Journal of Medical Research and Health Sciences

DOI: https://doi.org/10.52845/JMRHS/2022-5-4-2

JMRHS 5 (4), 1866−1875 (2022) ISSN (O) 2589-9031 | (P) 2589-9023

Research Article Open Access Journal

Impact of Briatric Surgery on The Sexual Health of the Morbid Obese

Roberto Eduardo Guerra Estrada1*, Guillermo David Barros Bohorquez2, Rosa
Angélica Osorio Burgos3, Matheus Jannuzzi Moreira de Mendonça4, Cindy Margoth
Mera Sabando5, Ana Julia Mera Sabando6, José Daniel Sierra Reyes7, Omar Avendaño
Solano8
Correspondence: Roberto Eduardo Guerra Estrada,MD. Radiologist, Universidad de Mariano Galvez
de Guatemala
1
MD. Radiologist, Universidad de Abstract: Morbid obesity is a multifactorial chronic disease associated
Mariano Galvez de Guatemala with important physical and psychological complications that contribute
2
Internist, Universidad Metropolita
na, Barranquilla
to reducing life expectancy and worsening its quality. Within its great
3
General Physician, Universidad del complexity, it can be a risk factor for sexual dysfunction (DS) in both
Sinú, Montería genders, since it leads to states of secondary hypogonadism in men and
4
Student of Medicine, Pontifícia hyperandrogenism in women, in such a way that it alters both normal and
Universidade Católica de Minas reproductive sexual activity. One of the most effective tools in the
Gerais, Brasil
5
General Physician, Universidad
treatment of obesity is Bariatric Surgery (BC) due to the loss of weight
Técnica de Manabí, Ecuador that is obtained, therefore, it is expected to have a favorable impact on
6
General Physician, Universidad sexual dysfunction.
Técnica de Manabí, Ecuador Keywords: sexual response, bariatric surgery, morbid obesity, post-
7
General Physician, Fundación surgical bariatric surgery.
Universitaria Juan N Corpas, Bogotá
8
General Physician, Corporación Copyright : © 2021 The Authors. Published by Medical Editor and Educational
Universitaria Remington, Colombia Research Publishers Ltd. This is an open access article under the CC BY-NC-
ND license (https://creativecommons.org/lic enses/by-nc-nd/4.0/).

Introduction and mortality. In adolescents (ages 10-19 years)

the global prevalence ranges between 6.9% and

O
besity is a chronic metabolic disease of
17.4%, showing an exponential trend in the same
multifactorial origin defined as excess
way. (4-5)
weight due to the accumulation of body
fat. Its prevalence has increased exponentially in Therefore, obesity is one of the most challenging
recent years, becoming a major public health problems and triggers of harmful psychological,
problem. The prevalence of Morbid Obesity (OM) metabolic, physical and social effects, as occurs
represents a public health problem, it is estimated with the alterations produced in the sexual
that up to 1.6 billion people in the world are response of the individual with OM, which is
overweight and 400 million are obese, with the composed of an important factor psychological.
consequent increase in cardiovascular morbidity (5)

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 Impact of Briatric Surgery on The Sexual Health of the Morbid Obese

