• 1.
  

  a) T b) T c) T d) F e) T

It is recommended to increase the angle of insertion up to 90 degrees as the fatty layer of the abdominal wall or panniculus is more prominent in obese patients resulting in caudal migration of the umbilicus (on average caudal displacement is 2.9 cm in patients with a BMI > 30. Despite these changes location of the intra-abdominal blood vessels remains constant. In cases of significant caudal displacement of the umbilicus Palmer’s point entry can be performed to allow for optimal triangulation of accessory trocars and insertion under direct vision. Veress needle entry was associated with an increased incidence of failed entry, extra-peritoneal insufflation and omental injury when compared to direct entry technique, with no difference in the incidence of visceral or vascular injury. Overall there is no evidence of advantage using any single technique in terms of preventing major complications such as bowel or vessel injury. The low rate of reported complications associated with laparoscopic entry may account for the lack of significant difference regarding major complications. Several studies have concluded that an intra-abdominal pressure of 10 m Hg or less indicates correct placement of the Veress needle irrespective of the women’s body habitus, parity or age. Additional tests such as the aspiration, hanging drop test and double click test provide very little information regarding placement of the Veress needle.

• 2.
  

  a) T b) T c) T d) T e) F

Sutures or devices such as the T-lift or sutures that can be passed through the epiplocal appendages so as to secure the bowel to the anterior abdominal wall thereby improving access to the pelvis and allowing identification of important anatomical structures are well recognized techniques. Head down tilt shifts organs cephalad and improves access to pelvic organs for the surgeon. A tilt of 15 degree serves as an indicator for the minimal head down tilt by which the surgeon is able to visualize organs and complete the procedure, whilst in some cases greater tilt may be needed. Long periods of head down tilt forces the diaphragm cephalad which may threaten to compact the base of the lungs and limit expansibility. During a steep tilt blood also gravitates towards the poorly ventilated apex resulting in ventilation perfusion mis-match. Increasing intermittent positive pressure in an attempt to ventilate the lung apices can lead to distension of more compliant caudal lung areas, increasing alveolar pressure in these areas to levels which exceed capillary pressure and may compromise alveolar perfusion. For these reason a minimal head down tilt as suggested in the answer is recommended. A low residue diet of 7 days has been shown to demonstrate minimal colonic faecal residue and may potentially decrease gaseous distension. Often a low residue diet is better tolerated by the patient in comparison to mechanical bowel preparation which can cause preoperative discomfort. Obese patients have a higher intra-abdominal pressure then their non-obese counterparts. The increased intra-abdominal pressure enhances venous stasis, reduces intraoperative portal venous blood flow, decreases intraoperative urinary output, lowers respiratory compliance, increases airway pressure and impairs cardiac function. Due to less efficient ventilation in obese patients, insufflation pressures should be maintained at a minimal level (i.e. 15 mm Hg) allowing the surgeon to safely perform the procedure whilst keeping physiological compromise to a minimum.

• 3.
  

  a) T b) T c) F d) F e) T

Obesity causes changes in skin barrier function, immune surveillance, collagen structure and function which all contribute to wound healing. Vascular supply is also impaired which can effect wound healing. These physiological changes in the context of a background of other comorbidities such as diabetes mellitus further increase the risk of postoperative wound infections. Using small incision sites and minimising trauma, as with laparoscopic procedures, reduces the risk of wound infections. According to Vircow’s triad the development of thromboembolism is dependent on 3 factors: hypercoagulability, venous stasis and vessel wall injury. Patients undergoing gynaecological surgery leads to alteration in these factors. This is further compounded by additional risk factors such as postoperative immobility, which can adversely affect drainage of blood from the lower extremities (predisposing to DVT) and obesity. Overall the incidence of VTE is significantly higher in open cases as compared to laparoscopic cases. Some laparoscopic procedures are associated with longer operating times. This is particularly relevant in obese patients where additional strategies are often required in order to adequately expose the operative field. Lengths of procedures, however, are often dependent on individual surgical expertise and nowadays more complex procedures are successfully being performed laparoscopically with comparable operating times. Studies have shown that laparoscopic procedures can significantly reduce blood loss. This may be due to the use of smaller incisions and therefore less trauma, in addition to image magnification allowing for meticulous haemostasis. Laparoscopy is associated with reduced postoperative pain thereby leading to faster recovery and resumption of daily activities.

