Glasgow Obstetrical & Gynaecological Society

4th Year University of Glasgow Medical Student

Table of Contents

1)Introduction/Background ………………………………. Page 3

2)Aims & Objectives …………………………………….…. Page 4

3)Methods …………………...………………………………. Page 4

4)Results ……………………………….……………………. Page 4

5)Discussion …………………………..……………………. Page 7

6)Conclusions ……………………………………………… Page 9

7)Limitations ………………………..………………………. Page9

8)References ………………………..………………………. Page 10

9)Acknowledgments ………………………..…………..…. Page 10

Introduction/Background

Obesity is a worldwide epidemic. The global prevalence of obesity has more than doubled since 1980 and has become a major health problem.1The World Health Organisation (WHO) estimated in 2005 at least 400 million adults (9.8%) were obese, with higher rates among women than men.1

Scotland has one of the poorest obesity records in the developed world, and one of the highest rates of all based on WHO Global Health Observatory figures.

The WHO has classified BMI into categories - underweight, normal (healthy) weight, overweight and obese – depending on BMI range.2A BMI >30 kg/m2 defines obesity.

Table 1: WHO BMI Classification2

Classification / BMI (kg/m2)
Underweight / < 18.5
Normal weight / 18.5 - 24.9
Overweight / 25 - 29.9
Obese

Class I (Moderately obese)
Class II (Severely obese)
Class III (Very severely obese)

/ ≥ 30
30 - 34.9
35 - 39.9
≥ 40

Obesity affects many aspects of ill health, such as cardiovascular and respiratory, additionally adverse effects on obstetrics and gynaecology. Obesity causes infertility and increases miscarriage risk. Obese women have increased rates of foetal abnormalities, gestational diabetes, venous thromboembolism, pre-eclampsia, dysfunctional labour and post-partum haemorrhage.3Obesity in pregnancy also holds a risk for the baby, with an increased risk of premature birth, congenital defects and neonatal deaths.

Evidence suggests that obesity is linked with poor sexual health outcomes including higher sexually transmitted infections (STIs) in obese males, females more likely to report unintended pregnancies and also using less reliable contraceptive methods. However, overall there are very limited studies of obesity in relation to sexual health.

Aims and Objectives

The aim of the study was to collect data from an obese Glasgow population attending Sandyford sexual health services and to identify markers for poor sexual health performance in the obese population.Several markers of sexual health were analysed including routine and emergency contraception use, rates of STIs, cervical cytologyscreening andpreconceptional advice. An additional aim was to see if there was any correlation with obesity and the prevalence of polycystic ovarian syndrome (PCOS) as co-morbidity.The final aim was to check the number of weight management referrals made in those eligible in the study sample.

Methods

A search was completed using National Sexual Health (NaSH) electronic record system used at the Glasgow Sandyford clinics. The search was to obtain a list of all patients with a BMI classified as obese with a BMI >35 kg/m2,whom had attended the Glasgow Sandyford services from the 4th of January 2012 to the 31st of March 2012 to obtain a case note review.

The search identified a total of 209 patients - 201 females and 8 males. Using the patient’s NaSH number each patient was searched to attain information using their clinical notes, episodes and test results. This information was then incorporated into an excel spread sheet document and the following were analysed:

General characteristics – age, gender, sexual orientation and BMI
Main reason for attendance

Contraception provision
Emergency contraception and quick start contraception

STIs

Cervical cytology screening attendance
Co-morbidities such as PCOS
Weight management referrals and preconceptional advice

Results

General Characteristics

There were a total of 19,740 individuals who attended Glasgow Sandyford clinics from the 4th of January to the 31st of March 2012.14,556 (74%) were female and 5,184 (24%) were males. During the same time period 209 patients attended with a documented BMI of >35 kg/m2. Similarly to the total individuals there were more female attendances than males with201 (96%) females and only 8(4%) males.

In the209 obese patients there was a wide age range from 15 to 57 year olds. The most common age group for presentation in the three months was in the 15-24 age group totalling 36% of the patients. Moreover, 71% of patients who attended were 34 years old or younger.

