What birth control options are suitable for a 19-year-old female with a weight of 222 pounds (obesity) and no other specified medical conditions?

Birth Control Recommendations for a 19-Year-Old Weighing 222 Pounds

For this 19-year-old patient weighing 222 pounds, I recommend starting with a long-acting reversible contraceptive (LARC) method—specifically either a levonorgestrel intrauterine device (LNG-IUD) or etonogestrel implant—as these provide the highest effectiveness regardless of weight and have minimal contraindications. 1, 2

Primary Recommendation: Long-Acting Reversible Contraceptives (LARCs)

Why LARCs Are Optimal

• LNG-IUD and implants have failure rates of less than 1% per year, making them the most effective reversible contraceptive methods available 3
• Weight does not affect the efficacy of LARCs, unlike some other hormonal methods 1
• No daily adherence required, eliminating the most common cause of contraceptive failure 3
• Can be initiated anytime if reasonably certain the patient is not pregnant 1

Specific LARC Options

LNG-IUD:

• Requires abstinence or barrier methods for 7 days if inserted >7 days after menses started 1
• Requires bimanual examination and cervical inspection before placement 1, 2
• No blood pressure measurement needed 2
• Provides contraception for 3-8 years depending on the device 1

Etonogestrel Implant:

• Requires abstinence or barrier methods for 7 days if inserted >5 days after menses started 1
• No examination required before initiation 1, 2
• Provides contraception for 3 years 1

Alternative Options If LARCs Are Declined

Depot Medroxyprogesterone Acetate (DMPA)

• Effective injectable contraceptive given every 3 months (13 weeks) with a 12-month failure rate of 0-0.7% 4
• Weight does not affect efficacy—dosage does not need adjustment for body weight 4
• Requires abstinence or barrier methods for 7 days if given >7 days after menses started 1
• No examination required before initiation 1
• Important caveat: Consider bone mineral density concerns with long-term use, particularly in adolescents 4

Combined Hormonal Contraceptives (CHCs)

Critical weight consideration: At 222 pounds, this patient exceeds the weight threshold where certain CHC methods show reduced efficacy:

• The transdermal patch has higher failure rates in women weighing >198 pounds (0.9% vs 0.3% in first 12 months) 1
• The patch should be avoided in this patient due to both reduced efficacy and 1.6 times higher estrogen exposure than low-dose oral contraceptives 1

If CHCs are chosen, use low-dose combined oral contraceptives:

• Require blood pressure measurement before initiation 1, 2
• Require abstinence or barrier methods for 7 days if started >5 days after menses started 1
• Typical use failure rate of 4-7% per year 3
• Pills containing levonorgestrel or norethisterone with ≤35 mcg ethinyl estradiol are first-line 5

Progestin-Only Pills (POPs)

• Norethindrone or norgestrel POPs: Require barrier methods for 2 days if started >5 days after menses 1
• Drospirenone POP: Requires barrier methods for 7 days if started >1 day after menses 1
• No examination required before initiation 1
• Important limitation: Require very stringent daily adherence, leading to higher failure rates than other hormonal methods 1

Copper Intrauterine Device (Cu-IUD)

• Highly effective non-hormonal option with no systemic effects 2
• Can be initiated anytime with no backup contraception needed 1
• Requires bimanual examination and cervical inspection 1, 2
• Provides contraception for up to 10 years 6
• Consider if patient has contraindications to hormonal methods (e.g., history of venous thromboembolism) 2, 6

Emergency Contraception Considerations

This patient's weight significantly impacts emergency contraception efficacy:

• Levonorgestrel emergency contraception may be less effective in women weighing >165 pounds 1
• Ulipristal acetate (UPA) is more effective than levonorgestrel in women weighing >165 pounds 1
• Copper IUD placement is the most effective emergency contraception method with <1% failure rate and can be used within 5 days of unprotected intercourse 1

Common Pitfalls to Avoid

• Do not prescribe the transdermal patch to patients weighing >198 pounds due to reduced efficacy 1
• Do not delay IUD placement for STI screening results if the patient has no visible purulent cervicitis 2
• Do not assume all hormonal methods have equal efficacy across weight ranges—weight affects some methods more than others 1
• Do not overlook counseling about expected bleeding changes with hormonal methods, as this affects adherence 7

Pre-Initiation Requirements Summary

• Blood pressure measurement: Required only for CHCs 1, 2
• Bimanual examination and cervical inspection: Required only for IUD placement 1, 2
• No examination needed: For implant, DMPA, or POPs 1
• STI screening: Perform if risk factors present, but do not delay contraception initiation 2