Executive Summary
Nearly 50% of bariatric surgery patients are reproductive-age women. Obstetric and gynecology as well as surgery professional guidelines recommend a delay of pregnancy one to two years post-surgery.
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Despite consistently recommending a delay in pregnancy, bariatric surgeons inconsistently address perioperative contraceptive needs of women of reproductive age, according to findings from a recent nationwide survey.
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The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010,gives a Category 3 rating (a condition for which the theoretical or proven risks usually outweigh the advantages of using the method) for use of combined hormonal pills or progestin-only pills in women after malabsorptive bariatric surgery.
Nearly 50% of bariatric surgery patients are reproductive-age women. Obstetric and gynecology as well as surgery professional guidelines recommend a delay of pregnancy one to two years post-surgery.1 What contraceptive options are available for these women?
What constitutes obesity? The Centers for Disease Control and Prevention estimate that 36.4% of U.S. women age 20 and older are obese (body mass index [BMI] at 30 or higher).2 Bariatric surgery is considered for those patients who have one of the following:
• BMI at or above 40;
• BMI 35 and up in association with major co-morbidities such as severe sleep apnea, Pickwickian syndrome, or obesity-related cardiomyopathy;
• BMI of 35 and up in association with obesity-induced physical problems with lifestyle, including joint disease or body size problems interfering with employment, family function, and ambulation.3
There are two approaches to bariatric surgery: restrictive and restrictive/malabsorptive surgeries. According to the American Society of Metabolic and Bariatric Surgeons, the most common bariatric procedures include adjustable gastric band and sleeve gastrectomy, both restrictive procedures; and gastric bypass (Roux-en-Y) and biliopancreatic diversion with duodenal switch, both malabsorptive procedures.4 Rapid weight loss is typical after either procedure and results in improvement of polycystic ovary syndrome, anovulation, and irregular menses, thus leading to higher fertility rates.5
Family planners might see reduced fertility in obese women, primarily due to oligoovulation and anovulation.
In women who become pregnant, obesity can increase risks of gestational diabetes mellitus, preeclampsia, cesarean delivery, and infectious morbidity. Operative morbidity also is increased, and obese women are less likely to have successful vaginal birth after a previous cesarean delivery.
Bariatric surgery can improve menstrual regularity and fertility in women.6 The American College of Obstetricians and Gynecologists and the American Society of Metabolic and Bariatric Surgeons recommend postponing pregnancy 12-18 months following bariatric surgery, as this is a time of rapid weight loss.7
Despite consistently recommending a delay in pregnancy, bariatric surgeons inconsistently address perioperative contraceptive needs of women of reproductive age, according to findings from a recent nationwide survey.7 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, says Patricia Chico, MD, resident physician in family medicine at the University of Illinois at Chicago. Chico received funding from the Society of Family Planning to perform the survey of American Society of Metabolic and Bariatric Surgeons members.
What are the options
For women who have undergone restrictive bariatric surgery, the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, rates all methods (combined hormonal ring, patch, and pills; contraceptive injection; the Copper-T and levonorgestrel intrauterine devices; progestin-only pills and progestin implant) as Category 1: "A condition for which there is no restriction for the use of the contraceptive method."8
However, after malabsorptive bariatric surgery, use of combined hormonal pills or progestin-only pills, the guidance issues as Category 3 rating: "a condition for which the theoretical or proven risks usually outweigh the advantages of using the method."8
Why the Category 3 rating? There are concerns for malabsorption of oral contraceptive hormones, as well as uncertainty as to whether this malabsorption translates to decreased efficacy, according to Anne Burke, MD, MPH, associate professor in the Department of Gynecology and Obstetrics at the Johns Hopkins University of School of Medicine in Baltimore. Burke spoke on the effect of obesity on contraceptive efficacy at the 2013 Contraceptive Technology Quest for Excellence conference. Evidence on this subject is limited to a handful of pharmacokinetic and observational studies, she notes.9
More adolescents are having bariatric surgery procedures performed, and these patients need highly effective contraception. Research indicates there is increasing experience and success with the levonorgestrel intrauterine device placed at the time of surgery.10
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American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009; 113(6):1,405-1,413.
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National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD; 2014.
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ASMBS Clinical Issues Committee. Bariatric surgery in class I obesity (body mass index 30-35 kg/m²). Surg Obes Relat Dis 2013; 9(1):e1-10.
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Armstrong C. ACOG guidelines on pregnancy after bariatric surgery. Am Fam Physician 2010; 81(7):905-906.
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American Society of Metabolic and Bariatric Surgeons. Bariatric surgery procedures. Accessed at http://bit.ly/ZwtYiw.
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Chor J, Chico P, Ayloo S, et al. Reproductive health counseling and practices: A cross-sectional survey of bariatric surgeons. Surg Obes Relat Dis 2014; doi: 10.1016/j.soard.2014.05.031.
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Centers for Disease Control and Prevention. U.S. medical eligibility criteria for contraceptive use. MMWR 2010; 59(RR04):1-6.
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Burke A. The effect of obesity on contraceptive efficacy: what we now know. Presented at the 2013 Contraceptive Technology Quest for Excellence conference. Atlanta; November 2013.
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Hillman JB, Miller RJ, Inge TH. Menstrual concerns and intrauterine contraception among adolescent bariatric surgery patients. J Womens Health (Larchmt) 2011; 20(4):533-538.
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Robinson JA, Burke AE. Obesity and hormonal contraceptive efficacy. Womens Health (Lond Engl) 2013; 9(5):453-466.
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Hillman JB, Miller RJ, Inge TH. Menstrual concerns and intrauterine contraception among adolescent bariatric surgery patients. J Womens Health (Larchmt) 2011; 20(4):533-538.
