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Obesity and
Menstrual
Disorders
Prof. Aboubakr Elnashar
Benha university Hospital,
Egypt
ABOUBAKR ELNASHAR
1. MENSTRUAL DISORDERS ASSOCIATED WITH
OBESITY
Abnormalities in
amount
duration,
length
regularity
HMB=Heavy Menstru...
Obese women with PCOS
: higher frequency of menstrual cycle irregularities
Obesity in adolescence
:increased the risk of...
2. PREVALENCE OF MENSTRUAL DISORDERS IN
OBESE WOMEN
Irregularities
significantly higher
HMB
more prevalent
Oligomenor...
3. PATHOPHYSIOLOGY
The effect of obesity on menarche
Leptin
main product of body fat
regulates the gonadotrophin surge...
The effect of obesity on menopause
several years earlier in obese than in normal-
weight women
(Seif et al.,2015)
ABOUBA...
Effect of obesity on Hormones
Increased
1. oestrogen
through peripheral conversion of androgens to
oestrogen, in partic...
Effect of Obesity and PCOS on endometrium
{chronic anovulation: prolonged endometrial
exposure to unopposed oestrogen in ...
TREATMENT OF OLIGOMENORHEA OR
AMENORHEA
1. Exclusion of pregnancy
2. Investigations
3. Progestogens
to induce a withdrawal...
MANAGEMENT OF HMB IN OBESE WOMEN
Challenges
Obesity is associated with numerous co-morbidities
hypertension
Diabetes
...
Investigations
1. Endometrial sampling:
{risk of endometrial hyperplasia is increased in
overweight women}
Indication:
...
2. Hysteroscopy
Indication
Intermenstrual bleeding
Sudden change in bleeding pattern.
Outpatient hysteroscopy. vaginos...
 Treatment
A. Medical
I. Weight loss:
1. may improve menstrual dysfunction.
2. Restore cyclicity
3. Restores regular mens...
II. Non hormonal treatment
1. Metformin
Obese women with insulin resistance may benefit
Restores normal menses in women ...
2. Tranexamic acid
During menstruation
Simple 1st -line measure
Menstrual blood loss reduced by up to 60%
[Leminen H, H...
3. Non-steroidal anti-inflammatory drugs (NSAIDs)
can be used alongside tranexamic acid
reduce symptoms of dysmenorrhoea...
III. Hormonal treatment
1. Combined oral contraceptive pill
used extensively to treat HMB
Additional benefit
1. Effectiv...
Avoidance of the COCP
1. Previous or current history of VTE,
2. Hypertension
3. Cardiovascular disease
4. Migraine with a...
IS COCP less effective in obese?
Yes:
Contraceptive failures were more common in
overweight or obese women
[Holt, 2005]...
No
1. No convincing evidence to suggest the COCP is
less effective in women with a raised BMI
(Trussell et al, 2009)
2. N...
Therefore, when considering treatment options for
obese women:
use of the COCP is a viable option in those with a
BMI of...
2. Oral Progestogens
Mechanism of action
antagonising the proliferative oestrogenic action on the
endometrium.
Ovulatio...
3. Progestagen-releasing IUCD (Mirena)
First-line treatment for HMB
[NICE, 2007].
slowly releasing a low dose of levonor...
4. Depot-medroxyprogesterone acetate injection
Effect on menstrual blood loss
very variable
30-100%: decrease in their m...
IM:
Serum levels of DMPA remain steady throughout
the 3-month period in both normally weighted and
overweight women.
SC...
Weight gain with hormonal preparations
important factor influencing women's choice
 main reason for discontinuing the m...
DMPA
Frequently labelled as a cause of weight gain
No convincing evidence that DMPA led to weight
gain
[Cochrane SR, 20...
B. Surgical treatments for HMB
Indication
1. Quality of life is severely affected
2. Medical therapies are not tolerated ...
1. Endometrial ablation
The first-generation ablative techniques
Endometrial laser ablation (ELA)
Rollerball endometria...
Second-line endometrial ablation techniques
do not require direct visualisation of the uterine
cavity.
Destruction is a...
2. Hysterectomy
Indication:
all other options have been reviewed
no longer wish to conceive.
Counseling
increased com...
Preoperative assessment
CV and respiratory
relevant examination
Anaesthetic
 airway management, as problems may occur...
