Updated Guidelines on Contraception Choice and Body Weight

As family doctors, we often provide contraception care for our patients and they ask many questions about what is the best choice for them. There are many factors that may contribute to our discussion with our patients, a patient’s body weight being just one of them.

We all know that some contraception methods have been shown to be less effective in patients with a body mass index (BMI) over 30. Additionally, many hormonal therapies are known to contribute to weight gain.

 

In August 2024, the Society of Family Planning set forth guidelines regarding contraception and body weight. The authors suggest that BMI may not be the best measure to use to reflect body size but suggest that it is the best we have. They state that we should refrain using the classification names contained within the BMI system: “healthy weight,” “obese,” etc. They caution against stigmatizing patients and bringing our own biases into the discussion.

It should be noted that no contraceptive method is contraindicated based on a patient’s body size. However, physicians should use evidence-based information to reach a shared decision with the patient. This should include risks based on body weight/size and its effect on contraception.

Although oral contraceptive pills (OCPs) affect the way steroid hormones are processed, efficacy is thought to be the same in all patients regardless of weight. Most contraception failures in patients taking OCPs are the result of incorrect use of the medication. It is important to note that in women with BMIs greater than 30 the risk of venous thromboembolism is increased with combined hormonal contraceptives. 

It is suggested that women with BMIs greater than 30 avoid hormonal transdermal patches because of higher rates of contraception failure. Vaginal rings have not been adequately studied regarding their effectiveness in patients with BMIs greater than 30.

Contraceptive implants are another good choice for women with BMIs greater than 30. Despite the serum level of etonogestrel being lower than in women with BMIs under 30, most remained high enough to suppress ovulation. IUDs and depo medroxyprogesterone shots also appear to be effective in those with higher BMIs, although there is a slight increased risk of venous thromboembolism in those utilizing depo medroxyprogesterone shots.

It is important for us to be very familiar with all methods of contraception and we need to be comfortable discussing the options with our patients. If a patient desires contraception to avoid pregnancy, she must be informed when effectiveness may be reduced. We also need to be aware of the side effects and let our patients know what to expect. They need as much data as possible to make an informed decision about which method they choose. We may not agree with their decision, but if a patient is aware of what may happen, it is her choice to make.

Many women feel uncomfortable bringing up the discussion of contraception. We need to address this with women of child-bearing age. Often, broaching the topic will open the door to a whole host of concerns. Women with overweight may avoid seeking care because they were made uncomfortable in the medical setting or were made to feel stigmatized. We will never fix the obesity epidemic in the United States if our patients avoid coming into the office.

The guidelines also discuss contraception choices that may lead to weight gain. The medication alone may not be responsible but rather it is a combination of genetic, environmental, and lifestyle factors. Along with the warning about weight gain, we should be counseling our patients regarding their lifestyle choices, such as diet and exercise.

The authors of this guideline paper do a great job exploring each contraception method for women with BMI over 30. However, many factors go into deciding which choice is the best for an individual patient. A patient may do poorly at taking pills every day. Another may dislike the concept of inserting a vaginal ring. Each patient should be approached individually and all these factors need to be taken into consideration. Weight is an important factor to consider, but there are many others. If we fail to acknowledge the complexity of our patients, we can never do our best for them.

 

Dr. Girgis is a family medicine practitioner, South River, New Jersey, and clinical assistant professor of family medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

As family doctors, we often provide contraception care for our patients and they ask many questions about what is the best choice for them. There are many factors that may contribute to our discussion with our patients, a patient’s body weight being just one of them.

We all know that some contraception methods have been shown to be less effective in patients with a body mass index (BMI) over 30. Additionally, many hormonal therapies are known to contribute to weight gain.

 

In August 2024, the Society of Family Planning set forth guidelines regarding contraception and body weight. The authors suggest that BMI may not be the best measure to use to reflect body size but suggest that it is the best we have. They state that we should refrain using the classification names contained within the BMI system: “healthy weight,” “obese,” etc. They caution against stigmatizing patients and bringing our own biases into the discussion.

It should be noted that no contraceptive method is contraindicated based on a patient’s body size. However, physicians should use evidence-based information to reach a shared decision with the patient. This should include risks based on body weight/size and its effect on contraception.

Although oral contraceptive pills (OCPs) affect the way steroid hormones are processed, efficacy is thought to be the same in all patients regardless of weight. Most contraception failures in patients taking OCPs are the result of incorrect use of the medication. It is important to note that in women with BMIs greater than 30 the risk of venous thromboembolism is increased with combined hormonal contraceptives. 

It is suggested that women with BMIs greater than 30 avoid hormonal transdermal patches because of higher rates of contraception failure. Vaginal rings have not been adequately studied regarding their effectiveness in patients with BMIs greater than 30.

Contraceptive implants are another good choice for women with BMIs greater than 30. Despite the serum level of etonogestrel being lower than in women with BMIs under 30, most remained high enough to suppress ovulation. IUDs and depo medroxyprogesterone shots also appear to be effective in those with higher BMIs, although there is a slight increased risk of venous thromboembolism in those utilizing depo medroxyprogesterone shots.

