A review article on the effects of bariatric surgery on reproductive function published this month in Fertility and Sterility highlights two studies suggesting that gastric bypass surgeries may make oral contraceptives less effective. (Note – this does not apply to simple gastric banding procedures that limit stomach size but don’t induce malabsorption.)
The studies are very small, but the findings are concerning.
In one study of 40 women, 2 of the 9 women using oral contraceptives became unexpectedly pregnant after jejunal-ilial bypass surgery, despite having used the same method before without failure. None of the women using other methods got pregnant. The second study, conducted in 7 bilio-pancreatic bypass subjects, found that hormone levels 8 hours after taking a progesterone-only birth control pill were lower compared with normal controls. By 24 hours, there was no difference in levels. No unplanned pregnancies were reported.
The paper’s authors hypothesize that malabsorption due to the bypass may be at work here. I also wonder if perhaps the pill’s “effectiveness” in subjects prior to bypass was really the negative impact of their weight on fertility, since we know bypass can improve ovulatory function.
What do we do with this information?
I don’t think that these data are enough to recommend that all women who have had a gastric bypass avoid all oral contraceptives, though it certainly gives one pause. I think it is worth discussing with your surgeon exactly what areas of the stomach and intestine were bypassed and what your risk of malabsorption is. Certainly if one is having diarrhea induced by a bypass procedure, then one must consider that medications are not being properly absorbed.
What I am doing at this point is avoiding the progesterone-only pill in the gastric-bypass population unless I have to use it, since in general, the efficacy of these pills occurs within a narrower range of serum levels. In women who are taking combination pills, I tell them to be extra careful with compliance, and if they miss a pill, to use back up barrier contraception for at least a week, especially if they notice spotting.
Heading to a standard 35 ug rather than a lower dose 20ug pill would be worth considering in this population. The Nuvaring also seems like it may be a good option, since it does not rely on intestinal absorption. Given that the estrogen exposure in the contraceptive patch is about 60% higher than in pills, I would still tend to avoid this method, even in this group, unless I know I have to use it to maintain levels. But that’s just me – talk to your doctor about what’s best for you.
We definitely need larger studies and some consensus guidance on this issue, since more and more women are undergoing bariatric surgery.
That's scary, and certainly something that the bypass community doesn't seem to be aware of, at least from the mailing lists and discussion boards that I've been a part of.
It's my firm belief that we need more information and studies on gastric bypass surgery, period. My husband had a RNY 6 years ago, and he certainly was not fully informed of the risks and likely outcomes. He did lose the weight- 385 down to 142 in 9 months is apparently considered a success by his surgeon, and the fact that he can no longer really eat anything seems to be beside the point. There needs to be more research done on all aspects of the surgery, as well as long-term consequences, instead of it usually being presented as an "easy fix". It's definitely a lifesaver in some cases, but there needs to be more research.
Mirena to the rescue!
Jen – that is incredible success for your husband, I know you would probably rather he had done it without surgery, but the upside for him is tremendous. I think patients sometimes see it as an easy fix, the docs I know who do it see it as a complicated solution to a very complicated problem. Would that it were an ideal world. Best to you and your husband.
Celeste –
You'r right – Mirena would be an option as well, as would the Paragard IUD. Or condoms, or diaphragm, or sterilization if they're done. What is so important is that women have options. Many options.
Best,
TBTAM
I have seen pregnancies during the first year after gastric bypass, but so far all these patients admit that after years of infertility, they saw no need to start using birth control. Most of the surgeons make a big deal about avoiding pregnancy during the first year and ask the patients to sign a pledge that they will use birth control to avoid it. My first question, "Have you told your surgeon you're pregnant?" is usually answered with a guilty-looking "Not yet." RuralObGyn
Dr.Polaneczky:
In fact that's not true ( IE you're response to Jen's remark.)
Since I am the person she refers to, please Doctor…Don’t congratulate me for losing 243 pounds in under a year. Congratulate me for surviving it.
Let me tell you first that no one considers it a success.Other then the doc who operated
The only other time when he did not assure me that everything was normal was when he was repeatedly accusing me of being psychiatrically unstable.
However upon the day after the surgery when they bring you to the room where they give you the radioactive liquid to drink, and take pictures of it going down to see if there’s a leak and during that same time when I sprang a 105 fever which persisted for eight days and the radiologist would not sign off on the paperwork saying I had no leak. He attempted to make me more and more psychiatrically unstable so if by some chance something happened to me he could in some way document that while attached to four IV poles and on morphine I became psychiatrically unstable enough to mitigate any surgical complication. In other words my crazy messed up his surgery. That pissed me off. You’re going to read about some unpleasant stuff but I never considered suing my doc once. Why? He did do exactly what I asked him to. And underneath all of this is the knowledge that, I did after all seek this out and go attend seminars and jump through hoops to have this done. No matter what you hear me say in this letter. This is my doing, because when I did it, I was fully aware of the possibility of serious complications. What angers me is how little the average person is.
Now that we are five years’ post operative let me tell you that aside from looking lovely in my size 30 (or whatever) jeans which makes me look like the latest in Auschwitz vogue. I am not a success story and I resent you congratulating my wife given the living hell she has gone though on a daily basis not just in trying to keep me alive, but in trying to keep me from giving up, and to keep me trying new foods.
