5.1.1

Reproductive and general health consequences of bariatric surgery

• 1.
  

  Increased fertility in a short period of time postoperatively. Weight-reduction has a positive effect on sex hormone profiles and ovulation.

  
  
• 2.
  

  Conception during rapid weight loss (12–24months) is associated with higher rate of nutritional deficiencies and obstetrics complications including higher incidence of still birth.

  
  
• 3.
  

  Effective and safe contraception is important to prevent an untimely pregnancy while the women is trying to achieve an optimal and a stable weight.

5.2.1

Immediate postsurgery contraceptive advice

• 1.
  

  Women should be warned about increased fertility within a mean of 3 months postoperatively by resumption of normal ovulatory cycles after weight reduction surgery.

  
  
• 2.
  

  It has been reported that conceiving during the period of rapid weight loss seen in the first 12–24 months following surgery is associated with higher rates of nutritional deficiencies and obstetric complications.

  
  
• 3.
  

  Women should be prescribed an effective and reliable method of contraception for the following 12–18 months.

Combined Hormonal contraception (UKMEC Category 2/3)

5.2.2

Oral preparations

• 1.
  

  Use of Combined Oral Contraceptive as well as other combined hormonal contraceptives (CHC) leads to an increase in the cardiovascular and metabolic risk proportionally to the BMI.

  
  
• 2.
  

  During postoperative recovery period, long-term diarrhoea and/or vomiting could probably decrease OC effectiveness.

  
  
• 3.
  

  COCs are metabolised by bacterial enzymes and the enzymes in the intestinal mucosa, before they enter the portal circulation. Very little is known about the metabolism of oral contraceptives following malabsorptive and restrictive malabsorptive bariatric procedures.

  
  
• 4.
  

  Oral CHC leads to an increase in the cardiovascular and metabolic risk proportionally to the BMI.

  
  
• 5.
  

  Due to unknown and potentially reduced efficacy of oral CHC in postbariatric patients, their use is not advised in patients after bariatric surgery.

Nonoral combined hormonal contraceptive (Patch, Ring)

• 1.
  

  Nonoral hormonal contraceptives have been studied in only small numbers of obese patients, but appear to be effective.

  
  
• 2.
  

  The American College of Obstetricians and Gynecologists suggests that women undergoing bariatric surgery with a significant malabsorption component who want to use hormonal contraception should preferentially consider nonoral delivery of the contraceptive hormones after weight stabilization and exclusion of other risk factors for cardiovascular disease.

5.3.1

Copper intrauterine device

Category 1 by the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC Category).

• 1.
  

  Their principle of action is by local inflammatory and spermicidal effect of copper ions. As this is a local action, it is expected not to be affected by BMI or changes in weight.

  
  
• 2.
  

  There are no studies comparing specifically the efficacy of Cu-IUD in obese women and women with normal BMI.

  
  
• 3.
  

  Although there are no research data available on use of the Cu-IUD after bariatric surgery, theoretically the effectiveness of the device should be the same due to its local mechanism of action.

  
  
• 4.
  

  There are no theoretical reasons for Cu-IUD to cause any specific health risks in postbariatric surgery women.

Types of devices:

There are different types of Cu-IUDs with variable amount of copper content, frames, and duration of action between 5 and 12 years.

The most commonly used are:

• 1.
  

  ParaGard

  
  

  Flexi-T

  
  

  Multiload-T

  
  
• 2.
  

  GyneFix.

Pearl Index: for ideal use is 0.6; and for typical use 0.8.

• 1.
  

  The real-life user failure is less than 1%.

  
  
• 2.
  

  The cumulative pregnancy rate is 1.6% at 7 years, and 2.2% at 8 and 12 years.

Health benefits:

• 1.
  

  Cu-IUD is not associated with any increased risk for cardiovascular diseases (VTE or cardiac event), diabetes, metabolic syndrome, or weight increase.

  
  
• 2.
  

  Cu-IUD has a protective effect on the endometrium against endometrial carcinoma.

Risks :

• 1.
  

  Uterine perforation at placement (0.1%)

  
  
• 2.
  

  Pelvic inflammatory disease (0%–2%), caused by a preexisting vaginal and cervical infection,

  
  
• 3.
  

  The overall cumulative risk of IUD expulsion is 10% over 3 years of use

  
  
• 4.
  

  No data available about perforation or expulsion rates in postbariatric surgery women

Side effects:

• 1.
  