It is important for us to be very familiar with all methods of contraception and we need to be comfortable discussing the options with our patients. If a patient desires contraception to avoid pregnancy, she must be informed when effectiveness may be reduced. We also need to be aware of the side effects and let our patients know what to expect. They need as much data as possible to make an informed decision about which method they choose. We may not agree with their decision, but if a patient is aware of what may happen, it is her choice to make.

Many women feel uncomfortable bringing up the discussion of contraception. We need to address this with women of child-bearing age. Often, broaching the topic will open the door to a whole host of concerns. Women with overweight may avoid seeking care because they were made uncomfortable in the medical setting or were made to feel stigmatized. We will never fix the obesity epidemic in the United States if our patients avoid coming into the office.

The guidelines also discuss contraception choices that may lead to weight gain. The medication alone may not be responsible but rather it is a combination of genetic, environmental, and lifestyle factors. Along with the warning about weight gain, we should be counseling our patients regarding their lifestyle choices, such as diet and exercise.

The authors of this guideline paper do a great job exploring each contraception method for women with BMI over 30. However, many factors go into deciding which choice is the best for an individual patient. A patient may do poorly at taking pills every day. Another may dislike the concept of inserting a vaginal ring. Each patient should be approached individually and all these factors need to be taken into consideration. Weight is an important factor to consider, but there are many others. If we fail to acknowledge the complexity of our patients, we can never do our best for them.

 

Dr. Girgis is a family medicine practitioner, South River, New Jersey, and clinical assistant professor of family medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

As family doctors, we often provide contraception care for our patients and they ask many questions about what is the best choice for them. There are many factors that may contribute to our discussion with our patients, a patient’s body weight being just one of them.

We all know that some contraception methods have been shown to be less effective in patients with a body mass index (BMI) over 30. Additionally, many hormonal therapies are known to contribute to weight gain.

 

In August 2024, the Society of Family Planning set forth guidelines regarding contraception and body weight. The authors suggest that BMI may not be the best measure to use to reflect body size but suggest that it is the best we have. They state that we should refrain using the classification names contained within the BMI system: “healthy weight,” “obese,” etc. They caution against stigmatizing patients and bringing our own biases into the discussion.

It should be noted that no contraceptive method is contraindicated based on a patient’s body size. However, physicians should use evidence-based information to reach a shared decision with the patient. This should include risks based on body weight/size and its effect on contraception.

Although oral contraceptive pills (OCPs) affect the way steroid hormones are processed, efficacy is thought to be the same in all patients regardless of weight. Most contraception failures in patients taking OCPs are the result of incorrect use of the medication. It is important to note that in women with BMIs greater than 30 the risk of venous thromboembolism is increased with combined hormonal contraceptives. 

It is suggested that women with BMIs greater than 30 avoid hormonal transdermal patches because of higher rates of contraception failure. Vaginal rings have not been adequately studied regarding their effectiveness in patients with BMIs greater than 30.

Contraceptive implants are another good choice for women with BMIs greater than 30. Despite the serum level of etonogestrel being lower than in women with BMIs under 30, most remained high enough to suppress ovulation. IUDs and depo medroxyprogesterone shots also appear to be effective in those with higher BMIs, although there is a slight increased risk of venous thromboembolism in those utilizing depo medroxyprogesterone shots.

It is important for us to be very familiar with all methods of contraception and we need to be comfortable discussing the options with our patients. If a patient desires contraception to avoid pregnancy, she must be informed when effectiveness may be reduced. We also need to be aware of the side effects and let our patients know what to expect. They need as much data as possible to make an informed decision about which method they choose. We may not agree with their decision, but if a patient is aware of what may happen, it is her choice to make.

Many women feel uncomfortable bringing up the discussion of contraception. We need to address this with women of child-bearing age. Often, broaching the topic will open the door to a whole host of concerns. Women with overweight may avoid seeking care because they were made uncomfortable in the medical setting or were made to feel stigmatized. We will never fix the obesity epidemic in the United States if our patients avoid coming into the office.

The guidelines also discuss contraception choices that may lead to weight gain. The medication alone may not be responsible but rather it is a combination of genetic, environmental, and lifestyle factors. Along with the warning about weight gain, we should be counseling our patients regarding their lifestyle choices, such as diet and exercise.

The authors of this guideline paper do a great job exploring each contraception method for women with BMI over 30. However, many factors go into deciding which choice is the best for an individual patient. A patient may do poorly at taking pills every day. Another may dislike the concept of inserting a vaginal ring. Each patient should be approached individually and all these factors need to be taken into consideration. Weight is an important factor to consider, but there are many others. If we fail to acknowledge the complexity of our patients, we can never do our best for them.

 

Dr. Girgis is a family medicine practitioner, South River, New Jersey, and clinical assistant professor of family medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.