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Received: 13 October 2018    Revised: 26 March 2019    Accepted: 1 July 2019    First published online: 22 July 2019

DOI: 10.1002/ijgo.12901

CLINICAL ARTICLE
Gynecology

Comparison of weight gain between levonorgestrel and

etonogestrel implants after 12 months of insertion

Temitope O. Okunola1,* | Sekinat B. Bola-Oyebamiji2 | Oluwaseun Sowemimo3

1
Department of Obstetrics and
Gynaecology, State Specialist Hospital, Ikere
Ekiti, Nigeria
2
Department of Obstetrics and
Gynaecology, LAUTECH Teaching Hospital,
Osogbo, Nigeria
3
Department of Obstetrics and
Gynaecology, Obafemi Awolowo University
Teaching Hospitals Complex, Ile-Ife, Nigeria
*Correspondence
Temitope O. Okunola, Department of
Obstetrics and Gynaecology, State Specialist
Hospital, Ikere-Ekiti, Ekiti State, Nigeria.
Email: bezaleelokunola@yahoo.com
Abstract
Objective: To compare weight gain between women using etonogestrel implants and
those using levonorgestrel implants 12 months after insertion.
Methods: A multicenter prospective cohort study was performed on women recruited
from family planning clinics between July 2016 and August 2017. The main study out-
come was mean weight gain after 12 months of insertion of the implants.
Results: The present study included 150 women (age range 18–45 years) using lev-
onorgestrel implants and 167 women using etonogestrel implants. The women recruited
had been using implants for less than 6 months; implants had been inserted 6–12 months
after their last pregnancy. Participants were followed up until 12 months after insertion
through telephone conversations. Baseline parameters were obtained from the clinic
records and weight was measured within 6 weeks of the 12-­month anniversary of inser-
tion of the implants. Data were analyzed with SPSS version 23. Weight gain in the lev-
onorgestrel group was significantly higher than in the etonogestrel group (3.16 ± 4.08 vs
0.77 ± 3.76, P = 0.013; relative risk 1.69, 95% confidence interval 1.46–1.96). There
were no differences in the occurrence of menstrual irregularities and client satisfaction.
Conclusion: Women using levonorgestrel implants were more likely to gain weight com-
pared to those using etonogestrel implants after 12 months of insertion.

KEYWORDS
Contraceptive; Etonogestrel; Implants; Levonorgestrel; Side effects; Weight gain

1 | INTRODUCTION 68 mg of etonogestrel, releasing 60–70 μg per day in early weeks.2,5

Long-­acting reversible contraceptives (LARC) are contraceptive
implants and intrauterine contraceptive devices (IUCD).1 Implants
are a good option for LARC, especially for those with contraindica-
tions to IUCDs. Levonorgestrel and etonogestrel are readily available
progestin-­containing implants in Nigeria. There have been reports of
increased uptake in different parts of the country.2,3 However, contra-
ceptive uptake and rates of continuation are being hampered by the
perceived and actual side effects.4
Levonorgestrel contains two rods, each containing 75 mg of levo-
norgestrel, and it releases 30 μg per day for 5 years,4 while etonogestrel
is a single-­rod progesterone-­only contraceptive implant that contains
Both implants are highly efficacious.6 Insertion and removal of both
implants are easy and fast in a trained hand. However, etonogestrel has
been found to be four times faster to insert and remove compared to
levonorgestrel; this significantly impacts counseling of these patients.7
Both implants contain progesterone with similar side effects. Side
effects include menstrual irregularities, weight gain, headaches, acne,
mood changes, breast pain, etc.6,8 Most reasons for discontinuation are
due to side effects, notably menstrual disturbances and weight gain.5,6
Concerns about weight gain have been found to influence use of
contraceptives.9 A substudy of the contraceptive choice project that
compared weight gain in progestin-­only contraceptives with copper
IUCDs reported a significant difference in weight gain in etonogestrel

