Polycystic Ovary Syndrome (PCOS) is a prevalent endocrine disorder affecting approximately 4 to 8% of women in the United States and is a leading cause of female infertility. While not exclusive to women with obesity, it's estimated that almost 50% of women with PCOS are also affected by obesity, complicating both conditions. This article explores the connection between PCOS and obesity, the impact of weight loss on PCOS symptoms, and the role of bariatric surgery as a treatment option, incorporating real-life examples and research findings.
Understanding PCOS
PCOS is characterized by a combination of factors, including:
- Irregular or Absent Menstrual Periods: Common symptoms can include irregular or prolonged periods (oligomenorrhea), or no periods at all (amenorrhea). Oligomenorrhea is a condition in which menstrual periods are highly irregular, but mostly infrequent, taking longer than 35 days to menstruate might be a symptom. Anovulation happens when the ovaries don’t release an oocyte during the menstruation cycle. For some women, this might happen during a single and random cycle, and that’s no reason to worry. However, when this happens more frequently, it leads to chronic anovulation and infertility.
- Hyperandrogenism: This is a condition in which females experience high levels of androgens, such as testosterone. Hyperandrogenism manifests in symptoms like hair loss, excess growth of body or facial hair (hirsutism), or acne.
- Polycystic Ovaries: This condition consists in the presence of more than 12 follicles in each ovary, or increased ovarian volume. Follicles are small collections of fluids, gathered together in the ovary. Having polycystic ovaries is not the only symptom that’s considered for the diagnosis of Polycystic Ovary Syndrome. Not all PCOS patients have cysts in their ovaries, and many healthy women without PCOS do have small cysts in their ovaries.
The mechanisms of PCOS are insulin resistance, which leads to increased production of insulin levels or hyperinsulinemia, and elevated levels of luteinizing hormone, due to excess of leptin.
PCOS is linked with type 2 diabetes mellitus. 35 to 45% of patients with PCOS will have impaired glucose tolerance, and 7 to 10% actually suffer from diabetes. 50 to 65% of PCOS patients suffer from obesity. Obesity has been linked to type 2 diabetes and cardiovascular diseases, as well as PCOS; however, the link between PCOS and obesity remains uncertain.
The Importance of Weight Loss in PCOS Management
It has been proven that losing a 5 to 10% of body weight corrects most of the symptoms of this disorder and leads to a higher quality of life. Weight loss is the first-line treatment in women with obesity and PCOS, who have failed at their attempts of getting pregnant. It has been reported that patients with PCOS and obesity are greatly benefited with a body weight loss of 5%. Weight loss improves insulin resistance and leptin levels, which in turn improves ovulatory function. Weight loss also helps regulating the menstrual cycle. Other treatments include lifestyle modifications, taking contraceptive pills, anti-androgens, and insulin sensitizers, but these don’t usually work by themselves in patients with obesity.
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However, losing weight, even a small percentage as 5%, is not that easy. Most lifestyle intervention programs fail during their first year, and average individuals are usually unable to maintain a 5% of weight loss in the long term.
Bariatric Surgery: A Viable Option for PCOS and Obesity
As bariatric surgery has clearly established itself as the most efficient method for losing weight in the short and long-term, its benefits on patients with PCOS should be seriously considered. When patients with obesity and PCOS have failed to lose the weight they need to improve their chances to conceive and get pregnant, bariatric surgery might be a valid alternative for a more successful treatment.
The European Society of Endocrinology recommended considering bariatric surgery as treatment for patients with morbid obesity and PCOS, on 2014. More recently, on 2017, the American Society for Metabolic and Bariatric Surgery, along with the American College of Obstetricians and Gynecologists and the Obesity Society, endorsed bariatric surgery as a safe and effective treatment for women struggling with obesity and infertility.
Real-Life Success Story: Katie's Journey
Katie's experience illustrates the potential benefits of weight loss surgery for women with PCOS. During her freshman year, she began to gain weight. Some of Katie’s weight gain was attributed to PCOS. With every diet attempt, she would lose up to 20 pounds, but nothing worked long term. The two dreamed of starting a family one day; however, Katie knew that her body was not healthy enough to carry a child. Katie researched bariatric surgery options and decided that the gastric sleeve procedure was the best option for her.