Regional anaesthesia
often considered
{this helps with postoperative analgesia and
reduces the risk of thromboembolism b...
Route
1. Vaginal:
first-line route for hysterectomy
(NICE, 2009)
2. laparotomy
associated with higher rates of
wound i...
3. Laparoscopic
could be considered in women who are morbidly
obese
{open approach with a total abdominal hysterectomy ma...
Satisfaction:
95% satisfaction rate up to 3 years after surgery
[Letaby et al, 2000].
Complications:
Haemorrhage
Infe...
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://ww...
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Obesity and menstrual disorders

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obesity and menstrual disorders

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Obesity and menstrual disorders

  1. 1. Obesity and Menstrual Disorders Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR
  2. 1. MENSTRUAL DISORDERS ASSOCIATED WITH OBESITY Abnormalities in amount duration, length regularity HMB=Heavy Menstrual Bleeding interferes with a woman's physical Social emotional or quality of life Oligomenorrhoea Amenorrhoea Irregular uterine bleeding In many cases, menstrual irregularities are often associated with episodes of DUB. ABOUBAKR ELNASHAR
  3. Obese women with PCOS : higher frequency of menstrual cycle irregularities Obesity in adolescence :increased the risk of menstrual problems ABOUBAKR ELNASHAR
  4. 2. PREVALENCE OF MENSTRUAL DISORDERS IN OBESE WOMEN Irregularities significantly higher HMB more prevalent Oligomenorrhoea Relative Risk (RR) of in woman with upper body fat predominance was 3.15 (P < 0.001) compared with women with lower body fat predominance ABOUBAKR ELNASHAR
  5. 3. PATHOPHYSIOLOGY The effect of obesity on menarche Leptin main product of body fat regulates the gonadotrophin surge: initiates the development of pubertal stages Changes in body weight and composition: crucial in regulating pubertal development in women Age of menarche at a younger age in obese girls ABOUBAKR ELNASHAR
  6. The effect of obesity on menopause several years earlier in obese than in normal- weight women (Seif et al.,2015) ABOUBAKR ELNASHAR
  7. Effect of obesity on Hormones Increased 1. oestrogen through peripheral conversion of androgens to oestrogen, in particular, androstenedione, in adipose tissue by aromatase 2. Insulin: stimulate the production of androgens in ovarian stromal tissue. 3. Testosterone Reduced SHBG :increased levels of circulating or free testosterone. ABOUBAKR ELNASHAR
  8. Effect of Obesity and PCOS on endometrium {chronic anovulation: prolonged endometrial exposure to unopposed oestrogen in the absence of sufficient progesterone: endometrial hyperplasia [Cheung, 2001; Schindler, 2009] Endometrial cancer: 3 times higher (odds ratio (OR) 2.70, 95% confidence interval (CI)1.00-7.29 [Chittenden et al, 2009].  9% lifetime risk of developing endometrial cancer in PCOS vs 3% in the general population ABOUBAKR ELNASHAR
  9. TREATMENT OF OLIGOMENORHEA OR AMENORHEA 1. Exclusion of pregnancy 2. Investigations 3. Progestogens to induce a withdrawal bleed 3-4 times a year in PCOS [RCOG37]. ABOUBAKR ELNASHAR
  10. MANAGEMENT OF HMB IN OBESE WOMEN Challenges Obesity is associated with numerous co-morbidities hypertension Diabetes Ischaemic heart disease increased risk of VTE Selection of modality of treatment  is based on a balance between expectant benefits and the potential risks (benefits/risk ratio). ABOUBAKR ELNASHAR
  11. Investigations 1. Endometrial sampling: {risk of endometrial hyperplasia is increased in overweight women} Indication: 45 years of age Persistent intermenstrual bleeding Unresponsive to treatment [NICE, 2007.} ABOUBAKR ELNASHAR
  12. 2. Hysteroscopy Indication Intermenstrual bleeding Sudden change in bleeding pattern. Outpatient hysteroscopy. vaginoscopy avoid anaesthesia and its associated risks removes the need for large speculae morbidly obese woman: examination couches tend to have an upper weight limit positioning of the patient may be difficult. any operative procedure, such as polypectomy, can be technically challenging due to the length of the scope and instruments. ABOUBAKR ELNASHAR
