Contraceptive use among women with a history of bariatric surgery: a systematic review

Body Mass Index and Levonorgestrel Device Expulsion in Adolescents and Young Adults

STUDY OBJECTIVE

To evaluate the relationship between body mass and levonorgestrel intrauterine device (LNG-IUD) expulsion in adolescents and young adults (AYA).

DESIGN, SETTING, PARTICIPANTS & INTERVENTIONS

A retrospective chart review was conducted of nulliparous females aged 10-24 years who had a 52-milligram LNG-IUD placed between November 2017 and May 2021 by pediatric and adolescent gynecology providers at a tertiary children's hospital, including those who underwent metabolic and bariatric surgery (MBS). Primary analysis focused on 10-19 year olds as they had comparable anthropometrics (namely BMI percentile [BMIP] as defined by the Centers for Disease Control). Descriptive statistics included means, standard deviations (SD), and ranges for continuous variables counts and percentages for categorical variables. Chi-square or Fisher's exact tests were used to assess associations. Logistic regressions were fit to test the associations between BMIP, MBS, and the odds of expulsion.

MAIN OUTCOME MEASURES & RESULTS

A total of 588 patients were included in the primary analysis (10-19 years). Mean age was 15.8 years (±2.0). Using BMIP, 15.5% (n = 91) of the sample was overweight and 22.3% (n = 131) were obese. Within 12 months, 33 patients (5.6%) experienced expulsion. Every one-unit increase in BMIP was associated with a 3% increase in the odds of expulsion (P = .008), and each increase in BMIP category (eg, overweight vs average/underweight) was significantly associated with increased odds of expulsion (OR = 2.77-4.28). Patients who had LNG-IUD placement during MBS (n = 43) had higher odds of expulsion (OR = 3.23; P = .024) than other patients.

CONCLUSION

AYA with higher BMIP and/or who undergo MBS are at increased risk of LNG-IUD expulsion within one year of placement.

Clinical pathways in the management of the obese: Pre- and postoperative aspects

INTRODUCTION

Bariatric surgery (BS) leads to substantial weight loss accompanied by reversal of several obesity-related co-morbidities and reduced mortality. However, surgery is associated with risks and its nearly irreversible characteristic requires a clearly established pre- and postoperative clinical pathway. In France, this pathway relies on recommendations made by the High Authority of Health (Haute Autorité de santé (HAS)) in 2009; an update is awaited in 2023.

PREOPERATIVE ASPECTS

BS should be proposed only after failure of well-conducted medical treatment and is intended for patients whose body mass index (BMI) is ≥40kg/m² or for those with BMI ≥35kg/m² who also have co-morbidities amenable to improvement, and in whom there are no contra-indications, particularly, those related to general anesthesia or psychological factors. The success and safety of surgical management requires preparation of the patient with regard to dietetic and nutritional counseling, and physical activity. The possibility of complications must be recognized and communicated, including, in view of the large variability of outcomes between individuals, the risk of failure and regain of weight.

POSTOPERATIVE ASPECTS

Prior to the operation, patients should be informed of and accept the program of postoperative clinical and laboratory follow-up, as well as the need for lifelong supplementation in micronutrients and the financial implications including what patients may have to pay out of their own pocket.

CONCLUSION

Surgical management of obesity cannot replace the multidisciplinary medical management of severe obesity. The results obtained by BS are sustainable only if the patient adheres to the proposed modalities. New drugs such a GLP-1 analogues have opened encouraging perspectives as possible alternatives to BS in certain indications.

The Impact of Preconception Gastric Bypass Surgery on Maternal Micronutrient Status before and during Pregnancy: A Retrospective Cohort Study in the Netherlands between 2009 and 2019

Post-bariatric weight loss can cause iatrogenic malnutrition and micronutrient depletion. In this study, we evaluated the impact of gastric bypass surgery (GB) and multivitamin supplement use on maternal micronutrient status before and across pregnancy. A retrospective medical chart review of 197 singleton pregnancies after GB with a due date between 2009 and 2019 was performed at a bariatric expertise center in the Netherlands. Hemoglobin, calcium, iron status, folate, vitamin D, vitamin B12 and ferritin levels were determined before and after GB during standard follow-up and at all gestational trimesters and analyzed using linear mixed models. Patients were prescribed standard multivitamin supplements or multivitamins specifically developed for post-bariatric patients (FitForMe WLS Forte (FFM)). Overall, hemoglobin and calcium levels decreased after surgery and during pregnancy, whereas folate, vitamin D, and vitamin B12 levels increased, and iron levels remained stable. FFM use was associated with higher hemoglobin, folate, vitamin D, and ferritin levels. In conclusion, through adequate supplementation and follow-up, GB does not have to result in impaired micronutrient status. Supplements developed specifically for post-bariatric patients generally result in higher micronutrient values than regular multivitamins before and during pregnancy. These data emphasize the urgent need for nutritional counseling including dietary and multivitamin supplement advise for post-bariatric women contemplating and during pregnancy.

