Human Reproduction Update 2000, Vol. 6, No. 5 pp.

427431

European Society of Human Reproduction and Embrology

Weight gain on the combined pillis it real?

Sunanda Gupta1
Forest Healthcare NHS Trust, Hurst Road Health Centre, Off Forest Road, Walthamstow E17 3BL, UK

Britain has one of the highest teenage pregnancy rates in Western Europe at 8.8 per 1000 live births. Adolescents are
very preoccupied with body image and fear weight gain with use of the combined oral contraceptive (COC) pill.
Compliance with contraception continues to be a major issue. Is there a real evidence of weight gain? Or are there
discrepancies between adolescent perceptions of weight gain with COC use and available scientic evidence? We
carried out a comprehensive literature search and did not nd evidence for the purported weight gain with use of low
dose COCs. Adolescents need reassurance by gynaecologists, general practitioners, family planning doctors and mass
media to remove such misperceptions. This will contribute in some way to reduce the high unintended pregnancy
rates.
Key words: adolescent/combined oral contraceptive pill/weight gain

TABLE OF CONTENTS
Introduction
Literature search
Non-comparative studies
Comparative studies
Double-blind studies
Discussion
Conclusions
References

Introduction
Britain has one of the highest teenage pregnancy rates in Western
Europe at 8.8 per 1000 live births (Birth Statistics, 1998). The
Governments sexual health strategy document (Social Exclusion
Unit, 1999) aims to reduce the teenage pregnancy rates by 50% by
the year 2010. The reasons for an unintended pregnancy in
adolescence are patchy sex education, poor parental guidance/
involvement, lack of something better to do, use of mass media
and peers as a source of information about sexuality and
contraceptives, poor access to contraception and poor compliance
(Pratt and Bachrach, 1987; Emans et al., 1987). Awareness of
contraception appears to be improving (Pearson et al., 1995) but,
discontinuations continue to be major issues in adolescence
(Emans et al., 1987; Pearson et al., 1995).
Worldwide, and in the USA, 46% of adolescents believe that
the pill increases the probability of weight gain (Emans et al.,
1987; Grubb 1987). In a British survey, 73% of women of all ages
quoted weight gain as being a disadvantage of the pill (Oddens et
al., 1994). Adolescents are very preoccupied with body image and
fear weight gain with use of the combined oral contraceptive pill
(COC) (Emans et al., 1987; Grubb 1987; Oddens et al., 1994).
Fear of weight gain leads to discontinuations and loss of both

contraceptive and non-contraceptive benets of the COC. Only

one third of adolescent COC users continued with the pill at 13
months follow-up in a US study (Emans et al., 1987). Adolescent
discontinuation rates of 25% due to weight gain and acne were
observed in another study (Pratt and Bachrach, 1987). Drop-outs
of 25% were noted in adolescence in another study (Dustenberg
and Brill, 1990). In a more recent study, 42% of COC users
discontinued the pill without consulting their providers, with 59%
specifying side-effects as the main reason for discontinuation
(Rosenberg and Waugh 1998). Weight gain predicted early COC
discontinuations with a relative risk of 1.4 in young European
women (aged 1630 years) in another study (Rosenberg et al.,
1995). However, are adolescent perceptions of a causal relationship between COC use and weight gain real? Do discrepancies
exist between adolescent perceptions of weight gain with use of
the COC and available scientic evidence?

Literature search
We carried out a comprehensive Medline and Embase database
literature search from 19851999 using Medical subject headings
(MeSH) and text words and relevant references were selected out.
The search strategy also included TRIP database which cross
searches 26 evidence-based practice resources, including the NHS
Centre for Research Dissemination (CRD) databases, US National
Guideline clearing house and Evidence Based Practice (EBP)
journals such as ACP journal club, Evidence Based Medicine and
Health Evidence Bulletins, Wales, the Cochrane Controlled trials
register and Fertility Review Group protocols and reviews (Issue
4, 1999). In addition, references of retrieved papers were
searched. As the number of references were fairly low, we also
searched for compliance with contraceptive use. We then
categorized studies addressing the combined oral contraceptive

1
To whom correspondence should be addressed at: 2 Willow Close, Buckhurst Hill, Essex IG9 6HS, UK. Phone: +44 0208 521 3631; Fax:+44 0208 521
5840; E-mail: s.gupta01@virginnet.co.uk

428

S.Gupta

pill usage and weight gain as: (i) non-comparative trials; (ii)
comparative, comparative and controlled trials; (iii) double-blind
randomized, multi-centre trials; (iv) double-blind cross-over
studies; and (v) reviews.
A meta-analysis on the data retrieved would be unrealistic and
has not been attempted. We are aware that entry of articles onto
databases may be open to human error from authors, editors and
librarians.

