eTable 1. Observed female sexual function index scores and sex hormone levels before and after bariatric surgery
eTable 2. Observed psychosocial measure scores before and after bariatric surgery
Sarwer DB, Spitzer JC, Wadden TA, Mitchell JE, Lancaster K, Courcoulas A, Gourash W, Rosen RC, Christian NJ. Changes in Sexual Functioning and Sex Hormone Levels in Women Following Bariatric Surgery. JAMA Surg. 2014;149(1):26-33. doi:10.1001/jamasurg.2013.5022
Copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
Obesity has been associated with impairments in sexual function and untoward changes in reproductive hormones in women. Relatively few studies have investigated changes in these domains following bariatric surgery.
To investigate changes in sexual functioning, sex hormone levels, and relevant psychosocial constructs in women who underwent bariatric surgery.
Design, Setting, and Participants
A prospective cohort study of 106 women from phase 2 of the Longitudinal Assessment of Bariatric Surgery who underwent bariatric surgery (median [interquartile range] body mass index, 44.5 [41.4-49.7]). Assessments were completed between 2006 and 2012.
Bariatric surgery was performed by a surgeon certified by the Longitudinal Assessment of Bariatric Surgery (85 women underwent a Roux-en-Y gastric bypass, and 21 women underwent laparoscopic adjustable gastric banding).
Main Outcomes and Measures
Sexual functioning was assessed by use of the Female Sexual Function Index. Hormones were assessed by use of a blood assay. Quality of life, body image, depressive symptoms, and marital adjustment were assessed by use of validated questionnaires.
Women lost a mean 32.7% (95% CI, 30.7%-34.7%) of initial body weight at postoperative year 1 and a mean 33.5% (95% CI, 31.5%-35.6%) at postoperative year 2. Two years following surgery, women reported significant improvements in overall sexual functioning and specific domains of sexual functioning: arousal, lubrication, desires, and satisfaction. They also experienced significant changes at 2 years in all hormones of interest. Women reported significant improvements in most domains of quality of life, as well as body image and depressive symptoms, within the first year after surgery, with these improvements being maintained through the second postoperative year.
Conclusions and Relevance
Women who underwent bariatric surgery had significant improvements in overall sexual functioning, in most reproductive hormones of interest, and in psychosocial status. Improvements in sexual health can be added to the list of health benefits associated with bariatric surgery.
clinicaltrials.gov Identifier: NCT00670098
The primary objective of all forms of obesity treatment is to improve morbidity and mortality. However, obesity is also associated with a significant psychosocial burden. Studies repeatedly have found a relationship between obesity and impairments in quality of life, as well as greater depressive symptoms and increased body image dissatisfaction.1- 6 Studies have repeatedly found an association between weight loss and most aspects of quality of life.7- 18
An important aspect of quality of life often overlooked in this research is sexual health. Persons with obesity frequently report untoward changes in sexual functioning and decreased sexual satisfaction.1,7,19- 22 We recently found that 51% of women who presented for bariatric surgery reported sexual dysfunction and that it was accompanied by significant psychosocial distress.20 Studies also have found a relationship between excess body weight and abnormal levels of female reproductive hormones, which also may impact sexual functioning.20,23- 28
Few studies have investigated changes in sexual functioning and sex hormone levels in women who have lost weight. At least 2 studies29,30 have suggested that weight loss following lifestyle modification or bariatric surgery is associated with significant improvements in sexual functioning. Weight loss also has been associated with changes in female reproductive hormones. Two studies have found a significant decrease in free testosterone31 and increases in sex hormone–binding globulin and estradiol25 following a weight loss of approximately 5%. Women who underwent bariatric surgery and lost approximately 40% of their initial weight experienced significant decreases in estradiol, total testosterone, and free testosterone, as well as increases in sex hormone–binding globulin and follicle-stimulating hormone levels.32
The present study was undertaken to examine changes in sexual function, sex hormone levels, and relevant psychosocial variables, including quality of life, body image, depressive symptoms, and relationship satisfaction, in women who underwent bariatric surgery. We hypothesized that participants would experience statistically significant improvements in these domains both 1 and 2 years after bariatric surgery.