Sexuality constitutes a basic function of the According to the World Health Organization,
human being that involves physiological, obesity is a chronic disease, characterized by
emotional and cognitive factors, and that is closely increased body fat, associated with a greater risk
related to the state of health and quality of life. (6) to health; This is classified based on the Body
Similarly, the potential impact that various Mass Index (BMI), which corresponds to the
medical problems can have on sexual health is relationship between weight expressed in
undeniable, as well as the determining role of kilograms and the square of height, expressed in
some psychological processes that can affect meters. In this way, people whose BMI
sexual functioning and the development of calculation is equal to or greater than 30 kg / m2
different sexual dysfunctions (7). ) are considered obese (10).
Bariatric Surgery (BC) is considered the most For Master and Johnson, the physiological sexual
effective treatment for patients with morbid response consists of four phases: Arousal,
obesity, since with it a weight loss that can exceed PLATEAU, ORGASM and RESOLUTION which
30% is obtained and is maintained in the long Kaplan and Leif modified to include the concept
term. (5) It is essential to note that the role of the of DESIRE, which reflect the psychological,
BC goes beyond the aforementioned weight loss. emotional and cognitive components of the sexual
In this sense, an improvement or remission of the response. At a certain moment, this physiological
different comorbidities after surgery has also been response can be altered in some of its phases,
shown. (6) All these beneficial effects of BC lead becoming states of sexual disease that are
to a decrease in mortality of almost 30% at 10 gathered under the name of sexual dysfunction. (8,
years, possibly due to a decrease in cardiovascular 9)
risk. (5) Currently, the studies that directly relate body
Materials and methods: weight and sexual functioning are minimal and the
vast majority only mention the male sexual
Scope: Descriptive. To survey the necessary
response as the central axis, necessary for study,
information used in this research project, an
due to the large number of male patients with
exhaustive search of historical data was carried
morbid obesity associated with erectile
out on the dates corresponding to the months of
dysfunction or responses ineffective, pleasurable
August, September and October of this year 2020,
or complete sexual activities, which degrades
which frame the results according to the
sexual life as a couple and alters psychological
experiments and investigations that were
steps in the patient. However, the improvement in
developed in different investigations. For the
sexual desire in the male population stands out
construction of this article, the following inclusion
with respect to the other domains of sexual
criteria were used: Articles that are related to the
response, being much more effective in gastric
topic to be developed in this review, articles
bypass. (7, 23)
published between the period 2002 to 2022,
review-type articles, originals and meta-analyzes, The rest of the studies focused on the female
articles found in the PUBMED, SCIELO and sexual response show more satisfactory results.
OVID databases, articles that had content written compared to men. This is basically due to the fact
in Spanish or English and the implementation of that the correction of excess weight in women has
logical operators "AND" and "OR" to establish a a favorable impact on a complete, full sexual
relationship for each term. Articles that were not function and does not alter psychological steps.
relevant within the subject or had no relation to That is, in women a less aggressive situation is
the subject provided, articles that were not contemplated and in them the treatment shows
released or that did not have free access, articles more effective results (24).
whose content was written in languages other than It is even interesting to note that some authors
English and Spanish, and articles that have been have found that in women improvements are
published less than 2002. Of the total articles obtained in all components of the sexual response,
found, 42 were analyzed that collect valuable while in men, improvements are only evidenced in
information and were used in this research article. the perception of sexual attractiveness
Results: (psychological component). That is, while in

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 Impact of Briatric Surgery on The Sexual Health of the Morbid Obese

women the improvement is usually complete, in dysfunction as "the various ways in which the
men there are only improvements in psychological individual is unable to engage in relational sexual
aspects (22). activity as he or she would like". This must be
seen from a bio-psychosocial sphere, which
Although it is true that there are many studies that
directly and indirectly impacts obesity in a
speak of the relationship between obesity and a
different way in each of its phases, finally
poor sexual response, metabolic pathways that are
reflected in what is known as sexual dysfunction,
altered and that have an impact on the sexual
whether male or female. (8)
gonads have not yet been confirmed, but it is
confirmed that a large part of This sexual In the obese male, states of excess visceral fat
deficiency is accompanied by a psychological become an important risk factor for the
component that improves after bariatric surgery or development of male hypogonadism, which, in
some other treatment behavior (23). this case, receives the specific name of MALE
OBESITY SECONDARY HYPOGONADISM
According to some authors, a relatively large
(MOSH). MOSH is reflected in testosterone
percentage of severely obese / morbid patients
deficiency, erectile dysfunction, and changes in
present problems of sexual satisfaction before
sperm and semen; that is, a state of sexual
surgery that improve significantly after 12 months
dysfunction occurs. (14) Testosterone deficiency
of follow-up, especially women. (twenty-one)
causes difficulties in achieving and maintaining an
Several studies have shown that Bariatric Surgery erection, the so-called erectile dysfunction, which,
produces improvement in the sexual sphere. in addition, can be aggravated in obese patients in
Specifically in men, they found improvement in the presence of other important comorbidities such
all spheres of sexuality, as well as in weight loss. as cardiovascular dysfunction and type 2 diabetes
In women, most studies have shown mellitus. (15,16 ).
improvements in sexuality in all domains. Only
The definition of female sexual dysfunction (FSD)
one study found no changes in desire and
includes persistent or recurrent disorders of sexual
lubrication at 6 months after surgery and another
interest / desire, subjective and genital arousal
found no difference between preoperative and
disorders, orgasmic disorders, and pain and
postoperative measures (21)
difficulty with attempted or incomplete
Discussion: intercourse. (17)
Morbid Obesity is a metabolic disease of complex In women, obesity leads to a state of
pathogenesis and in part not very well known, hyperandrogenemia, which is frequently translated
which develops from the interaction of the as anovulatory infertility. This association
predisposing genotype and the environment, and becomes more apparent with increasing BMI.
which includes environmental factors conditioning Similarly, the obesity-polycystic ovary syndrome
intake and energy expenditure, which determine association and the cause-effect relationship of
the onset, development and magnitude of obesity. obesity with the decrease in lividity are well
(12) known. (19) In addition, for women, physical
Obesity can be a risk factor for sexual dysfunction appearance translates into a subjective and
in both genders and there is a strong association intersubjective assessment of herself.
between obesity and erectile dysfunction (ED). The sexual response in women has some
However, the influence of obesity on sexual variations; The most important of them is that it is
function is not clear. Men with a BMI greater than not a purely linear but circular process according
28.7 Kg / m2 have a 30% increase in the risk of to Basson's model, based on the fact that the
Erectile Dysfunction compared to those with a sexual response of women is not always uniform
normal BMI. (13) and linear, but rather that it poses sequential
Sexuality is a dimension of the personality that stages (Table 1) that can be seen altered in obese
encompasses the physiological and psychological patients for the reasons described above, thus
processes inherent to sexual development and the giving rise to the most frequent types of sexual
sexual responses of the individual, both in men dysfunction in these types of patients (4, 9)
and in women. (1) The WHO defines sexual

