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Contraception in women with obesity with special reference to gastric bypass surgery
Linköping University, Department of Clinical and Experimental Medicine, Division of Children's and Women's health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The prevalence of obesity is increasing worldwide. The treatment of morbid obesity is dominated by bariatric surgery, for example Roux-en-Y gastric bypass (RYGB) surgery. If other contraceptive options are available, women with obesity should not be prescribed combined hormonal contraceptives due to the obesity-related increased risk of venous thromboembolism. Women are advised not to become pregnant during the first 12-18 months after RYGB surgery. There is a lack of knowledge of what type of contraceptive methods women with obesity are prescribed and whether they experience more or different side effects compared to normal-weight women. It is not known if the absorption and pharmacokinetic profile of progestins are affected by RYGB. The aim of this thesis was to investigate the pattern of contraceptive use in women with obesity, what type of contraceptive counselling was given to women in relation to RYGB, and whether the pharmacokinetics of two different progestins were affected by RYGB surgery.

Material and Methods: Paper I is a retrospective cohort study analysing the patterns of contraceptive prescription, adverse effects, duration of treatment, reasons for discontinuation and bleeding pattern in 371 women with obesity compared with 744 normal-weight women. Medical records were scrutinised from 1 Jan 2010 until 31 Dec 2014. Paper II is based on a questionnaire sent to 987 women who had undergone RYGB during 2010. The questionnaire concerned preoperative and present contraceptive use, contraceptive counselling in relation to surgery and what type of recommendations they had received regarding pregnancy after RYGB. Papers III and IV are experimental studies investigating the pharmacokinetics of desogestrel (etonogestrel) and levonorgestrel in relation to RYGB.

Results and conclusions: The most commonly prescribed contraceptive method for women with obesity was the progestin-only pill but many women with obesity were prescribed combined hormonal contraceptives despite the current recommendations of cautious prescription of oestrogen-containing methods. There were no differences in adherence to contraceptive method between women with obesity and normal-weight women. Despite the uncertainties regarding absorption, almost 10 % of women continued using oral contraceptives after RYGB. Nearly 40% were not aware of the recommendation to avoid pregnancy in the first year after RYGB and almost one third did not use any contraception during this period. This could be due to a lack of information or that the women did not retain the given information to avoid pregnancy. We found no clinically significant differences in the steady state pharmacokinetics of desogestrel before compared with after RYGB, or in single dose pharmacokinetics of levonorgestrel in women with BMI< 30 having undergone RYGB compared with BMI-matched non-operated women. This suggests that oral contraceptives containing desogestrel and levonorgestrel might be used after RYGB surgery.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. , p. 75
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1677
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:liu:diva-156643DOI: 10.3384/diss.diva-156643ISBN: 9789176850961 (print)OAI: oai:DiVA.org:liu-156643DiVA, id: diva2:1313186
Public defence
2019-05-29, Berzeliussalen, Universitetssjukhuset, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2019-05-02 Created: 2019-05-02 Last updated: 2019-05-02Bibliographically approved
List of papers
1. Contraceptive Use Before and After Gastric Bypass: a Questionnaire Study
Open this publication in new window or tab >>Contraceptive Use Before and After Gastric Bypass: a Questionnaire Study
2015 (English)In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 25, no 11, p. 2066-2070Article in journal (Refereed) Published
Abstract [en]

At present, women are recommended to avoid pregnancy 12-18 months after bariatric surgery. Our aim in this study was to describe patterns of contraceptive use before and after gastric bypass in Sweden, and to describe the contraceptive counseling given preoperatively to women undergoing gastric bypass. In October 2012, a questionnaire was sent to 1000 Swedish women who all had undergone gastric bypass during 2010. The women had been included in the Scandinavian Obesity Surgery Register at time of surgery. The main outcome measures were patterns of use of contraception before and after bariatric surgery. The response rate was 57 %. The most commonly used contraceptive methods were intrauterine devices, 29 % preoperatively and 26 % postoperatively even though there was a postoperative switch from the copper intrauterine device to the levonorgestrel intrauterine system. Thirty percent did not use any contraceptive during the first 12 months after surgery. Sixty percent of the responders were aware of the recommendations to avoid pregnancy after surgery. Many women who undergo bariatric surgery are not using any contraceptive method despite the recommendation that they should avoid pregnancy for at least 12 months. There is a great need to improve contraceptive counseling for this growing group of women.

Place, publisher, year, edition, pages
SPRINGER, 2015
Keywords
Gastric bypass; Pregnancy; Contraception; Obesity
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-122518 (URN)10.1007/s11695-015-1641-7 (DOI)000362578700048 ()25744304 (PubMedID)
Note

Funding Agencies|Bayer AB, Sweden

Available from: 2015-11-09 Created: 2015-11-06 Last updated: 2019-05-02
2. Plasma concentrations of etonogestrel in women using oral desogestrel before and after Roux-en-Y gastric bypass surgery: a pharmacokinetic study
Open this publication in new window or tab >>Plasma concentrations of etonogestrel in women using oral desogestrel before and after Roux-en-Y gastric bypass surgery: a pharmacokinetic study
Show others...
2019 (English)In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 126, no 4, p. 486-492Article in journal (Refereed) Published
Abstract [en]

Objective

To investigate whether Roux‐en‐Y gastric bypass (RYGB) affects oral desogestrel (etonogestrel) pharmacokinetics.

Design

Single centre, open label, phase‐2 pharmacokinetic study.

Setting

University hospital of Linköping, Sweden.

Population

Fourteen women with planned RYGB surgery were included; nine women aged 18–45 years using 75 micrograms desogestrel completed the study.

Methods

Steady‐state etonogestrel pharmacokinetic (PK) parameters were measured on three occasions for each individual (at 8 ± 6 weeks before surgery, and at 12 ± 2 and 52 ± 2 weeks after surgery). Each patient served as her own control. On each occasion, serum samples were collected during a 24‐hour period and etonogestrel concentrations were determined with ultra‐performance liquid chromatography/tandem mass spectrometry.

Main outcome measures

Area under the plasma concentration time curve of etonogestrel (AUC0–24 hours).

Results

All women had significant postoperative weight loss. There were no significant differences in AUC0–24 hours, terminal half‐lives (t½), time to peak serum concentrations (Tmax), or apparent oral clearances of etonogestrel (CLoral) before and after gastric bypass surgery on any occasion. Peak serum concentrations (Cmax) increased after 52 ± 2 weeks compared with preoperative values (0.817 ng/ml versus 0.590 ng/ml, P = 0.024).

Conclusion

To our knowledge, this is the first study to investigate the effects on desogestrel pharmacokinetics after RYGB. This study did not reveal any clinically significant changes in etonogestrel pharmacokinetics, suggesting that oral desogestrel may be used by women after RYGB surgery. The sample size was limited, however, and therefore the results should be interpreted cautiously.

Place, publisher, year, edition, pages
Wiley-Blackwell Publishing Inc., 2019
Keywords
Contraceptives; desogestrel; etonogestrel; gastric bypass surgery; hormonal contraception; obesity; oral contraceptives; pharmacokinetic; Roux-en-Y gastric bypass
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-154831 (URN)10.1111/1471-0528.15511 (DOI)000458702400012 ()30347490 (PubMedID)2-s2.0-85056623277 (Scopus ID)
Note

Funding Agencies|county council of Ostergotland (ALF)

Available from: 2019-03-07 Created: 2019-03-07 Last updated: 2019-07-05Bibliographically approved

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Division of Children's and Women's healthFaculty of Medicine and Health SciencesDepartment of Gynaecology and Obstetrics in Linköping
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