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Contraception - Management
How does obesity influence choice?

  • Body mass index >= 30–34 kg/m2
    • Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (IUS), barrier methods, and natural family planning.
    • Methods that can generally be used (advantages generally outweigh the risks): combined oral contraceptives (COCs), combined contraceptive patch, combined contraceptive vaginal ring.
    • Sterilization can be used with caution (i.e. extra preparation, precautions, and counselling).
    • There are no methods that should not be used (because of unacceptable risk).
  • Body mass index >= 35 kg/m2
    • Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper IUDs, the levonorgestrel-releasing IUS, barrier methods, and natural family planning.
    • Sterilization can be used with caution (i.e. extra preparation, precautions, and counselling).
    • Methods that are not usually recommended (risks usually outweigh the advantages): COCs, combined contraceptive patch, combined contraceptive vaginal ring.
  • In addition, note that:
    • Weight greater than 70 kg — the desogestrel-only pill, Cerazette®, should be considered in preference to other progesterone only pills.
    • Weight greater than 90 kg — the combined contraceptive patch should not be used.
    • 'Heavier women' — the progestogen-only contraceptive implant may need to be removed earlier than the licensed 3 years.
Basis for recommendation
  • Obesity
    • These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FSRH, 2009b] and the Summary of Product Characteristics (SPC) of Evra® transdermal contraceptive patch [ABPI Medicines Compendium, 2009a].
    • For women who are obese and use combined oral contraceptives (COCs), the combined contraceptive patch, or combined contraceptive vaginal ring, there is an increased risk of:
      • Venous thromboembolism: compared with non-users, but the absolute risk of thromboembolism is still small. The risk of venous thromboembolism increases with increasing body mass index, and the use of COCs increases this risk further.
      • Contraceptive failure: compared with women who are not obese, but the data on the impact of obesity on the effectiveness of COCs are limited.
    • Women who are obese are more likely to have complications when undergoing sterilization. There is an increased risk of wound infection and disruption.
  • POP and weight greater than 70 kg
    • The FFPRHC on reviewing the available evidence concluded that POPs may be less effective in women who weigh more than 70 kg (except for the desogestrel-only pill, Cerazette®) [FFPRHC, 2007c].
  • The progestogen-only contraceptive implant and obesity
    • The manufacturer states that the contraceptive effect of Implanon® is related to the plasma levels of etonogestrel, which are inversely related to body weight, and decrease with time after insertion. The clinical experience with Implanon® in heavier women in the third year of use is limited. Therefore it cannot be excluded that the contraceptive efficacy in these women during the third year of use may be lower than for women of normal weight. Clinicians may therefore consider earlier replacement of the implant in heavier women [ABPI Medicines Compendium, 2006].

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