Our study used data collected from the Longitudinal Assessment of Bariatric Surgery (LABS) consortium. Details of the LABS study design were provided previously.33- 35 Phase 2 of LABS (LABS-2) is investigating the long-term effects of bariatric surgery on the weight of patients, as well as on their physical and mental health. The present study is considered an ancillary study of LABS-2 because it extends the lines of investigation to more specific questions.
A total of 106 consecutive women undergoing bariatric surgery and participating in the LABS-2 study from 2 of the 10 LABS sites (the Neuropsychiatric Research Institute in Fargo, North Dakota, and the University of Pittsburgh Medical Center in Pittsburgh) were recruited for participation (Figure 1). Data were collected between 2006 and 2012. Participants were assessed prior to surgery and again 1 and 2 years later. Year 2 is the primary point of interest because most patients who have undergone bariatric surgery reach maximum weight loss by this time.36 The trial was approved by the institutional review boards at the Neuropsychiatric Research Institute, the University of Pittsburgh Medical Center, and the University of Pennsylvania in Philadelphia. Written informed consent was received from all participants.
Participants met the inclusion criteria of the LABS-2 study (at least 18 years old and seeking a first bariatric surgical procedure) and also all the medical and mental health criteria for bariatric surgery. Persons who were nonambulatory or had significant or uncontrolled medical or psychiatric conditions were excluded. Participants had to report involvement in a relationship for at least 12 months that provided them with the opportunity for sexual activity with a partner. Participants received a $40 gift card (to a local department or bookstore) following completion of each assessment.
Surgery was performed by a LABS-certified surgeon. Eighty-five women underwent a Roux-en-Y gastric bypass, and 21 women underwent laparoscopic adjustable gastric banding. Both procedures were performed using standing surgical techniques and approaches.
The Female Sexual Function Index (FSFI) is a 19-item questionnaire that assesses 6 domains of sexual functioning: desire (range, 1.2-6); arousal (range, 0-6); lubrication (range, 0-6); orgasm (range, 0-6); satisfaction (range, 0.8-6); and pain (range, 0-6).37 Lower scores indicate poorer function. The subscales can be summed to create a total score (range, 2-36); a total score of 26 or lower in a sexually active woman is indicative of female sexual dysfunction.38
Blood samples (20 mL) were obtained from participants after an overnight fast. Samples were cooled on ice and centrifuged within 15 minutes of collecting. Plasma was removed from the vacutainer 15 minutes after centrifugation, placed into polypropylene tubes, and shipped in bulk to the Clinical Translational Research Center at the University of Pennsylvania for analysis. The levels of estradiol, total testosterone, follicle-stimulating hormone, luteinizing hormone, sex hormone–binding globulin, and dehydroepiandrosterone sulfate (DHEA-S) were assessed. Total testosterone, sex hormone–binding globulin, and DHEA-S assays were analyzed using standard enzyme-linked immuno assay kits (IBL International). Estradiol and luteinizing hormone levels were analyzed by means of chemiluminescent laboratory assays (Roche Elecys Systems). These assays were selected for their reliability and cost efficiency.
The 36-item Short Form Health Survey was used to assess health-related quality of life.39 Eight subscales were used to assess separate domains of health and related functioning. Items on the physical functioning, physical role functioning, pain, and general health subscales can be used to calculate a physical health summary score. Items on the vitality, social functioning, emotional role functioning, and mental health subscales can be used to calculate a mental health summary score. Higher scores indicate a more positive health-related quality of life.
The Impact of Weight on Quality of Life–Lite is a more specific measure of weight-related quality of life.40- 42 The measure contains 31 items, with each beginning with the phrase “because of my weight.” The measure examines 5 domains: work, physical function, public distress, sex life, and self-esteem. Responses are combined to calculate a total score that ranges from 0 to 100; higher scores indicate a better quality of life.