• 4.
  

  a) T b) F c) F d) F e) T

Just over a quarter of adults were classified as obese in the UK. The current cost to the NHS of treating obesity related condition exceeds £5 billion per year with indirect costs to wider society at approximately £20 billion per year. This data is based on a meta-analysis published in the Lancet. The effect of obesity on mortality and average life expectancy (by about age 60) was reduced by 8-10 years in the morbidly obese group (BMI 40–50 kg/m ² ) and by 2–4 years in the BMI range 30–35 kg/m ² ). According to WHO and NICE definitions raised waist circumference in women is > 88 cm and > 102 cm in men. Increased waist circumference is associated with a higher risk of developing type 2 diabetes, hypertension and CVD. Increased waist circumference can be a marker for increased risk of developing comorbidities even in non-obese patients (this is particularly relevant in women of Asian descent). For those with a BMI > 35, waist circumference has little added predictive power.

• 5.
  

  a) F b) T c) F d) T e) F

Several studies have examined the relationship of body mass to age at menopause, with inconsistent findings. Some of these inconsistent findings may be explained by differences in study design or analysis. The better designed and analyzed studies have shown no relation of body mass or body fat distribution to age at the final natural menstrual period. Smoking has been the single most consistent environmental effect on age at menopause. Women who smoke stop menstruating 1-2 years earlier than comparable non-smokers and have a shorter peri-menopause. Studies have shown a dose-response effect of smoking on atrophy of ovarian follicles. Very little is known about the effect of passive smoke exposure on the age at which the final natural menstrual period is experienced. Race and ethnicity have not been consistently shown to be associated with the age at menopause. Some studies have reported that African American and Latina women have natural menopause about 2 years earlier than white women, others showed that Asian women tend to have similar age at menopause to Caucasian women. Data from SWAN reported no difference between African Americans and Caucasians, and that Japanese women have a later natural menopause than Caucasian, African-American, Hispanic, or Chinese women do. A number of studies have observed that lower social class, as measured by the woman’s educational attainment or by her own or her husband’s occupation, is associated with an earlier age at natural menopause. A number of studies have reported that women who have used OCs have a later age at natural menopause. However, the finding has not been wholly consistent across studies.

• 6.
  

  a) T b) T c) F d) F e) T

Large studies like POAS and SWAN have reported that obese premenopausal women have lower levels of estradiol. The POAS suggested that findings were similar when measures of central adiposity, such as waist circumference and waist-hip ratio, were utilized to categorize obese and non-obese women. FSH has also been reported to be lower in obese women prior to menopause. The different levels of estradiol between obese and non-obese women have been shown to reverse after FMP. The lesser estradiol decline observed in obese women may result from enhanced aromatization rates given their excess adipose tissue. Although the pattern of observed hormone changes in estradiol and FSH were similar in obese and non-obese women until approximately 2 years before the FMP, after this point there was a blunted hormone change surrounding the FMP in obese versus non-obese women. FSH continued to be lower in obese postmenopausal women compared to non-obese women. Inhibin B was shown to be lower in obese women prior to menopause in POAS.