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 Impact of Briatric Surgery on The Sexual Health of the Morbid Obese

Table 1: Female Sexual Dysfunction

FEMALE SEXUAL DYSFUNCTION

DYSFUNCTION DESCRIPTION
Female organic It is defined as the persistent absence of orgasm after an adequate
disorder arousal phase.

Sexual Interest Hypoactive sexual desire or inhibited sexual desire: lack of interest in
Disorder / Female sexual activity.
Arousal
Arousal disorders: persistent or recurrent inability to obtain and
maintain the lubrication and tumescence typical of the arousal phase
until the end of the sexual act.

Persistent sexual arousal disorder: it is a rare condition, and consists

of intrusive, spontaneous and unwanted genital arousal in the absence
of sexual interest and desire.

Genito-pelvic pain Dyspareunia: is the appearance of recurrent genital pain associated

disorder on with sexual intercourse and that also produces interpersonal
penetration discomfort.

Vaginismus: It is the involuntary, recurrent spasm of the outer third

of the vagina that interferes with sexual activity and causes
interpersonal discomfort.
Ramirez Durán G, Barriento García M. Sexual and reproductive health. 1st ed. Vol. 31,
Cuban Journal of Nursing. UNIVERSITY OF ALMERIA; 2015. (34)
Sources X. Human Sexuality and Sexual Dysfunctions Human Sexuality and Sexual
Dysfunctions. Rev Chil Urol. 2016 [cited 2020 Sep 10]; 81: 39-41. (18)

Male Sexual Dysfunction: would lead to suppression of hypothalamic

gonadotropin-releasing hormone and pituitary
The frequency of sexual disorders in men in
gonadotropin secretion. This would result in a
adulthood is estimated at 20-30% and shows a
reduction of testosterone secretion by Leydig cells
tendency to increase with age. (18) One of the
and of spermatogenesis in the seminiferous
mechanisms involved in the presentation of sexual
tubules (8,9). Additionally, there is a strong
dysfunction in obese patients is the increase in the
correlation between free testosterone levels and
Aromatase activity due to increased adipose
the degree of relaxation of the trabecular smooth
tissue, leading to increased conversion of
muscle during erection (Table 2). (17)
testosterone to estradiol, and increased estradiol
Table 2: Male Sexual Dysfunction

MALE SEXUAL DYSFUNCTION

DYSFUNCTION DESCRIPTION

Erectile It is the persistent inability to obtain or maintain a proper erection

dysfunction

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 Impact of Briatric Surgery on The Sexual Health of the Morbid Obese

Premature Ejaculation that always occurs before or during the first minute of
ejaculation vaginal penetration causing negative personal consequences such as
distress, frustration and / or avoidance of sexual intimacy.

Male orgasmic It includes two clinical pictures:

dysfunction - Anejaculation
- Delayed ejaculation

Hypoactive Permanent and persistent absence of erotic fantasies and motivation to