  Prolonged/heavy menstrual bleeding

  
  
• 2.
  

  dysmenorrhea, lower abdominal pain/discomfort

Contra-indications:

• 1.
  

  Severe uterine cavity anatomic distortion

  
  
• 2.
  

  Cervical stenosis

  
  
• 3.
  

  Uterine fibroids

  
  
• 4.
  

  Active pelvic infection

  
  
• 5.
  

  Suspected pregnancy

  
  
• 6.
  

  Wilson’s disease or copper allergy

  
  
• 7.
  

  Unexplained abnormal uterine bleeding

Levonorgestrel containing intrauterine device (LNG-IUS)

Category 1 UKMEC

Mode of action:

• 1.
  

  The progestin secreted from the IUS causes thickening of cervical mucus.

  
  
• 2.
  

  The progestin in the uterine cavity also cause increase in expression of glycodelin A in endometrial glands which inhibits binding of sperm to the egg cell.

  
  
• 3.
  

  Serum concentrations of progestin can partially inhibit the ovarian follicular development and lead to anovulation (a majority of women tend to have ovulatory cycles).

  
  
• 4.
  

  UK Faculty for Sexual and Reproductive Health recommended the use of long-acting reversible contraceptive in the first 2 years after surgery.

Types of IUS currently available:

• 1.
  

  LNG 52 with an average daily release of 20 µg LNG and is effective for up to 5 years.

  
  
• 2.
  

  LNG 14 with an average daily release of 6 µg LNG and is effective for up to 3 years.

  
  
• 3.
  

  LNG 20 with an average daily release of 9 µg LNG and is effective for up to 5 years.

Efficacy:

• 1.
  

  PI for all the three IUS is around 0.2.

  
  
• 2.
  

  The cumulative pregnancy rate is 0.5%–1.1% after 5 years of continuous use with the LNG 20 IUD, 0.9 with LNG 14.

  
  
• 3.
  

  Available evidence suggests that LNG-IUS effectiveness is not reduced by higher BMI or body weight. It seems likely that malabsorptive surgery do not reduce its efficacy.

  
  
• 4.
  

  There are no statistically significant differences in contraceptive failure rates during the first 2–3 years of use among IUC users (Cu-IUD and LNG52) even among obese users. The overall failure rate was <1 per 100 women-years.

  
  
• 5.
  

  The presence of coexisting risk factors (smoking, diabetes, hypertension, history of VTE) in addition to obesity puts LNG-IUS into UKMEC category 2.

Health benefits:

• 1.
  

  There is no increased risk of cardiovascular diseases.

  
  
• 2.
  

  The risk of confirmed VTE was not increased in LNG-IUS users.

  
  
• 3.
  

  There are contradictory data about slightly increased risk of lobular and ductal cell cancer of Breast among women where LNG-IUS has been used for heavy menstrual bleeding (up to 1.3 times).

  
  
• 4.
  

  No impact on weight gain.

  
  
• 5.
  

  Reduction in heavy menstrual bleeding and dysmennorhea.

  
  
• 6.
  

  Protection from PID due to cervical mucus thickening.

  
  
• 7.
  

  Treatment of endometriosis.

  
  
• 8.
  

  Can be used for treatment of endometrial hyperplasia and cancer.

  
  
• 9.
  

  Risk reduction of endometrial cancer.

  
  
• 10.
  

  Fewer painful crises in women with sickle cell disease.

Side effects:

• 1.
  

  Irregular bleeding during the first 3–6 months.

  
  
• 2.
  

  By 24 months, 50% women have amenorrhea, 30% have oligomenorrhea, and 11% have spotting.

  
  
• 3.
  

  Mood changes: increased risk of being prescribed antidepressants which is of importance in those women who suffer from preclinical or undiagnosed perimenopausal depression.

Contraindications:

• 1.
  

  Current or active breast cancer or personal history of breast cancer in the past 5 years with no active disease

  
  
• 2.
  

  Active liver disease

  
  
• 3.
  

  Severe anatomical deformity of the uterine cavity

  
  
• 4.
  

  PID

  
  
• 5.
  

  Suspected pregnancy

  
  
• 6.
  

  Unexplained vaginal bleeding

Progestogen-only implant

UKMEC Category 1/Category 2 (coexisting risk factors)

The matrices of implants consist of small flexible biologically degradable inserted under the skin of the upper arm.

Preparations:

• 1.
  

