Clinical Review
A guide for clinicians: Bariatric surgery and the ObGyn patient
A boom in surgical weight-loss procedures means you will be called on to manage women who have undergone—or are considering—one of these...
In clinical practice, weight problems are very common. Among US women, about one-third are obese, with another one-quarter overweight. As we know, obesity is a risk factor for many medical problems, including diabetes, hypertension, elevated cholesterol, stroke, heart disease, many cancers, sleep apnea, and arthritis.1 Obesity is also a risk factor for a long list of serious obstetric problems, including gestational hypertension, preeclampsia, gestational diabetes, fetal malformations, macrosomia, stillbirth, prematurity, and an increased rate of cesarean delivery.
Clearly, collectively, we need to play more of an active role in our patients’ weight loss and subsequent weight-maintenance efforts. To help us achieve this goal, we should be familiar with our patients’ weight status and comorbidities and offer helpful nonpharmacologic weight-loss interventions. We also should be cognizant of current pharmacologic and surgical options, and, when appropriate, be prepared to counsel patients about their efficacy.
Routinely calculate BMI and assess comorbidities
The body mass index (BMI) of every patient should be calculated and recorded in her medical record.
Be familiar with her BMI. For white, Hispanic, and black women, overweight is defined as a BMI between 25 and 29 kg/m2, and obesity is defined by a BMI of 30 kg/m2 or more.2 For Asian women, overweight begins at a BMI of 23 kg/m2, and obesity begins at a BMI of 25 kg/m2.
If she’s overweight, determine her comorbidities. For your patients with a BMI of 25 kg/m2 or more, assess them for medical comorbidities such as hypertension, dyslipidemia, diabetes, heart disease, and sleep apnea, as the presence of any of these conditions markedly increases the risk of adverse health outcomes. To determine if metabolic syndrome is a concern, measure blood pressure; waist circumference; and fasting triglyceride, fasting glucose, and serum high-density lipoprotein (HDL)-cholesterol levels. To detect prediabetes or diabetes mellitus, consider the hemoglobin A1c (HbA1c) test. The American College of Obstetricians and Gynecologists recommends that clinicians test for diabetes in all women aged 45 and older every 3 years.3
Start with the basics—diet and exercise
It is very difficult for women, and men, who are overweight or obese to successfully lose weight and maintain a normal BMI over time. Many overweight or obese women have attempted to lose weight on many occasions by implementing changes in lifestyle, including diet and exercise, but have had only temporary success.
If your patient is motivated to begin a first or repeat attempt at weight loss, there are several helpful interventions you could recommend, including:
- consult with a nutritionist
- use smartphone apps to help
- support the diet plan (to track caloric intake, daily exercise, etc.)
- increase daily exercise to 1 hour
- join a group weight-loss program or support group
- eat breakfast every day
- avoid food binges on weekends and at night
- practice stress-reduction techniques.
If the combination of basic approaches do not result in her achieving sufficient weight loss, pharmacologic therapy can be considered.
Pharmacologic options
Pharmacologic therapy can be offered to all women with4:
- BMI of 30 kg/m2 or more
- BMI of 27 kg/m2 or more with comorbidities, such as hypertension, diabetes, dyslipidemia, or heart disease.
Pharmacologic options for long-term therapy include lorcaserin, orlistat, and phentermine-topiramate. Because of a risk of fetal malformations, women of childbearing age should have a monthly pregnancy test while taking phentermine-topiramate. Here, I focus on lorcaserin and orlistat, two agents that do not require monthly laboratory testing (TABLE). It is important to note that no weight-loss medicine should be prescribed to pregnant women.
Lorcaserin
Lorcaserin is a selective serotonin 2c receptor agonist. Lorcaserin reduces appetite and food intake. Other serotonergic medications previously used for weight loss, such as fenfluramine, stimulated the serotonin 2b receptor, which may have contributed to an increased risk of cardiac valve disease. Because lorcaserin is a selective serotonin 2c receptor agonist, it is less likely to cause cardiac valve disease.
Lorcaserin is taken as a 10-mg tablet twice daily.5 In one large trial, approximately 50% of patients who took the drug for 12 months lost at least 5% of their body mass.6 For those patients taking lorcaserin who do not lose 5% or more of their body mass by 12 weeks of therapy, it is recommended that the medication be discontinued because successful weight loss may not occur with continued therapy. These women could be offered treatment with orlistat.
The most common side effects of lorcaserin are headache, dizziness, fatigue, nausea, dry mouth, and constipation. The drug is contraindicated in those with renal failure or in patients who are taking other serotonergic medications, such as selective serotonin reuptake inhibitors, bupropion, tricyclic antidepressants, or monoamine oxidase inhibitors.