The Body Image Quality of Life Inventory is a 19-item self-report measure of the positive and negative impact of body image on quality of life.43 Respondents’ feelings are assessed with regard to beliefs about the effect of body image on emotional states, same-sex and other-sex relationships, eating and exercise, grooming activities, sexual experiences, family, and work/school. Participants respond to the items using a 7-point scale ranging from −3 (“very negative effect”) to 3 (“very positive effect”); 0 is labeled “no effect.” Higher scores suggest a more positive body image.
The Body Shape Questionnaire is a 34-item self-report questionnaire designed to evaluate dissatisfaction with body shape.44 Each item is rated on a scale of 1 (“never”) to 6 (“always”) based on how the participant has been feeling over the last 4 weeks. Higher scores indicate greater dissatisfaction.
Relationship satisfaction was assessed by use of the Dyadic Adjustment Scale.45 The measure addresses 4 domains that measure the quality of marriage or similar dyads. In addition to a total score, the 4 domains measured are dyadic consensus, dyadic satisfaction, dyadic cohesion, and affectional expression. Higher scores indicate higher levels of satisfaction.
The Beck Depression Inventory–I is a widely used measure of depressive symptoms.46 Scores range from 0 to 63, with higher scores indicating a greater number of symptoms.
Descriptive statistics were used to summarize the baseline characteristics of the study participants. Frequencies and percentages were used for categorical data; median values and interquartile ranges were calculated for continuous data.
An intercept and time point–only normal mixed model with a heterogeneous compound symmetry covariance matrix was used to report the changes in sexual functioning scores, sex hormone levels, psychosocial scores, and weight. For each assessment, pairwise comparisons were made between each combination of the 3 time points; P values and confidence limits were adjusted for the multiple comparison using simulation. The reported modeling values and changes were used to account for missing data at each time point. (The observed mean values and standard deviations of each assessment are reported in the eTables 1 and 2 in Supplement. The observed values were very similar to the modeled values.)
Growth mixture models were used to estimate individual changes in total FSFI score over time and to classify those individuals with similar estimated trajectories into groups. The number of groups was determined by minimizing the Bayesian information criteria. In Figure 2, the modeled trajectories of each group are plotted, with the vertical bars indicating the interquartile range of the observed total FSFI score at each time point for participants within a group.
Analyses were conducted using SAS version 9.2 (SAS Institute Inc) and Mplus version 7 (Muthen & Muthen). All reported P values are 2 sided; P < .05 was considered to be statistically significant.
A total of 147 women initially provided informed consent. Thirty-nine women were found to be ineligible; 28 women were not in a romantic relationship for at least 1 year. Two participants did not subsequently provide any baseline data. Of the 106 consenting and eligible women with baseline data, 102 completed at least 1 follow-up assessment. Eighty-nine participants completed both a year 1 and a year 2 assessment; 9 participants completed only a year 1 assessment, and 4 participants completed only a year 2 assessment (Figure 1). Participants were considered as having data if any of the following were completed: physical measurements, blood samples, or at least 1 self-assessment measure.
Baseline demographic and descriptive characteristics are presented in Table 1. (They also were presented in detail in Sarwer et al.20) Participants had a median body mass index of 44.5 (calculated as weight in kilograms divided by height in meters squared) and a median waist circumference of 126.5 cm. Nearly all patients were white (96%), and more than 75% reported some education beyond high school.
There were 97 participants with weight measurements at year 1 and 93 participants at year 2. Women lost a mean 32.7% (95% CI, 30.7%-34.7%) of initial body weight at year 1 and a mean 33.5% (95% CI, 31.5%-35.6%) at year 2. There was no significant change in percent weight loss from year 1 to year 2.
Participants reported significant improvement from baseline to year 1 for the total FSFI score, as well as for the desire domain score and the satisfaction domain score (Table 2). By the second postoperative year, women also reported statistically significant improvements in arousal and lubrication subscale scores. The orgasm subscale improved over time, but the changes were not statistically significant. There were no significant changes on the FSFI score between year 1 and year 2.
