Weight Change and Hormonal Contraception: Fact and Fiction

Mags E Beksinska; Jenni A Smit; Franco Guidozzi

Expert Rev of Obstet Gynecol. 2011;6(1):45-56.

Abstract and Introduction

Abstract

Weight gain is commonly cited as a side effect of hormonal contraception, and may lead to discontinuation or reluctance to initiate. This view is widely held among clients and providers. Combination contraceptives are not associated with weight gain, although among users of depot-medroxyprogesterone acetate weight gain may occur, which may be limited to adolescent users who are overweight or obese at initiation of depot-medroxyprogesterone acetate. Users who rapidly gain weight initially may also be at higher risk of greater weight increase. There is limited information on other progestin-only methods. Women who request contraceptive methods need reassurance and advice from providers to allay their fears of weight gain. The providers, in turn, need to be aware of the available evidence.

Introduction

Weight change can occur through gains and losses in fat deposition and body fluids. These changes can be caused by alterations in dietary habits, physical activity, illness, psychological factors, aging and lifestyle factors. Hormonal contraception use has been implicated in weight changes, particularly in weight gain. Weight gain is commonly cited as a side effect of hormonal contraceptives by clients and providers, and is one of the frequent reasons given for method discontinuation.^[1–11] The role of progestins and estrogens in hormonal contraception, and the possible mechanisms through which weight change could occur, are complex.^[12,13] However, a recent Cochrane systematic review found that there was insufficient evidence to determine the effect of combination contraceptives on weight.^[14] The data on progestogen-only contraceptives have produced conflicting results, with many studies reporting weight gain in depot-medroxyprogesterone acetate (DMPA) users,^[15–28] while fewer have found no significant weight gains compared with other hormonal method users, or nonuser controls.^[29–32] The main body of literature on weight and hormonal contraception is concentrated on combined oral contraceptives (COCs) and DMPA, with patchy data on other hormonal methods.

This article summarizes the evidence of the effect of hormonal contraceptive use and weight change for each hormonal contraceptive method available. This article also highlights gaps and limitations in research, and considers how perceptions of weight gain may have developed over time and have affected continuation of hormonal methods.