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© 2019 International Federation of Int J Gynecol Obstet 2019; 147: 54–58
Gynecology and Obstetrics
Okunola ET AL.
implant and depot medroxyprogesterone acetate users and copper
9
IUCD users. However, an important finding from the study was that
the black race was a significant risk factor for weight gain irrespec-
tive of method of contraception. This is not unexpected as weight
gain is a recurring reason for the discontinuation of these implants in
4
Nigeria. Hence, it is necessary to explore weight gain in blacks across
these methods of contraception. The aim of the present study was to
compare weight gain between users of etonogestrel and users of levo-
norgestrel 12 months after insertion in southwestern Nigeria.
2 | MATERIALS AND METHODS
The present multicenter prospective cohort study was carried out between
July 2016 and August 2017 in two states in southwestern Nigeria. The fam-
ily planning clinics involved were LAUTECH Teaching Hospital, Osogbo,
State Specialist Hospital, Ikere-­Ekiti, and Comprehensive Health Centre,
Ado-­Ekiti. Ethical clearance was obtained from the Ethics and Research
Committee of Ekiti State Teaching Hospital, Ado-­Ekiti. These facilities have
trained midwives who were trained by Marie Stopes International in the
insertion and removal of the implants, measurement of baseline parame-
ters such as body weight, and record keeping. The weighing scales and con-
traceptive commodities were provided by this organization, in conjunction
with the Federal Ministry of Health. The implants used were levonorgestrel
(Jadelle Bayer Healthcare, Berlin, Germany) and etonogestrel (Implanon;
Merck & Co, Kenilworth, NJ, USA).
The sample size was calculated with a formula for comparing
means10; imputing findings from Vickery et al.,9 95% confidence inter-
val [CI], 80% power, and minimum detectable difference of 2 kg with
10% attrition rate; a detectable difference minimum of 157 partici-
pants in each group is required. Inclusion criteria were women aged
18–45 years using levonorgestrel or etonogestrel implants for less than
6 months; the implant should have been inserted 6–12 months after
the last pregnancy. Exclusion criteria were metabolic disorders such
as diabetes mellitus, thyroid disorders, and menstrual disorders before
insertion of the implants. Women with body mass index (BMI, calcu-
lated as weight in kilograms divided by the square of height in meters)
less than 18.5 or more than 35 were excluded. Out of the 685 clients
using levonorgestrel and etonogestrel implants assessed for participa-
tion in the study, 333 were recruited; 317 completed the study.
The clients were invited to participate in the study through tele-
phone conversations by the midwives at various family planning
clinics. Oral consent was obtained from each participant at recruit-
ment. A proforma was then filled from the clinic records to obtain
the baseline characteristics. The participants were followed up with
telephone calls. They were then seen at the clinics within 6 weeks of
the 12-­month anniversary of insertion of the implants. Information
about age, marital status, educational level, religion and ethnic group,
weight, BMI, and menstrual irregularities are included in the proforma.
The weight of each participant was taken by a trained midwife. The
weights were taken with the women fully dressed and using the same
weighing scales provided by Marie Stopes. The main study outcome
was weight change at 12 months after insertion.
|
      55
Data were analyzed with SPSS version 23 (IBM Inc., Armonk,
NY, USA). Social class was classified into five groups, according to
Olusanya et al.,11 using patients’ educational status and partners’ sta-
tus. Means and standard deviations were used to summarize continu-
ous variables while frequency and percentages were used for discrete
variables. Paired t-­test was used to compare the mean difference in
baseline weight and after 1 year of insertion of the implants, while
independent t-­test was used to compare the mean difference in weight
between both groups. Menstrual irregularities and client satisfaction
were compared using χ2 test. A P value less than 0.05 was considered
statistically significant.
3 | RESULTS
Of the 333 women recruited from 685 women using implants dur-
ing the study period, 150 participants and 167 participants using lev-
onorgestrel and etonogestrel, respectively, completed the study and
were analyzed (Fig. 1). The majority of the baseline characteristics of
both groups were comparable (Table 1). There were no statistically sig-
nificant differences in age (33.32 ± 5.09 vs 32.60 ± 6.25, P = 0.844),
educational status (χ2 = 3.21, P = 0.6182), occupation (χ2 = 0.22,
P = 0.914), marital status (χ2 = 1.89, P = 0.809), social class (χ2 = 3.62,
p = 0.585), and ethnic group (χ2 = 3.88, P = 0.410) between both
groups. There was, however, a statistically significant difference in par-
ity (3.12 ± 1.51 vs 2.64 ± 1.20, P = 0.002) (Table 1). None of the par-
ticipants drank alcohol or smoked cigarettes during the study period.
The baseline weight (mean difference 2.65, P = 0.121) and baseline
BMI (mean difference 1.35, P = 0.162) did not differ between the two
685 women using implants
were assessed for
parcipaon
333 women were recruited
155 women using 178 women using
levonorgestrel etonogestrel were
were recruited recruited
167 women using
150 women using
etonogestrel
levonorgestrel
completed the study
completed the study
and were analyzed
and were analyzed
F I G U R E   1   Participant flow chart.
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56       Okunola ET AL.