Möglichkeiten der Kontrazeption bei Übergewicht und Adipositas

Die weltweit steigende Prävalenz von Übergewicht und Adipositas betrifft zunehmend Frauen im fertilen Alter. Ungewollte oder ungeplante Schwangerschaften treten bei Frauen mit Übergewicht häufiger auf, was sowohl auf die mangelnde Anwendung einer effektiven Kontrazeption als auch auf die pathophysiologischen Besonderheiten, die mit einem erhöhten Körperfettanteil einhergehen, zurückzuführen ist. Eine adäquate Kontrazeptionsberatung adipöser Frauen ist daher essenziell für ihre Gesundheit und Lebensqualität. Unter den kombinierten Kontrazeptiva stellen orale Präparate, die Ethinylestradiol und Levonorgestrel (LNG) enthalten, eine effiziente Option dar, vorausgesetzt, es bestehen zusätzlich zum erhöhten Body-Mass-Index (BMI) keine weiteren Risikofaktoren für kardiovaskuläre oder thrombembolische Ereignisse. Rein gestagene Präparate zeichnen sich durch ihre geringen gesundheitlichen Risiken aus. Die Angst vor einer weiteren Gewichtszunahme ist ein häufiger Grund für das Sistieren der Einnahme, wobei dieser Zusammenhang außer für Depot-Medoxyprogesteronacetat für die meisten Präparate wissenschaftlich nicht belegt wurde. Die Wirksamkeit intrauteriner Kontrazeptiva entfaltet sich unabhängig vom Körpergewicht. Als Notfallkontrazeption ist die Einlage eines kupferhaltigen Intrauterinpessars die sicherste Methode, jedoch erheblich aufwendiger und teurer als eine orale Notfallkontrazeption. Die orale Einnahme von Ulipristalacetat 30 mg ist aufgrund der potenteren Ovulationshemmung und der stärkeren Reduktion unerwünschter Schwangerschaften gegenüber LNG 1,5 mg zu bevorzugen.

The effects of bariatric surgery on periconception maternal health: a systematic review and meta-analysis

BACKGROUND

Worldwide, the prevalence of obesity in women of reproductive age is increasing. Bariatric surgery is currently viewed as the most effective, long-term solution for this problem. Preconception bariatric surgery can reduce the prevalence of obesity-related subfertility and adverse maternal, pregnancy and birth outcomes. Maternal health during the periconception period is crucial for optimal gametogenesis and for embryonic and fetal development which also affects health in the later lives of both mother and offspring. Although preconception bariatric surgery improves several pregnancy outcomes, it can also increase the prevalence of pregnancy complications due to excessive and rapid weight loss. This can lead to iatrogenic malnutrition with vitamin deficiencies and derangements in metabolic and endocrine homeostasis. Thus, bariatric surgery can greatly influence periconception maternal health with consequences for reproduction, pregnancy and health in later life. However, its influence on periconception maternal health itself has never been reviewed systematically.

OBJECTIVE AND RATIONALE

The aim of this review was to investigate associations between bariatric surgery and determinants of periconception maternal health such as endocrine changes, fertility, vitamin status, irregular menstrual cycles, miscarriages and congenital malformations.

SEARCH METHODS

Medline, Embase, PubMed, Web of Science, Google Scholar and the Cochrane databases were used for the literature search until 1 November 2020. The search strategy terms included, among others, bariatric surgery, hormones, fertility, malformations, miscarriages and vitamin status. We searched for human studies that were written in English. Abstracts, reviews, meta-analyses and conference papers were excluded. The ErasmusAGE score was used to assess the quality of the included studies.

OUTCOMES

A total of 51 articles were analysed. The mean quality score was 5 (range 2-8). After bariatric surgery, hormonal axes normalized and menstrual cycle regularity was restored, resulting in increased fertility. Overall, there were no short-term risks for reproductive outcomes such as the increased risk of miscarriages or congenital malformations. However, the risk of vitamin deficiencies was generally increased after bariatric surgery. A meta-analysis of 20 studies showed a significant decrease in infertility (risk difference (RD) -0.24, 95% confidence interval (CI) -0.42, -0.05) and menstrual cycle irregularities (RD -0.24, 95% CI -0.34, -0.15) with no difference in rates of miscarriage (RD 0.00, 95% CI -0.09, 0.10) and congenital malformations (RD 0.01, 95% CI -0.02, 0.03).

WIDER IMPLICATIONS

The current systematic review and meta-analysis show associations between bariatric surgery and periconception maternal health and underlines the need for providing and personalizing preconception care for women after bariatric surgery. We recommend preconception care including the recommendation of postponing pregnancy until weight loss has stabilized, irrespective of the surgery-to-pregnancy interval, and until vitamin status is normalized. Therefore, regular monitoring of vitamin status and vitamin supplementation to restore deficiencies is recommended. Furthermore, this systematic review emphasizes the need for a long-term follow-up research of these women from the periconception period onwards as well as their pregnancies and offspring, to further improve care and outcomes of these mothers and children.

Women in larger bodies' experiences with contraception: a scoping review

Background

As the prevalence of obesity increases and the age of onset decreases, more women of reproductive age will be living in larger bodies. Research on weight-related efficacy and safety has informed clinical guidelines for routine and emergency contraceptive use by women with a higher body mass index; however, patient perspectives are needed to understand women in larger bodies’ experiences with contraception and contraceptive care. This scoping review summarizes the literature on women in larger bodies’ experiences with contraception with the goal of gaining a better understanding of the nature of these experiences and identifying gaps in the existing research.

Methods

Following Arksey and O’Malley’s framework, a scoping review of the literature was conducted. Four databases (PubMed, PsycINFO, SCOPUS, and CINAHL) were searched for peer-reviewed, empirical articles published in English between 2010 and 2020, with a focus on North America, Europe, Australia, and New Zealand. Data were summarized by identifying key themes in the reviewed literature.

