Contraception After Bariatric Surgery
With regard to obesity, the problem of contraception after bariatric surgery should definitely be addressed. The most commonly used procedures in Germany are sleeve gastrectomy and proximal gastric bypass. The latter is a malabsorptive procedure that affects the absorption of oral contraceptives. A planned conception is only recommended at 12–18 months after such an operation, to avoid risks for the child (1).
Sparse data exist in the literature on the pharmacokinetics of oral contraceptives postoperatively. Limited experience postulates failure of low-dose progestin-only mini-pills. Etonogestrel implants appear to be effective and safe after proximal bypass surgery. A consensus statement recommends a preoperative consultation about oral contraception, and postoperative avoidance of them. Copper-containing intrauterine devices and progestin implants are recommended (1).
In diabetes mellitus, the low-dose pill (e.g., less than 35 µg ethinyl estradiol) is preferable; I miss a clear statement about this in the present article by Römer (2). Here, the risk of macrovascular damage or arterial thromboembolic events is especially increased in diabetes mellitus. I would like to mention a large-scale study of around 150 000 women with diabetes, which reports a higher risk of arterial thrombosis than of venous thrombosis. The risk for the transdermal contraceptive patch and vaginal ring was increased. The use of oral progestin-only pills and of injection of depot progestins is associated with a four-fold increased risk of arterial thrombosis (3).
The review (2) by Römer briefly mentions the topic of hyperlipidemia. A systematic review by the World Health Organization in collaboration with the United States Center for Disease Control and Prevention suggests that women with known hypercholesterolemia using oral contraception have a 25-fold increased risk of myocardial infarction, while the risk of venous thromboembolism or cerebrovascular accidents is minimally increased (4).
Dr. med. Athanasios Alexopoulos
Kurpark-Klinik, Bad Nauheim; Germany
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Shawe l, Ceulemans D, Akhter Z, et al.: Pregnancy after bariatric surgery: consensus recommendations for periconception, antenatal and postnatal care. Obes Rev 2019; 20: 1507–22 CrossRef MEDLINE PubMed Central|
|2.||Römer T: Medical eligibility for contraception in women at increased risk. Dtsch Arztebl Int 2019; 116: 764–74 VOLLTEXT|
|3.||O`Brien SH, Koch T, Veseli SK, Schwarz EB: Hormonal contraception and risk of thromboembolism in women with diabetes. Diabetes Care 2017; 40: 233–8 CrossRef MEDLINE|
|4.||Dragoman M, Curtis KM, Gaffield ME: Combined hormonal contraceptive use among women with known dyslipidemias: a systematic review of critical safety outcomes. Contraception 2016; 94: 280–7 CrossRef MEDLINE|