  Norplant II: two flexible silicone rods, each containing 75 mg of LNG, lasting for 5 years.

  
  
• 2.
  

  Implanon: a single rod, containing 68 mg ENG, lasting for 3 years.

Efficacy :

• 1.
  

  The PI is 0.05.

  
  
• 2.
  

  In the US contraceptive choice project, the pregnancy rate at 4 years follow-up of ENG implant use was extremely low in overweight and obese women.

  
  
• 3.
  

  Pharmacokinetics studies suggest that the serum levels of ENG depend on body weight and decrease at a higher rate in women with obesity due to increased volume of distribution, effects on plasma protein binding, and altered clearance.

  
  
• 4.
  

  There is evidence suggesting lower serum ENG concentration after malabsorptive surgery when the weight has decreased after surgery, but the implant is still protective for at least 6 months.

Safety:

• 1.
  

  Implant can be used in cases of ore-existing CVD risk factors.

  
  
• 2.
  

  There is no evidence of increased risk of VTE or MI.

  
  
• 3.
  

  Studies on procoagulatory values or blood pressure did not show any difference.

  
  
• 4.
  

  No negative effects of carbohydrates or lipid metabolism.

  
  
• 5.
  

  No concern as regards loss of bone mass.

  
  
• 6.
  

  There are no data available regarding the risk of breast cancer.

  
  
• 7.
  

  In one study, implants users had an additional weight increase as compared with Cu-IUD users.

Health benefits

• 1.
  

  Alleviates dysmenorrhea and ovulatory pain.

Challenges :

• 1.
  

  With significant weight loss after surgery, loose skin may make it challenging to insert implant correctly.

Contraindications:

• 1.
  

  Active or recent breast cancer

  
  
• 2.
  

  Active and chronic liver disease except nodular hyperplasia

  
  
• 3.
  

  If on treatment with antiviral drugs

5.3.2

Progestogen-only injection

UKMEC Category 2/3

Depot preparations of progestin-only contraceptive provide reversible contraception

Preparations: currently three are available

• 1.
  

  Medroxy-progesterone acetate (DMPA) as intramuscular, every 13 weeks

  
  
• 2.
  

  Medroxy-progesterone acetate (SC), administered subcutaneously every 13 weeks

  
  
• 3.
  

  Norethisterone enanthate as intramuscular, every 8 weeks

Efficacy:

The PI range for perfect use is 0.2 and 6 for typical use.

• 1.
  

  There are limited data relating to DMPA use in women with obesity or after bariatric surgery, but the available evidence suggests that its effectiveness is not reduced.

  
  
• 2.
  

  Prolonged DMPA use and bariatric surgery both appear to be associated with the loss of bone mineral density but there is no data available for an additive effect of those two factors relating specifically to risk for osteoporosis or fracture.

  
  
• 3.
  

  There are no data on the casual association between DMPA use and the risk of VTE.

Side effects:

• 1.
  

  DMPA use is associated with some weight gain

Health benefits:

• 1.
  

  Treatment of heavy menstrual bleeding, dysmenorrhea, and for pain associated with endometriosis.

  
  
• 2.
  

  Offers some protection against ovarian and endometrial cancers.

Practical tips:

• 1.
  

  DPMA–IM injection is given in deltoid muscle, or use a longer needle to reach the muscle layer in gluteal region.

  
  
• 2.
  

  Alternatively DMPA-Sc should be used.

Relative contraindication:

• 1.
  

  Young adolescent, <18 years with BMI >30 are at increased risk of weight gain, so alternative preparations should be considered.

5.3.3

Barrier methods

UKMEC Category 1

Methods :

• 1.
  

  Male and female condoms

  
  
• 2.
  

  Cervical caps

  
  
• 3.
  

  Diaphragms

Efficacy:

• 1.
  

  PI of condoms is 18 by typical use and 2 by perfect use.

  
  
• 2.
  

  PI of female diaphragm is 12 by typical use and 6 by perfect use.

  
  
• 3.
  

  The reliability of barrier methods is not affected by bariatric procedure.

Health benefit:

• 1.
  

  Offer additional protection against sexually transmitted infections.

Practical tip

• 1.
  

  Weight loss or gain can alter the fit of a cap or diaphragm.

  
  
• 2.
  

  Check regularly to see if it still fits during the period of rapid weight loss phase.

Emergency contraception (EC):

Women should be offered Cu-IUD if there are no contraindications.

There is no data available on the effectiveness of oral EC