Results

Twenty-nine articles meeting the eligibility criteria were reviewed. The literature was predominantly quantitative (n = 27), with only one qualitative study and one systematic review, respectively. Five themes were identified, including (1) use of contraception among women in larger bodies; (2) knowledge, attitudes towards and beliefs about contraception; (3) contraceptive (dis)satisfaction among women in larger bodies; (4) contraceptive counseling; and (5) barriers to contraception. The findings revealed that women in larger bodies may have unmet contraceptive care needs. Despite many articles addressing the need to improve contraceptive counseling for women in larger bodies (n = 26), few explored how women felt about their care (n = 2). Finally, only two articles focused on emergency contraception, indicating a need for further research.

Conclusion

This scoping review emphasizes the pressing need for qualitative research to explore women in larger bodies’ experiences with routine and emergency contraception, as well as receiving contraceptive counseling and care. Future research exploring the lived experiences of women in larger bodies is necessary to better characterize their contraceptive needs and identify avenues to improve patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01139-2.

As obesity becomes more prevalent, more women of reproductive age will be living in larger bodies. This review highlights what is known about women in larger bodies’ experiences with contraception and suggests where future research is needed. We searched four databases for papers published in English from 2010 to 2020. Our review included 29 articles. Nearly all of the studies were quantitative, with one qualitative study and one review. Most articles talked about contraceptive use, but few of them included emergency contraception. Some papers highlighted women’s knowledge and opinions about contraception, whereas others talked about their contraceptive (dis)satisfaction. Many articles discussed contraceptive counseling. Finally, some papers considered potential barriers to contraception. Our findings suggest that women in larger bodies have unmet contraceptive needs. Notably, this review aimed to focus on patient experiences but women’s voices were rarely represented. Future qualitative research on women’s lived experiences will provide a better understanding of women in larger bodies’ contraceptive needs and suggest how care can be improved.

Pharmacokinetics of oral levonorgestrel and ethinylestradiol in women after Roux-en-Y gastric bypass surgery

BACKGROUND

Most patients undergoing Roux-en-Y gastric bypass (RYGB) are women in reproductive age. It is not known if bariatric surgery affects the pharmacokinetics of oral contraceptives.

OBJECTIVES

The primary objective was to evaluate ethinylestradiol (EE) and levonorgestrel (LNG) absorption in women undergoing RYGB, compared with nonoperated controls matched by age and body mass index (BMI). A secondary objective was to assess whether the time since surgery and BMI in the postoperative period influenced the absorption parameters.

SETTING

University hospital, Brazil.

METHODS

This study was designed to compare the maximum plasma concentration (C_max), the time to the peak plasma level (T_max), the area under the curve (AUC_0-8 and AUC_0-∞) after a single dose of a combined oral contraceptive with 0.03 mg EE and 0.15 mg LNG among 20 women after RYGB and 20 controls. Blood samples were obtained for 8 hours.

RESULTS

The mean LNG AUC_0-8 and LNG AUC_0-∞ were higher in RYGB group (P = .048 and P = .004, respectively). We found a positive correlation for LNG AUC_0-8 (P = .045) and AUC_0-∞ (P = .004) and the time since surgery, and we found a negative correlation for LNG C_max (P = .018), AUC_0-8 (P = .003), and AUC_0-∞ (P = .001) and BMI.

CONCLUSION

No significant differences were found in oral EE pharmacokinetics. The operated group showed higher mean LNG AUC_0-8 and AUC_0-∞ but it was not considered clinically significant. The present study suggests that RYGB may not affect EE and LNG absorption.

ACOG Practice Bulletin No. 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions

Although numerous studies have addressed the safety and effectiveness of hormonal contraceptive use in healthy women, data regarding women with underlying medical conditions or other special circumstances are limited. The U.S. Medical Eligibility Criteria (USMEC) for Contraceptive Use, 2016 (), which has been endorsed by the American College of Obstetricians and Gynecologists, is a published guideline based on the best available evidence and expert opinion to help health care providers better care for women with chronic medical problems who need contraception. The goal of this Practice Bulletin is to explain how to use the USMEC rating system in clinical practice and to specifically discuss the rationale behind the ratings for various medical conditions. Contraception for women with human immunodeficiency virus (HIV) (); the use of emergency contraception in women with medical coexisting medical conditions, including obesity, (); and the effect of depot medroxyprogesterone acetate (DMPA) on bone health () are addressed in other documents from the American College of Obstetricians and Gynecologists.

Contraception, Menstruation, and Sexuality after Bariatric Surgery: a Prospective Cohort Study

BACKGROUND

Women with a history of bariatric surgery are recommended to avoid pregnancy at least 12 months after surgery. Evidence on the impact of bariatric surgery on contraception, menstrual cycle, and sexuality in the first year postoperative is therefore indispensable.

OBJECTIVES

The objective of this paper is to prospectively study changes in contraception, menstrual cycle and sexuality in women of reproductive age following bariatric surgery.

SETTING

The study was conducted in two secondary medical centers and a tertiary academic medical center.

METHODS

Women attending for bariatric surgery or who recently underwent bariatric surgery completed online questionnaires about contraception, menstrual cycle, and sexual behavior before surgery and 6 and 12 months after surgery.

