A bariatric surgeon explains the link between PCOS, weight loss surgery and getting pregnant.
Polycystic ovarian syndrome is an often frustrating condition many women face. Some women with PCOS also become obese, which brings with it further health difficulties. But weight loss surgery may be an effective treatment and provide a solution.
At Vanderbilt’s Surgical Weight Loss program, surgeon Meredith Duke, M.D., answers questions about PCOS, how these surgeries can help, and how some women have discovered an additional benefit to having the surgery: restored fertility.
Question: What is PCOS?
Answer: PCOS is polycystic ovarian syndrome, which is a hormonal imbalance. The exact cause isn’t completely understood, but it’s associated with obesity, and it’s certainly associated with insulin resistance as well as hyperandrogenism, which means just an increase of hormones that is abnormal.
Q: How can weight loss surgery help? Is that something across the board people would need? In what instances would that make sense?
A: Up to 80% of patients who should undergo weight loss surgery are women, and up to 50% of those have PCOS. So it’s a really common disorder. We have found that PCOS is associated with infertility. Many women who undergo either medical or surgical weight loss — it improves their fertility significantly.
Q: Why is that?
A: It’s poorly understood, but the thought is that the adipose tissue — the fatty tissue — actually converts estrogen into more of an androgen (a type of hormone associated with male characteristics). You’ll see that one of the signs of the disease is kind of dark hair growing on the face and chin. You can also get thinning of your hair, abnormal menses (menstrual cycles) or the lack of having periods. With the reduction of adipose tissue (fat) then you start improving your hormonal cycle back to normal levels. So up to 70% of women who were not having normal periods before surgery will develop normal periods after surgery. This can happen really quickly, too, up to the month after PCOS-related weight loss surgery. A lot of the women are surprised that they are now fertile when they hadn’t been before.
Q: Should women be concerned about getting pregnant soon after weight loss surgery?
A: We like to talk about the timing of pregnancy after bariatric surgery. Some women who were not fertile before can develop fertility rapidly after surgery. So we usually recommend waiting 12 to 18 months after bariatric surgery before trying to become pregnant. The thought is that you’re going into breakdown state when you’re losing weight, and then to add on top of it that you’re growing another body, we worry about the micronutrient deficiencies and those kinds of things. We like to get your body into more of a steady state before you add on to it the changes of pregnancy.
Q: So it’s safe to become pregnant after surgery, just not right away.
A: Data on this is really hard to interpret because none of this is like a randomized control trial per se. There are plenty of women who send me emails right after surgery, or call the clinic and say, “I’m pregnant and I’m three months outside of surgery! What do I do?” The answer is, it really needs to be individualized care. We need to monitor you really closely for nutrient deficiencies … and follow you for the typical complications of bariatric surgery, things like dehydration and ulcers. We need to be aware of that; we have to make sure medications that you’re taking are at the appropriate levels. You just need close follow-up. So yes, we believe it is safer outside of the 18-month term but if it happens, we have to be monitoring and careful.
Q: Is there birth control you recommend during that 12- to 18-month period after a PCOS-related weight loss surgery?
A: We tend to recommend that if you want to use a hormonal form of birth control that you avoid an oral hormonal form (the pill) — especially if you’ve had a malabsorptive procedure. We’re not certain that you’re going to get the level of hormones from the pill that you need to provide adequate contraception. So either use a barrier method or non-oral medication: things like Depo (Depo-Provera hormone injection), implants or injections; the Nuvaring; patches — patches might also be a little bit difficult to interpret. Use something that’s not oral, or use a barrier method (such as condoms, contraceptive sponge, cervical cap and/or a diaphragm).
Q: What about additional pregnancies after the first one, post-surgery?
A: One of the things obesity is associated with is increased pregnancy complications. It can be things like gestational diabetes, preeclampsia (pregnancy-related high blood pressure), the baby being large or small for gestational age. After the 12 to 18 months after bariatric surgery, a lot of these complications are treated or improved — hypertension, diabetes, those kinds of things. It looks like it’s probably safer and healthier to wait that long. But like I said, we have still had a number of very successful pregnancies sooner after bariatric surgery.
Q: Can you share some success stories of women who really struggled with PCOS and how weight loss surgery helped them?
A: I’ve had a number of patients who have contacted me after surgery to say, “This is what I really wanted. I wanted a family, I wanted to become pregnant and I couldn’t before surgery.” So many patients have been able to achieve this, and that’s really a gratifying part of this job, to be able to get birth announcements from these patients. I get to ask them how their babies are doing and they love to show pictures; what mom doesn’t? It’s incredibly gratifying.
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The Vanderbilt Center for Surgical Weight Loss is a BlueCross BlueShield Center of Excellence. Learn more about whether you’re a candidate and how to get started by calling 615-600-4837.