Non-comparative studies
Table I shows the results from 11 non-comparative studies. A
large proportion of studies are with the third generation
progestogen-containing pills (with Desogestrol, Gestodene) and
two with a triphasic COC. At least ve studies were initiated by
pharmaceutical rms, marketing the relevant COC preparations
(Schering AG, Organon and Cilaag). Overall, all these studies
point to a small proportion of women experiencing a minimal
increase in body weight ranging from 0.3 kg to slightly >2 kg.
Such changes in weight in young women are more likely to reect
a consequence of natural growth than a result of COC use (Rekers
et al., 1988). Such small increases in body weight are comparable
to body weight demographics in women not using COCs
(Lammers and Berg, 1991). These studies appear to be of little
scientic merit, as they have never been compared with a similar
group of women not using COCs and fail to include controls.

Comparative studies
Table II shows the comparative trials. Some studies compare one
COC brand with another brand or brands, and, others compare the

COC with other contraceptive methods (IUD, Depo Provera) etc.

For example, only Risser's study (1999) denes what weight gain
is considered as excessive (>10% of baseline weight). Only 7% of
COC users gained weight with such criteria. The study of
Carpenter and Neinstein (1986) has a control arm of only 35
women who used barriers, but, in both the COC and the control
group, 3133% women gained <2 kg weight at 1 year, 17% of the
user group and 23% of non-users gained 24 kg. However, it is
not clear from the study whether the control group was already
dieting and a similar proportion (3940%) of women lost weight
in both the COC and control groups. These comparative studies
had no control group using barrier methods and, it is therefore
difcult to ascertain to what extent the weight changes were a
result of the use of hormones.
Table III summarizes the comparative controlled studies,
which, specically address changes in body weight in COC users
compared with non-users. They have a more robust methodology,
in, that age- and weight-matched controls were studied (Reubinoff
et al., 1995) and diet and physical activity were accounted for.
Ensuring adherance to diet can be difcult and this may explain
the short follow-up of 6 months to 1 year in all the studies. A
similar proportion (3035%) of 1625 year old COC users and
non-users gained weight > 0.5 kg at 6 months follow-up in a study
from Israel (Reubinoff et al., 1995). This weight gain was due to a
signicant increase in body fat (2226%), and the percentage of
body water remained stable. The authors of this study felt that
such weight changes may represent normal growth and development in the late teenage years. The second well designed
Australian study (Diffey et al., 1997) showed no signicant
differences in absolute basal metabolic rate (BMR), body mass,
body weight and waist hip ratios in COC and non-COC users at 6

Table I. Non-comparative trials

Author

Year

Org

Product

No of women Duration

No change

Increase

Rekers

1988

Organon

EE + DSG

1613

2 years

70%

18% by >2 kg 12%

Wouters and Karba

1988

EE + LNG

4342

5 years

1.11.7 kg

Dustenberg and Brill

1990

University of EE + GSD
Berlin

6854

1 year

0.77 kg

Brill et al.

1991

Schering

96000

Most

Renier and Buytaert

1991

University of EE + GSD
Belgium

2378

6/12 months

0.3 kg

Lammers and Berg

1991

Organon

EE + DSG

1684

1 year

Most 2029 year olds

0.38 kg in
<19 year olds

Runnebaum et al.

1992

Cilaag

EE + Norges- 59701
timate

6/12 months

Walling

1992

UK general
practice

EE + DSG

1221

18/12 months

<1.5% mean
increase

Brill

1994

Schering

EE + GSD

5602

6/12 months

91%

Comparato et al.

1998

Argentina

EE + DSG

407

6/12 months

72%

Rosenberg

1998

USA

Triphasic
COC

128

4/12 months

72%

EE + GSD

EE = ethinyl oestradiol; DSG = Desogestrel; GSD = Gestodene; COC = combined oral contraceptive.

Decrease

Weight gain on the combined pill

months follow-up. When body weight and physical activity were
used in analysis of covariance, a signicant increase in BMR (5%)
was observed in COC users compared with non-users. In the third
controlled study (Franchini et al., 1995), body mass index (BMI),
weight, total body water and body cellular mass remained
unchanged when measured at entry, 6 months and 1 year. Here,
body composition was analysed by biochemical impedance
analysis (Franchini et al., 1995).

Double-blind studies
Table IV shows the double-blind studies addressing the issue of
weight gain and COC use. One is a randomized controlled design,
one is a placebo controlled cross over and the other is a crossover, but not placebo-controlled study. Goldzeiher's study (1971)
has good scientic merit and was specically designed to study
changes in body weight in COC users compared with non-users
and compared four different COC preparations with a placebo.
This study was able to analyse placebo effect and found that a
uniform 30% of all groups gained weight of 2 kg. This is a very
important study, but, placebo controlled studies can be rather
difcult with such a personal issue as contraception and the study
goes back many years, with a rather short period of follow-up. An
interesting result was that weight gain was similar among the
different COC user groups and the non-user group, though the

429

dose of oestrogen was higher in the COC formulations (0.1 mg

ethinyl oestradiol, 0.10.5 mg mestranol). Slightly more increase
in weight with higher oestrogen dose (50 mg ethinyl oestradiol)
containing COCs compared with lower oestrogen COCs (35 mg
ethinyl oestradiol) was observed in one study (Neel et al., 1987).