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Table 1. Evidence for depot-medroxyprogesterone acetate and weight change from trials including comparative groups.
Authors (year), location	Study design	Population	Weight measure	Results	Limitations	Ref.
DMPA-IM
WHO (1983), multicentered international study at 13 sites	RCT, women assigned to either DMPA-IM or NET-EN; follow-up: 2 years	1587 adult subjects recruited	Weight (kg) at every visit	Mean change in weight: DMPA 1 year: +1.9 kg; 2 years: +3.3 kg NET-EN 1 year: +1.7kg; 2 years: +3.3 kg	Lack of nonhormonal control group No information on BMI at baseline	[3]
Rissir et al. (1999), USA	Retrospective 1-year chart review	130 adolescents; mean age 16.6 years (44 DMPA; 86 OC)	Weight (kg) and BMI	Mean change in weight: DMPA 1 year: +3.0 kg COC 1 year: +1.3 kg Women gaining >5% of baseline weight at 3 months were at higher risk of more weight gain at 1 year	No follow-up of discontinuers; lack of nonhormonal control group	[23]
Bahamondes et al. (2001), Brazil	Prospective study, DMPA-IM and IUD users; new initiators matched by weight; follow-up: 5 years	206 adults; mean age 33 years (103 DMPA; 103 IUD)	Weight (kg) at end of each year of use analyzed	Mean change in weight: DMPA 5 years: +4.3 kg IUD 5 years: +1.8 kg	No follow-up of discontinuers	[15]
Mangan et al. (2002), USA	Retrospective 1-year chart review	239 adolescents; age 12–19 years (117 DMPA; 122 COC)	Weight (Ibs) and BMI	Mean weight gain: DMPA: +8.9 Ibs COC: +4.9 Ibs Initial overweight DMPA group gained more than not overweight DMPA group	Lack of nonhormonal control group No follow-up of discontinuers	[27]
Clark et al. (2005), USA	Prospective 30-month cohort study	323 adults; age 18–35 years (178 DMPA; 145 nonhormonal controls)	Weight (kg) and BMI; total fat and lean mass measures using DEXA	Mean weight change: DMPA 30 months: +6.1 kg; no change in control group DMPA users increased in all fat measures compared with no change in controls	[17]
Bonny et al. (2006), USA	Prospective 18-month cohort study	450 adolescents; age 12–18 years (115 DMPA; 17 COC; 160 nonhormonal controls)	Weight (kg) and BMI at each visit, baseline weight stratified by obesity status (<30 kg/m²: non-obese; ≥30 kg/m²: obese	Weight change at 18 months in obese groups: DMPA: +9.4 kg COC: +0.2 kg Control: +3.1 kg Weight change at 18 months in non-obese groups: DMPA: +4.0 kg COC: +2.8 kg Control: +3.5 kg	High discontinuation and method-switching rates	[26]
Berenson et al. (2009), USA	Prospective 36-month cohort study	703 adults; mean age 24.3 years (240 DMPA; 245 COC; 218 nonhormonal controls)	Weight (kg) and BMI, total fat and lean mass measures using DEXA	Weight change at 36 months: DMPA: +5.1 kg COC: +1.47 kg Control: +2.05 kg DMPA users had increases in body fat compared with no change in COC and control groups DMPA discontinuers lost 0.42 kg over 6 months	High discontinuation and method-switching rates	[18]
Pantoja et al. (2010), Brazil	Retrospective cohort study	379 adult current or past DMPA compared with 1074 IUD users matched by age and BMI	Weight (kg) and BMI	Weight increased in more in the normal and overweight IUD users compared with IUD users; obese DMPA and IUD users did not increase in weight	No information on women who discontinued over the same time period	[22]
Beksinska et al. (2010)	Prospective cohort study	487 adolescents; aged 15–19 years (115 DMPA; 115 NET-EN; 116 COCs; 144 nonhormonal controls)	Weight (kg) and BMI measured every 6 months Baseline weight stratified by obesity status (normal: 18.5–24.9 kg/m²; overweight: 25.0–29.9 kg/m²; obese: >30 kg/m²)	Weight change at 5 years in DMPA, NET-EN or switchers between: DMPA/NET-EN: +6.2 kg COC: +2.3 kg Nonusers: +2.8 kg No evidence in difference between obese and non-obese at baseline with subsequent weight change	High discontinuation and method-switching rates	[28]
DMPA-SC
Westhoff et al. (2007), North/South America	Data from one 36-month comparative RCT (DMPA-IM and DMPA-SC) clinical trial	534 adult women; aged 18–49 years (268 DMPA-IM; 266 DMPA-SC)	Weight and BMI measured every 3 months	Weight change at 36 months: DMPA-IM: +5.8 kg DMPA-SC: +4.5 kg No difference in weight gain by BMI baseline category	Lack of nonhormonal control group	[63]

COC: Combined oral contraceptive; DEXA: Dual-energy x-ray absorptiometry; DMPA: Depot-medroxyprogesterone acetate; DMPA-IM: DMPA-intramuscular; DMPA-SC: DMPA-subcutaneous; IUD: Intrauterine device; NET-EN: Norethisterone enanthate; OC: Oral contraceptive; RCT: Randomized controlled trial.

Box 1. Response to weight change in the Family Planning Global Handbook for Providers.
"Most women do not gain or lose weight due to COCs. Weight changes naturally as life circumstances change and as people age. Because these changes in weight are so common, many women think that COCs cause these gains or losses in weight. Studies find, however, that on average, COCs do not affect weight. A few women experience sudden changes in weight when using COCs. These changes reverse after they stop taking COCs. It is not known why these women respond to COCs in this way."
COC: Combined oral contraceptive. Taken from [39].

Box 2. Weight change advice for the progestogen-only injectable contraceptive in the Family Planning Global Handbook for Providers.
"Women gain an average of 1–2 kg per year when using DMPA-IM. Some of the weight increase may be the usual weight gain as people age. Some women, particularly overweight adolescents, have gained much more than 1–2 kg per year. At the same time, some users of progestin-only injectables lose weight or have no significant change in weight. Asian women in particular do not tend to gain weight when using DMPA."
DMPA: Depot-medroxyprogesterone acetate; DMPA-IM: DMPA-intramuscular. Taken from [39].

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