~ ~ Ladies Only! Female Issue ~ ~

Hi All, I just got my period......for the 3rd time in 4 weeks!! Each time, it lasts 2-3 days. I have bad cramps each time (I always got bad cramps...since I was a teenager, so that's nothing new). But....3 times?!?! I'm 10 months post-op. This did not happen up until now. I recently saw my OB/GYN for my annual exam and everything was fine. Has anyone else experienced anything like this? Thanks, Karen

Good morning, I've had fluctuations with my period.  All my life, my periods were like clockwork.  After the surgery, I had two periods in one month and then it skipped a month.  Since I am almost 48, I am not sure if it's perimenopause or the changes in my  body. You've lost a great deal of weight very quickly so I think that it's got to be your body adjusting to this.  Your exam was fine, so I'd just keep tracking it and if it happens again, I'd call the GYN, but for now I wouldn't worry about it (other than it's a pain not being able to tell when it will hit.) Good luck, Sue

I have a period then spotting most of the month.  I've read other posters here and in the main forum who have the same.  You're lucky it's taken this long!  LOL  I had a Mirina IUD put in 2 years ago January, so I hadn't had even spotting, much less a period since then...until surgery!  Oh well...guess I'd rather buy the products and be -50...for now!

I am 2 months out, 66 pounds lost and now on YAZ birth control...I had three cycles in one month just like you said....my doc said hormones are changing...my body was regulating it self and a low dose will help.  SO I am at the end of my first pack...doing great...about to start, lol

Oh, the delightful side effects of anestisia (sp).  When I had arthroscopic knee surgery I had the same thing happen. I haven't had it with RNY as I'm on BCP and very closely watched because I have PCOS.  Trust me this too shall pass sometimes it takes a year or so to clear. **This post is filled with pure scarcism!!

Karen, I can not say I have this problem after surgery, I got my period the day after surgery so nothing seems to stop it at this point!  Though I have noticed that it is a little off and slower when I am low on my iron, I am not sure if that has anything to do with it but I would have your levels checked and see. This journey is a trial and error thing it seems.  We are all so different and it effects us differently it seems. Keep us posted hun and I hope it works its way out soon....

 

 

Karen, parts of this article may help you understand hormonally what may be going on, yes yes yes I had similar issues, no period then for a full month the 2 in  month, especially during the first 6 mo for me when I lost almost all my wt!!! We r high risk for pregnancy at this time due to free floating estrogen etc, read on for all the hormonal changes due to obesity and subsequent wt loss. I know whole article doesnt pertain but may be of value to you, also anyone who is on bcps post rny beware they may not be effective!, LAPBAND IS DIFFERENT ISSUE THOUGH. Hugs Jamie if it continues even if your eam was normal wort a call to see if any labs are needed esp iron panel u can become anemic really quick which can be difficult to tret if left too long.... Worth the Weight Pregnancy After Gastric Bypass Surgery

 

 from Advance Newsmagazine for Nurse Practitioners

 

Vol. 13 •Issue 11 • Page 45 Worth the Weight

 

Pregnancy After Gastric Bypass Surgery

 

By Joy Burt, NP

 

Kerry, age 32, is 5 feet 3 inches and 185 pounds. She presents for an obstetric appointment and states that she has mixed emotions about her surprise pregnancy. Kerry had gastric bypass surgery 6 months ago and has lost 112 pounds since.

 

She says she has experienced increased self-esteem since the surgery and is overjoyed with her increased energy, which enables her to play more often with her 4-year-old son, Andrew. Kerry tried for several years to conceive Andrew and was unsuccessful until her third round of in vitro fertilization. When she decided to have gastric bypass surgery, Kerry did not think she would have more children. She had been taking oral contraceptives since the birth of Andrew and had continued after surgery, but ended up pregnant. She is unsure of her last menstrual period and often experiences nausea (a side effect of the surgery). She didn't know she was pregnant until she realized her weight loss stopped and she began experiencing breast tenderness.

 

A bimanual exam indicates that Kerry is 12 weeks pregnant. Kerry is concerned because she was cautioned not to get pregnant for the first 2 years after surgery.

 

You schedule Kerry for an ultrasound to date the pregnancy more precisely and ask the name of her bariatric surgeon so that you can contact her about necessary follow-up secondary to pregnancy.

 

Obesity

 

Nearly 35% of U.S. residents are overweight and 25% of adults are obese.¹ For many people, the struggle with weight has been a lifelong battle.

