Evaluation of the Quality of Life in Women of Reproductive Age After Bariatric Surgery

Abstract

Purpose:

To evaluate the life quality of women of reproductive age in the late postoperative period of bariatric surgery, in addition to analyzing the physical and emotional difficulties related to the sexuality among these patients.

Methods:

A cross-sectional study, carried out in 2018 at Hospital das Clínicas, Federal University of Pernambuco, that analyzed the quality of life through the WHOQOL-Bref instrument, and the sexual experience of 49 women of reproductive age who had undergone bariatric surgery.

Results:

The mean age of the sample was 39.4 years. The mean weight before surgery was 116.8 kg, decreasing to 75.4 kg in the postoperative period. Sleeve gastrectomy was performed in 57.1% of the sample, and Roux-en-Y gastric bypass was performed in the remaining 42.9%. The mean follow-up time was 2.5 years. Infertility, depression, and polycystic ovary syndrome presented a statistically significant reduction in the postoperative period. In relation to the difficulties regarding sexual experience, the whole sample significantly improved after surgery. The great majority of patients positively classified their quality of life.

Conclusion:

Bariatric surgery leads to better quality of life in women of reproductive age, reducing comorbidities and improving their sexual experience in both physical and emotional scopes.

Introduction

According to the World Health Organization (WHO), obesity is considered one of the biggest public health problems in the world, and it is estimated that about 2.3 billion adults will be overweight and over 700 million will be obese by 2025.¹ Over 50% of the population in Brazil is overweight and 20% of adults are obese.²

Conservative treatment based on outpatient follow-up is known to be ineffective in patients who have been severely obese for more than 2 years. Thus, bariatric surgery is considered the most suitable alternative for rapid weight loss, improvement in life expectancy and quality of life, as well as reduction or even remission of comorbidities in these cases.³

Most bariatric procedures are performed on obese women of childbearing age, and at least one in three of these women has menstrual dysfunction.⁴ In this sense, bariatric surgery also improves the factors underlying fertility and pregnancy, generating fewer harmful maternal and neonatal outcomes.⁵

Therefore, it is necessary that the multidisciplinary team is prepared to serve this population more individually, as well as providing women of childbearing age with the necessary reception and support to better conduct the proposed treatment. However, studies evaluating quality of life after bariatric surgery in this population group are still scarce.

The present study aimed to evaluate the quality of life of women of childbearing age in the late postoperative period of bariatric surgery, as well as to analyze the physical and emotional difficulties related to sexual experience in these patients.

Methods

A cross-sectional study conducted at the Clinical Hospital of the Federal University of Pernambuco during 2018, which assessed the quality of life and sexual satisfaction of women of childbearing age after undergoing bariatric surgery.

The sample consisted of 49 female patients aged between 18 and 49 years and BMI between 35 and 50 kg/m², in the late postoperative period (at least 1 year of follow-up) of vertical gastrectomy or Roux-en-Y gastric bypass (RYGB). Any patients who were alcoholics or had another chemical dependence, severe psychotic disorder, or recent history of attempted suicide were excluded from the study.

The study implemented a questionnaire containing socioeconomic and demographic data, the presence or absence of comorbidities, symptoms related to physical and emotional aspects regarding sexual experience, and the WHOQOL-Bref version quality-of-life assessment instrument in Portuguese. Data collected from medical records were taken into account to indicate the presence or remission of the studied comorbidities (infertility, depression, polycystic ovary syndrome [PCOS], and stress urinary incontinence [SUI]).

This study was approved by the Research Ethics Committee of the Federal University of Pernambuco—CAAE: 69256217.4.0000.5208, created by the National Health Council Resolution No. 466/2012, following the principles of the Helsinki Declaration for Human Research.

Statistical procedures for data analysis were applied such as database processing, coding, and organization. Nonparametric tests and estimators were applied to the collected information after preprocessing the information. Descriptive data analysis was applied to each of the variables in which it was possible to observe characteristics such as mean, standard deviation, and minimum and maximum values. Significance and reliability information were presented by the McNemar and alpha Cronbach's test, with a significance level of 95%.