• 7.
  

  a) F b) F c) F d) T e) F

Weight gain during menopausal transition has been examined as potentially a major contributing factor to midlife body weight. Cross-sectional and longitudinal studies have shown that chronological age and sedentariness were associated with higher risk of overweight and obesity. Body weight increases with age in both normal weight and obese individuals. Weight gain at midlife is partially attributed to the reduction in energy expenditure (EE). Possible explanations for this observed reduction in EE include a reduction in leisure time physical activity, loss of lean body mass causing basal EE decline as well as a loss of the luteal phase increases in EE described in the premenopausal years. Menopause is associated with an increase in abdominal subcutaneous and visceral fat as seen in various studies. Interventions to treat obesity include physical activity, calorie controlled diet, pharmacotherapy or bariatric surgery. Life style modifications with healthy diet and exercise remain the best measures to prevent morbidities related to obesity and ageing. Changes have been described as a transition from a gynaecoid to an android pattern of fat distribution.

• 8.
  

  a) F b) F c) T d) T e) T

It is estimated that approximately 20% of cancer cases are related to obesity. Increased trunk-abdominal fat, as measured by either the waist-to-hip ratio (WHR) or the waist circumference (WC), is associated with an increased risk of several types of cancer, independently from BMI. Moreover, trunk-abdominal fat appears to be strongly and positively associated with cancer mortality. Postmenopausal breast cancer, endometrial cancer and, to a lesser extent, ovarian cancer are among the malignancies most commonly associated with obesity. A modest positive association between BMI and cervical cancer has also been found: this may possibly be due to the lack of regular screening and/or to an increased risk of adenocarcinoma of the cervix. The mechanisms involved in the promotion of malignancies include, among others, endogenous sex hormones, insulin resistance and associated hyperinsulinaemia, adipokines, cytokines, and chronic inflammation. Obesity is a major preventable risk factor for cancer development and mortality and there is clear evidence that a 15–30% weight loss in women is associated with a reduced risk of cancer, as shown by follow-up of patients who undergo bariatric surgery. Clinicians should be aware that preventing/treating obesity should be considered part of cancer prevention.

• 9.
  

  a) T b) F c) F d) F e) T

The association between obesity and the overall increased risk of breast cancer has been widely demonstrated in post-menopausal women. There is still controversy on the impact of obesity on the risk of premenopausal breast cancer. Body fatness is considered as possibly protective against pre-menopausal breast cancer. General adiposity appears to be more strongly related to the risk of breast cancer than measures of abdominal adiposity in post-menopausal breast cancer. On the other hand, body fat distribution could play a relevant role in the relative risk of developing pre-menopausal cancer. While confirming the inverse correlation with BMI, results of a recent meta-analysis showed a linear positive correlation between WHR and the incidence of pre-menopausal breast cancer. The correlation between obesity and the increased incidence of postmenopausal breast cancer seems to be confined to ER-positive/PR-positive cancers. Similarly, in premenopausal women, the inverse association between BMI and breast cancer seems to apply to receptor-positive breast cancers only, whereas no correlation exists with receptor-negative premenopausal breast cancers. The obesity-dependent risk appears to be lower for women under post-menopausal estrogen-progestin therapy, suggesting that hormonal therapy is a confounding factor in the obesity-cancer relationship, according to the hypothesis that the effect of obesity on postmenopausal women is probably mediated by endogenous sex hormones.

• 10.
  

  a) F b) T c) F d) F e) F

It has been shown that capping chemotherapy at a maximum body surface area of 2 m ² in patients with endometrial cancer could be associated with an increased risk of death for obese patients. There is no proof that either short- or long-term toxicity is increased among obese patients receiving full weight-based doses. Therefore, the American Society of Clinical Oncology recommends chemotherapy doses to be calculated on actual body weight and that clinicians respond to toxicities similarly in obese and non-obese patients, with resumption of full weight-based doses as soon as toxicity has been resolved. Adjuvant therapy with aromatase inhibitors may be less effective in obese post-menopausal women with breast cancer, as they tend to have higher concentrations of circulating estrogens under such therapy. It has been suggested that higher doses of aromatase inhibitors might be necessary. A recent pilot study showed that obese women with ovarian cancer treated with chemotherapy and bevacizumab had a shorter recurrence-free survival than those treated with chemotherapy alone, suggesting that obese women may not gain significantly from bevacizumab adjuvant therapy. This could be due to the association between excess body fat and up-regulation of pro-angiogenic and inflammatory cytokines, which may confer resistance to anti-VEGF therapy. The gold standard for primary debulking surgery in ovarian cancer should be the absence of any residual macroscopic tumour. A BMI ≥ 40 kg/m ² is an independent predictor of severe complications and mortality related to surgery. Morbidly obese patients are at a higher risk of post-operative complications and they are more likely to succumb early on to severe complications, or they are unable to recover sufficiently well to start chemotherapy and die as a result of progressive disease or a shift toward palliative treatment, despite initial aggressive surgical efforts.