Jonathan Thompson, MD, bariatric surgeon at the UC Health Weight Loss Center, performed Katie’s sleeve gastrectomy on Oct. 10, 2017. Gastric sleeve is a minimally invasive, laparoscopic surgery where the surgeon makes tiny incisions, less than one-half inch each in the abdomen, rather than a single, large incision, like traditional surgery. It involves removing about 80% of the stomach, leaving a long banana-shaped sleeve that acts as the new, smaller stomach. Katie lost 125 pounds and decreased her Body Mass Index (BMI) by 20 points.
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“With weight loss following bariatric surgery, regular cycles and spontaneous ovulation return in a majority of patients. We do recommend that patients wait 18 months after surgery to get pregnant. In the end, Katie’s hard work paid off and her periods became regular, and she was ovulating on schedule. On July 15, 2019, Baby Blaire entered the world surrounded by much love and adoration.
Types of Bariatric Surgery
Several types of bariatric surgery are available, each with its own advantages and considerations:
- Gastric Sleeve (Sleeve Gastrectomy): This procedure, like the one Katie underwent, involves removing a large portion of the stomach, creating a smaller, sleeve-shaped stomach. This restricts the amount of food a person can eat and can also affect gut hormones, potentially improving insulin resistance.
- Gastric Bypass (Roux-en-Y Gastric Bypass): This surgery involves creating a small pouch from the stomach and connecting it directly to the small intestine, bypassing a portion of the stomach and small intestine. This limits food intake and reduces nutrient absorption.
- Duodenal Switch: Patients with a BMI higher than 50 might need a combination of procedures, like the duodenal switch.
Positive Impacts of Bariatric Surgery on PCOS Symptoms
The impact of bariatric surgery on PCOS has been proven beneficial in the alleviation of many of its symptoms. A meta-analysis of 13 studies, involving a total of 2,130 female patients who underwent bariatric surgery, gathered evidence of the effects of bariatric surgery on PCOS. From that sample, 45.6% of the patients had PCOS before their operation. At 12-month follow up after surgery, only 6.8% of the patients persisted with PCOS. Other benefits were also registered. 56.2% of the patients had reported irregular menstrual cycles before their surgery; 12 months after their surgical procedure, only 7.7% still had this irregularity. Before surgery, 67% of the patients had hirsutism, the excessive growth of facial and body hair; after surgery, at the 12-month follow up, incidence of hirsutism had decreased to 38.6%, and to 32% at the study end.
These findings are in line with a more recent study, with a sample of 50 Indian females, out of which 18 (36%) were diagnosed to have PCOS, and an additional 8 women (16%) had irregular cycles, before their surgery. Bariatric surgery resulted in the improvement of all parameters of PCOS, with complete resolution of irregular menstruation and metabolic syndrome at the 12-month follow up. Bottom line, the effects of bariatric surgery on PCOS are highly positive, and they also manifest in the regulation of menstrual cycles, and the decrease of hirsutism and infertility.
Improved Fertility and Pregnancy Outcomes
The British Fertility Society advices that fertility treatments should be provided to women with a body mass index (BMI) lower than 35, or under 30 if they are younger than 37 years of age. For women dealing with severe obesity, these fertility treatments are not at their reach. To obtain them, they need to lose a lot of weight. The typical candidate for weight loss surgery is a patient with a BMI higher than 40. But bariatric surgery has shown great effects on infertility, even eliminating the need for these fertility treatments.
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A systematic review of 75 studies looking at pregnancy and fertility after bariatric surgery on 2008 showed evidence of better pregnancy outcomes for female patients that underwent weight loss surgery. A study from 2004 reported that out of 298 female patients that had a delivery after bariatric surgery, 6.7% required a fertility treatment after their surgical intervention. Another study of that same year showed that, from a sample of 32 women who were unable to get pregnant before surgery, 15 (46.9%) were able to get pregnant after surgery. However, more evidence is needed to track constant tendencies in bariatric surgery outcomes in fertility and PCOS, since there are no randomized control trials exploring this subject. The limited evidence we have now does show congruent results between studies, but more research is still needed.
Studying fertility outcomes is a complicated matter, because one cannot isolate that variable from others that might also be involved. Infertility is influenced by many different factors. For example, if a female patient with PCOS and obesity has an obese male partner, “infertility” might be the result of low fertility rates in both female and male subjects. The female patient might increase her fertility after surgery, but this will not show with a male partner who is still struggling with infertility. Another example is age.