 

The majority of morbidity and mortality associated with obesity is related to comorbid conditions. In addition, serious medical problems such as obstructive sleep apnea, gastroesophageal reflux, abdominal wall hernias, biliary tract disease, urinary stress incontinence, venous disease, degenerative joint disease, infertility, depression and other psychiatric disorders are associated with obesity. Several malignancies, including colon, breast and ovarian cancer, occur at higher rates in people who are obese.^2-4

 

Obesity and Reproduction

 

Obesity is of particular importance to women's health care providers because the majority of obese people are women, and obesity has significant consequences for the reproductive system.^5,6 Although increased body fat is an essential requirement for reproductive health, greater than normal amounts of fat can lead to menstrual abnormality, infertility, miscarriage and difficulties with assisted reproduction.⁶

 

Massively obese people have decreased levels of sex hormone-binding globulin (SHBG), whi*****reases circulating androgens. The androgens are converted to estrogens in the stroma of the adipose tissue by a process of aromatization.⁷

 

Thus, morbidly obese women have elevated levels of free androgens and estrogens. This causes hirsutism and can result in irregular menses, oligomenorrhea or amenorrhea, anovulatory cycles or infertility. The elevated estrogen levels can also lead to endometrial hyperplasia and uterine and breast cancer. Sex hormone levels normalize after loss of the excess weight.⁸

 

For morbidly obese people who do get pregnant, maternal obesity has been associated with an increased risk of gestational diabetes, pregnancy-induced hypertension and pre-eclampsia.^3,5,9 High prepregnancy weight and excessive weight gain during pregnancy appear to be associated with fetal macrosomia, labor abnormalities, postdatism, meconium staining and cesarean section.¹⁰

 

If substantial weight loss occurs before another pregnancy, these comorbidities are not increased.⁸

 

Treatment

 

The treatment of obesity is difficult. Like many chronic diseases, obesity cannot be rapidly or easily resolved. The need to treat obesity and the aggressiveness of treatment depend on current complications and the risk of future complications. A modest planned weight loss of 5% of initial body weight can improve many of the medical conditions related to obesity, as well as prevent or delay onset of further obesity-related conditions.¹¹

 

Treatment of obesity should be tapered to the patient's willingness to receive therapy and ability to comply with recommendations. Fundamental basics of obesity treatment include behavior modification, dietary intake changes and regular physical activity. Pharmacotherapy and bariatric surgery can be useful adjuncts in certain patients.⁹

 

Gastric Bypass Surgery

 

Long-term data on diet, exercise, behavioral and pharmacologic treatments demonstrate only a modest weight reduction in severely obese patients. Consequently, surgical treatment is sometimes recommended for these patients.2,10 Bariatric surgery, a term that encompasses all weight loss surgeries, is the most effective technique for achieving long-term weight loss in the morbidly obese and those with multiple severe obesity-related conditions.²

 

Gastric bypass (GBP) surgery is a type of bariatric surgery that involves reducing the size of the gastric reservoir and bypassing a small segment of intestines by constructing a Y-shaped limb of small bowel.¹² Patients lose weight because they consume fewer calories as a result of the reduced reservoir capacity of the small stomach pouch.

 

Weight reduction surgery can improve comorbid conditions.¹¹ In two recent studies, patients who underwent GBP experienced marked improvement in their type 2 diabetes. In the first study, type 2 diabetes resolved or improved in 97% of patients who had GBP.^12,13 In the second study, the mortality rate was three times greater for patients treated medically compared with patients who underwent GBP.^12,13 Other benefits documented in the study included increased mobility and stamina, better mood, improved self-esteem and enhanced quality of life.¹⁴

 

Birth Control

 

Pregnancy is contraindicated for the first 18 to 24 months after GBP. During this time, the body is adjusting to its new gastric capacity and absorption processes. In fact, almost half of excess weight is lost in the first 12 to 18 months.¹² In this rapid weight loss period, vomiting and food intolerances are common, and pregnancy during this time would be a strain on the body as well as a risk to the fetus.¹⁵ Therefore, it is essential to address birth control issues prior to surgery.^12,15,16

 

Because absorption of food and medications is varied due to bypass of some of the intestine, women should not rely on oral contraceptives as a means of contraception. Prior to surgery, a woman should meet with her women's health provider for consultation about appropriate contraception.¹⁵ Due to the rapid weight loss after surgery, ovulation and fertility are likely to return quickly in women who were previously anovulatory. Regardless of prior fertility prevention needs, these women should begin contraceptive use prior to surgery — the same as ovulatory women.¹⁵

 

Women who become pregnant unintentionally should be encouraged to openly express their feelings about the pregnancy. Some women who were previously unable to conceive may view the pregnancy as a gift. However, women who have recently gone through a total body transformation may be apprehensive about the possibility of gaining weight during pregnancy.

