Reproductive and Other Health Considerations for Women Undergoing Bariatric Surgery

Feature |
February 21, 2017

Reproductive and Other Health Considerations for Women Undergoing Bariatric Surgery

  1. McKenzie Eakin, BBA, Kimberley E. Steele, MD and
  2. Anne Burke, MD, MPH

Weight loss surgery can have lasting ramifications for contraception, pregnancy, and bone health.

  1. McKenzie Eakin, BBA, Kimberley E. Steele, MD and
  2. Anne Burke, MD, MPH

Bariatric surgery continues to gain popularity as a means of attaining durable weight loss and ameliorating obesity-related comorbidities, such as cardiovascular disease, sleep apnea, diabetes, and hypertension. Because most bariatric surgical patients are women (primarily of reproductive age), women's healthcare providers must pay close attention to the implications of this procedure for contraception, pregnancy, and bone health. In 2013, the American Society of Metabolic and Bariatric Surgery (ASMBS) published new nutritional recommendations to better guide physicians in the management of bariatric surgical patients.1 These guidelines represent an excellent resource for day-to-day clinical care of such patients.

Contraceptive Recommendations

When morbidly obese women lose weight, menstrual cycles can normalize and fertility can improve. Women wishing to prevent or postpone pregnancy should use effective contraception both pre- and postoperatively. Most medical organizations recommend that women delay pregnancy for 1 to 2 years after bariatric surgery,1 as conception that occurs too early in the postoperative period may impede maternal nutrition and fetal growth.2

Available contraceptives include combined hormonal methods (pills, patches, and vaginal rings), progestin-only systemic contraceptives (pills, injectables, and implants), and intrauterine contraception (IUC; copper and levonorgestrel). In the absence of other contraindications, all are considered safe following bariatric surgery (see U.S. Medical Eligibility Criteria for Contraceptive Use); however, because of concerns about efficacy, recommendations for oral contraceptive use vary depending on whether the surgery was malabsorptive (e.g., Roux-en-Y gastric bypass [RYGB]) or restrictive (e.g., gastric sleeve, gastric band). For malabsorptive procedures, anecdotal reports suggest that oral contraceptive efficacy is impaired3; thus, guidelines recommend against the use of contraceptive pills unless alternatives are unavailable. Restrictive bariatric surgical procedures do not alter oral contraceptive efficacy.

Although obesity does not seem to hinder the effectiveness of nonoral contraceptives, some data suggest that obesity-related alterations in pharmacokinetics may diminish the efficacy of oral contraceptives. In general, shorter-acting contraceptives have failure risks 20 times that of long-acting reversible contraceptives (LARC) such as intrauterine devices (IUDs) and implants (NEJM JW Womens Health Jun 2012 and N Engl J Med 2012; 366:1998). Thus, counseling should emphasize highly effective LARC methods. Case reports in women using etonogestrel implants after RYGB showed that postoperative hormone levels remained sufficient for effective contraception.4 The patient's age need not restrict options: In one small study with adolescent bariatric patients, 92% chose IUD placement after their surgery.5

Women who are using estrogen-containing contraceptives should discontinue their method several weeks before bariatric surgery to help curtail elevated preoperative thrombotic risk, particularly as estrogen use and obesity independently increase risk for thrombotic events.6 Progestin-only and intrauterine contraceptives do not raise thrombotic risk, and these highly effective reversible methods offer contraceptive protection for several years. As such, they represent a safe and effective perioperative alternative to estrogen-containing methods.

Pregnancy

Following bariatric surgery, pregnancy necessitates counseling about proper nutrition and appropriate use of nutritional supplements, because both restrictive and malabsorptive procedures can trigger vitamin and mineral deficiencies.1 Consensus is lacking about monitoring of nutritional deficiencies during pregnancy after bariatric surgery. In 2009, the American College of Obstetricians and Gynecologists (ACOG) recommended monitoring complete blood count, iron, ferritin, calcium, and vitamin D every trimester.2 If deficiencies are identified or clinically suspected, more-frequent monitoring may be necessary.7

The diagnosis of iron deficiency in pregnant bariatric patients may be complicated by simultaneous deficiencies in vitamin B12 and folate (which cause macrocytosis) and vitamin B6 (which causes microcytosis), leading to a spuriously normal mean corpuscular volume. In addition, ferritin — an acute phase reactant — may be elevated following surgery and therefore an unreliable indicator of iron deficiency.8 While providers often do not test patients for nutritional deficiencies unless anemia is present, vitamin B12 deficiency is sufficiently common in postbariatric pregnant patients that routine antenatal screening is recommended to prevent complications of vitamin B12 deficiency anemia, including neurological consequences in the mother8 and excess risk for neural tube defects9 or development of insulin resistance10 in the offspring. Nonetheless, any link between postbariatric micronutrient deficiencies in pregnant and postpartum women and subsequent adverse neonatal outcomes remains weak.9

Risk for Osteoporosis

As with all patients experiencing significant weight loss, risk for bone loss is elevated in bariatric patients. Specific recommendations for monitoring and preventing bone loss vary somewhat by type of bariatric procedure, but supplementation with calcium and vitamin D is a mainstay.11 Such supplementation is particularly important to avoid osteoporosis or osteomalacia in patients (especially postmenopausal women) undergoing malabsorptive procedures such as gastric bypass.12

Serum calcium and vitamin D levels should be monitored at regular intervals, typically 3, 6, and 12 months post–bariatric surgery and annually thereafter. For patients with known deficiencies in calcium or vitamin D, more-frequent monitoring may be necessary.1 Bone density tests such as dual-energy x-ray absorptiometry areal bone-mineral density (DXA aBMD) and quantitative computed tomography volumetric bone-mineral density (QCT vBMD) may help in assessing a bariatric surgical patient's bone health, although both tests have unique limitations in efficacy specific to obese patients.13 Baseline preoperative DXA can be performed for any patient deemed at risk (such as postmenopausal women or those with other risk factors for bone loss) but is not routinely recommended for preoperative patients and is not part of standard postoperative follow-up in the absence of other indications.11 Measurement of serum albumin, calcium, parathyroid hormone, and 25-hydroxyvitamin D levels is recommended at baseline and postoperatively, and assessment of bone turnover markers may also be recommended.11, 13

Conclusion

Bariatric surgery can have lasting effects on a woman's physiology. Postsurgical changes in weight and fertility make provision of effective contraception during the first 18 months after surgery crucial for women of childbearing age. Changes in absorption necessitate additional nutritional monitoring during pregnancy and for optimization of bone health. For both pregnant and nonpregnant patients, coordinating nutritional care with the bariatric surgery team is advisable.

Ms. Eakin is a researcher in the Department of General Internal Medicine, Johns Hopkins University School of Medicine. Dr. Steele is Associate Professor of Surgery and Director of Adolescent Bariatric Surgery, The Johns Hopkins Center for Bariatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine. Dr. Burke is Associate Professor, Department of Gynecology and Obstetrics and Department of Population, Family, and Reproductive Health, Johns Hopkins University School of Medicine and Bloomberg School of Public Health.

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