18% of children and adolescents
in the United States aged 6–19 are considered obese, defined as having a body mass index (BMI) for age and gender in the 95th percentile or greater.1
As more children and adolescents have become overweight or obese, it has become apparent that obesity affects nearly every organ system, including the reproductive organs.2,3
For example, menstrual disorders, such as dysfunctional uterine bleeding, secondary amenorrhea, and polycystic ovary syndrome (PCOS), are increasingly recognized among severely obese adolescent females. In addition to the menstrual concerns, such medical comorbidities as hypertension, hypertriglyceridemia, pseudotumor cerebri, and increased risk of venous thromboembolic events can be contraindications for hormonal contraceptives, which adds to the complexity of addressing menstrual concerns and providing contraception counseling for severely obese adolescents.4,5
In the last decade, bariatric surgery has become an option for treatment of morbidly obese adolescents, and the number of bariatric procedures performed on adolescents increased 5-fold from 1997 to 20036
and continues to increase. Current guidelines for bariatric surgery recommend avoidance of pregnancy for at least 1 year postoperatively.7
The American College of Obstetricians and Gynecologists (ACOG) recommends postponing pregnancy for 12–18 months after bariatric surgery.8
Although the risk of anovulatory infertility is high among women with obesity,9
loss of as little as 5% of excess body weight can restore ovulatory function in obese adult women with or without PCOS.10
Changes in self-esteem, body image, and increased fertility after bariatric surgery may in part account for an increase in unplanned pregnancies among adult11
and adolescent females.12
Roehrig et al.12
documented a 12.8% pregnancy rate among a cohort (n
=47) of adolescent females who underwent gastric bypass surgery, which was more than double the rate among their peers (www.odh.ohio.gov
). Thus, it has become imperative that adolescent females undergoing bariatric surgery have comprehensive contraception counseling before surgery. Additionally, any other menstrual and reproductive health concerns among obese adolescents should be addressed.
Although there are numerous contraceptive options for healthy adolescents, the options for morbidly obese adolescent females may be limited by the presence of medical comorbidities and concerns about decreased efficacy of some methods with increasing obesity.13–15
When counseling patients in the perioperative period, one must consider the risk of perioperative venous thrombosis, possible postsurgical malabsorption,16,17
minimization of menstrual blood loss, and treatment of reproductive and obesity-related comorbidities (e.g., PCOS, dysfunctional uterine bleeding).18,19
Currently available contraceptive methods offer a range of contraceptive and noncontraceptive benefits. In terms of safety and efficacy in the severely obese adolescent, the levonorgestrel-releasing intrauterine device (IUD), the Mirena®
IUD, appears to have a favorable profile compared to alternatives. In addition, insertion at the time of weight loss surgery is desirable in that it is convenient for the patients and ensures no unplanned pregnancies in the postoperative rapid weight loss period.
Acceptance and uptake of intrauterine contraception are a complex matter that involves cultural, financial, and educational factors.20
In the United States in 2002, IUDs were used among 1.3% of women of reproductive age, or 2.1% of contracepting women.20
Less is known about the feasibility and acceptance among adolescents, especially among severely obese adolescents. In addition, with the increasing prevalence of severe obesity during adolescence comes an increase in relevant obesity-related comorbidities and obesity-related menstrual concerns. Therefore, the aims of this study were to evaluate (1) the prevalence of menstrual problems and related medical comorbidities and (2) the acceptance rate of the levonorgestrel-releasing IUD placed at the time of bariatric surgery among a sample of severely obese adolescents.