RESULTS

The study included data from 71 women, including 70 and 47 women at 6 and 12 months after bariatric surgery, respectively. Preoperatively, 43.6% (n = 31/71) used a short-acting hormonal contraceptive, the usage of which decreased significantly to, respectively, 32.8% (n = 23/70; p = .031) and 27.7% (n = 13/47; p = .022) 6 and 12 months post-surgery. Usage of long-acting contraceptive methods increased from 26.7% (n = 19/71) preoperatively to 38.6% (n = 27/70; p = .021) and 42.6% (n = 20/47; p = .004) at 6 and 12 months. Combined oral contraceptives (COC) remained used (39.4% preoperatively, 27.1 and 14.9% at 6 and 12 months postoperatively). Menstrual cycle (frequency, pattern, duration of the cycle, and the menstruation itself) and sexual behavior (intimate relationship, frequency of intercourse, and satisfaction) did not differ significantly before and after surgery.

CONCLUSIONS

Women undergoing bariatric surgery appear to switch their type of contraceptive from oral, short-acting hormonal contraceptives to non-oral, long-acting contraceptives. No changes in menstrual cycle and sexual behavior were shown.

Healthcare provider knowledge regarding oral contraception effectiveness for women with a history of bariatric malabsorptive procedures

BACKGROUND

Clinical practice guidelines that recommend women avoid pregnancy immediately after bariatric surgery, highlighting the need for effective contraception. However, women with a history of malabsorptive bariatric procedures should generally not use oral contraceptives, as these procedures may decrease oral contraceptive effectiveness.

OBJECTIVES

To identify provider characteristics associated with knowledge of combined oral contraceptive (COC) effectiveness.

SETTING

United States.

METHODS

We analyzed weighted survey data collected from national samples of public-sector health centers and office-based physicians who regularly provide family planning services (N = 2060). We asked providers about the effectiveness of COCs for women with a history of malabsorptive procedures compared with healthy women, giving them the response options of more/equally effective, less effective, and do not know. We used multinomial logistic regression to calculate adjusted odds ratios and 95% confidence intervals to identify characteristics associated with knowledge of COC effectiveness.

RESULTS

Approximately 55% of providers correctly answered that COCs are less effective for women with malabsorptive procedures; 25% considered COCs more/equally effective, and 20% were uncertain. Among public-sector providers, the adjusted odds of uncertainty were significantly higher for those whose clinical focus was not reproductive health, for nurses versus advanced practice clinicians, and for providers working in clinics without Title X funding. For office-based physicians, adolescent medicine providers had higher odds of uncertainty versus obstetrician-gynecologists. Physicians practicing in settings classified as "other" (such as community health centers) had higher odds of considering COCs effective compared with those practicing in hospital or university clinics.

CONCLUSIONS

Substantial proportions of surveyed providers had inadequate knowledge of COC effectiveness for women with a history of malabsorptive procedures.

Contraception for Adolescents with Medically Complex Conditions

Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have developed, published, and updated evidence-based guidelines to support medical providers in the provision of contraceptives to patients with specific medical conditions or characteristics. The goal of these guidelines is to provide recommendations on the safe use of contraceptives with the goal of removing unnecessary medical barriers to access and use of contraceptives, thus decreasing the number of unintended pregnancies. Many medical conditions increase a patient's risk of venous thromboembolism; a risk that may also be increased with specific contraceptives. Specific conditions that require more enhanced contraceptive counseling due to their frequency in adolescence and their association either with adverse events during pregnancy or with increased risk for specific contraceptives are detailed by the WHO and CDC and are summarized herein. Adolescents with morbid obesity, migraine headache, cardiac conditions, hypertension, diabetes mellitus, hyperlipidemia, systemic lupus erythematosus, sickle cell anemia, cystic fibrosis, inflammatory bowel disease, or seizure disorders would benefit from greater attention to the urgency of exploring highly effective contraceptive methods. Details of the considerations that should be used in providing contraceptive care to adolescents with each of these medical conditions, as per WHO and CDC guidelines, are provided in this review. The ultimate goal in contraceptive counseling is the balancing of risk and benefit to arrive at the best therapeutic option, maintaining patient preference as a priority, as that will enhance adherence and comfort with the contraceptive method. Each patient must be assessed for pregnancy risk and be allowed full risk reduction and education regarding contraceptive options.

Plasma concentrations of etonogestrel in women using oral desogestrel before and after Roux-en-Y gastric bypass surgery: a pharmacokinetic study

OBJECTIVE

To investigate whether Roux-en-Y gastric bypass (RYGB) affects oral desogestrel (etonogestrel) pharmacokinetics.

DESIGN

Single centre, open label, phase-2 pharmacokinetic study.

SETTING

University hospital of Linköping, Sweden.

POPULATION

Fourteen women with planned RYGB surgery were included; nine women aged 18-45 years using 75 micrograms desogestrel completed the study.

METHODS

Steady-state etonogestrel pharmacokinetic (PK) parameters were measured on three occasions for each individual (at 8 ± 6 weeks before surgery, and at 12 ± 2 and 52 ± 2 weeks after surgery). Each patient served as her own control. On each occasion, serum samples were collected during a 24-hour period and etonogestrel concentrations were determined with ultra-performance liquid chromatography/tandem mass spectrometry.

MAIN OUTCOME MEASURES

Area under the plasma concentration time curve of etonogestrel (AUC_{0-24 hours} ).

RESULTS

All women had significant postoperative weight loss. There were no significant differences in AUC_{0-24 hours} , terminal half-lives (t_½ ), time to peak serum concentrations (T_max ), or apparent oral clearances of etonogestrel (CL_oral ) before and after gastric bypass surgery on any occasion. Peak serum concentrations (C_max ) increased after 52 ± 2 weeks compared with preoperative values (0.817 ng/ml versus 0.590 ng/ml, P = 0.024).

