Sarah asked
Generally speaking, which progesterone and ethinyl estradiol combinations are less likely to cause cellulite, weight gain, and water retention?
At a glance
- The side effect profile of birth control pills is largely determined by the number of hormones contained and the type of progestin used.
- Progestins are separated into 'generations', each with varying effects.
- Drospirenone, a 'fourth-generation' progestin, is the least associated with weight gain and will often cause weight loss due to its diuretic effect. It may, however, increase the risk of blood clots and elevate potassium levels.
Answer
The side effect profile of a particular birth control pill depends on two main factors:
- The type of progestin contained in the birth control pill.
- The amount of estrogen (if your pill contains one) and progestin.
Most birth control pills are 'combined hormone' pills, meaning they contain both an estrogen and a progestin. There are pills, however, that only contain a progestin, and those are known as 'progestin-only pills' (POP) or "mini-pills".
While the amount of estrogen in a pill can certainly influence both tolerability and efficacy, it is the progestin that is the most significant factor when it comes to the side effect profile of a specific birth control pill (including which is associated with the most weight gain).
The vast majority of birth control pills use the same estrogen, ethinyl estradiol, although there a few exceptions. Progestins however vary considerably. They are classified by their generation (more about this in the next section) and it is the specific progestin used that makes the biggest difference when it comes to side effects.
In regard to the characteristics you mention in your inquiry (e.g. weight loss, fluid retention), two particular progestins are associated with the least risk, and they are:
Before going into more detail about drospirenone and dienogest, first, we will discuss the differences in progestin characteristics.
Progestins In Birth Control Pills
Progestins are separated into 'generations', and each 'generation' is associated with specific effects.
Below is a chart that shows the currently available progestins and which generation they are classified as.
Progestin In Birth Control
| Generation | Name | Characteristics | Notes |
|---|---|---|---|
| First | Norethindrone acetate Ethynodiol diacetate | Moderate/Potent Progestin Moderate Androgen | |
| Second | Norgestrel | High Progestin High Androgen | Less Spotting Less Breakthrough Bleeding Possible Weight Gain Worsen Acne |
| Third | Moderate Progestin Low Androgen | Low Risk Of Weight Gain Low Risk Of Acne Increased Risk Of VTE | |
| Fourth | Drospirenone | Moderate Progestin Anti-Androgen | Can Reduce Acne Can Cause Weight Loss Increased RIsk Of VTE |
As you can see in the above table, each generation of progestin is associated with certain characteristics and effects. They all differ in terms of their progestational and androgenic activity, which have different effects on the body.
Second-generation progestins, for example, may reduce spotting and breakthrough bleeding due to their strong effects on progesterone receptors but, due to their high androgenic activity, can cause acne and weight gain.
Conversely, third and fourth-generation progestins have a low risk of weight gain and acne. The fourth-generation progestin drospirenone (Yaz, Yasmin) may actually reduce acne and cause weight loss.
Birth Control With Least Weight Gain
If you are looking for a birth control pill that is least associated with weight gain and fluid retention, that would be with the fourth generation progestin drospirenone.
Drospirenone is unique in that it has:
- Anti-androgen effects (decreases testosterone production).
- Diuretic effects (it is chemically related to spironolactone).
Based on how drospirenone works, it can have the following effects:
- Decrease weight (via water loss).
- Improve acne and decrease excess hair growth (via anti-androgen effects).
- Improve symptoms of PMDD (premenstrual dysphoric disorder), such as irritability.
- It is FDA approved for this indication
However, drospirenone doesn't come without drawbacks, including:
- Can increase potassium levels, causing hyperkalemia.
- Increase the risk of VTE (blood clots).
The overall increase in risk blood clots isn't well known but due to it, drospirenone isn't generally recommended in those with significant risk factors, such as a history of smoking or in women over 35 years old.
As a side note, the fourth-generation progestin, dienogest, is similar to drospirenone but does not share the diuretic properties, so is less likely to cause weight loss.
Drospirenone is available in a variety of birth control products including:
- Yasmin
- Yaz
- Beyaz
- Gianvi
- Loryna
- Syeda
- Ocella
- Vestura
Be sure to speak with your doctor regarding the appropriate birth control choice for your needs and medical situation.
References
- Using progestins in clinical practice. PubMed
- Birth control pills with drospirenone for treating premenstrual syndrome. Cochrane
- Yasmin Prescribing Information. PubMed
- A comparative investigation of contraceptive reliability, cycle control and tolerance of two monophasic oral contraceptives containing either drospirenone or desogestrel. PubMed
- Types of progestogens in combined oral contraception: effectiveness and side-effects. PubMed
- Using Progestins in Clinical Practice. AAFP