Discussion
Several mechanisms have been postulated of how and why COCs
may cause weight gain: stimulation of renin angiotensinogen
mechanism, increased uid retention, alteration of carbohydrate
metabolism and alteration of brain metabolism with a resultant
increase in uid intake (Karlsson et al., 1992). A suppression in
serum cholecystokinen with COC use, may be related to increased
appetite and weight gain (Karlsson et al., 1992). It has also been
suggested that there is a marginal interaction of COC use with
total energy intake (P = 0.06), with COC users consuming a
greater proportion of energy as fat (P = 0.02), and a lesser
percentage of energy as carbohydrate (P = 0.008) (Eck et al.,
1997). The future may lie in designer oral contraceptive pills
containing an anti-mineralo-corticoid progestogen, drosperinone
(Oelkers et al., 1995) which may lead to a small decrease in body
weight and prove suitable for women susceptible to weight gain.
Available evidence suggests, that, for most women who use
COCs there is no greater risk of weight gain than for other

Table II. Comparative trials

Author

Year

Product

Year

Organization

No of users

No change

Increase

Decrease

Moore et al.

1995

COC/depo

1 year

Highlands Ranch
USA

50 COC and
50 depo

0.06 kg depo
group

0.93 kg COC
0.8 kg Norplant

Berenson et al.

1997

COC/implants

1 year

Oelker et al.

1995

Microgynon/
DSP 3 groups
COC

6/12
months

Risser et al.

1999

COC/depo

1 year

Texas University
USA

Houston USA

56 COC,
56 implant

2 kg COC,
4 kg Norplant

80

0.7 kg COC
group

0.81.7 kg DSP
group

2883

>10% no
change

7% of COC
users

70% COC users

DSP = drosperinone-containing COC.

Table III. Comparative controlled studies
Author

Year

Organization Product

No of women

Duration

Reubinoff et al.

1995

Israel

Increase

Decrease

49 COC
31 controls

6/12 months

0.5 kg in 30%

Diffey et al.

1997

Australia

6/12 months Most

Increase in BMR
in 5%

Carpenter et al.

1986

Los Angeles 138 COC, 35 barrier

USA

1 year

Most

3.7% how much

Franchini et al.

1995

EE + DSG/EE + GSD

1 year

Most

EE + GSD

80 controls
20 COC

No change

EE = ethinyl oestradiol; DSG = Desogestrel; GSD = Gestodene; COC = combined oral contraceptive; BMR = basal metabolic rate.

430

S.Gupta

Table IV. Double-blind studies

Author

Year

Product

Design

No. of women

Duration

Goldzeiher et al.

1971

4 prep

DB placebo
cross-over

398

3/12 months Texas University

USA

Neel et al.

1987

EE 50 &
35 mg + NET

DB cross-over
not RCT

Akerlund et al

1998

EE + DSG

DB RCT

55
1000

Organization

4/12 months
1 year

No change

Increase

In 30% 2 kg
Slight increase with
50 mg COC

Sweden

0.57 kg Marvelon,
0.21 kg Mercilon

COC = combined oral contraceptive; DB = double-blind; RCT = randomized control trial; NET = Norethisterone.

sexually active women, and, body weight remains essentially

unchanged, or only minor changes are reported. (Darney, 1997;
Diffey et al., 1997; Fotherby, 1995). No change in weight was
observed with the type of COC preparation used (Darney, 1997;
Diffey et al., 1997). However, it is prudent to refrain from
drawing too many conclusions as time, population and geographical differences may exist in the reporting of side-effects
(Goldzeiher et al., 1971) and results may vary in two countries or
even in different geographical areas of the same country.
Applicability of results may thus become limited. Most studies
appear not to have a consensus on what constitutes excessive
weight gain. Bias may have ensued if, women, who experienced a
large weight gain may have stopped using COC and did not attend
for follow-up to give results of a denitive increase. There is a
need for prospective studies assessing weight changes in women
using COC and barrier methods over a period of time, longer than
1 year.

Conclusions
Teenagers are at high risk of an unintended pregnancy and
can form erroneous perceptions which may inuence their
personal use of the combined pill. Gynaecologists, general
practitioners and family planning doctors comprise 65% of
source of contraceptive information with mass media providing
25% of such information (Oddens et al., 1994). Efforts are
required by doctors and the mass media to emphasize the
positive benets of the pill (improvement of menstrual
irregularity, dysmenorrhoea, acne and ability to manipulate
menstrual bleeding) and reassure on lack of evidence of
weight gain with use of low dose COCs. Such information
and dialogue may improve compliance, help minimize COC
discontinuations, and, contribute in some way to reducing the
high unintended pregnancy rates in teenagers.

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Received on March 6, 2000; accepted on May 4, 2000