CONCLUSION

To our knowledge, this is the first study to investigate the effects on desogestrel pharmacokinetics after RYGB. This study did not reveal any clinically significant changes in etonogestrel pharmacokinetics, suggesting that oral desogestrel may be used by women after RYGB surgery. The sample size was limited, however, and therefore the results should be interpreted cautiously.

TWEETABLE ABSTRACT

The pharmacokinetics of oral desogestrel does not appear to change after gastric bypass surgery.

Perioperative pregnancy interval, contraceptive counseling experiences, and contraceptive use in women undergoing bariatric surgery

BACKGROUND

Reproductive-aged women represent about half of those undergoing bariatric surgery in the United States. Obstetric and bariatric professional societies recommend that women avoid pregnancy for 12-18 months postoperatively due to concern for increased pregnancy risks, and that providers should counsel women about these recommendations and their contraceptive options. However, knowledge about women's experience with perioperative counseling and postoperative contraceptive use is limited.

OBJECTIVE

We sought to: (1) determine prevalence of perioperative contraceptive and pregnancy interval discussions among women who have recently undergone bariatric surgery; and (2) describe postoperative contraceptive use within the first year of surgery in this population.

STUDY DESIGN

We performed a cross-sectional study of US women, aged 18-45 years and recruited through Facebook, who underwent bariatric surgery within the last 24 months.

RESULTS

We enrolled 363 geographically diverse women. Three-quarters recalled perioperative pregnancy or contraceptive discussions, the majority with a bariatric provider. Half felt it was "very important" to discuss these issues perioperatively, and 41% of those who reported discussions wished they had had more. Of the 66% of women who reported using contraception in the first 12 months postoperatively, 27% used oral contraceptives and 26% used an intrauterine device. One third of contraceptive users who had undergone Roux-en-Y gastric bypass, a combined restrictive-malabsorptive procedure, were using oral contraceptives. Perioperative contraceptive or pregnancy discussions were independently associated with increased postoperative contraceptive use (odds ratios, 2.5; 95% confidence interval, 1.5-4.3, P < .001).

CONCLUSION

A substantial proportion of women who had undergone bariatric surgery reported having had no perioperative pregnancy or contraception counseling, and many women who had felt the discussions were insufficient. Those who had had perioperative discussions were more likely to use contraception postoperatively. Reproductive-aged women should be routinely counseled perioperatively about pregnancy and contraception in the context of their reproductive desires, so they can make informed decisions about perioperative pregnancy prevention and contraceptive method use.

Management of Pregnant Women after Bariatric Surgery

The prevalence of obesity is growing worldwide, and strategies to overcome this epidemic need to be developed urgently. Bariatric surgery is a very effective treatment option to reduce excess weight and often performed in women of reproductive age. Weight loss influences fertility positively and can resolve hormonal imbalance. So far, guidelines suggest conceiving after losing maximum weight and thus recommend conception at least 12-24 months after surgery. As limited data of these suggestions exist, further evidence is urgently needed as well for weight gain in pregnancy. Oral glucose tolerance tests for the diagnosis of gestational diabetes mellitus (GDM) should not be performed after bariatric procedures due to potential hypoglycaemic adverse events and high variability of glucose levels after glucose load. This challenges the utility of the usual diagnostic criteria for GDM in accurate prediction of complications. Furthermore, recommendations on essential nutrient supplementation in pregnancy and lactation in women after bariatric surgery are scarce. In addition, nutritional deficiencies or daily intake recommendations in pregnant women after bariatric surgery are not well investigated. This review summarizes current evidence, proposes clinical recommendations in pregnant women after bariatric surgery, and highlights areas of lack of evidence and the resulting urgent need for more clinical investigations.

Contraceptive Care of Obese Women

Importance

In the United States, 27% of reproductive-aged women are overweight, and 35% are obese. Until recently, contraceptive research excluded women greater than 130% of their ideal body weight. Gaps in data limit evidence-based decision making for effective contraceptive counseling and management in this rapidly growing population.

Objectives

The aims of this summary are to review the benefits, adverse effects, and risk factors associated with contraceptive methods in obese women, with special attention to effectiveness, and provide contraceptive management and counseling recommendations for best clinical practice.

Evidence Acquisition

We performed a thorough search of PubMed for current literature, including original research articles, review articles, and guidelines on contraceptive counseling and management in obese women in the United States. We reviewed the body of evidence with special attention to studies published since recent Cochrane and systematic reviews on this topic.

Conclusions

Contraceptive use is safer than pregnancy, especially for obese women who have increased pregnancy risks. Baseline health is compromised by obesity, but contraceptive risks remain low. Long-acting, reversible contraceptive methods offer superior effectiveness, minimal risk, and numerous noncontraceptive benefits across body mass index groups. No substantial evidence supports ineffectiveness of any method in obese women except oral emergency contraception and the patch. Pharmacokinetic changes of obesity associated with other oral methods do not seem to result in clinically significant declines in effectiveness. Future contraceptive efficacy studies should include obese women to better discuss their contraceptive needs.

Relevance

This review is beneficial for all providers caring for reproductive-aged women wanting to avoid unintended pregnancy.

Nutrition Recommendations in Pregnancy and Lactation

The nutritional status of a woman during pregnancy and lactation is not only critical for her health but for future generations. Although a nutritionist or registered dietitian can help facilitate dietary counseling and interventions, physicians also need to be cognizant of nutritional needs during pregnancy because they differ significantly compared with nonpregnant populations. Furthermore, an individualized approach to nutritional counseling that considers a woman's nutritional status and body mass index is recommended.