• 11.
  

  a) F b) F c) T d) T e) T

Most of the available information on risk factors, including the strong association with obesity, pertains primarily to low-grade endometrioid cancers. Recent data, however, suggest that type I and type II tumors could share several pathogenetic factors, such as hyper-insulinaemia, chronic inflammation, and oxidative activity, which are commonly associated with obesity. Studies on obesity and recurrence of endometrial cancer have failed to find an association with BMI, whereas decreased overall survival has been found only in morbidly obese patients. A potential reduction in survival rates would be in most cases the consequence of co-morbidities, as many of these women suffer from type II diabetes, hypertension, heart disease, osteoarthritis and pulmonary disease. A very recent large cohort study found a hazard ratio for endometrial cancer of 1.62 (95% CI 1.56–1.69) per 5 kg/m ² increase in BMI. More than 40% of the endometrial cancers recorded in the study could be attributed to overweight and obesity. Women with PCOS have a significantly increased risk of endometrial cancer (OR, 2.79). PCOS shares some risk factors with endometrial cancer. It is unclear whether the increased risk of endometrial cancer is due to individual risk factors (i.e. diabetes, obesity) or whether PCOS itself, with its specific metabolic features (e. g. hyperinsulinism, hyperglycaemia, insulin resistance, hyperandrogenism), increases the risk of cancer. Metformin has been associated with a significant improvement in the overall survival of diabetic patients with endometrial cancer.

• 12.
  

  a) T b) T c) T d) F e) T

Adiposity is indeed thought to play a crucial role in both the development and maintenance of PCOS. While several mechanisms have been implicated in the development of infertility in obese women with PCOS, insulin resistance is thought to play a major role.

• 13.
  

  a) T b) F c) F d) F e) F

Metformin and clomiphene together has the best evidence for ovulation induction compared to single agent or other combinations.

• 14.
  

  a) F b) F c) F d) T e) T

Bariatric surgery increases urinary LH and FSH levels. There is conflicting data regarding improved miscarriage rates with the most recent suggesting there is no improvement in miscarriage rates. Observational data however has shown improved conception rates after bariatric surgery. Decreased duration of the follicular phase of the menstrual cycle has been seen.

• 15.
  

  a) T b) T c) F d) T e) F

Obesity was associated with lower estradiol levels however with increased doses of gonadotrophins the success of treatment cycles was comparable with normal weight women. BMI was inversely associated with the estradiol (E ₂ ) level per produced pre-ovulatory follicle and the number of medium-size follicles, but once medication dosages were adjusted to overcome the weight effect, the success of the treatment cycle was comparable to that of normal weight women. The number of oocytes retrieved was found to be the same regardless of BMI. There is a higher rate of euploid miscarriages. Response to clomiphene is dampened in obesity.

• 16.
  

  a) F b) T c) T d) F e) F

Leptin is produced by fat cells, so obese women have a higher number of fat cells, and hence higher leptin levels than women of normal weight. Obese women have higher levels of circulating oestrogen, primarily caused by the increased peripheral aromatisation of testosterone to oestrone in adipose tissue. Obesity is associated with hyperinsulinaemia. With progressive obesity, there is an increased impairment of glucose tolerance despite higher insulin levels. There is no difference in plasma cortisol and urinary free cortisol levels between obese and normal weight women. Women who are obese have higher LH pulse frequency not higher circulating LH levels, indeed, they have lower levels of LH than non-obese women.