Figure 2 gives the common patterns of change in FSFI total score. Five unique trajectory groups best characterize the data. Group 1 (n = 13; 13.4%) represents those women with the lowest baseline FSFI total scores (reflecting poorest sexual functioning). These women reported dramatic increases in the quality of their sexual functioning within the first year of surgery, similar to that of the women in group 2 (n = 51; 52.6%) who reported high levels of functioning at baseline and showed only modest improvement by postoperative year 1. For both of these groups of women, these improvements were well maintained at postoperative year 2. Women in group 3 (n = 11; 11.3%) reported moderate levels of sexual functioning at baseline, although the mean was below the cutoff of 26 or lower, which suggests the presence of sexual dysfunction. These women reported a decline in sexual functioning at postoperative year 1 but reported improvements in sexual functioning by postoperative year 2. The average woman in group 4 (n = 15, 15.5%) and in group 5 (n = 7, 7.2%) had a sexual dysfunction (FSFI score ≤26) at baseline and had no improvement at follow-up.
Table 2 displays the sex hormone data. At the year 1 assessment, women were observed to have statistically significant improvements in all the hormone levels of interest with the exception of DHEA-S. At postoperative year 2, all hormone levels, including DHEA-S, were significantly improved from baseline. Women experienced significant improvements from year 1 to year 2 in total testosterone and follicle-stimulating hormone levels.
Results of the psychosocial variables of interest are found in Table 3. Women reported statistically significant improvements in both health- and weight-related quality of life at postoperative year 1 and year 2 compared with preoperative levels. They also reported statistically significant improvements in body image and depressive symptoms at both postoperative time points. Women also reported statistically significant improvements in overall relationship satisfaction as measured by use of the Dyadic Adjustment Scale, as well as by use of the Consensus and Affectional Expression subscales, at both postoperative time points.
Our study provides new information on changes in sexual functioning, sex hormone levels, and associated domains of psychosocial functioning following bariatric surgery. Women who underwent bariatric surgery lost, on average, approximately one-third of their initial body weight 2 years after surgery and experienced significant improvements in overall sexual functioning and sexual arousal, lubrication, desires, and satisfaction, as well as several relevant improvements in sex hormone levels. Replicating previous studies, we found that women who underwent surgery experienced significant improvements in health-related quality of life, as well as weight-related quality of life, body image, depressive symptoms, and most domains of romantic relationship satisfaction.
Women reported significant improvements in overall sexual functioning, as well as improvements in sexual desire and satisfaction with their sexual functioning at postoperative year 1 following a weight loss of 32.7%. At postoperative year 2, women had lost slightly more weight (33.5% of their initial body weight) and also reported improvements in arousal and lubrication while maintaining improvements in the other domains. Women who reported the poorest quality of sexual functioning prior to surgery reported dramatic improvements in functioning 1 year after surgery, comparable to those women who reported the highest quality of functioning before surgery. This group of women maintained these improvements through the second postoperative year.
