Written by Catherine Casado-Pabon, MD

Body image and perception of weight gain influence both patients’ and clinicians’ contraception decision-making and counseling. Nearly half of women* using contraception will switch or discontinue their selected contraceptive method within the first year of use.¹ While there are many reasons people discontinue or change their contraceptive method as needs change over time, several systemic reviews conclude that negative perception of weight gain (among other physical side effects) is a common reason for contraception non-use or discontinuation.^2-4

While people may believe that hormonal contraceptives cause weight gain, the available evidence indicates that, apart from injectable medroxyprogesterone (DMPA), there is no direct link between hormonal contraceptive use and weight gain.^5,6 Combined hormonal contraceptives (pill, patch, and ring) do not have a statistically significant effect on weight regardless of hormone dosage or regimen; however, there is insufficient evidence for a definitive recommendation.^6,7 A 2016 Cochrane review demonstrated limited evidence of weight or body composition change with use of progestin-only contraceptives, including pills, injections (DMPA), the etonogestrel (ENG) implant, and the levonorgestrel intrauterine device (LNG-IUD).^8,9 Overall, most of these studies showed an associated mean weight gain of less than five pounds within one year of use across progestin-only contraceptives; the quality of this evidence was low to moderate.⁸ More recent studies show evidence of significant weight gain with DMPA use.^10-12 Reproductive-age women may gain up to 5.8% of their baseline body weight; with adolescents gaining significantly more weight than adults, independent of initial BMI.¹⁰

A BMI greater than thirty is not an absolute contraindication to any hormonal contraceptive method.¹³ Data on the safety and efficacy of hormonal contraceptive methods in those with a BMI greater than 40 is limited. A 2016 Cochrane review analyzing the effectiveness of hormonal contraceptives in pregnancy prevention among people with high BMI generally did not demonstrate lower contraception efficacy.¹⁴ Most contraceptive methods are safe and effective regardless of BMI, apart from the hormonal contraceptive patch, which carries an FDA-issued black box warning for use in people with a BMI greater than thirty due to decreased efficacy and higher risk for thromboembolism. The risk of thromboembolism with any estrogen-containing method must be considered when counseling patients with higher BMI.¹³

The current available evidence demonstrates that hormonal contraception, apart from DMPA, is not associated with statistically significant weight gain. More research is needed to draw definitive conclusions on the association between DMPA and weight gain across age, BMI, and race.¹⁵ Although evidence indicates that most hormonal contraception is weight-neutral, this may not reflect people’s lived experiences. Patient-centered contraceptive counseling prioritizes patients’ preferences, values, and satisfaction. Clinicians should provide evidence-based, person-centered contraceptive care regardless of body weight or size, and counsel about the potential for weight change with hormonal contraception.

*The studies cited in this Pearl use the term “women.” RHAP recognizes that this language is not inclusive of all people who seek care. A person’s biology does not determine their gender.

RHAP Resources:

Your Birth Control Choices Fact Sheet

Medical Eligibility Criteria for Initiating Contraception

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Sources:

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