• 17.
  

  a) T b) F c) F d) F e) T

The Cochrane review concluded that there is no evidence to suggest decreased efficacy in overweight women, compared to normally weighted women. The POP is preferable to the COCP in women with current or a history of VTE, or thrombogenic mutations, as all of these conditions are given a category 4 by UK MEC with the COCP. The evidence for the POP suggests that the benefits outweigh the risks, and it is given a category 2. There is no evidence to suggest that the depot medroxyprogesterone acetate DMPA should be given more frequently in overweight women. For all women it should be given every 12 weeks. The progesterone implant is not associated with weight gain, however DMPA is, and often weight gain is more marked in women who are already overweight. The UK Medical Eligibility Criteria suggests that in women with current ischaemic heart disease the theoretical risks of continuing with this form of contraception may outweigh its likely benefits. However it suggests referral to a specialist contraceptive provider and review of other possible methods, as if other appropriate methods are not available or acceptable, it is likely to be preferable to the higher risk of pregnancy.

• 18.
  

  a) F b) F c) T d) F e) T

Endometrial thickness over 4mm is of significance in postmenopausal women, who should have an atrophic endometrium. In women that continue to menstruate the thickness of the endometrium will vary throughout the cycle. Findings of a polyp or fibroid on scan may suggest the cause of heavy bleeding and should be investigated with hysteroscopy. Although women with endometrial hyperplasia may present with some symptoms of post-coital bleeding, predominantly post-coital bleeding is a symptom of a cervical abnormality such as cervical erosion, polyp or at times neoplasia. Endometrial hyperplasia is more likely to present with heavy, prolonged bleeding refractory to treatment or inter-menstrual bleeding. NICE guidance suggests that the Mirena can be used as a first line treatment in women with no red flag symptoms. Some hormonal treatments will not suitable in obese women due to existing co-morbidities, therefore a surgical option such as endometrial ablation may be the best treatment option, especially if it can be carried out under local anaesthetic. Although a difficult point to answer, the effectiveness of the Mirena IUS in obese women has been stipulated from patient satisfaction studies. Comparatively, it seems that there is a higher level of satisfaction with endometrial ablation, as 93% of women were satisfied in published studies.

• 19.
  

  a) T b) T c) F d) T e) T

The estimated incidence is about 15% and is mainly dependent on women’s age. Both live birth rate and the abnormal rate of embryos decreases with the number of previous miscarriages. The abnormal embryonic karyotype is a predictor of subsequent live birth.

Identifiable causes of RPL are antiphospholipid syndrome, uterine anomalies and abnormal chromosomes, particularly a translocation in either partner.

• 20.
  

  a) T b) T c) T d) F e) F

There are a limited number of manuscripts relating to the association between RPL and obesity in which the World Health Organization (WHO) BMI classification were used and maternal age was considered an independent confounding factor. However, statements a-c were reported. The reliability of the association between underweight and RPL may be small because the sample size of underweight was small, only 10 patients.

• 21.
  

  a) T b) T c) T d) T e) F

Adjusted for confounders such as pre-eclampsia, diabetes mellitus, obesity, and smoking, a history of RPL remained independently associated with cardiovascular hospitalizations. Unexplained RPL with a euploid embryo may be a common disease caused by both polymorphisms of multiple susceptibility genes and lifestyle such as women’s age, obesity, smoking and caffeine. Our previous study including 2733 Japanese women showed the existence of a relationship between a history of RPL and the occurrence of gastric ulcer, gastritis, fatty liver, and atopic dermatitis. There is no data to assess the effect of weight loss on the outcome of subsequent pregnancies in patients with RPL.