Results

Forty-nine women of childbearing age in the late postoperative period of bariatric surgery were evaluated. The average age of the patients in the sample was 39.4 years, with a predominance (22.4%) of those aged between 32 and 36 years. The mean weight before surgery was 116.8 kg, falling to 75.4 kg postoperatively (p < 0.001).

The most commonly used surgical technique was vertical gastrectomy in 57.1% of cases. RYGB was performed in the other 42.9% of the sample. The average follow-up time was 2.5 years, with the largest portion (32.7%) referring to the 2-year follow-up consultation.

Among the studied comorbidities, it was observed that all presented considerable reduction after surgery, except for SUI, which showed no statistically significant reduction (Table 1).

Table 1.

Analysis of the Studied Comorbidities

Comorbidities	Before (%)	After (%)	p
Infertility	6.1	0.0	—
Depression	20.4	8.2	0.070
PCOS	16.3	2.0	0.016
SUI	6.1	4.1	1.000

PCOS, polycystic ovary syndrome; SUI, stress urinary incontinence.

Regarding difficulties in the physical sphere related to sexual experience, it was evidenced that all evaluated factors showed a statistically significant reduction after bariatric surgery, some even reaching zero postoperative cases, such as fatigue, mobility difficulties, and dyspareunia (Table 2).

Table 2.

Physical Factors Related to Sexuality Before and After Surgery

Factors	Before (%)	After (%)	p
Fatigue	77.6	0.0	0.001
Mobility difficulty	75.5	0.0	0.001
Decreased physical endurance	85.7	4.1	0.001
Dyspareunia	18.4	0.0	0.004
Lack of libido	75.5	6.1	0.001
Discomfort	65.3	2.0	0.001

Regarding the difficulties in the emotional sphere relating to sexual experience, it was observed that all presented a significant reduction after surgery, with p < 0.001 in the analysis of all factors (Table 3).

Table 3.

Emotional Factors Related to Sexuality Before and After Surgery

Factors	Before (%)	After (%)	p
Low self-esteem	67.3	14.3	0.001
Body shame	73.5	26.5	0.001
Fear of not being accepted	57.1	4.1	0.001
Fear of relationships	55.1	4.1	0.001
Fear of failing and not satisfying partner	55.1	2.0	0.001
Shyness	63.3	18.4	0.001
Sadness	53.1	6.1	0.001

Table 4 presents the application of the WHOQOL-Bref questionnaire, including the following domains: general, physical, emotional, social, and environmental. It can be seen that the vast majority of participants positively rated their quality of life.

Table 4.