AURORA: bariatric surgery registration in women of reproductive age - a multicenter prospective cohort study

Background

The expansion of the obesity epidemic is accompanied with an increase in bariatric procedures, in particular in women of reproductive age. The weight loss induced by the surgery is believed to reverse the negative impact of overweight and obesity on female reproduction, however, research is limited to in particular retrospective cohort studies and a growing number of small case-series and case-(control) studies.

Methods/design

AURORA is a multicenter prospective cohort study. The main objective is to collect long-term data on reproductive outcomes before and after bariatric surgery and in a subsequent pregnancy. Women aged 18–45 years are invited to participate at 4 possible inclusion moments: 1) before surgery, 2) after surgery, 3) before 15 weeks of pregnancy and 4) in the immediate postpartum period (day 3–4). Depending on the time of inclusion, data are collected before surgery (T1), 3 weeks and 3, 6, 12 or x months after surgery (T2-T5) and during the first, second and third trimester of pregnancy (T6-T8), at delivery (T9) and 6 weeks and 6 months after delivery (T10-T11). Online questionnaires are send on the different measuring moments. Data are collected on contraception, menstrual cycle, sexuality, intention of becoming pregnant, diet, physical activity, lifestyle, psycho-social characteristics and dietary supplement intake. Fasting blood samples determine levels of vitamin A, D, E, K, B-1, B-12 and folate, albumin, total protein, coagulation parameters, magnesium, calcium, zinc and glucose. Participants are weighted every measuring moment. Fetal ultrasounds and pregnancy course and complications are reported every trimester of pregnancy. Breastfeeding is recorded and breast milk composition in the postpartum period is studied.

Discussion

AURORA is a multicenter prospective cohort study extensively monitoring women before undergoing bariatric surgery until a subsequent pregnancy and postpartum period.

Trial registration

Retrospectively registered (July 2015 - NCT02515214)

Pregnancy and perinatal outcomes according to surgery to conception interval and gestational weight gain in women with previous gastric bypass

OBJECTIVE

To compare perinatal and pregnancy outcomes including adherence to the Institute of Medicine's (IOM) recommendations for gestational weight gain (GWG) in pregnant women with conception <18 months (early group) compared to ≥18 months following gastric bypass (late group).

METHODS

Retrospective cohort study comprising 71 women with gastric bypass and a singleton pregnancy presenting at Odense University Hospital, November 2007-October 2013. Data were extracted from medical records and laboratory systems. The primary outcomes were timing of pregnancy and adherence to the IOM's recommendations for GWG. Secondary outcomes were birthweight, preterm delivery, cesarean section (CS), iron deficiency and post partum hemorrhage (PPH).

RESULTS

Forty-three (61%) women conceived less than 18 months after gastric bypass surgery. Women in the late group had a significantly higher risk of requiring CS or receiving intravenous iron supplementation compared to the early group (57% versus 30%, p = 0.03 and 29% versus 7%, p = 0.02, respectively). Early conception was not significantly associated with insufficient GWG, preterm delivery or birthweight. Among 54 women with information on GWG, only 13 (24%) had an appropriate GWG.

CONCLUSION

The majority of pregnant women with gastric bypass did not fulfill guidelines for GWG; however, this study could not support the recommendation to postpone pregnancy.

[Gender Obesity Report--Influence of obesity on Reproduction and Pregnancy]

Obesity influences reproduction in men and women at all ages. The increasing prevalence of obesity is associated with rising numbers of reproductive disorders in both sexes. Obesity influences menstrual cycle and ovulation irregularities, increases pregnancy complications and complication rates in assisted reproductive technologies in women and in men obesity is associated with lower semen parameters. Weight loss through lifestyle changes or bariatric surgery has positive effects on hormonal parameters and fertility in both men and women.

[Contraception and obesity]

The prevalence of obesity is increasing massively over several decades in industrialized countries. Obese women are sexually active but they use fewer contraceptive methods and are at high risk of unintended pregnancy. In addition, obesity is an important risk factor for venous thromboembolism events and arterial thrombosis (myocardial infarction and ischemic stroke). All of these data are to be considered in choosing a contraceptive method for obese women. Except depot medroxyprogesterone acetate injection, the progestin-only contraceptives (progestin only pills and etonogestrel subdermal implant) and the intra-uterine devices are the preferred contraceptive methods in obese women. The combined estrogen-progestin contraceptives (pill, patch and vaginal ring) may be proposed in very strict conditions (no other associated vascular risk factor). Obesity does not increase the risk of failure of most contraceptive methods. Bariatric surgery is a complex situation. It requires to program a possible pregnancy and contraception is needed for several months. Some bariatric surgical techniques such as by-pass can induce gastrointestinal malabsorption. In this situation, all oral contraceptives are not recommended because of a higher risk of failure.

Obesity and reproduction: a committee opinion

The purpose of this ASRM Practice Committee report is to provide clinicians with principles and strategies for the evaluation and treatment of couples with infertility associated with obesity. This revised document replaces the Practice Committee document titled, "Obesity and reproduction: an educational bulletin," last published in 2008 (Fertil Steril 2008;90:S21-9).

Obesity and menstrual disorders

Obese women often present with oligomenorrhoea, amenorrhoea or irregular periods. The association between obesity and heavy menstrual bleeding is not well documented and data on its prevalence are limited. While the investigation protocols should be the same as for women of normal weight, particular focus is required to rule out endometrial hyperplasia in obese women. The treatment modalities of menstrual disorders for obese women will be, in principle, similar to those of normal weight. However, therapeutic outcomes in terms of effectiveness and adverse outcomes need special consideration when dealing with women with a high body mass index (BMI). Here, different treatment strategies are reviewed paying particular attention to the effect of weight on their efficacy and the challenges of providing each treatment option. This chapter aims to review the current literature and address areas where further evidence is needed, which will subsequently influence clinical practice.