• 22.
  

  a) F b) T c) F d) T e) F

Visceral adipose tissue (VAT), but not subcutaneous adipose tissue (SAT), is strongly associated with insulin resistance and many studies have investigated whether there are differences in VAT and SAT (body fat distribution) between PCOS and normal women. So far, these studies have shown that probably there are no differences in SAT amounts, but data regarding VAT were conflicting. Therefore, it cannot be stated that fat distribution differs significantly in women with PCOS from BMI-matched normal women. Adipocytes from women with PCOS are hypertrophic compared to BMI-matched control women (their diameter is 25% greater) and their hypertrophy is strongly associated with insulin resistance. This characteristic may be due to alterations in storage and adipocyte lipolytic capacity. Serum leptin levels in women with PCOS have not been found to differ from weight-matched controls, while circulating leptin levels did not differ significantly between ovulatory and anovulatory PCOS women. Two meta-analyses have shown that women with PCOS compared to normal women had lower levels of adiponectin, independently of BMI. Decrease of adiponectin levels in PCOS women may intensify insulin resistance and hyperinsulinaemia. Furthermore, there are data suggesting that adiponectin may reduce insulin-induced androgen production, while on the other hand, androgen excess may decrease adiponectin secretion. Most studies have shown that resistin levels in the circulation are similar between PCOS and normal women. Besides, no difference was found in plasma resistin levels between PCOS and control women with or without insulin resistance.

• 23.
  

  a) T b) F c) F d) T e) F

Obesity may amplify hyperandrogenism in PCOS. A meta-analysis showed that overweight/obese women with PCOS had increased total testosterone, free androgen index and decreased SHBG. In obese PCOS women, LH levels, LH/FSH ratio, LH amplitude and LH response to GnRH have been found to be lower as compared to lean PCOS women. This effect of BMI is mediated by mechanisms acting at the pituitary level. In obese PCOS women, insulin resistance and insulin levels are higher than in lean women with PCOS. Serum visfatin was found increased in the lean but not obese PCOS patients as compared to normal women, and has been found to correlate with insulin resistance and markers of hyperandrogenism in lean PCOS women only.

• 24.
  

  a) T b) F c) F d) F e) F

Clomiphene citrate has been used for induction of ovulation in anovulatory infertile patients for several decades. This drug leads to ovulation in a high rate of cycles and to an acceptable pregnancy rate. Clomiphene is cheap, simple to use (oral administration) and has few side-effects. Therefore, compared to more sophisticated and complicated treatments, this drug has been established as the first-line approach worldwide. The recommended daily dose is 50 mg for five days and on average 50% of the pregnancies are achieved on this dose. Reduction of body weight in obese women is very important and should be always recommended. Various studies have shown that obesity itself has a negative impact on the outcome of pregnancy. On the other hand, it is not clear as yet whether body weight reduction during the peri-conceptual period has an impact on the conceptus. In any case, patients are advised to lose weight before they attempt to become pregnant. Nevertheless, when an obese patient with PCOS complains of infertility, it is obvious that she would prefer any method that would make her pregnant as soon as possible. Therefore, medical treatment in the majority of cases comes first. Laparoscopic ovarian drilling (LOD) nowadays is an effective method for ovulation induction without affecting the function of the female internal genital organs. Nevertheless, it may result in complications associated with the surgical procedure, particularly in obese women. For these reasons, LOD is not recommended as a first-line approach except in some specific cases. Application of LOD before the administration of clomiphene in naïve PCOS patients is not recommended. However, in clomiphene resistant women LOD may sensitize the ovaries to this drug. Metformin is inferior to clomiphene regarding induction of ovulation. In addition, pregnancy and live birth rates are lower with metformin. Metformin in the context of a diet and lifestyle program is not superior to placebo. This drug according to existing data is not considered an ovulation-inducing agent, but it may be useful in clomiphene resistant patients before moving to a second-line treatment. In vitro fertilization (IVF) is very efficacious, even in women with PCOS. Nevertheless, its complicated nature as well as the high cost preclude the use of it as a first-line approach. Based on existing recommendations, IVF is considered a third-line treatment.