Quality-of-Life Assessment Using the WHOQOL-Bref Questionnaire

Question	Response	Percentage (%)
How would you rate your quality of life?	2. Bad	4.1
	3. Neutral	10.2
	4. Good	22.4
	5. Very good	63.3
How satisfied are you with your health?	2. Bad	2.0
	3. Neutral	12.2
	4. Good	28.6
	5. Very good	57.1
To what extent do you think your (physical) pain prevents you from doing what you need to do?	1. Very bad	57.1
	2. Bad	4.1
	3. Neutral	22.5
	4. Good	10.2
	5. Very good	6.1
How much do you need any medical treatment to lead your daily life?	1. Very bad	12.2
	2. Bad	28.6
	3. Neutral	30.6
	4. Good	14.3
	5. Very good	14.3
Do you have enough energy for your daily life?	2. Bad	6.1
	3. Neutral	10.2
	4. Good	22.5
	5. Very good	60.2
How well are you able to get around?	3. Neutral	4.0
	4. Good	10.0
	5. Very good	84.0
How satisfied are you with your sleep?	1. Very bad	8.2
	2. Bad	8.2
	3. Neutral	24.5
	4. Good	16.3
	5. Very good	42.8
How satisfied are you with your ability to perform your daily activities?	2. Bad	4.1
	3. Neutral	12.2
	4. Good	20.4
	5. Very good	63.3
How satisfied are you with your ability to work?	2. Bad	4.1
	3. Neutral	8.2
	4. Good	20.4
	5. Very good	67.3
How much do you enjoy life?	1. Very bad	2.0
	2. Bad	2.0
	3. Neutral	14.3
	4. Good	30.6
	5. Very good	51.1
To what extent do you think your life has meaning?	2. Bad	4.1
	3. Neutral	8.2
	4. Good	18.4
	5. Very good	69.3
How much are you able to concentrate?	2. Bad	6.1
	3. Neutral	14.3
	4. Good	36.7
	5. Very good	42.9
Are you able to accept your physical appearance?	1. Very bad	2.0
	2. Bad	4.1
	3. Neutral	12.2
	4. Good	26.5
	5. Very good	55.1
How satisfied are you with yourself?	2. Bad	10.2
	3. Neutral	8.2
	4. Good	24.6
	5. Very good	57.0
How often do you have negative feelings (moodiness, despair, anxiety, depression)?	1. Very bad	6.1
	2. Bad	32.7
	3. Neutral	40.8
	4. Good	16.3
	5. Very good	4.1
How satisfied are you with your personal relationships (friends, relatives, acquaintances, colleagues)?	2. Bad	2.0
	3. Neutral	16.3
	4. Good	36.7
	5. Very good	44.9
How satisfied are you with your sex life?	1. Very bad	12.2
	2. Bad	6.1
	3. Neutral	20.4
	4. Good	14.3
	5. Very good	46.9
How satisfied are you with the support you get from your friends?	1. Very bad	4.1
	3. Neutral	12.2
	4. Good	20.4
	5. Very good	63.3
How confident do you feel about your daily life?	2. Bad	4.1
	3. Neutral	14.3
	4. Good	36.7
	5. Very good	44.9
How healthy is your physical environment (weather, noise, pollution, attractive)?	2. Bad	4.1
	3. Neutral	14.3
	4. Good	36.7
	5. Very good	44.9
Do you have enough money to satisfy your needs?	1. Very bad	4.1
	2. Bad	22.4
	3. Neutral	46.9
	4. Good	18.4
	5. Very good	8.2
How available to you is the information you need in your day to day?	2. Bad	4.1
	3. Neutral	14.0
	4. Good	20.4
	5. Very good	61.2
To what extent do you have opportunities to perform leisure activities?	1. Very bad	2.0
	2. Bad	10.2
	3. Neutral	24.5
	4. Good	20.4
	5. Very good	42.9
How satisfied are you with the conditions of the place where you live?	2. Bad	8.2
	3. Neutral	14.3
	4. Good	20.4
	5. Very good	57.1
How satisfied are you with your access to health services?	1. Very bad	2.0
	2. Bad	8.2
	3. Neutral	32.7
	4. Good	24.5
	5. Very good	32.7
How satisfied are you with your means of transport?	1. Very bad	2.0
	2. Bad	16.3
	3. Neutral	26.5
	4. Good	28.6
	5. Very good	26.5

Discussion

We can observe that a large percentage of the sample was among women who were followed for up to 2 years, a period considered the “honeymoon.” This phase comprises the first 24 months after surgery, during which the person is generally very motivated, faithfully following the nutritionist's guidelines, with little appetite, receiving various compliments about their appearance, and performing physical activity with enthusiasm. However, as time goes on, their appetite increases, their weight stabilizes, and emotional difficulties may return along with old habits.⁶ One study found that there is a loss of progressive follow-up of patients in medical–surgical consultations starting from the second postoperative year.⁷

Sexuality in women is closely linked to subjective aspects related to psychological, cultural, and social conditions, in addition to body perception.⁸ In addition to having negative repercussions for female sexuality, obesity also affects ovulation, which culminates in fertility impairments.⁹ Excess weight alone has a deleterious effect on reproductive status in overweight and obese patients.¹⁰

Although we know that the main mechanism of infertility in obese women is chronic anovulation—which can be solved by using ovulation inducers—physical exercise and the adoption of healthy habits should always be emphasized.¹¹

Regarding the studied comorbidities, there was a decrease in all after surgery, especially PCOS, which had the best level of statistical significance (p-value = 0.016). This finding is corroborated by Machado Júnior et al., who assessed the impact of vertical gastrectomy on the hormonal profile of obese women with PCOS, and found attractive results regarding the remission of the syndrome, showing an inversion in the gonadotropin secretion pattern in the postoperative period.¹²

