Letters to the Editor

Effects of Contraceptives on Weight Gain or Loss

 

Am Fam Physician. 2017 Dec 15;96(12):online.

Original Article: Update on Office-Based Strategies for the Management of Obesity

Issue Date: September 1, 2016

See additional reader comments at: http://www.aafp.org/afp/2016/0901/p361.html

to the editor: In their article, Erlandson and colleagues do a good job of providing physicians with up-to-date and practical information on the outpatient management of obesity. However, in Table 4 in the row for hormones, progestins are incorrectly labeled as weight negative and estrogens are incorrectly labeled as weight positive. In a recent Cochrane review, progestin-only contraceptives (POCs) were found to be weight neutral or modestly weight positive (weight gain of about 4.4 lb [2 kg] over six to 12 months).1 Another study looking specifically at injectable progestin-only contraceptives (i.e., medroxyprogesterone [Provera]) shows more robust weight gain of 13.7 lb (6.2 kg) over five years.2  In addition to weight effects, many obese females on progestin-only contraceptives struggle with hyperandrogenic symptoms such as acne, facial hair, and dyslipidemia. These effects can be exacerbated depending on the generation of progestin used, with third-generation progestins being the most advantageous (Table 1).

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Table 1.

Progestinic and Androgenic Effects of Contraceptives

GenerationMedicationEffect

First

Norethindrone

Androgenic

Second

Levonogesterel

Most androgenic

Third

Norgestimate (Ortho-Cyclen)

Nonandrogenic

Table 1.

Progestinic and Androgenic Effects of Contraceptives

GenerationMedicationEffect

First

Norethindrone

Androgenic

Second

Levonogesterel

Most androgenic

Third

Norgestimate (Ortho-Cyclen)

Nonandrogenic

Estrogens are generally not considered weight-positive medications. In a Cochrane review of 49 trials, mixed oral contraceptives and contraceptive patches were found to be weight neutral.3 Compared with a sham method, oral contraceptives and patches did not lead to additional weight gain, a perception of additional weight gain, nor discontinuation because of weight gain.3 Family physicians should reassure their female patients about the generally weight-neutral effects of these medications. The optimal oral contraceptive for an obese patient would be an estrogen plus third-generation progestin.

Author disclosure: No relevant financial affiliations.

REFERENCES

1. Lopez LM, Ramesh S, Chen M, et al. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev. 2016;(8):CD008815.

2. Beksinska ME, Smit JA, Kleinschmidt I, Milford C, Farley TM. Prospective study of weight change in new adolescent users of DMPA, NET-EN, COCs, non-users and discontinuers of hormonal contraception. Contraception. 2010;81(1):30–34.

3. Gallo MF, Lopez LM, Grimes DA, Carayon F, Schulz KF, Helmerhorst FM. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2014;(1):CD003987.

in reply: I would like to thank Dr. Virji for his comments regarding the effect of estrogens and progestins on weight. Estrogens and progestins are hormonal agents that are used in a wide range of doses and combinations and for multiple indications, making generalizations about their effects difficult. Our characterization of these medications was taken from the Obesity Medicine Association's obesity algorithm, which has been updated recently to include potential weight gain with progestins.1 I agree that the cited reviews show limited effect on weight when these agents are used for contraception, despite common perceptions. In addition, systematic reviews have shown that postmenopausal hormone therapy, including unopposed estrogen and combination therapy, has no effect on weight.2,3 It does seem appropriate to classify estrogens and progestins as weight neutral, with progestins having the potential to be mildly weight positive. This is consistent with the Endocrine Society's 2015 clinical practice guideline that recommends choosing an oral contraceptive over an injectable option in women with a body mass index greater than 27 kg per m2 or greater than 30 kg per m2 in those with comorbidities.4

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Obesity Medicine Association. Obesity algorithm [registration required]. https://obesitymedicine.org/obesity-algorithm. Accessed April 25, 2017....

2. Casanova G, Bossardi Ramos R, Ziegelmann P, Spritzer PM. Effects of low-dose versus placebo or conventional-dose postmenopausal hormone therapy on variables related to cardiovascular risk: a systematic review and meta-analyses of randomized clinical trials. J Clin Endocrinol Metab. 2015;100(3):1028–1037.

3. Norman RJ, Flight IH, Rees MC. Oestrogen and progestogen hormone replacement therapy for peri-menopausal and post-menopausal women: weight and body fat distribution. Cochrane Database Syst Rev. 2000;(2):CD001018.

4. Apovian CM, Aronne LJ, Bessesen DH, et al.; Endocrine Society. . Pharmacological management of obesity: an Endocrine Society clinical practice guideline [published correction appears in J Clin Endocrinol Metab. 2015;100(5):2135–2136]. J Clin Endocrinol Metab. 2015;100(2):342–362.

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