Graph 1: BMI Distribution according to WHO Classification

Main Reason for Attendance

70% (137/201) attended for routine contraception provisionally and 2.5%(5/201) of female patients attended for emergency contraception as their main reason. Reasons for attendance are summarised in the table below.

Table 4: Main Reason for Attendance

Main Reason for Attendance / Number of Patients
Contraception-Routine / 137
Contraception-Emergency / 5
Contraception-Complex Problems / 6
Pregnancy-Concerns Termination / 2
Pregnancy-Concerns Tests / 6
STI Test (No symptoms) / 8
STI Test (Symptoms) / 7
STI Partner Has Infection / 2
Women’s Health/Gynaecology / 18
Vasectomy / 5
Sexual Dysfunction / 2
Other / 11

Contraception

Long acting reversible contraception (LARC) was used by 80(40%) of the females, of which the most common contraception choice was the contraceptive implant. 97 (48%), nearly half of the females were using the progesterone only pill (POP) as their method of contraception. No contraceptive method was used in 13 (6.5%) of the 201 females, 7 of whom were planning a pregnancy. A full breakdown of the number of women using each contraceptive method can be seen in the graph below.

Graph 2: Contraception Method

With regards to emergency contraception 10 (5%) females attended requesting a form of emergency contraception. Levonelle was prescribed for 8 females and the remaining 2 opted for an intrauterine device (IUD). A longer term method of contraception (quick start) was commenced in 7 of the 8 patients receiving levonelle, with 6 choosingPOP and 1 implant. .

Sexually Transmitted Infections

There were a total of 60 sexual health screens (SHS) performed. There were 5 new cases of chlamydia, 1 case of gonorrhoea and 2cases of genital warts idenified. This audit looked at SHS specifically in the under 25 age group. There were a total of 76 SHScarried out and 100% of the positive STI diagnoses were in this age group. The table below summaries the number of patients in each category.

Graph 3: < 25 Year Olds Sexual Heath Screen

Cervical Cytology

Of the 201 women attending 60% (128/201) were up to date with their cervical cytology.A total of 12% (25/201) were not invited for routine screening on the premises of age and one patient not being sexually active. It was noted that 14% (20/201) of females were due their screening test and 4% (8/201) had never had a cervical smear test performed. Some of these women were significantly overdue with their cervical cytology with 1 female being 19 years overdue and a further 3 being overdue by at least 8 years.

Graph 4: Smear Test Attendance

Weight Management Referral and Preconceptional Care

Less than 1%(2/209)of patients attending were offered a direct weight management referral to Glasgow and Clyde Weight Management Service (GCWMS). Additional referrals included3 dietician referrals and 1 general practitioner referral which brought the total percentage of referrals to 3% (6/209). From these referrals the patient acceptancerate was 100%. In 77% (160/209) of cases there were no referral or discussion about weight management documented in the patient’s clinical notes including the females whom were planning pregnancy.

Discussion

Studies have shown that obese women are more likely to use less reliable methods of contraception.There is no comparison to healthy weight individuals in this study a comparison cannot be made. However, figures show that a significant portion of the study population were using less reliable methods of contraception such as progesterone only pill (POP), condoms and some females using no contraception. A comparison to healthy weight females using the same service was not performed due to time constraints.

There were also a substantial number of females changing from LARC to less reliable methods of contraception. This could lead to increased number of unplanned pregnancies which could have an impact on the patient emotionally and pose a major challenge for reproductive health with regards to the associated mortality and morbidity risk of obesity in pregnancy.

Studies have provided evidence that there is a high rate of unintended pregnancies in obese females, most likely due to their reliance on less effective contraceptive methods.Surprisingly nearly 10% of females were using Depo-Provera as their contraception in this audit population. This is the only contraceptive method with known evidence to increase weight in some women.This may not be the best method of contraception for women who are already obese as a further increase in weight gain could have a significant effect on their health with increased rates of cardiovascular and cerebrovascular disease. Nevertheless, this method may be the only one that suits them best for various reasons such as being an unreliable “pill taker”or in an aim to achieve amenorrhoea.