T A B L E   1   Comparison of baseline characteristics between the two groups.a

Characteristics Levonorgestrel Etonogestrel χ2 P value

Age (years) 33.32 ± 5.09 32.60 ± 6.25 1.66 0.844

Parity 3.12 ± 1.51 2.64 ± 1.20 3.14 0.002 b
2
BMI (kg/m ) 25.66 ± 6.97 27.01 ± 5.32 1.47 0.155
Occupation trading 36 (40.9) 52 (59.1) 0.22 0.914
Farming 30 (36.6) 52 (63.4)
Schooling 30 (53.6) 26 (46.4)
Housewife 6 (42.9) 8 (57.1)
Civil service 48 (62.3) 29 (37.7)
Marital status 1.89 0.809
Married 142 (46.9) 161 (53.1)
Single 6 (50) 6 (50)
Religion 0.14 0.714
Christianity 108 (48) 117 (52)
Islam 42 (45.7) 50 (54.3)
Educational status 3.21 0.618
Primary 60 (52.6) 54 (47.4)
Secondary 66 (53.2) 58 (46.8)
Tertiary 24 (30.4) 55 (69.6)
Social class 3.62 0.585
1 42 (51.2) 40 (48.8)
2 24 (41.4) 34 (58.6)
3 42 (44.7) 52 (55.3)
4 37 (54.4) 31 (45.6)
5 5 (50) 5 (50)
Ethnic group 3.88 0.410
Yoruba 126 (52.7) 113 (47.3)
Ibo 6 (12) 44 (88)
Hausa 16 (72.7) 6 (27.3)
Others 2 (50) 2 (50)

Abbreviation: BMI, body mass index.

a
Values are given as mean ± standard deviation or number (percentage).
b
Statistically significant.

groups (Table 2). Twelve months after insertion of the implants, the
weight (mean difference 0.27, P = 0.888) and BMI (mean difference 0.44,
P = 0.358) did not differ between the two groups (Table 2). However,
there was a significant difference in weight gain between the two groups
(3.16 ± 4.08 vs 0.77 ± 3.76, mean difference 2.39, P = 0.013) (Table 2).
The weight gain in the levonorgestrel group was in the range of
−5.22 to 19.03 while the weight gain in the etonogestrel group was
in the range of −8.29 to 11.63. The mean weight difference in the
levonorgestrel group was 3.16 (P = 0.004), while the mean weight
difference in the etonogestrel group was 0.77 (P = 0.041) (Table 3).
Women that gained weight were compared with those that did not
2 
gain weight in both groups (χ = 55.44, P < 0.001) (Table 4). Participants
that used the levonorgestrel implant were more likely to gain weight
(relative risk [RR] 1.69, 95% CI 1.46–1.96). Observed menstrual dis-
turbances were amenorrhea, hypomenorrhea, prolonged bleeding,
and intermenstrual bleeding. Menstrual irregularities were reported in
about one-­half of the participants, with no statistical difference in the
occurrence between the two groups (χ2 = 0.73, P = 0.946) (Table 4).
Of the participants, 84% and 81.4% were satisfied with levonorgestrel
and etonogestrel, respectively (χ2 = 2.26, P = 0.113).
4 | DISCUSSION
In the present study, there was a significant difference in weight gain
between the levonorgestrel group and etonogestrel group, although
both groups gained weight considerably. In addition, when women
who gained weight were compared with those who did not gain weight,
participants using levonorgestrel were more likely to gain weight than
those using etonogestrel. The baseline characteristics of the two
Okunola ET AL. |
      57

T A B L E   2   Change in weight between the two groups.

Levonorgestrela Etonogestrela Mean difference 95% CI P value

Baseline weight (kg) 57.80 ± 7.93 60.45 ± 7.29 2.65 −0.53 to 7.21 0.121

Weight after 12 months (kg) 60.96 ± 10.36 61.22 ± 8.29 0.27 −4.23 to 3.71 0.888
Weight change (kg) 3.16 ± 4.08 0.77 ± 3.76 2.39 2.08–6.57 0.013b
Baseline BMI (kg/m2) 25.66 ± 6.97 27.01 ± 5.32 1.35 −0.61 to 3.42 0.162
BMI after 12 months (kg/m2) 28.83 ± 5.47 28.39 ± 4.88 0.44 −0.75 to 7.48 0.358
BMI change (kg/m2) 3.17 ± 5.89 1.38 ± 3.69 1.79 0.64–2.49 0.042b

Abbreviations: CI, confidence interval; BMI, body mass index.

a
Values are given as mean ± standard deviation.
b
Statistically significant.