 

Preconception Consultation

 

After the rapid weight loss period in the 18 to 24 months post surgery, women who desire to conceive should schedule a preconception consultation.15 At that time, a thorough review of medical records and current medications is necessary. In addition to consultation with the primary care or women's health provider, the woman should contact her bariatric surgeon to discuss her specific plan of care.

 

Since there are significant differences between restrictive operations and those that cause malabsorption, as well as many combinations of the two surgeries that pose various risks, collaboration with the surgeon is recommended. The bariatric surgeon will best understand the physiologic changes secondary to surgery, as well as specific behaviors important to follow after GBS.¹⁶

 

Nutritional Evaluation

 

Once pregnancy is achieved, early prenatal care is essential for pregnancy dating and nutritional evaluation. Establish baseline nutritional status, especially if deficiencies need to be corrected. Ideally, the nutritional deficiencies would be addressed in the preconception consultation.¹⁶

 

Iron deficiencies are not uncommon after GBP, secondary to the lack of contact of food iron with gastric acid and its ability to convert the iron from the insoluble ferrous to the more absorbable ferric form.¹⁵ In addition, vitamin B12 deficiency may result because food no longer is coming in contact with gastric intrinsic factor. Vitamin D and calcium absorption may also be reduced, since the duodenum and proximal jejunum, which are the preferred sites of absorption, are bypassed by GBP. Therefore, lifelong supplements of multivitamins, vitamin B12, iron and calcium are mandatory after surgery.¹²

 

Vitamin and iron supplementation are important in all pregnancies. This supplementation is even more important for pregnant women who have had bariatric surgery. Prenatal vitamins should be given in addition to — not instead of — the patient's usually prescribed vitamin regimen.¹⁶ Following gastric bypass surgery, vitamins may need to be taken in liquid or chewable form.⁸

 

Iron and B12 supplements should be added as indicated based on red blood cell indices, serum B12, iron and ferritin levels. Prenatal vitamins usually include 30 mg to 90 mg elemental iron and 0.8 mg to 1 mg folic acid. Additional supplements should take the form of the specific nutrient requiring supplementation.¹⁵ If additional iron is needed, ferrous fumerate is best tolerated and provides the most effective iron supplementation when the duodenum is bypassed.¹⁶ Vitamin B12 can be administered 500 mcg orally daily or 1,000 mcg intramuscularly each month. Adequate calcium intake or supplementation should be ensured to support mineralization of the fetal skeleton.⁸

 

Advise patients to avoid taking more than twice the recommended daily allowance of fat-soluble vitamins A, D, E and K. Taking multiple prenatal vitamins increases the risk of ingesting excess nutrients, and vitamin A in doses of 5,000 IU/day or more may be teratogenic. Nutritional consultations may be necessary.¹⁵

 

Due to possible malabsorption, the risk for open neural tube defects in the fetus of a pregnant woman who has had GBP is potentially increased.¹⁵ To reduce this risk, prescribe folic acid supplements of at least 400 mcg/day orally 1 month prior to conception and 12 weeks after conception. In addition, a maternal serum alpha-fetoprotein screen should be offered between the 15th and 21st weeks of gestation. A targeted fetal ultrasound at 18 to 20 weeks' gestation will aid in detecting any fetal anatomy.¹⁵

 

Weight Gain and Fetal Growth

 

During a normal pregnancy, optimal maternal weight gain is 25 to 35 pounds. For obese women, pregnancy is not an appropriate time for major weight loss. The obese pregnant woman should strive to limit weight gain to 15 to 25 pounds during pregnancy.¹⁷ Weight should be monitored closely. The pregnant bariatric patient should eat two to four well-balanced, high-protein meals each day. She should not eat six small meals throughout the day because such habits will probably continue postpartum and risk sabotaging the overall success of weight loss.¹⁶

 

The primary focus for a pregnant woman who has had GBP should be on proper weight gain. If the pregnant woman does not gain weight, or gains very little during pregnancy, the fetus is at risk for intrauterine growth retardation, fetal abnormalities and low birth weight.⁸ Monthly ultrasounds to evaluate fetal growth should begin at 24 weeks' gestation.¹⁵

 

Maternal Dumping Syndrome

 

Gastric bypass patients experience a "dumping" syndrome if they ingest large quantities of simple sugar. This may cause cramping, diarrhea, nausea, lightheadedness and palpitations.^15,16 This is especially important to keep in mind around 28 weeks' gestation, when the glucose tolerance test for gestational diabetes is typically ordered. Since the 50-g glucose bolus used for this test could make the patient quite ill, it should be avoided.^15,16 Instruct the woman to perform fasting and 2-hour postprandial finger sticks for 1 week. Target ranges are 90 mg/dL or lower for fasting and 120 mg/dL or lower for postprandials.¹⁵ If results are questionable, order an Hgb A1C.¹⁶