The number of females withdrawing from contraception as they are planning pregnancy without adequate preconceptional advice is concerning. Statistics show that more than half of maternal deaths are in obese females.3Obese women should be advised about the risk of obesity with pregnancy and childbirth and they should be supported on how to lose weight before pregnancy to reduce the risk of associated morbidities and mortality. These women also have to be advised before pregnancy regarding the increased risk of foetal neural tube defects. There is evidence to suggest that women with a BMI>30 kg/m2 should have 5 milligrams of folic acid daily compared with 400 microgram for females with a normal BMI, to prevent neural tube defects.5Suggested weight loss, folic acid supplements or the associated risks in pregnancywere not documented as being discussed with the 7 females planning pregnancy. Additionally, the need for vitamin D replacement therapy should be discussed.

Evidence has shown that STIs are most common in the under 25 year old age group.Young people account for a minority of Scotland’s population, but account for the majority of STI diagnoses. In the Glasgow Sandyford obese study population 100% of STI diagnoses were in the under 25 age group. It is extremely important that all under 25 year olds should be offered SHS when attending the Sandyford services to help prevent spread of infection and prevent the associated health and fertility problems caused by pelvic inflammatory disease due to long standing chlamydia and gonorrhoea infections.

With regards to cervical cytology attendance, in the 4% that had never attended for a cervical smear test embarrassment may be the main issue. Studies have shown that one of the main reasons for cervical cytology non-attendance is emotional issues such as embarrassment. It is thought that obese females are more likely to feel embarrassed about their body and less likely to attend such an intimate procedure.It is important for all women to attend as the screening programme has proved to be very effective in detecting cervical pre-cancerous changes. Cervical screening can prevent up to 80% of cervical cancer cases in women who attend regularly and have appropriate follow up.4 It is even more important that obese females attend as they have higher mortality rates for cervical cancer.4 This highlights the need for greater awareness in the obese population and the importance of regular cervical cytology screening.

Reviewing the patients past medical history it was evident that PCOS was a common occurrence.PCOS has a complex and multifactorial aetiology.The exact aetiology is uncertain but there is strong genetic evidence (around 50% inheritance risk mother to daughter). There is also evidence to suggest that adipose tissue has a significant role in the expressionand maintenance of PCOS phenotype.

PCOS is one of the leading endocrine conditions in females. It is estimated thatapproximately 50% of women with PCOS are overweight.There were 11 (5%) females with a BMI >35kg/m2 attending Sandyford in the 3 month period with a confirmed diagnosis of PCOS. The prevalence in obese patients in the Glasgow Sandyford population is not as high as some studies findings, however there are potentially many more PCOS cases in the other 190 women that are currently undiagnosed as not all women attending were screened for PCOS.

Conclusion

Analysing contraception use in the study itshowed high percentages of obese females were using POP and condoms rather than LARC methods which are more effective as they eliminate user reliability issues.This is alarming due to the associated mortality and morbidity risks of obesity in pregnancy.

The number of weight management referrals was highlighted to be an issue with only 1% of the obese study population being offered a referral and none of the 7 females planning a pregnancy received adequate preconceptional advice.

With the obesity epidemic becoming more of a problem its effects on health and wellbeing follow. Trying to interpret the relationship between obesity and sexual health is important to help identify areas where obesity is linked to poor sexual outcomes. This will then allow these areas to be targeted better, preventing unintended pregnancies, careful planning of pregnancies, STIs and cervical cancers.

Limitations

Currently weight is not routinely documented in all patients attending the service therefore this study population isn’t a true representation of all obese patients attending Sandyford.

It would have been useful to have a comparison population of normal (healthy) BMI patients attending in the same time period to allow conclusions to be drawn about contraception method, STI and cervical cytology attendance.

Total Word Count = 1,990

References

1)WHO – Overweight and Obesity; ; Updated May 2012; Accessed 13/09/12

2)WHO - BMI Classification; ; Updated 13/09/12; Accessed 13/09/12

3)Yu CKU et al; Obesity in pregnancy; British Journal of Obstetrics and Gynaecology; 2006; 113: 1117–25

4)Cervical cancer - UK mortality statistics; Accessed 14/09/12; Updated 04/05/10

5)The Impact of Obesity on PCOS and Reproductive Health; ; Updated 05/12/09; Accessed 19/09/12

Acknowledgements

I would like to thank my supervisor Dr Guttinger for all her advice and support throughout this audit project.

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