sexual desire access sexual relations.
disorder
Ramirez Durán G, Barriento García M. Sexual and reproductive health [Internet]. 1st ed.
Vol. 31, Cuban Journal of Nursing. UNIVERSITY OF ALMERÍA; 2015. (34)
Sources X. Human Sexuality and Sexual Dysfunctions Human Sexuality and Sexual
Dysfunctions. Rev Chil Urol. 2016 [cited 2020 Sep 10]; 81: 39-41. (18)
Regarding gender differences, as in sexual
Sexual Dysfunction in Morbid Obesity
functioning, it has been found that couple
Taking into account that obesity is both a physical relationships are more affected in the case of
disorder (accompanied by different comorbidities obese women than in that of men. Obese women
and hormonal alterations), as well as a have more problems having a sexual partner than
psychological one, the sexual life of patients who
present it can be significantly altered (7, 21). normal-weight women. Within the general health
report higher rates of sexual dysfunction among of the individual, sexuality is a key element for
people who are in poor physical and emotional physical and mental well-being. The treatment of
health. Several studies also suggest an inverse obesity can have very positive effects on a
relationship between BMI and sexual function. In woman's sexual health, since it can improve
particular, obesity and / or various obesity-related certain sexual dysfunctions and certain aspects
comorbidities can affect sexual function and related to contraception, pregnancy, fertility and
quality of sexual life. (22) menopause. (24)
To assess ED in man, some indices are available. This weight loss is achieved through nutritional
The most widely used worldwide is the measures and physical activity planned in the first
International Index of Erectile Dysfunction (IIEF). instance, however, the group of patients with
This modelIt has been known since 1996-1997 morbid obesity will usually require some type of
and is an adjunct to the drug use clinical trial surgical intervention (Bariatric Surgery) to
program. It is currently available in more than 32 achieve the goal of losing weight. desired weight
languages around the world. The IIEF stands as (28)
the "gold standard" in treatment outcomes for It is of interest for public and clinical health to try
clinical trials in ED. to understand how sexual satisfaction evolves in
Another frequently used tool is the Brief Sexual obese patients after BC. However, to date, it is
Function Inventory (BSFI, for its acronym in unknown how BC influences the degree of sexual
English; O'Leary et al., 1995), that It is a brief satisfaction of patients with severe / morbid
self-report that allows evaluating the sexual obesity. (twenty-one)
functioning of the man in the last 30 days. It has It is established, yes, that BC for weight loss
been validated in various countries, including improves hypogonadism secondary to obesity in
Spain (26). men, and hyperandrogenemia in women, with the
Results of Bariatic Surgery in the Sexuality of consequent improvement of the individual's sexual
the Morbid Obese According to Their Gender: activity. What remains in conflict is the evidence
that these surgeries may have some positive effect
on fertility. (31) SEE ANNEX 5

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 Impact of Briatric Surgery on The Sexual Health of the Morbid Obese

In fact, BC, whatever it may be, causes an contribute to male hypogonadism and
immediate and sustained reduction in BMI, much hyperandrogenemia. female, with which favorable
more than medical therapy, which leads to an effects are achieved on the erectile function of
improvement in pathophysiological alterations men and sexual satisfaction of women (31)
(hormonal and metabolic profile) that cause or
Table 3: Results in Women

Table 4: Results in Men

Studies: Brazil 3, European countries 6,

USA 2, China 1
Conclusions
Currently obesity has had a progressive increase women more than men due to the influence of
throughout the world, being considered a public weight on their self-esteem.
health problem; therefore, adequate management Sexual dysfunction occurs with a higher
must be had to improve people's quality of life. prevalence in women than in men because in them
Bariatric surgery is considered the most effective there is a greater influence of weight on their self-
long-term treatment for people with morbid esteem. Bariatric Surgery improves sexual
obesity, since a weight loss of 30% or more is function in obese patients, but its scope remains
obtained, consequently obtaining improvement in unknown. Patients undergoing Bariatric Surgery
the different comorbidities, and also a sample of show significant changes in their sexual function,
large significant changes in the sexual function of
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 Impact of Briatric Surgery on The Sexual Health of the Morbid Obese

being more evident in women than in men. The are very few or almost null in relation to obtaining
most noticeable changes in women are expressed orgasm, while in men the recovery of the erection
in an improvement in total sexual satisfaction, and in all its components stands out more.
Annex 5 Effects of Bariatric Surgery

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 Impact of Briatric Surgery on The Sexual Health of the Morbid Obese

Levels of evidence based on the Oxford Center for 7. Pomares-Callejón MA, Ferrer-Márquez M,
Evidence Based Medicine criteria Solvas-Salmerón MJ. Changes in the sexual
health of obese patients after bariatric surgery.
OCN, osteocalcin; SHBG, serum hormone binding
Cir and Cir. English Ed. 2018
globulin; IIEF, International Index of Erectile
8. Lopez, A. San Martin, C. Sexuality in obese
Function; HDL, high-density lipoprotein; CRP, C-
women
reactive protein; FSH, follicle stimulating
9. Kingsberg, S. Woordard, T. Female Sexual
hormone. Taken from: Di Vincenzo A, Busetto L,
Dysfunction With Focus on Decreased Desire.
Vettor R, Rossato M. Obesity, malereproductive
Clinical specialty series. (Obstet Gynecol
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2015; 125: 477-86)
(2018).
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52845/JMRHS/2022-5-4-2

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