Obesity and Contraception: An Approach to Clinical Practice

    

    

    Figure 1: Eligibility criteria of the World Health Organization, 2015.
(Adapted from the Medical Eligibility Criteria for Contraceptive Use - Fifth edition - 2015) [9].
    
    

In the presence of risk factors for ACVD, the use of Progestogen- Only Contraceptives (POCs) and copper Intrauterine Device (IUD) may be safe and effective. In particular, Long-Acting Reversible Contraceptive (LARC) methods [etonorgestrel implant, Copper IUD, and Levonorgestrel-Releasing Intrauterine System (LNGIUS)] [8] offer greater contraceptive efficacy and higher continuity rates when compared to other hormonal methods. According to the CHOICE trial, an American cohort study that included more than 10,000 women, the continuity rate was 88%, 84%, and 83% a year after Copper IUD insertion, LNG-IUS insertion, and etonorgestrel implant, respectively, while the discontinuation rate ranged from 49.1% to 56.5% in the same period among users of non-LARC methods (oral contraceptives, injectable methods, vaginal ring, and transdermal contraceptive patches) [10].

As the risk of vascular thrombosis can increase about two to threefold in obese women [11], the European Society of Contraception and Reproductive Health (ESCRH) recommends that CHCs should only be prescribed for obese women with a BMI ≥35 kg/m² if other safer options are not available (such as POCs or non-hormonal methods). On the other hand, the ESCRH recommends that any contraceptive method may be prescribed for women with a BMI <35 kg/m² [12]. In addition to their safety from a cardiovascular perspective, the use of POCs is associated with non-contraceptive benefits, such as reduced menstrual bleeding associated with leiomyomatosis or anticoagulant use, improvement in pelvic pain related to endometriosis or adenomyosis [13], improvement in quality of life, as aid in the treatment of endometrial hyperplasia, and a reduced risk of endometrial cancer. The Copper IUD might decrease the risk of uterine and endometrial cervical cancer, making it another attractive option for patients with cardiovascular risk [14].

Bariatric surgery is the most effective and long lasting treatment for morbid obesity, allowing for weight reduction, compared to behavioral measures or pharmacological interventions [15]. Since approximately 50-80% of patients undergoing bariatric surgery are women of reproductive age [16,17], the prescription of hormonal contraceptives in this group deserves further attention. The American Congress of Obstetricians and Gynecologists (ACOG) and the American Society for Metabolic and Bariatric Surgery recommend that pregnancy should not occur until 12-18 months after surgery [18,19], due to unique risks in women who undergo bariatric surgery:

1) The prevalence of cardiovascular risk factors is higher in women suffering from morbid obesity [8,9].

2) Metabolic and nutritional changes that occur after bariatric surgery may increase maternal morbidity and interfere with fetal development [such as prematurity, small for gestational age (birth weight below the 10th percentile for gestational age)] [20].

3) Infertility associated with an ovulation caused by polycystic ovary syndrome is more frequent in obese women and postoperative weight loss (5-10%) may restore ovulation [21,22].

4) Twelve months after surgery, the sexual desire is likely to increase, allowing for an improved sexual function [23] and increasing the risk of unplanned pregnancy in the absence of a proper guidance on contraception.

The type of bariatric surgery may interfere with the effectiveness of oral hormonal contraceptives. Malabsorptive bariatric procedures are associated with a higher failure rate of oral hormonal contraceptives. On the other hand, oral compounds are safe for women who undergo restrictive surgery [24]. Therefore, the CDC recommends that women should not take oral CHCs or oral progestogen (category 3) after undergoing malabsorptive bariatric surgery. Only non-oral methods are recommended, after taking into account the presence of associated comorbidities, medications, and associated habits [9].

Even though both gynecological and surgical societies recommend delaying pregnancy after bariatric surgery, 35% of surgeons are unaware of their patients’ contraceptive history. This represents a clinical concern and suggests the need to intensify multidisciplinary collaboration among bariatric surgeons and gynecologists in order to minimize the inherent risks from inappropriate contraceptive use in the postoperative period [25].

