Emergency Contraception and Higher Weight People
With US Supreme Court attacking reproductive freedom, there has been a great deal of talk about stocking up on emergency contraceptives like Plan B. Unfortunately, this is complicated for fat* people and I’ve received numerous requests to write about this, so here it is. Note that, as with everything I write here, I’m not a doctor and this is intended for informational purposes and not as medical advice. Please consult a (preferably weight-neutral) healthcare provider.
As always if a study or article is based in – or contains – weight stigma I don’t link to it, but provide enough information for someone to search for it online if they are interested.
Here is the very short version:
Levonorgestrel pills - brand names include Plan B One Step, Take Action, My Way, Option 2, Norlevo, My Choice etc. They typically have to be taken within 3 days and are more effective the sooner you take them. They can be less effective at higher weights (starting at around 165lbs) and can be completely ineffective for those above 176 pounds. Still, if it’s the only thing available to you, it’s likely better than nothing.
Ulipristal acetate pills - sold under the brand name Ella, must be taken within 5 days, and is more effective the sooner you take it. This may be less effective at higher weights, but has been shown to be more effective (about 50% fewer pregnancies) than the Levonorgestrel options. It requires a prescription.
All experts agree that you SHOULD NOT take a double dose of these medications.
Copper IUDs are the most effective and have not shown efficacy differences for higher-weight people. If inserted within 5 days there is a less than 1% failure rate. They require a healthcare provider for insertion.
Levonorgestrel IUDs - these are not FDA approved as emergency contraception yet, but some research has shown them to be non-inferior to Cooper IUDs
Here are the details:
There are two basic options for emergency contraception (which is contraception that is taken to prevent pregnancy after a situation which may result in pregnancy has already occurred.) The first is certain Intrauterine Devices (IUDs), the second is medication.
There is a near-complete (and absolutely unacceptable) lack of inclusion of trans and nonbinary people in the research and documentation around these options. A paper from the American Society for Emergency Contraception states “There are no specific studies of EC use among transgender and nonbinary individuals. However, expert consensus and experience with other contraceptive methods indicate no reason to expect drug interactions or loss of efficacy for either ECPs or testosterone when used together.” That paper (which links to additional resources for patients and practitioners, but does not specifically speak to higher-weight patients) can be found here.
Copper IUDs can be used for emergency contraception and are the most effective option. If inserted within 5 days there is a less than 1% failure rate. Once someone has an IUD inserted, they can choose to keep it in as long-term contraception. They require a prescription and a trained medical professional to insert them.
Copper IUDs have the same efficacy for people of all weights (which is not necessarily the case with pills.) In terms of safety for fat people, I was not able to find a study for the copper IUD (if you know of one, please feel free to put it in the comments,) but Saito-Tom et al.’s paper Levonorgestrel Intrauterine Device Use in Overw*ight and Ob*se Women looked at an ethnically diverse population of cis women and found “No statistically significant difference emerged in 12-month IUD continuation between the BMI groups (P =. 73). Complications were higher in the normal weight (11%) and ob*se (11%) groups compared to the overw*ight group (4%), but were not statistically significant (P =. 47).“ (with a content note that this study is deeply fatphobic, including blaming fat bodies for the poor treatment they receive.)
Unfortunately, as with all medical care, fat people may experience medical weight stigma when trying to access an IUD which, of course, becomes even more of an issue when someone is trying to access an IUD for emergency contraception. While this shouldn’t be necessary, it may be best to find a place where an IUD can be accessed prior to needing one as emergency contraception, calling ahead to make sure that they will help you without weight stigma. Often Planned Parenthood offers emergency contraception services.
This option can also be difficult or undesired for trans and nonbinary people, those with gender dysphoria, and/or those who have survived sexual trauma, especially if trauma-informed care is not practiced.
One final note, while copper IUDs are the only IUDs currently approved for emergency contraception, in their January 2021 paper, “Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception,” Turok et al., found that “The levonorgestrel IUD was noninferior to the copper IUD for emergency contraception” so we may see that change in the future.
There are two types of emergency contraception pills:
Ulipristal acetate (UPA ECP) - This is sold under the brand name Ella and has to be taken within 5 days.
Levonorgestrel (LNG ECP)- brand names include Plan B One Step, Take Action, My Way, Option 2, Norlevo, My Choice etc. This typically has to be taken within 3 days.
Both are more effective the earlier they are taken.
If you google “Morning after pill weight limits” you’ll find everything from sites claiming that there is no efficacy difference for fat people, to sites claiming that it becomes less effective or ineffective at various weights and/or BMIs. I dug around to find the original research.
Glasier et al.’s 2011 paper “Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel” looked at efficacy of both types of pills and found that:
Women with a body mass index (BMI) of 25 or higher experienced decreased efficacy, and the pill stopped working entirely in obe*e women with a BMI of 30 or higher.
The risk of pregnancy was more than threefold greater for ob*se women compared with women with normal body mass index whichever EC was taken. However, for ob*se women, the risk was greater for those taking levonorgestrel than for UPA users
Based on those findings the French pharmaceutical company HRA Pharma, manufacturer of the emergency contraceptive Norlevo (an LNG ECP which, again, is the same drug and dose as in Plan B and many other emergency contraceptive pills) changed its package insert to read “Studies suggest that Norlevo is less effective in women weighing 165 pounds or more and not effective in women weighing 176 pounds or more”
According to a 2013 article in The Guardian:
“Anna Glasier, a lead researcher in the study, said that the research wasn't designed to look specifically at the effect of weight on emergency contraception. She said the study included only about 1,700 women.