• 25.
  

  a) T b) F c) F d) F e) T

Diet and lifestyle changes have become an established way to reduce weight in obese women with PCOS. This is particularly important for those patients for whom there is no time limit for the achievement of a pregnancy. Such interventions improve biochemical and endocrinological parameters including insulin resistance and hyperandrogenaemia. Nevertheless, quality of life and patient satisfaction need to be further investigated. Treatment with metformin reduces insulin resistance and improves menstruation. Nevertheless, it does not reduce body weight more than lifestyle changes. In addition, metformin has not been approved by the FDA as a weight-reducing agent. Experience on the use of anti-obesity drugs in obese women with PCOS is limited. Only orlistat has been approved by the FDA. Prospective randomized trials are needed to test the effectiveness of anti-obesity drugs in PCOS. The oral contraceptive pill has several benefits in anovulatory women with PCOS, such as protecting the endometrium from the unopposed effects of estrogens. However, these drugs have no potential to reduce body weight. On the contrary, with some of the preparations in use, body weight may be increased. Bariatric surgery is an established method for the treatment of obesity. Although the use of these methods in PCOS is limited, evidence has been provided that they may benefit PCOS patients. Prospective randomized trials are needed.

• 26.
  

  a) T b) T c) F d) F e) T

The ATP III criteria for metabolic syndrome are abdominal obesity (waist circumference >102cm, triglycerides > 150 mg/dL, high-density lipoprotein cholesterol (HDL) <40 mg/dL, blood pressure > 130/86 mmHg and fasting glucose > 110 mg/dL. Although the patient has an elevated random blood glucose level of 150 mg/dL, he should undergo a fasting blood glucose level.

• 27.
  

  a) F b) F c) F d) F e) F

There have been no randomized clinical trials examining the treatment of metabolic syndrome and its individual components on male fertility. A small study of 45 patients by Morgante et al. demonstrated improvement in semen parameters and sex hormone levels with metformin, simvastatin and weight loss. Antioxidants have been examined in animal models but not in randomized human trials. Scrotal lipectomy in humans have been reported to improve male fertility but has not been substantiated by randomized clinical trials and is not a common treatment for male infertility.

• 28.
  

  a) T b) F c) T d) T e) F

Diabetes has been linked to lower SHBG and free testosterone levels. Erectile dysfunction and retrograde ejaculation are known neurologic sequelae of diabetes. While at an increase risk for infections, there is no evidence to suggest that testicular abscesses are a main contributor to male infertility.

• 29.
  

  a) F b) T c) T d) F e) T

No differences in sexual behaviour have been found between adult women of obese or normal weight. Additionally, no differences have been found in the rates of hetero/homosexual behaviour. Body habitus and self-image appear to have a greater impact on adolescents as obese teens have been found to be at increased risk for riskier sexual behaviours. Increasing BMI appears to be inversely related to having more than one sexual partner in the last year. However, the number of lifetime partners is similar between obese and normal weight women.

• 30.
  

  a) T b) T c) F d) T e) T

The advantages of combined hormonal contraceptives, methods that contain both estrogen and progestin, generally outweigh the proven risks for obese women (category 2). Therefore an obese woman can safely use combined hormonal contraceptive methods. The main risk of combined hormonal contraceptives is the risk of thromboembolism and obese individuals have an increased baseline risk of thromboembolic disease. Intrauterine devices can be safely used in obese women (category 1). There may be technical difficulties that arise for the provider placing the device but this method of contraceptive is safe to use. The advantages of depot medroxyprogesterone acetate (DMPA) generally outweigh the risks for obese adolescents (category 2). However, obese teens who gain more than 5% of the body weight within the first 6 months of use may continue to have an excess weight gain on the method and this is why it is given a category 2 instead of a category 1.

DMPA and contraceptive implants can be safely used in obese women (category 1).