(Table 1) shows the eligibility criteria for the contraceptive methods used by obese women and the most common comorbidities in this group, according to the CDC, 2013 [9] and the WHO guidelines [8] updated in 2015.

  

    

    
CHC 
    
POP 
    
DMPA 
    
ETG Implant 
    
LNG-IUS 
    
Cu-IUD 
  
  

    
Obesity 
    
(2)
    
(1)
    
(1/2)
    
(1)
    
(1)
    
(1)
  
  

    
Bariatric surgery 
    

  
  

    
Restrictive    procedures 
    
(1)
    
(1)
    
(1)
    
(1)
    
(1)
    
(1)
  
  

    
Malabsorptive    procedures 
    
COC (3) Others (1)
    
(3)
    
(1)
    
(1)
    
(1)
    
(1)
  
  

    
Uncontrolled SAH    (mmHg) 
    

    

    

    

    

    

  
  

    
-140-159 x 90-99 
    
(3)
    
(1)
    
(2)
    
(1)
    
(1)
    
(1)
  
  

    
- ≥ 160 x ≥ 100 
    
(4)
    
(2)
    
(3)
    
(2)
    
(2)
    
(1)
  
  

    
SAH plus Vascular    disease 
    
(4)
    
(2)
    
(3)
    
(2)
    
(2)
    
(1)
  
  

    
Dyslipidemia with    no other risk factors 
    
(2)
    
(2)
    
(2)
    
(2)
    
(2)
    
(1)
  
  

    
Dyslipidemia with    other risk factors 
    
(3/4)
    
(2)
    
(3)
    
(2)
    
(2)
    
(1)
  
  

    
Personal history of    DVT/PE or Thrombophilia 
    
(4)
    
(2)
    
(2)
    
(2)
    
(2)
    
(1)
  
  

    
Family history of    DVT/PE (1st degree relatives) 
    
2
    
(1)
    
(1)
    
(1)
    
(1)
    
(1)
  
  

    
Current presence or    history of ischemic heart disease 
    
(4)
    
(2/3)* 
    
(3)
    
(2/3)* 
    
(2/3)* 
    
(1)
  
  

    
History of ischemic    heart disease 
    
(4)
    
(2/3)* 
    
(3)
    
(2/3)* 
    
(2/3)* 
    
(1)
  
  

    
Multiple    cardiovascular risk factors (MeTS) 
    
(3/4)
    
(2)
    
(3)
    
(2)
    
(2)
    
(1)
  
  

    

    
CHC
    
POP
    
DMPA
    
ETG Implant
    
LNG-IUD
    
Cu-IUD
  
  

    
DM2 (regardless of    insulin use) 
    

  
  

    
- non-vascular    disease 
    
(2)
    
(2)
    
(2)
    
(2)
    
(2)
    
(1)
  
  

    
-nephropathy,    retinopathy, neuropathy or another vascular disease or diabetes of > 20    years duration 
    
(3/4)
    
(2)
    
(3)
    
(2)
    
(2)
    
(1)
  
  

    
*If the ischemic episode occurred    during the use of POC (POP, Implant and LNG-IUS), the method is defined as    category 3; if the patient has a personal history of ischemic heart disease    and the event occurred before the use of POC, the method is defined as    category 2 and can be started.
      
CHC: Combined Hormonal Contraceptives;    COC: Combined Oral Contraceptives; POP: Progestogen-Only Pill; DMPA: Depot    Medroxyprogesterone Acetate; ETG: Etonogestrel; LNG-IUS:    Levonorgestrel-Releasing Intrauterine System; Copper IUD: Copper Intrauterine    Device; SAH: Systemic Arterial Hypertension; DM2: Diabetes Mellitus Type 2;    MetS: Metabolic Syndrome; DVT/PE: Deep Venous Thrombosis/Pulmonary Embolism
      
*Adapted from Center for Disease    Control and Prevention [9] and the Medical    Eligibility Criteria for Contraceptive Use - Fifth edition - 2015 [8].
      
 
  

Table 1:  Reversible contraceptive methods for obese women and possible associated comorbidities.