Spotlight on … obesity

Obesity is a problem of enormous proportions in the UK and worldwide. Projections by the World Health Organization and UK-based research predict that 74% of men and 64% of women in the UK will be overweight by 2030.1 Obesity has significant and far-reaching implications on gynaecological health at all stages of a woman's life cycle – from the early pubertal years to the reproductive and post-reproductive years. The Royal College of Obstetricians & Gynaecologists recently proposed the ‘Women's Health Strategy’, which involves a paradigm shift away from the focus being on treatment to that of prevention, hence a spotlight on obesity and its impact on gynaecological health is timely. The Women's Health Strategy is built around focusing on key waypoints in a woman's life and using these interactions as an opportunity to ensure long-term health and wellbeing, with the final aim of achieving an overall improvement in the health of women. In the last 15 years, The Obstetrician & Gynaecologist (TOG) has published several review articles covering obesity and its effects on gynaecological health throughout various points in a woman's life cycle. The age of menarche is determined by various factors, one of which is nutrition. The USA has seen a decrease in the mean age of menarche at a rate of 4 months per decade over the last 100 years, and this has been attributed to changes in nutritional status over time. Hickey and Lester (TOG 2003;5:136–41) explored this in their article looking at the relationship between body weight and the onset of menarche. Benign gynaecological conditions such as endometrial polyps and fibroids are more commonly seen in obese women, possibly secondary to the effects of excess estrogen. As such, obese women may more frequently require treatment for these benign conditions. Biswas and Hogston (TOG 2011;13:87–91) examined the surgical risks from obesity in gynaecology in terms of the pre-, intra- and post-operative issues, discussed tips for tackling these issues and suggested alternative treatment options for this high-risk group of patients. Contraception is another important aspect of gynaecological health that may be affected by obesity. Gupta (TOG 2006;8:26–31) examined the impact of obesity on the efficacy of hormonal contraceptives and discussed studies looking at whether there was a causal relationship between hormonal contraception and weight gain. Obesity is associated with subfertility and also affects success rates of fertility treatments. Several causative mechanisms for the association between obesity and infertility have been suggested. One mechanism involving the role of leptin in the regulation of the reproductive axis was discussed by Sam and Shillo (TOG 2010;12:231–236). Khairy and Rajkhowa (TOG 2017;19:47–54) also explored a similar mechanism relating to gut and adipose tissue hormones, as well as another postulated mechanism involving immune cells in adipocytes inciting a systemic inflammatory response that then leads to a negative impact on fertility rates. The latter article also included a literature review of the effect obesity has on assisted reproductive treatment (ART) outcomes and suggested potential interventions for obese women prior to ART to optimise their success rates. Ethical issues relating to the cost-effectiveness of ART in obese women and withholding ART from obese women were also explored in this article. The impact of obesity on obstetric outcomes and obstetric practice was presented by Stewart et al. (TOG 2009;11:25–31), with a wide range of topics discussed. These include the impact of obesity in the antenatal period, such as the increased incidence of miscarriage, congenital malformations and metabolic complications such as gestational diabetes mellitus and pre-eclampsia; the increased risk of intrapartum and postpartum complications in obese women; and the short- and long-term implications on the fetus of an obese mother. The article also summarised a list of recommendations for clinical management prior to and during pregnancy for obese women. Khan et al. (TOG 2013;15:37–43) looked at the more specific topic of pregnancy outcome following bariatric surgery – a procedure which has seen an exponential increase among morbidly obese women of childbearing age, especially after publication of the National Institute for Health and Care Excellence (NICE) guidelines recommending bariatric surgery as an option in morbidly obese women when lifestyle and/or medications have been ineffective. Issues surrounding potential complications specific to the different types of bariatric surgery were discussed, and recommendations for the management of the pre-conception, antenatal, intrapartum and postpartum period were also provided. The perimenopausal period is associated with a rapid increase in fat mass, with redistribution from subcutaneous to visceral sites. Early postmenopausal women have an increased intra-abdominal adiposity and total fat mass compared with premenopausal women, and this has been shown to be associated with an increased risk of metabolic diseases such as cardiovascular disease and type 2 diabetes mellitus. Lumsden and Hor (TOG 2015;17:201–8) looked at the impact of obesity on perimenopausal and menopausal women and examined the effects of obesity on hormonal profile, menstrual irregularities and menopausal symptoms. The incidence of pelvic floor disorders increases with the incidence of obesity. Jain and Parsons (TOG 2011;13:133–142) reviewed the literature on the role of obesity in the causation of pelvic floor damage, discussing the increased incidence of urinary incontinence, overactive bladder syndrome and pelvic organ prolapse in obese women. They also explored the impact obesity had on the outcomes of urogynaecological surgeries. Obesity is associated with an increased risk of endometrial and breast cancer. This is possibly caused by the raised estrogen levels in obese women from peripheral aromatisation of androgens and reduced hepatic synthesis of sex hormone-binding globulin levels due to high circulating insulin from underlying insulin resistance. Lumsden and Hor (TOG 2015;17:201–8), as well as examining the above-mentioned impact of obesity on post-reproductive health, also discussed the association between obesity and the above two cancers. An online collection of all TOG articles on obesity and gynaecological health is available at http://onlinetog.org.