Contraception for obese and super obese women

1.
Obesity continues to be a major public health concern across the globe.
2.
The prevalence of obesity has doubled over the past 30 years with 15% of women worldwide classified as obese as of 2014.
3.
It is reported that obese women have less contraceptive usage, more contraceptive failure, and lower intake of preconceptional folic acid, which can greatly compromise prepregnancy and pregnancy care.
4.
Prevention of untimed pregnancy in obese women is a major priority for health care professionals.

4.1 Risks associated with obesity during pregnancy

Maternal obesity is linked with a range of serious maternal and foetal outcomes

1.
Metabolic syndrome
2.
Diabetes mellitus
3.
Essential hypertension
4.
Cardiovascular disease including myocardial infarction,
5.
Venous thromboembolism
6.
Breast cancer
7.
Endometrial cancer
8.
Changes in the metabolism of sex steroids used in hormonal contraception
9.
May influence half-life, clearance (area under the curve), and time to reach steady state

1.
Obesity can have profound effects on different physiologic processes, including absorption, distribution, metabolism, and excretion of contraceptive drugs.
2.
Obesity is also associated with altered body composition with an increase in fat mass, which can affect the distribution of hydrophilic and lipophilic drugs.
3.
Other physiological alterations in obesity that can have a potential impact in contraceptive drug metabolism and excretion include increased splanchnic and renal flow.
4.
In spite of all the potential mechanisms by which obesity could affect contraceptive efficacy, there have been few studies to date that have investigated the pharmacokinetics of contraceptive steroids in obese women.

1.
In one study, the half-life of levonorgestrel (LNG) in obese subjects was twice that of normal BMI subjects.
2.
In one study of oral contraceptives, obese women had a lower area under curve and lower maximum value for ethinylestradiol than normal weight women.
3.
In a longitudinal study of depot Medroxy progesterone (DMPA) in different classes of obese women, median MPA was consistently lowest among class 111 obese women, but above the levels needed to inhibit ovulation.
4.
European Society of Contraception has concluded that there is no robust evidence for decreased efficacy of different contraceptive methods in overweight or obese women.

1.
Historically, overweight and obese women have been excluded from trials in contraception, leading to a lack of robust evidence.
2.
As a generalisation, women tend to blame contraception for weight gain. This perceived weight gain is a leading cause of discontinuation of contraception at least in some parts of the world.
3.
Obesity doubles the risk of venous thromboembolism as compared with someone with a normal BMI.
4.
In principle, choice for contraception should take account of possible adverse metabolic effects associated with various hormonal methods of contraception,
5.
Procedure-dependent contraceptive methods [intrauterine devices (IUDs) and sterilisation] are technically more challenging to perform in an obese woman than their normal BMI counterparts.

1.
Many women and clinicians worldwide believe that an association exists between weight gain and oral contraceptives.
2.
Perception about weight gain can also lead to early discontinuation among users of contraception.
3.
More importantly, most of those who discontinued, failed to adopt another method of contraception, exposing themselves to an increased risk of pregnancy,
4.
Weight gain is due to one of the following factors: fluid retention, fat deposition, or muscle mass.
5.
A causal relationship between combined oral contraceptives and weight gain has not been clearly established.
6.
Progestogen-only contraception is ideally suited for women who have contraindications to or who are unable to tolerate oestrogens.
7.
There is limited evidence for weight gain when using progestogen-only contraception.

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