  13.  Treatment A. Medical I. Weight loss: 1. may improve menstrual dysfunction. 2. Restore cyclicity 3. Restores regular menstrual function 1. decreasing the aromatisation of androgens to oestrogens in adipose tissue 2. increasing insulin sensitivity. Obese women also have a degree of insulin resistance, a characteristic feature of PCOS Bariatric surgery [Teitelman et al, 2006]. 71.4% regained normal menstrual cycles ABOUBAKR ELNASHAR
  14. II. Non hormonal treatment 1. Metformin Obese women with insulin resistance may benefit Restores normal menses in women with HMB [Essah et al, 2006]. ABOUBAKR ELNASHAR
  15. 2. Tranexamic acid During menstruation Simple 1st -line measure Menstrual blood loss reduced by up to 60% [Leminen H, Hurskainen, 2012]. Anti-fibrinolytic agent that: inhibiting the action of plasmin, the enzyme that breaks down fibrin. Contraindication: {its effect on clotting: potential increased risk of VTE}. 1. Obesity, alongside other significant risk factors for VTE 2. Women already taking the COCP { avoid the cumulative thrombogenic effect of these two agents}. ABOUBAKR ELNASHAR
  16. 3. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used alongside tranexamic acid reduce symptoms of dysmenorrhoea [NICE, 2007]. avoiding the risks of hormonal preparations. ABOUBAKR ELNASHAR
  17. III. Hormonal treatment 1. Combined oral contraceptive pill used extensively to treat HMB Additional benefit 1. Effective contraception 2. Cycle control 3. In PCOS treatment of the acne and hirsutism 4. Progestogen on the endometrium: reduces the risk of endometrial hyperplasia and endometrial cancer. ABOUBAKR ELNASHAR
  18. Avoidance of the COCP 1. Previous or current history of VTE, 2. Hypertension 3. Cardiovascular disease 4. Migraine with aura 5. Breast cancer. Obesity alone should not rule out the use of the COCP. (WHO) BMI: 30-34 kg/m2= category 2= benefits outweigh the risks [Medical Eligibility Criteria 2015]. BMI >35=category 3 risks outweigh benefits. ABOUBAKR ELNASHAR
  19. IS COCP less effective in obese? Yes: Contraceptive failures were more common in overweight or obese women [Holt, 2005]. ABOUBAKR ELNASHAR
  20. No 1. No convincing evidence to suggest the COCP is less effective in women with a raised BMI (Trussell et al, 2009) 2. No significant discrepancy amongst women using the COCP regardless of BMI (Dinger et al, 2009) 3. Effect on the endometrium: Treatment of HMB, should be similar amongst normal-weight and overweight (Westhoff et al, 2010) 4. BMI did not affect the efficacy of the COCP. (Cochrane SR, Lopez et al, 2010) ABOUBAKR ELNASHAR
  21. Therefore, when considering treatment options for obese women: use of the COCP is a viable option in those with a BMI of up to 35, bearing in mind the frequently occurring co- morbidities, which increase the risks associated with this modality of treatment. ABOUBAKR ELNASHAR
  22. 2. Oral Progestogens Mechanism of action antagonising the proliferative oestrogenic action on the endometrium. Ovulation is possibly {ovary is not fully suppressed} Protective effect on the endometrium is unlikely to be compromised [Edelman et al, 2008]. Oral intake in over weight Peak levels: lower Trough levels: similar [Dinger et al, 2009]. Half life: longer Elimination: slower Time to steady state: longer ABOUBAKR ELNASHAR
  23. 3. Progestagen-releasing IUCD (Mirena) First-line treatment for HMB [NICE, 2007]. slowly releasing a low dose of levonorgestrel: preventing endometrial proliferation: endometrial thinning: reduce amount of blood lost during menstruation . Category 1: in obese Category 2: in women with multiple CV risk factors advantages outweigh risks in many obese women avoiding the need for surgery will be of greater benefit than any of the possible risks. {levonorgestrel on lipid metabolism may increase the risk of thrombosis}. ABOUBAKR ELNASHAR
  24. 4. Depot-medroxyprogesterone acetate injection Effect on menstrual blood loss very variable 30-100%: decrease in their menstrual blood 15-20%: achieving amenorrhoea [Ruminjo et al, 2009]. Can be given as either IM SC ABOUBAKR ELNASHAR