Women also experienced statistically significant improvements in total testosterone, estradiol, follicle-stimulating hormone, luteinizing hormone, and sex hormone–binding globulin levels 1 year after bariatric surgery. Improvements in DHEA-S levels did not reach statistical significance from baseline to postoperative year 1 but did from baseline to postoperative year 2. Total testosterone and estradiol are the female reproductive hormones most commonly associated with sexual behavior, and our observations replicate those from a recent study47 that also found statistically significant reductions in both hormone levels after bariatric surgery. Follicle-stimulating hormone, luteinizing hormone, and sex hormone–binding globulin are most commonly associated with female fertility rather than sexual functioning. The statistically significant improvements in these hormone levels provide indirect evidence of the potential impact of surgically induced weight loss on reproductive status, which, for some women, is a primary motivator for both surgical and nonsurgical weight loss.1
Replicating previous investigations, we found that weight loss was associated with improvements in psychosocial functioning within the first postoperative year. Women who underwent bariatric surgery reported significant improvements in all domains of health- and weight-related quality of life. These observations replicate those of other studies of bariatric surgery patients8,48 but contrast with those of studies of lifestyle modification for weight loss,18 in which patients typically lose less weight and report improvements in the physical domains of quality of life but not in the mental domains. Women who underwent bariatric surgery also reported significant improvements in body image dissatisfaction, depressive symptoms, and several domains of romantic relationship functioning. These improvements occurred within the first postoperative year, when patients lost the largest percentage of their weight, but were well maintained in the second postoperative year, when the rate of weight loss had slowed. These observations suggest that improvements in psychosocial functioning occur as patients are losing weight and prior to reaching their maximum weight loss.10
The present study has several limitations. Our sample of participants was almost exclusively white and had a relatively high level of education. Thus, our ability to comment on the variables of interest in nonwhite women who undergo bariatric surgery is limited. Despite the efforts of our study staff members, as well as the use of honorariums to incentivize the completion of assessments, we still experienced some loss to follow-up, in which participants completed some, but not all, of the study measurements. In addition, in the absence of reliable information on menstrual or menopause status, we are unable to specifically comment on how changes in the sex hormone levels may be associated with menopause status.
In summary, our study provides new information on changes in sexual functioning, reproductive hormone levels, and psychosocial functioning in women in the first 2 years after bariatric surgery. These results suggest that improvements in sexual health may be added to the list of benefits associated with large weight losses seen with bariatric surgery. Future studies should investigate if these changes endure over longer periods of time, and they should investigate changes in sexual functioning in men who undergo bariatric surgery.
Accepted for Publication: October 1, 2013.
Corresponding Author: David B. Sarwer, PhD, Department of Psychiatry, Center for Weight and Eating Disorders, Perelman School of Medicine at the University of Pennsylvania, 3535 Market St, Ste 3120, Philadelphia, PA 19104 (email@example.com).
Published Online: November 4, 2013. doi:10.1001/jamasurg.2013.5022.
Author Contributions: Drs Sarwer and Christian had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Sarwer, Wadden, Rosen.
Acquisition of data: Spitzer, Mitchell, Lancaster, Courcoulas, Gourash.
Analysis and interpretation of data: Sarwer, Mitchell, Rosen, Christian.
Drafting of the manuscript: Sarwer, Spitzer, Rosen, Christian.
Critical revision of the manuscript for important intellectual content: Sarwer, Wadden, Mitchell, Lancaster, Courcoulas, Gourash, Rosen, Christian.
Statistical analysis: Christian.
Obtained funding: Sarwer, Wadden, Mitchell, Rosen.
Administrative, technical, or material support: Sarwer, Spitzer, Courcoulas, Gourash.
Study supervision: Sarwer, Mitchell, Rosen.
Conflict of Interest Disclosures: Dr Sarwer has served as a paid consultant for Allergan, BariMD, BAROnova, EnteroMedics, and Ethicon Endo-Surgery, which are manufacturers of products for nonsurgical weight loss treatment and bariatric surgery. At the time of the conduct of the study, he also was on the board of directors of the Surgical Review Corporation, which created the International Center of Excellence for Bariatric Surgery program to evaluate bariatric surgeons and hospitals around the world. Dr Wadden serves on advisory boards for Novo Nordisk and Orexigen Pharmaceuticals. Dr Courcoulas has received research grants from Allergan, Pfizer, Covidien, EndoGastric Solutions, and Nutrisystem and is on the scientific advisory board of Ethicon J&J Healthcare System. No other disclosures were reported.
Funding/Support: This ancillary study to the LABS-2 was funded by National Institute of Diabetes and Digestive and Kidney Diseases grant R01DK072452.
Role of the Sponsors: The National Institute of Diabetes and Digestive and Kidney Diseases provided funding support for the study. The Program Officers provided input on the design and execution of the study.
Additional Information: This article is to be presented on November 14, 2013, at Obesity Week in Atlanta, Georgia.