However, women struggling with obesity can rest assured that pregnancy after weight loss surgery is possible and a viable choice. It’s safe to get pregnant after having weight loss surgery, but it should be delayed to at least 1 year of post-operation, preferably 18 months or more. Currently, the Centers for Disease Control recommends the usage of contraception during the first 2 years of post-operation.
Considerations and Potential Risks
Bariatric surgery in PCOS patients should be preceded by a proper evaluation to discard any other illnesses that might affect expected outcomes. An endocrinologist evaluation should rule out pituitary or thyroid disease as the cause of anovulation.The benefits of weight loss surgery are plenty, but they are not solely achieved by the surgery. It’s very important to acknowledge that the outcomes of bariatric surgery highly depend on the kind of surgical intervention, as malabsorptive and restrictive procedures have different impacts in the patients’ metabolic system, and, most importantly, they depend on the patients’ compromise in maintaining a healthy lifestyle.
Women who get pregnant after a bariatric surgery face higher risk of anemia due to micro-nutrient deficiencies, especially vitamin B12. Women who have undergone weight loss surgery should check with their doctor about nutritional testing, as well as dietary requirements and supplements.
Long-Term Outcomes in Adolescent Girls
Researchers analyzed data from 155 adolescent girls enrolled in the Teen-LABS longitudinal bariatric surgery cohort. Outcomes assessed included body mass index (BMI) reduction, time to BMI nadir, and changes in PCOS symptoms at 1-year post-surgery, BMI nadir, and peak BMI after weight regain. Before MBS, 23.8% of girls had PCOS, 53.5% were at risk for PCOS, and 22.8% were normal. Among patients with PCOS at 1-year post-surgery, 41% had improved symptoms, 23% reached remission, and 35% had persistent symptoms. Among patients with PCOS at BMI nadir, 58% improved, 11% achieved remission, and 32% persisted. After weight regain, 33% of those with prior PCOS cases improved while 67% of these patients stabilized.
Benefits Beyond PCOS
Treatment with bariatric surgery has shown to be very effective in the reduction of euglycemia, insulin, and blood glucose levels, in just days after the procedure. It leads to the amelioration, and in some cases resolution, of the metabolic syndrome, joint pain relief, hypertension, cardiovascular diseases, and remission of type 2 diabetes.
Surgical treatments for obesity significantly diminish the risks of developing gestational diabetes, hypertension, and pre-eclampsia, once the patient gets pregnant. Bariatric surgeries have also shown to prevent fetal macrosomia, in which the newborn baby weights more than 8 pounds, and reduce the baby’s chances to suffer from obesity-related diseases in early and late infancy.
Is Bariatric Surgery Right for You?
Your eligibility for bariatric surgery will depend on many different factors. The presence of PCOS in patients does not affect the efficacy of weight loss surgery. If you suffer from severe obesity and you have exhausted all your options for losing weight, you might be eligible for bariatric surgery. If you have a BMI above 40, you might be a candidate for a gastric sleeve. If you have a BMI of 40, but you also suffer from severe metabolic conditions, you might be eligible for a gastric bypass. Adolescents might also be eligible, if they have a BMI of 35 or higher and face life threatening medical conditions.
To know if you’re eligible for weight loss surgery, call our clinic for a consultation. An interview with your doctor and previous testing will be needed to assess the most convenient treatment for your case. An interview with your doctor and previous testing will be needed to assess the most convenient treatment for your case.
Seeking Comprehensive Care
If you’re interested in knowing more about the effects of bariatric surgery in PCOS, you can contact our clinic, LIMARP International Center of Excellence for Obesity. Our facilities have been recognized for their excellence and quality care, meeting international standards. We provide integral obesity treatments that include, not only the surgical treatment, but nutrition plans, exercise and physical activity programs, psychological therapy, and long-term follow up consults. We also offer non-invasive obesity treatments.
Our clinic is located at Tijuana, Mexico, just 15 minutes away from the International Border Crossing of San Ysidro. Our treatments are all-inclusive, with hospitalization stay, but also with access to the luxury hotel next door Grand Hotel Tijuana. You’ve never experienced care like this before. Our focus is on high excellence and certified medical care, but we also take pride in providing a relaxing environment. Our recovery rooms have breathtaking views to the Tijuana’s Country Club Golf Course.
Our services are affordable, and comply with international requisites for insurance coverage. Ask for our financing plans, we will find the best option to fit your needs. To schedule a consultation with Dr. Liza María Pompa González and to learn more about our treatments, message our office today. You can get in contact with us through any of our social media pages.