceptive option.

Contraceptive Options for Obese Individuals

Long-Acting Reversible Contraceptives (LARCs)

• LARCs are the most effective reversible contraceptive methods with failure rates less than 1% 1
• Weight and BMI measurements are not needed to determine medical eligibility for any contraceptive methods as all methods can be used (U.S. MEC 1) or generally can be used (U.S. MEC 2) among patients with obesity (BMI ≥30 kg/m²) 1
• The subcutaneous implant has the lowest failure rate (0.05%) among all contraceptive methods 1

Intrauterine Devices (IUDs)

• The copper T-380A IUD has a remarkably low failure rate of less than 1 per 100 women in the first year of use 2
• The Cu-IUD can be used for up to 10 years and is hormone-free, making it an excellent option for women with obesity 1, 2
• The LNG-IUD is effective for 3-5 years and has the added benefit of reducing or eliminating menstrual bleeding 1
• IUDs do not show reduced effectiveness in women with higher BMI 3

Injectable Contraceptives

• Depot medroxyprogesterone acetate (DMPA) effectiveness is not associated with higher BMI or weight 3
• DMPA can be started at any time with no examinations or tests needed before initiation 1

Combined Hormonal Contraceptives (CHCs)

• Some studies suggest variable effectiveness of combined hormonal contraceptives in overweight or obese women 3
• One study found higher pregnancy risk for overweight women using norethindrone acetate and ethinyl estradiol, while another found no pregnancies in obese women using levonorgestrel and ethinyl estradiol 3

Specific Recommendations for a 39-Year-Old with BMI 36

First-Line Options:

• Copper IUD (Cu-IUD):

  • Most effective emergency contraception method (>95% prevention) 4
  • No hormonal side effects 2
  • Can be used for up to 10 years 2
  • No reduction in effectiveness with obesity 3
  • Can be inserted at any time during the menstrual cycle 1

• Levonorgestrel IUD (LNG-IUD):

  • Highly effective with failure rates <1% 1
  • Reduces menstrual bleeding, which can be beneficial 1
  • Can be inserted at any time during the menstrual cycle 1
  • No reduction in effectiveness with obesity 3

Second-Line Options:

• Contraceptive Implant:

  • Highly effective (0.05% failure rate) 1
  • Can be inserted at any time during the menstrual cycle 1
  • Minimal to no bone loss 1

• DMPA Injection:

  • Effectiveness not impacted by BMI 3
  • Can be started at any time 1

Considerations for Emergency Contraception

• The copper IUD is the most effective emergency contraception method, preventing over 95% of unwanted pregnancies when inserted within 5 days of unprotected intercourse 4, 5
• Ulipristal acetate may be more effective than levonorgestrel in women who are overweight or obese 6, 7
• Emergency contraceptive pills can be less effective in obese women 7

Practical Implementation

• For IUD insertion, a bimanual examination and cervical inspection are needed 1
• Most patients do not require additional STI screening at the time of IUD placement unless they have risk factors for STIs 1
• After IUD placement, no additional contraception is needed with the Cu-IUD, while abstinence or barrier methods are recommended for 7 days after LNG-IUD insertion if placed >7 days after menses started 1

Common Pitfalls and Caveats

• The most common reasons for discontinuation of Cu-IUD are menstrual bleeding and dysmenorrhea 2
• Despite this, cumulative discontinuation rates of Cu-IUD are lower than reported for other methods 2
• After 5 years, approximately 50% of women with a Cu-IUD continue to use this method 2
• For the LNG-IUD, irregular bleeding may occur initially but often improves over time with many users experiencing lighter periods or amenorrhea 1