Thus, when a woman begins to lose weight, the tendency for improvement or even remission in the condition is evidenced. Research analyzing fertility in women after bariatric surgery has shown that weight loss has a beneficial effect on fertility and regularity of menstrual cycles in most studied patients.¹³

All physical and emotional aspects related to sexuality were significantly improved after surgery. In this sense, it is necessary to promote some contraceptive method in the first 12–18 months after surgery, clarifying obstetricians about the high risk of pregnancy in these patients undergoing bariatric surgery.¹⁴

Obese people are more exposed to prejudice and discrimination even among their peers, which can lead to low self-esteem and depression. Another issue is the imposition by the media of a stereotype of beauty that matches a slim and healthy body, increasing the stigma and feeling of social exclusion in the severely obese and negatively influencing the sexual experience of these individuals.¹⁵

Such facts may explain the higher percentages of physical and emotional difficulties in experiencing sexuality before surgery. These difficulties decreased after surgical treatment, with consequent improvement in sexual function. Despite the positive results after the procedure, it was observed that 13 women replied that they still feel “body shame” regarding this question. This finding may be linked to the difficulty of accepting self-image due to the excess skin that many patients have when losing weight.

From the analysis of the data obtained from the quality-of-life test, the WHOQOL-Bref, it was found that the answers to the general questions (“How would you rate your quality of life” and “how satisfied are you with your health?”) were considered good or very good in 85.7% of the total sample. This finding is in agreement with results of another study that, using the BAROS questionnaire, found positive results after bariatric surgery, with 36.17% of their sample referring “excellent” quality of life after this procedure and 40.43% referring it as “very good.”¹⁶

Regarding the facets of the physical domain, the results were positive regarding the patients' quality of life, corroborating the hypothesis that people who suffered from obesity and who underwent surgery for at least 1 year had improved quality of life in this domain. Most patients rated their walking ability as “very good” or “good,” confirming one of the expectations of these patients for increasing their mobility.¹⁷

Still according to the facets of the physical domain and specifically regarding the ability to perform after surgery, it was observed that most were satisfied with their ability to perform daily activities, with 20.4% considered good and 63.3% very good. Thus, regarding the ability to perform activities, it was evidenced that most are satisfied in the postoperative period.

We also obtained positive results regarding the psychological domain. However, for the question of the frequency of negative feelings such as moodiness, despair, anxiety, and depression, it was noted that most responses were neutral (neither good nor bad) or negative (bad or very bad). This finding regarding negative feelings may be a cause for lack of concentration also being very prevalent, among other factors.¹⁸ Silva et al. have observed that patients submitted to bariatric surgery experience improvements in their psychologic status after weight loss.¹⁸

Thus, we understand that the treatment of obesity needs multidisciplinary follow-up, where mental health should be important, guiding the patient in resignifying their new body and even a new life.

Regarding the social domain, we found that most of the interviewees considered their social relationships as good or very good. Such a response pattern reflects a high degree of satisfaction in this area. The improvement in the quality of life in this area reinforces what we find in the literature: that obesity causes harm in social relationships, since the obese face discrimination and prejudice in many ways. The expectations of patients undergoing bariatric surgery include feeling socially included and improving social, family, and work relationships.¹⁷

The limitations of the study are the cross-sectional design, as well as the sample size of 49 women, in which we faced difficulties in capturing these patients in the postoperative follow-up. Such difficulty may have been due to overcoming the “honeymoon,” period as well as social and financial issues to travel to the service.

Conclusion

The quality of life of women of childbearing age assessed by the study after bariatric surgery was considered good or very good by the WHOQOL-Bref score in all studied domains, namely, physical, emotional, social, and environmental. We can conclude that bariatric surgery promotes a good quality of life for women of childbearing age, reducing comorbidities and bringing benefits to sexuality in the physical and emotional spheres.

Moreover, it is important to consider that because the demand for women undergoing bariatric surgery is higher than men, in addition to the fact that most of these women are in the age group that corresponds to the fertile age, a more specific treatment is necessary for this patient group. In this sense, we observed that inserting a gynecologist professional in the follow-up may be indicated for this specific group, so that they can better direct the treatment together with other professionals.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The authors declare no financial support for this research.

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