Ob-Gyns Address Ethical Issues in Caring for Women Affected by Obesity

New Guidelines Emphasize Medical Implications of Living With Obesity

May 21, 2014

Washington, DC — Given the changing demographics of weight and the increasing rate of obesity in the United States, ob-gyns must be prepared to care for patients who are obese in an ethical, nonjudgmental manner while being cognizant of the medical and social implications of obesity, according to new guidelines from the American College of Obstetricians and Gynecologists (the College). The recommendations on “Ethical Issues in the Care of the Obese Woman” are presented in a Committee Opinion released today by the College.

Ethical Issues in the Care of the Obese WomanThe prevalence of obesity has skyrocketed over the past several decades. At present, all 50 states and the District of Columbia have an obesity rate of more than 20%, and more than a dozen states have an obesity rate of greater than 30%. With approximately 36% of adult women in the United States affected by obesity, physicians have been faced with the challenges inherent in caring for these patients.

Ob-gyns play an integral role in making recommendations to promote behavioral change for women who are obese or at risk of obesity. “As physicians, we must serve as advocates for our patients who are affected by obesity, while providing them with the resources necessary to deliver the  best possible care,” said Sigal Klipstein, MD, chair of the College’s Committee on Ethics, which developed the Committee Opinion. “We must be prepared to meet these challenges with compassion and to respect each patient’s autonomy.”

One way to reduce bias is to classify obesity as a medical condition, says the Committee Opinion. The Opinion also recommends that a focus on the specific medical, cultural, and social issues of the obese woman be incorporated into physician education at all levels to assist ob-gyns in appropriately caring for their patients.

Other conclusions presented in the Committee Opinion include the following:

  • Physician recommendations for a patient’s weight-loss plan should be based on medical considerations.
  • By recognizing that weight loss entails more than simply counseling a woman to eat less and exercise more, and by  learning about the particular causes of a patient’s obesity, ob-gyns and other health care professionals can more effectively counsel and care for their patients.
  • It is unethical for physicians to refuse to accept a patient or decline to continue care that is within their scope of practice solely because the patient is obese.

“It is our responsibility as ob-gyns to recognize the medical risks associated with obesity and to counsel patients affected by obesity in an unbiased manner, while avoiding blame and maintaining their dignity,” said Dr. Klipstein.  “We must recognize and remember that obesity is a medical condition, much like hypertension. This will allow us as physicians to objectively counsel and care for our patients in the manner that they deserve.”

Committee Opinion #600, “Ethical Issues in the Care of the Obese Woman,” is published in the June issue of Obstetrics & Gynecology.

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Other recommendations issued in the June Obstetrics & Gynecology:

Committee Opinion #601 "Tamoxifen and Uterine Cancer" (Revised)

ABSTRACT: Tamoxifen, a nonsteroidal antiestrogen agent, is widely used as adjunctive therapy for women with breast cancer, and it has been approved by the U.S. Food and Drug Administration for adjuvant treatment of breast cancer, treatment of metastatic breast cancer, and reduction in breast cancer incidence in high-risk women. Tamoxifen use may be extended to 10 years based on new data demonstrating additional benefit. Women taking tamoxifen should be informed about the risks of endometrial proliferation, endometrial hyperplasia, endometrial cancer, and uterine sarcomas, and any abnormal vaginal bleeding, bloody vaginal discharge, staining, or spotting should be investigated. Postmenopausal women taking tamoxifen should be closely monitored for symptoms of endometrial hyperplasia or cancer. Premenopausal women treated with tamoxifen have no known increased risk of uterine cancer and require no additional monitoring beyond routine gynecologic care. Unless the patient has been identified to be at high risk of endometrial cancer, routine endometrial surveillance has not proved to be effective in increasing the early detection of endometrial cancer in women using tamoxifen and is not recommended. If atypical endometrial hyperplasia develops, appropriate gynecologic management should be instituted, and the use of tamoxifen should be reassessed.

Committee Opinion #602 "Depot Medroxyprogesterone Acetate and Bone Effects" (Revised)

ABSTRACT: Depot medroxyprogesterone acetate (DMPA) is a highly effective injectable contraceptive that affords privacy and has a convenient dose schedule of four times per year, making it appealing to many users, especially adolescents. Although the use of DMPA is associated with loss of bone mineral density (BMD), current longitudinal and cross-sectional evidence suggests that recovery of BMD occurs after discontinuation of DMPA. No high-quality data answer the important clinical question of whether DMPA affects fracture risk in adolescents or adults later in life. The effect of DMPA on BMD and potential fracture risk should not prevent practitioners from prescribing DMPA or continuing use beyond 2 years. The potential health risks associated with the bone effects of DMPA must be balanced against a woman’s likelihood of pregnancy using other methods or no method, and the known negative health and social consequences associated with unintended pregnancy, particularly among adolescents. Health care providers should inform women and adolescents considering initiating DMPA or continuing to use the method about the benefits and the risks of DMPA and should discuss the U.S. Food and Drug Administration “black box” warning and use clinical judgment to assess appropriateness of use.

Committee Opinion #603 "Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment" (NEW!)

ABSTRACT: Stress urinary incontinence (SUI) is a condition of involuntary loss of urine on effort, physical exertion, sneezing, or coughing that is often bothersome to the patient and frequently affects quality of life. When women are evaluated for SUI, counseling about treatment should begin with conservative options. The minimum evaluation before primary midurethral sling surgery in women with symptoms of SUI includes the following six steps: 1) history, 2) urinalysis, 3) physical examination, 4) demonstration of stress incontinence, 5) assessment of urethral mobility, and 6) measurement of postvoid residual urine volume. For women with uncomplicated SUI in whom conservative treatment has failed and who desire midurethral sling surgery, evidence indicates that the performance of preoperative multichannel urodynamic testing versus a basic evaluation does not affect treatment outcomes. However, women who have complicated SUI may benefit from multichannel urodynamic testing and other diagnostic tests before initiation of treatment, especially surgery. Clinical judgment should guide the health care provider’s decision to perform preoperative multichannel urodynamic testing or to refer to a specialist with appropriate training and experience in female pelvic medicine and reconstructive surgery.

Committee Opinion #604 "OnabotulinumtoxinA and the Bladder" (NEW!)

ABSTRACT: In January 2013, the U.S. Food and Drug Administration approved the use of onabotulinumtoxinA (also known as Botox A) for the treatment of overactive bladder, thus providing another treatment option for women. Symptoms of overactive bladder have been shown to significantly improve after onabotulinumtoxinA injections compared with no intervention, placebo, pharmacological treatments, and bladder instillation technique. Before considering medical or surgical treatment, all patients in whom overactive bladder is diagnosed should receive instruction in behavioral techniques (eg, bladder retraining drills and timed voids), fluid management, or pelvic muscle exercises with or without physical therapy. Intradetrusor onabotulinumtoxinA may be a second-line treatment option for overactive bladder in appropriate patients, and consideration of its use requires shared decision making between the patient and health care provider. Patients who are candidates for onabotulinumtoxinA injections into the bladder should be counseled about its risks and possible postprocedure adverse events, including the risk of postprocedure urinary retention, urinary tract infections, hematuria, pain, and transient body weakness. Health care providers who perform onabotulinumtoxinA injections must have appropriate training and experience in treating women with pelvic floor disorders, operative cystoscopy privileges, and the ability to diagnose and manage any adverse outcomes after onabotulinumtoxinA injections into the bladder.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization.

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