Can you imagine how frustrating it must be for a woman to spend 7 hours cooking a dish because you casually mentioned that you thought maybe one day if you found it somewhere you might try it because it looks like something I might eat only to have me taste one teaspoon of it, raise my eyebrows and smile and sloooowly take a second teaspoon and then run out of the room and vomit, only to have her try another dish the same day and the next day another dish? And the day after that, and they day after that?
My wife brought me to another country to live with her, be an emotional support to her and to help her, she has three children who are all disabled to some degree and one is a cancer survivor , they are all autistic and now after all that hope what she has now is a fourth child which she gave up all forms of public assistance for three years to import , so I could be here with her, be a stepdad to her children and also to help out by working and taking a little slack off her already brutal life where she had not had a moments rest for what was then 9 and is now 14 years.
I am her fourth child and I have no doubt in my mind that if or when I do recover and am able to have some sort of functional life we are going to see a rebound effect on her like some prisoner of war out of years of torture in some jungle hidden in a bamboo cage for years on end.
Have you ever wished in your guts that your spouse would go off and quietly have an affair with some decent person who could give her a bit of adult company and comfort that you know she needs so that some of your guilt is mitigated?
MARK – Clearly I've offended you – I apologize. Never meant to minimize what appears to be a terribly difficult experience for you.
I've removed the additional three comments, because I think you've said it all in this one.
Best,
TBTAM
And I sort of wish we hadn't left off with "Have you ever wished in your guts that your spouse would go off and quietly have an affair with some decent person who could give her a bit of adult company and comfort that you know she needs so that some of your guilt is mitigated?"
Because without some of the rest it looks weird. I accept your apology doc. And I'm not against this thing. I'm against it being mass pushed and I'm against it being looked at and pushed off as a casual easy way to solve all your problems.
They really don't talk as much about the possibilities of negative complications as they should. I have no qualms about anyone dong anything they are truly well informed about. Obesity and the social stigma that gos with it are the hardest ones to deal with. Lets face it on most blogs if I admitted I was a sex addict a few people would be curious or show their friends. If I was a cleptomaniac ..why no one would know without my telling them. We allow so much weakness from people while not wholly judging them. The overwight don't get that opportunity. You know if you start hearing voices in your hrad, no one will know unless you start talking to the,. Go to the doctors and he'll do everything he can and assure you it isnt your fault. People in 12 step programs admit first that they are powerless over anything. yet we allow them after attending them to get their drivers licensese back afer having driven drunk.
Yet If I have a problem I'm powerless over and you can see it as I walk by. It's somehow a different thing. Whats the difference between calling some one a fat F*&ck and the N word. I don;'t know but before I lost my wight I would get called a fat f*ck almost weekly. That makes people desperate. Because you can't make fun of a mans color or religion anymore but it;s still ok to laugh at Monica in the fat suit of Friends. It's still ok for a public figure to go and say that we need to beat up on the chubby kids more , because that what our society needs to head off the Obesity problem
http://tinyurl.com/ybjb6f5
I could be a known heroin addict and get a date tomorrow. Or I could be fat and smart and caring and funny and disgust everyone around me. Just because one disability shows and one doesn't. Does not make that disability worse, or better.
I'm just tired of people taking about how strong I am or how much I have overcome, or how proud my wife probably is of me. I would bet you she would take any amount of money to have me back overweight and functional then the way I am now..
I had an operation and I'm trying to live through the repercussions ( which I add almost kill my wife on a day to day basis). If I had run track or dieted or done something radically different in my life and lost the weight I would take your congratulations and thank you. I had a weakness I could not overcome. I took the only way out that seemed likely to keep me on the straight and narrow. I guess it's like antibuse for the overweight. I just can't help thinking that if I had a drug problem , or if I was a sex addict or had depression but looked normal. I might have had more time and willingness to do it the real way and not take the shortcut which has so many repercussion. We give passes to people for so many things. But fat people aren't just judged as having a food problem., they are also lazy, slovenly, stupid, and disgusting. I could have been a peeping tom and gotten arrested for it and probably be treated better by the public at large . We as a society are disgusted by fat people and if we aren't, it's socially indoctrinated into us through the media and through interpersonal relationships. It makes people do desperate things. I had surgery because I could not deal with how the world saw me. I should have just kept my eye on the ball and concentrated on the few people who it never mattered to. In the end they have remained the only constant and trustworthy people people in my life.
would Tony Bourdain say this about the mentally ill? And if he did how long would his show remain on the air. yet he just insulted what they now say is 60% of the USA, and nothing? He advocated the beating of kids and thats it, we just shut up? How about people on public assistance who smoke and get cancer. Don't they also cost the country millions of dollars.
How come I never hear about that? oh, well they have cancer. No one can tell it;s from smoking. They have insurance, They aren't trying to sit next to you on the subway or take the center seat on an air plain I guess.
When was the last time you saw someone made fun of , especially in an unpleasant way about his religion or his race. Now when was the last time you heard a fat joke on TV?
One of the newer techniques in bariatric surgical procedures, the endoscopic approach to bariatric surgery is considered minimally invasive, and is actually considered a nonsurgical approach to treat obesity through the restriction of the size of the stomach