 

Labor and Delivery

 

The timing and mode of delivery are based on obstetric indications. Obesity is associated with an increased risk of cesarean delivery and postoperative morbidity. Consider antibiotic prophylaxis and deep vein thrombosis prophylaxis perioperatively if cesarean section is necessary.¹⁵

 

Breastfeeding

 

GBP is not associated with any contraindications to breastfeeding.¹⁵ However, pediatricians should be made aware of the maternal history of bariatric surgery due to the increased risk of neonatal megaloblastic anemia.¹⁵

 

Keys to Successful Outcomes

 

As women's health and primary care providers, we must support our patients in their journey toward optimal health. For morbidly obese women of childbearing age, this may mean assisting them to evaluate the decision to have bariatric surgery and subsequently become pregnant. Helping women see the benefits of a planned pregnancy is the key to a healthy delivery.

 

References

 

1. Mokad AH, Derdula MK, Dietz WH, et al. The spread of the obesity epidemic in the United States. 1991-1998. JAMA. 1999;282:1519-22.

 

2. Patterson EJ, Urbach DR, Swanstrom LL. A comparison of diet and exercise therapy vs. laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model. J Am Coll Surg. 2003;196:379-384.

 

3. Lu GC, Rouse DJ, DuBard M, et al. The effect of the increasing prevalence of maternal obesity on perinatal morbidity. Obstet Gynecol. 2001;185:845-849.

 

4. Flancbaum L, Choban PS. Surgical implications of obesity. Ann Rev Med. 1998;49:215-234.

 

5. Perlow JH, Morgan MA, Montgomery D, et al. Perinatal outcome in pregnancy complicated by massive obesity. Am J Obstet Gynecol. 1992;167:958-962.

 

6. Norman RJ, Clark AM. Obesity and reproductive disorders: a review. Reprod Fertil Dev. 1998;10:55-63.

 

7. To TB, Deital M, Stone E, et al. Sex hormonal changes after loss of massive excess weight. Surg Forum. 1987;38:465-467.

 

8. Deitel M. Pregnancy after bariatric surgery. Obesity Surg. 1998;8:472-475.

 

9. Baeten JM, Bukusi EA, Lambe M. Pregnancy complications and outcomes among overweight and obese nulliparous women. Am J Public Health. 2001;91:436-440.

 

10. Gurewitsch ED, Smith-Levitin M, Mack J. Pregnancy following gastric bypass surgery for morbid obesity. Obstet & Gynecol. 1996;88(4):658-661.

 

11. Sadovsky R. Management of obesity: an official recommendation. Am Fam Phys. 2003;67(2):379-380.

 

12. American Society for Bariatric Surgery. Rationale for the surgical treatment of morbid obesity. Available at: http://www.asbs.org/html/patients/rationale.html. Accessed July 29, 2005.

 

13. Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003;238(4):467-484.

 

14. Kral JG, Sjostrom LV, Sullivan MB. Assessment of quality of life before and after surgery for severe obesity. Am J Clin Nutr. 1992;55(2):611S-614S.

 

15. Casco Bay Surgery. Bariatric surgery program. Guidelines for preconception and prenatal care following bariatric surgery. Available at: http://www.cascobaysurgery.com/Bariatric%20Surgery%20Program /prenatal%20care.htm. Accessed July 29, 2005.

 

16. Wittgrove AC, Jester L, Wittgrove P, Clark GW. Pregnancy following gastric bypass for morbid obesity. Obes Surg. 1998;8:461-464.

 

17. Platt MO. Nutrition and pregnancy. In: Handbook of Obstetrics, Gynecology, and Primary Care. St. Louis: Mosby Inc; 1998:236-237.

 

Joy Burt is a women's health nurse practitioner who is director of the postpartum and normal newborn nursery at Akron General Medical Center in Akron, Ohio. http://nurse-practitioners.advanceweb.com/common/EditorialSearch/printerfriendly.aspx?AN=NP_05nov1_npp45.html&AD=11-01-2005    Search Archives

 

 

 

Copyright ©2005 Merion Publications 2900 Horizon Drive, King of Prussia, PA 19406 • 800-355-5627 Publishers of ADVANCE Newsmagazines www.advanceweb.com

Issue Date: November 01, 2005

 

 

 

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forgot to say this is my 3rd year with my mirena iud and I love it hardly any periods at all if I do it is spotting on a panty liner for 1 day, havent had to buy feminine products in many yrs.....Jamie!