Combined hormonal contraceptives: prescribing patterns, compliance, and benefits versus risks

Combined hormonal contraceptives [combined oral contraceptives (COCs)] have been available for over 50 years and the impact of this invention may not be overestimated. Today over 100 million women are current users and in Western Europe and the United States approximately 80% of women of fertile ages can be considered as ever-users. Over the years several drawbacks have been identified and media alarms on risks are frequently presented, resulting in suboptimal compliance and low compliance and continuation rates. Poor compliance and discontinuation is a big problem and is not generally identified by prescribers. During ideal use COCs offer very good protection against unwanted pregnancies, however there is a big problem with compliance and continuation and thus the 'real-life' efficacy is much lower. Reasons for poor compliance include side effects and fear of side effects and it is crucial that the prescriber gives the individual woman thorough and balanced information on the benefits and risks. Most well known is the increased risk of venous thromboembolism, but also an elevated risk of arterial thrombosis and several types of cancer has been reported. The risk estimates are low but according to the large number of users a substantial number of extra cases will occur. However, use of COCs also offers several additional health benefits with significant impact on morbidity and quality of life. COC use is associated with a substantial decrease in the risk of ovarian cancer, endometrial cancer and colorectal cancer. Moreover, COCs are a major option of treatment for women suffering from heavy menstrual bleeding and dysmenorrhea as well as hirsutism and acne vulgaris. The net effect of the additional health effects of COC- use may very well be positive, i.e. a slight increase in life expectancy.

Roles of the pharmacist in the use of safe and highly effective long-acting reversible contraception: an opinion of the women's health practice and research network of the American College of Clinical Pharmacy

The U.S. population continues to experience an alarmingly high rate of unintended pregnancies that have an impact on individual families and society alike. Lack of effective contraception accounts for most unintended pregnancies, along with incorrect use of contraceptives. The most common reversible contraceptive method used in the United States is the oral contraceptive pill, which has significant failure and discontinuation rates. Use of long-acting reversible contraceptive (LARC) methods has been increasing in recent years after efforts to educate providers and patients. Women are more likely to use LARC methods when barriers such as access and cost are removed. An uptake in the use of LARC methods would allow for markedly reduced contraception failure rates and higher user satisfaction and thus higher continuation rates than those seen with current contraception use. Promoting the use of LARC methods is an important strategy in improving both individual and public health outcomes by reducing unintended pregnancies. The pharmacist's role in family planning is expanding and can contribute to these efforts. Although knowledge regarding LARC has not been studied among pharmacists, a knowledge deficit exists among health care professionals in general. Thus pharmacist education and training should include LARC methods along with other contraceptives. The American College of Clinical Pharmacy Women's Health Practice and Research Network advocates for the pharmacist's role in the use of safe and highly effective LARC methods. These roles include educating patients, informing providers, facilitating access by providing referrals, and modifying institutional procedures to encourage provision of LARC methods.

Reproductive health counseling and practices: a cross-sectional survey of bariatric surgeons

BACKGROUND

Nearly 50% of bariatric surgery patients are women of reproductive age. Both obstetric and gynecology and surgery professional guidelines recommend a delay of fertility 1-2 years postbariatric surgery.

METHODS

We sought to assess bariatric surgeons' perioperative reproductive counseling and contraceptive provision for women of reproductive age. We conducted a cross-sectional, national 32-question mail survey of bariatric surgeons. Survey topics included demographic factors, contraceptive counseling and provision, and method preference. Descriptive statistics were reported and Χ2 tests compared results among respondent demographic characteristics.

RESULTS

A total of 574 of 1,935 physicians returned surveys (30%). After excluding 41 surveys due to missing data, we analyzed 533 (27%) surveys. Mean respondent age was 48.1 years. Most respondents were male (89%), white (78%), and completed residency training ≥10 years ago (72%). The majority of respondents' bariatric surgery patients were female (77%), 63% of which were of reproductive age. Most respondents recommended that their female patients delay pregnancy 12-24 months (87%). Whereas 70% of respondents did not require preoperative contraception, 52% always required postoperative contraceptive use. Although the majority of respondents (64%) referred patients to an obstetrician-gynecologist or primary care physician to obtain contraception, 35% did not know how their female patients obtained contraception. Female respondents were more likely than male respondents to always require a medicine consultation and preoperative contraception, P<.05.

CONCLUSION

Despite consistently recommending a delay in pregnancy, bariatric surgeons inconsistently address perioperative contraceptive needs of women of reproductive age. These findings highlight the need for greater collaboration between bariatric surgeons and women's healthcare providers to address the reproductive health needs of women having bariatric surgery.

Obesity and hormonal contraceptive efficacy

Obesity is a major public health concern affecting an increasing proportion of reproductive-aged women. Avoiding unintended pregnancy is of major importance, given the increased risks associated with pregnancy, but obesity may affect the efficacy of hormonal contraceptives by altering how these drugs are absorbed, distributed, metabolized or eliminated. Limited data suggest that long-acting, reversible contraceptives maintain excellent efficacy in obese women. Some studies demonstrating altered pharmacokinetic parameters and increased failure rates with combined oral contraceptives, the contraceptive patch and emergency contraceptive pills suggest decreased efficacy of these methods. It is unclear whether bariatric surgery affects hormonal contraceptive efficacy. Obese women should be offered the full range of contraceptive options, with counseling that balances the risks and benefits of each method, including the risk of unintended pregnancy.