groups were similar in age, occupation, marital status, religion, educa-
tional status, social class, and ethnic group. Baseline weight and BMI
were also comparable between the levonorgestrel and etonogestrel
groups. These similarities form a good template for comparing the
weight gain between both groups. However, four participants within
the levonorgestrel group had significantly higher parity than those in
the etonogestrel group. This implies that women with higher parity
opted for levonorgestrel with a longer duration of action, probably
because they were using it to limit the size of their family. Meanwhile,
etonogestrel users might be using contraceptives for spacing out their
children, thereby requiring a shorter duration.
There was significant weight gain in both groups, as expected in a
black population.9,12,13 A study on the incidence of major weight gain
reported a 50% higher incidence among black women than white
14
women aged 30–55 years. There was a wide range of weight change
in both groups; this was similar to previous reports by other studies.9,15
The mean change in weight in this study was slightly higher than reports
from many studies.9,15 This may be due to the fact that all the partic-
ipants in this study were black. Most studies reported a weight gain
of less than 2 kg for progesterone-­only contraceptives.4,15 However,
findings are comparable to a mean weight gain of 4.8 kg reported by
Sule et al.16 among Norplant users in Zaria, Nigeria. Vickery et al.9
also reported a weight gain of more than 2 kg for etonogestrel users
among blacks. There was a significant difference in the change in weight
between both groups. Participants using levonorgestrel were almost
twice as likely to gain weight than those using etonogestrel within
12 months of insertion despite comparable baseline weight and BMI.
Several lifestyle behaviors are known to affect weight gain
over a period. These factors include diet, smoking, alcohol intake,
sleep, and physical activity.17 However, metabolic factors, diet, and
physical activities have been found to be influenced by genetic
traits.18,19 Weight gain is therefore an aggregate of interwoven
factors. In the study population, participants in both groups were
similar in occupation and socioeconomic classification. It is thereby
unlikely for the groups to differ in lifestyle behaviors since they live
within the same community.
Menstrual irregularities were comparable between the two groups
and were similar to findings from similar studies.4,5,20,21 The rates of
satisfaction were high in both groups, comparable with findings from
previous studies.21,22
Unlike most studies that compared progesterone-­only contracep-
tives to IUCDs to ascertain differences in weight gain,9,16 this study
compared two progesterone-­only implants. This will assist in counsel-
ing the women about the two available implants in this environment. It
is a prospective study about weight gain in black women, thereby min-
imizing missing data unlike previous studies.16 The women not being
randomized was a limitation of this study.
In conclusion, levonorgestrel-­releasing implants increased the probabil-
ity of weight gain compared to etonogestrel-­releasing implants 12 months
after insertion among the black population studied. This may help when
counseling clients on the probable side effects of these implants. A ran-
domized controlled trial may be necessary to confirm this finding.
AU T HO R CO NT R I B U T I O NS
OTO contributed to the study conception, study design, data collec-
tion and analysis, write-­up, and review of the paper. BSB was respon-
sible for the study conception, study design, data collection and
analysis, write-­up, and review of paper. SO contributed to the study
design, data collection and analysis, and write-­up.

T A B L E   3   Change in weight within the groups.

Weight after 12 months

Baseline weight (kg)a (kg)a Mean difference 95% CI P value

Levonorgestrel 57.80 ± 7.93 60.96 ± 10.36 3.16 1.47–4.84 0.004b

Etonogestrel 60.45 ± 7.29 61.22 ± 8.28 0.77 0.32–1.65 0.041b

Abbreviation: CI, confidence interval.

a
Values are given as mean ± standard deviation.
b
Statistically significant.
 |
58       Okunola ET AL.

T A B L E   4   Comparison of outcomes between both groups.a

Outcome Levonorgestrel Etonogestrel χ2 P value

Weight change 55.44 <0.001 b

Weight gain 138 (92) 91 (54.5)
No weight gain 12 (8) 76 (45.5)
Menstrual irregularities 0.73 0.9465
None 115 (46.2) 134 (53.8)
Present 35 (51.5) 33 (48.5)
Clients’ satisfaction 2.26 0.113
Satisfied 126 (84) 136 (81.4)
Not satisfied 24 (16) 31 (18.6)
a
Values are given as number (percentage).
b
Statistically significant.

ACKNOWLE DG ME NTS 9. Vickery Z, Madden T, Zhao Q, Secura G, Allsworth JE, Peipert JF.
Weight change at 12 months in users of three progestin-­only contra-
The authors thank the trained midwives working in the facilities ceptive methods. Contraception. 2013;88:503–508.
that assisted with data collection. They also appreciate Marie 10. Kirkwood BR, Sterne JAC, eds. Essential Medical Statistics, 2nd edn.
Massachusetts: Blackwell Science Ltd.; 2003.
Stopes Nigeria for training the midwives and provision of the con-
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traceptive commodities.
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1985;4:205–211.
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CO NFLI CTS OF I NTE RE ST Race/ethnicity, life-­course socioeconomic position, and body weight
trajectories over 34  years: The Alameda County Study. Am J Public
The authors have no conflicts of interest.
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13. Truong KD, Sturm R. Weight gain trends across sociodemographic
groups in the United States. Am J Public Health. 2005;95:1602–1606.
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