Access to bariatric surgery should be increased as part of the main treatment considerations in women with obesity and polycystic ovarian syndrome (PCOS). The paper, ‘A Review of the Impact of Bariatric Surgery in Women With Polycystic Ovary Syndrome’, published in Cureus, led by California Institute of Behavioral Neurosciences & Psychology, Fairfield in the US, also recommends that additional research with better study designs are required in the future to investigate the relationship between PCOS and bariatric surgery.
The authors noted that PCOS is the most common endocrine disorder in reproductive-age women and can cause infertility. Furthermore, a systematic review and meta-analysis by Lim et al (Overweight, obesity and central obesity in women with polycystic ovary syndrome: a systematic review and meta-analysis. Human Reproduction Update; November/December 2012; 18; 6; 618–637), concluded that obesity was more prevalent in women with PCOS as opposed to women without PCOS
In 2017, the American Society for Metabolic and Bariatric Surgery stated that there is some evidence that bariatric surgery can improve fertility, how surgery improves the conditions is not fully understood. In addition, recommendations for surgery after failure of other treatments for PCOS have not been fully established. Therefore, the authors undertook a literature review to identify studies that evaluate the clinical application of bariatric surgery in the treatment of PCOS. They identified ten studies (n= 225 women) that evaluated multiple outcomes related to PCOS and bariatric surgery.
The researchers reported that in of the studies, surgery resulted in significant decrease in BMI for PCOS patients. In five of the studies, nearly all PCOS patients discontinued their medications for dyslipidaemia and/or hypertension. Weight loss after surgery also reduced PCOS patients of insulin resistance with nearly all patients showed resolution of T2DM or normalisation of insulin levels.
Extra-gonadal aromatization of testosterone leads to increased levels of estrogenic. Theis subsequently affects upstream feedback loops that result in altered FSH/LH ratios, ultimately leading to phenotype changes in the ovary in the form of PCOS. In total, five studies reported complete restoration of menstrual cycle, three found that almost all women had a complete restoration, while two studies had non-significant changes at the end of the study period.
Following restoration, many women seeking to become pregnant were successful via natural conception, while a few utilised assisted reproductive techniques. Three of the studies discovered little to no change in ovarian volume even with the restoration of their menstrual cycles.
“The results show that bariatric surgery generally has a beneficial effect on re-establishing regular menstrual cycles,” they write. “However, even with postoperative pregnancy success, there is no clear, direct link between ovarian morphology normalization and bariatric surgery.”
The authors call for a large, multi-centre, randomised controlled trial to fully determine the effects of each surgery type on women with obesity and PCOS. They also noted that as PCOS impact multiple demographics, current bariatric surgery guidelines might not be sufficient and should be amended. Finally, a comparison of fertility rates after different types of bariatric surgery would also greatly contribute to the understanding of PCOS treatment, they write.
“Bariatric surgery has become the leading option for lasting weight loss in obese individuals and has been utilised in a few cases of obese women with PCOS, but we must consider if bariatric surgery is an effective treatment option for PCOS…” the authors concluded. “Ultimately, upon reviewing the results, we recommend a more widespread implementation of bariatric surgery in treatment options for obese women with PCOS. However, more comprehensive studies with longer follow-up time are needed to study the role of bariatric surgery in obese women with PCOS.”
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