Answering your questions on DMPA use and weight

Should a woman who is obese and continues to gain weight on Depo-Provera [depot medroxyprogesterone acetate (DMPA), Pfizer, New York City] be allowed to continue its use if she so desires? Are providers contributing to the health risk of obesity by allowing a woman to do so?

These questions are addressed by two members of the Contraceptive Technology Update editorial advisory board: Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta, and Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville.

Hatcher: You raise several very important questions:

  • How much weight gain is to be expected in Depo-Provera patients?
  • How much is too much weight gain?
  • Are we neglecting major amounts of weight gain in our Depo patients?
  • What should be our approach to weight gain when we see it happening?

The Depo-Provera package insert informs each clinician prescribing and each woman using it that after one year, the average weight gain is 5.4 pounds; and after five years, the average gain is 16.5 pounds.1

In my opinion, and all do not agree with me, we need to become quite concerned when a woman gains 10, 20, and then 30 pounds, and we need to counsel her repeatedly that this weight gain may be in part related to her use of Depo, that it should not continue indefinitely, that she should consider switching to other methods, and that there are a number of approaches to losing weight that should become a priority for her.

Seldom is it wise to categorically refuse to give Depo-Provera against the patient’s wishes (even after 40, 50, or 60 pounds of weight gain). Better to get her to consider an effective alternative. Refusal to provide Depo can lead, of course, to an unwanted pregnancy.

Do these approaches make sense to you? This is such a tough problem.Unfortunately, we see so many very overweight patients that we occasionally fail to realize that it is a drug we have administered that has caused one of our patients to increase from an acceptable initial weight of 125 to 175 pounds, for example.

Kaunitz: One component of this clinical case relates to the question: What impact does DMPA use have on weight? Because no large randomized clinical trials address the impact (if any) that use of DMPA has on weight, this issue continues to be surrounded by controversy.

What seems likely is that some women who use DMPA contraception have an intrinsically higher risk for weight gain than do women who choose to use other birth control methods.2

A second component of this question relates to the safety of DMPA use by overweight women. Obesity represents an independent risk factor for venous thromboembolic disease (VTE). In addition, obesity in the setting of pregnancy is associated with higher maternal risks. Use of combination estrogen-progestin contraceptives increases VTE risk, while use of progestin-only methods (notwithstanding outdated package labeling for many progestin-only medications) does not increase VTE risk, and therefore is safe in high-risk women.

Finally, it is possible, but certainly not proven, that the efficacy of combination oral contraceptives is reduced in obese women.

Putting all of the above observations together, this woman’s obesity should be addressed focusing on conventional lifestyle recommendations (e.g., exercise and diet). Given her obesity, ongoing DMPA use strikes me as a particularly appropriate contraceptive choice from the perspectives of safety and efficacy.

References

1. Schwallie PC, Assenzo JR. Contraceptive use — efficacy study utilizing medroxyprogesterone acetate administered as an intramuscular injection once every 90 days. Fertil Steril 1973; 24:331-339.

2. Westhoff C. Depot-medroxyprogesterone acetate injection (Depo-Provera): A highly effective contraceptive option with proven long-term safety. Contraception 2003; 68:75-87.