Bariatric surgery in women of childbearing age

BACKGROUND

Although bariatric surgery in women of childbearing age reduces the risks of pregnancy complications associated with maternal obesity, little is known of the effect of gestation on weight loss outcomes.

AIM

To study weight loss and pregnancy outcomes after bariatric surgery in women of childbearing age.

DESIGN AND METHODS

We performed a retrospective, observational cohort analysis of women aged 18-45 years in a university teaching hospital. The results shown represent mean ± standard deviation where appropriate.

RESULTS

A total of 232 women aged 34.0 ± 5.9 years with pre-operative weight 137.7 ± 21.3 kg and body mass index (BMI) 50.6 ± 7.2 kg/m(2) underwent bariatric surgery that included 197 (84.9%) gastric bypass, 19 (8.2%) gastric banding, 8 (3.4%) sleeve gastrectomy and 8 other procedures. Twenty-one women had 28 pregnancies following bariatric surgery, of which 24 (85.7%) resulted in live births, 3 (10.7%) terminations of pregnancy and 1 (3.6%) spontaneous miscarriage. The pregnancy group was younger compared with the non-pregnancy group (28.0 ± 5.4 vs. 34.6 ± 5.6 years; P < 0.001) but well matched for pre-operative weight (136.5 ± 18.5 vs. 137.8 ± 21.6 kg), BMI (49.2 ± 7.4 vs. 50.7 ± 7.2 kg/m(2)) and bariatric procedure. The interval between bariatric surgery and first pregnancy was a median 11 months. The pregnancy group lost 70.4% of excess weight compared with 70.0% in the non-pregnancy group at median 30 months of follow-up.

CONCLUSION

Pregnancy after bariatric surgery is safe and does not adversely affect weight loss outcomes.

Obesity and reproductive function

Obesity is associated with multiple adverse reproductive outcomes, but the mechanisms involved are largely unknown. Obesity has been referred to as a "complex system," defined as a system of heterogeneous parts interacting in nonlinear ways to influence the behavior of the parts as a whole. Human reproduction is also a complex system; hence the difficulty in identifying the mechanisms linking obesity and adverse reproductive function. This review discusses the adverse reproductive outcomes associated with obesity and the mechanisms involved and concludes with a discussion of public health policy with respect to the treatment of infertility in obese women.

Endocrine changes (beyond diabetes) after bariatric surgery in adult life

Bariatric surgery is nowadays an effective therapeutic option for morbid obesity. Endocrinologists may thus have a growing opportunity to diagnose and treat obese patients eligible for surgery in pre- and post-operative phase. This requires a better understanding of endocrine changes caused by either obesity or weight loss surgery. Despite the large number of studies available in literature, only limited well-designed clinical trials have been performed so far to investigate changes of endocrine axes following bariatric procedures. There are still areas of unclear results such as female and male fertility, however, weight loss after bariatric surgery is considered to be associated with favorable effects on most endocrine axes. The aim of this clinical review is to overview the available literature on the effects of weight loss after bariatric surgery on the endocrine systems to suggest the most appropriate pre- and post-operative management of obese patients undergoing bariatric surgery in terms of "endocrine" health.

The influence of bypass procedures and other anatomical changes in the gastrointestinal tract on the oral bioavailability of drugs

The gastrointestinal (GI) tract plays an important role in the absorption of orally administered drugs. However, in some cases the anatomy of the GI tract is changed due to GI surgery, which has the potential of influencing drug bioavailability. In this review, we aim to compile, review, and comment the existing but sometimes fragmented scientific data regarding the impact of GI surgery on the oral bioavailability of drugs. Relevant reports were gathered through the PubMed database from database inception through January 2012. Drugs for which at least one trial or case report suggested a change in oral bioavailability or absorption caused by GI surgery are discussed in detail. Major methodological differences, such as study design, number of subjects and choice of reference group, were observed in the reported studies. Predicting the impact of GI surgery on the oral bioavailability was therefore difficult to perform, even the most sophisticated classification systems could not be used for predicting purposes.

Obesity and oral contraceptives: a clinician's guide

Obesity and unintended pregnancy are two of the major health epidemics we are currently facing worldwide. Patient education is a clinician's greatest tool in combating both epidemics but many clinicians may be uncomfortable with counselling and prescribing contraception for obese women. Overall, the prevention of unintended pregnancy in obese women far outweighs any risk associated with oral contraceptive use. This review aims to provide the clinician with a practical guide to the use of oral contraceptive pills in obese women.

Concepts of contraception for adolescent and young adult women with chronic illness and disability

Sexual behavior is common in adolescents and young adults with or without chronic illness or disability, resulting in high levels of unplanned pregnancy and STDs. Individuals with chronic illness or disability should not receive suboptimal preventive health care. These individuals have a need for counseling regarding issues of sexuality and contraception. Sexually active adolescent and young adult women can be offered safe and effective contraception if they wish to avoid pregnancy. Women with chronic illnesses and disabilities who are sexually active should also be offered contraception based on their specific medical issues. Condoms are also recommended to reduce STD risks. Table 36 summarizes basic principles of contraception application for specific illnesses, which have been identified since the release of the combined OC in 1960. Clinicians should also consider the noncontraceptive benefits of this remarkable and life-changing technology that allows all reproductive age women to improve their lives, including those with chronic illnesses and disabilities.