”It is not my place to comment as to whether the company's decision to change advice is premature," she said in an email. She also noted another previous analysis that found there was no solid evidence to show that hormonal contraceptives were less effective in overw*ight women, but the quality of the studies was low.”
Vogel’s 2015 paper “Rethink weight limits on morning-after pill” outlines the pushback, including that
a European Medicines Agency review later in 2014 determined that the “data available are too limited and not robust enough to conclude with certainty that contraceptive effect is reduced with increased bodyweight.”
The Society of Obstetricians and Gynaecologists of Canada has taken a similar stance, recommending that, until better evidence is available, women with a BMI over 30 “should not be discouraged” from using levonorgestrel if they can’t access or don’t want a copper intrauterine device (IUD) — the only alternative emergency contraceptive available in Canada.
It should be noted that the impetus for the paper was that Vogel, herself, was seeking emergency contraception and was turned away by a pharmacist who said “I can’t sell you this. Have you heard about the weight limit? Health Canada says this won’t work if you weigh more than 165 pounds.” Vogel then went to a second pharmacy and was sold the medication by a pharmacist who responded to Vogel’s queries about whether her weight would impact efficacy by telling her to see a doctor. So her argument isn’t necessarily that there is no efficacy difference, but rather that, given limited options, fat people shouldn’t be denied the medication.
In 2016 Jatlaoui and Curtis published an analysis of the existing research (trigger warning for the use of stigmatizing “person first” language)
While data are limited and poor to fair quality, findings suggest that women with ob*sity experience an increased risk of pregnancy after use of LNG ECP compared with those normal/underweight. Women with ob*sity may also experience an increased risk of pregnancy compared with women without ob*sity after use of UPA ECP, though differences did not reach statistical significance.
If you look at Plan B (an LNG ECP) website FAQs, it doesn’t actually discuss the possible efficacy differences.
Does Plan B work for women with a BMI over 25?
We hold the same belief as the FDA, which states that there are no safety concerns that preclude the use of levonorgestrel emergency contraceptives in women generally, and continue to believe that all women, regardless of how much they weigh, can use these products to prevent unintended pregnancy following unprotected sex or contraceptive failure.
Note that when they say they hold the same belief as the FDA, they are only talking about safety and not efficacy. When they say they “continue to believe” that this works regardless of weight, they are not offering any evidence or support for that belief. Also, since Plan B doesn’t include any discussion of efficacy differences for higher weight people, the FDA regulations prevent generics of Plan B from including it.
Ella’s detailed patient labeling says:
Subgroup analysis of the pooled data by BMI showed that for women with BMI > 30 kg/m (16% of all subjects), the observed pregnancy rate was 3.1% (95% CI: 1.7, 5.7), which was not significantly reduced compared to the expected pregnancy rate of 4.5% in the absence of emergency contraception taken within 120 hours after unprotected intercourse. In the comparative study, a similar effect was seen for the comparator emergency contraception drug, levonorgestrel 1.5 mg. For levonorgestrel, when used by women with BMI > 30 kg/m , the observed pregnancy rate was 7.4% (95% CI: 3.9, 13.4), compared to the expected pregnancy rate of 4.4% in the absence of emergency contraception taken within 72 hours after unprotected intercourse.
So Ella may have a decreased efficacy for higher weight people, but did demonstrate 50% fewer pregnancies than for higher weight cis women taking levonorgestrel. Unfortunately, unlike levonorgestrel, Ella requires a prescription, creating another possible barrier.
When I set out to write this, I honestly thought that things were going to be far more clear. What I learned (over hours of research and reading, the highlights of which you’ve just read) was that there are few clear answers.
There is general agreement that the IUD is the best option for higher weight people. If an IUD isn’t an option for any reason, while there does appear to be possible lower efficacy of emergency contraception for higher weight people (with less efficacy at higher weights) emergency contraception pills do appear to be better than nothing and Ella may be better than one of the Levonorgestrel options if it’s obtainable. (Again, it does require a prescription but services like Planned Parenthood Direct can make that easier.) Also, there do not seem to be additional or higher risks for higher weight people who take emergency contraceptives
One thing everyone seems to agree on is that higher weight people should NOT double the dose of emergency contraception pills, at least not without consulting their healthcare practitioner.
Of course, the core problem here is that the original research didn’t do enough to include higher weight (and trans and nonbinary) people to begin with (when the initial studies were being conducted the average weight of a cis woman in the US was around 165lbs, so the fact that the research samples don’t reflect that is a clear issue.)
This is an issue we see across the research and is another clear example of the ways in which a health system that is mired in weight stigma (with research conducted based on the idea that thinner people deserve to be the majority in research, even if they are the minority of the population,) harms fat people. All healthcare related research should be required to include higher-weight (and trans and nonbinary) people, preferably at the rates in which we exist in the world. It is unacceptable for research to be undertaken as if fat (and trans and nonbinary) people don’t exist, or as if we have less of a right to research-based healthcare than thin (and cis) people do.
If you are looking for more information about gender-inclusive fat reproductive health, Nicola Salmon and I are offering a workshop on reproductive health for fat people as part of my Fat Healthcare Summer Workshop Series. You can get details and register here!
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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.