  25. IM: Serum levels of DMPA remain steady throughout the 3-month period in both normally weighted and overweight women. SC serum levels of DMPA tend to be lower in overweight women, especially those with a BMI >40 This did not lead to the occurrence of ovulation in studies less effective particularly when used for treating heavy blood loss in obese women. ABOUBAKR ELNASHAR
  26. Weight gain with hormonal preparations important factor influencing women's choice  main reason for discontinuing the medication COCP No association between use of COCP and weight gain in normally weighted and overweight women [Curtis, 2009]. ABOUBAKR ELNASHAR
  27. DMPA Frequently labelled as a cause of weight gain No convincing evidence that DMPA led to weight gain [Cochrane SR, 2006]. Tendency towards weight gain Adolescent overweight [Bonny et al, 2006]. ABOUBAKR ELNASHAR
  28. B. Surgical treatments for HMB Indication 1. Quality of life is severely affected 2. Medical therapies are not tolerated or ineffective Desire for future fertility needs to be taken into consideration {ablation and hysterectomy are incompatible with future pregnancy} ABOUBAKR ELNASHAR
  29. 1. Endometrial ablation The first-generation ablative techniques Endometrial laser ablation (ELA) Rollerball endometrial ablation (RBEA) Compared to hysterectomy comparable Efficacy Safety patient satisfaction among obese and non- obese women (Madsen et al, 2013). Women with an increased BMI Endometrial hyperplasia should be excluded by an endometrial biopsy prior to ablation ABOUBAKR ELNASHAR
  30. Second-line endometrial ablation techniques do not require direct visualisation of the uterine cavity. Destruction is achieved through high-temperature fluids bipolar electrical microwave energy second-line vs first-line ablative techniques in obese women Limited data exist on the efficacy performed under local anaesthetic (LA) and/or as an outpatient procedure. ABOUBAKR ELNASHAR
  31. 2. Hysterectomy Indication: all other options have been reviewed no longer wish to conceive. Counseling increased complication rate {major surgical procedure} long recovery time. technical difficulties definitive surgical treatment for HMB 100% success rate in amenorrhoea high levels of satisfaction With this in mind, many women prefer a less invasive treatment, even though the success rate is lower ABOUBAKR ELNASHAR
  32. Preoperative assessment CV and respiratory relevant examination Anaesthetic  airway management, as problems may occur due to adipose tissue in the neck and limited neck/cervical spine movement. ABOUBAKR ELNASHAR
  33. Regional anaesthesia often considered {this helps with postoperative analgesia and reduces the risk of thromboembolism by half} [NICE, 2009]. ±difficult or even impossible in obese patients, but should be used when feasible. ABOUBAKR ELNASHAR
  34. Route 1. Vaginal: first-line route for hysterectomy (NICE, 2009) 2. laparotomy associated with higher rates of wound infection healing and herniation. VTE respiratory tract infection ABOUBAKR ELNASHAR
  35. 3. Laparoscopic could be considered in women who are morbidly obese {open approach with a total abdominal hysterectomy may lead to a higher rate of complications, such as wound dehiscence}. {abdominal wall anatomy is distorted by the overhanging skin and fat: umbilicus is low and caudal to its normal position: insertion of the Veress needle difficult}. Incision: at the base of the umbilicus Veress needle: inserted vertically Morbid obese: open (Hasson) technique or entry at the Palmer's point =Left upper quadrant [RCOG, 2008]. ABOUBAKR ELNASHAR
  36. Satisfaction: 95% satisfaction rate up to 3 years after surgery [Letaby et al, 2000]. Complications: Haemorrhage Infection wound healing problems longer hospital stay  early ovarian failure [Farquhar et al, 2005]. Postoperative: Morbidly obese patients may frequently be admitted to a high-dependency unit post-operatively. ABOUBAKR ELNASHAR
  37. ABOUBAKR ELNASHAR
  38. ABOUBAKR ELNASHAR You can get this lecture from: 1.My scientific page on Face book: Aboubakr Elnashar Lectures. https://www..com/groups/2277 44884091351/ 2.Slide share web site [email protected] 4.My clinic: Elthwara St. Mansura
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