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This systematic literature review aims to point out sex-specific special features that are important in the bariatric treatment of women suffering from severe obesity. After the literature selection, the following were determined: sexuality and sexual function; contraception; fertility; sex hormones and polycystic ovary syndrome; menopause and osteoporosis; pregnancy and breastfeeding; pelvic floor disorders and urinary incontinence; female-specific cancer; and metabolism, outcome, and quality of life. For each category, the current status of research is illuminated and implications for bariatric treatment are determined.

A summary that includes key messages is given for each subsection.

An overall result of this paper is an understanding that sex-specific risks that follow or result from bariatric surgery should be considered more in aftercare. In order to increase the evidence, further research focusing on sex-specific differences in the outcome of bariatric surgery and promising treatment approaches to female-specific diseases is needed. Nevertheless, bariatric surgery shows good potential in the treatment of sex-specific aspects for severely obese women that goes far beyond mere weight loss and reduction of metabolic risks. The prevalence of obesity has increased in the last decades.

Therefore, the prevalence tripled from This classification is criticized because of the low sensitivity, large interindividual variability in relative body fat, and its attribution to age, sex, and ethnicity. Nevertheless, BMI is the most commonly used instrument in epidemiology and clinical practice due to its simplicity [ 45 ]. Children and adolescents are overweight if their BMI is more than one standard deviation higher than the reference BMI and obese if their BMI deviates by more than two standard deviations.

Depending on the database, rates of overweight are similar in men and women or slightly higher in men.

Obesity occurs more often in women [ 126 ]. Although the main causes, hypercaloric nutrition and physical inactivity, affect both men and women, there are differences in the development and in symptoms and associated comorbidities depending on sex [ 7 ]. Regarding treatment and therapeutic approaches, sex-specific aspects must be taken into consideration, too. Overweight and obesity are major risks for a of diseases and comorbidities, including diabetes mellitus, cardiovascular diseases, cancer, and musculoskeletal diseases [ 8 ].

As therapy, conservative and surgical procedures are available.

Due to both the increased prevalence of obesity and the available evidence for bariatric surgery, the of bariatric therapies has increased in the last two decades. Especially in morbidly or severely obese people, bariatric procedures show ificantly better than conservative therapies. An increasing of national therapeutic guidelines for the treatment of obesity and metabolic diseases recommend bariatric surgery after conservative weight loss or even if initial treatment fails, depending on BMI and comorbid diseases [ 91011 ]. Effective bariatric procedures are sleeve gastrectomy, Roux-en-Y gastric bypass, omega-loop gastric bypass, and biliopancreatic diversion with or without duodenal switch.

Currently, Roux-en-Y gastric bypass and sleeve gastrectomy are the most commonly performed procedures [ 1011 ]. Traditionally, restrictive bariatric operations are differentiated from malabsorptive procedures. While primary restrictive procedures such as sleeve gastrectomy induce weight loss mostly as a result of restricted dietary intake, malabsorptive procedures such as biliopancreatic diversion are mostly based on restricted nutrient absorption. However, a clear separation is not possible because primary restrictive procedures also benefit from complex, systemic mechanisms such as hormonal changes.

Roux-en-Y gastric bypass relies on both restrictive and malabsorptive effects as well as their interaction and is therefore classified as an intermediate procedure. Currently, the proximal Roux-en-Y gastric bypass is the gold standard and globally the most commonly performed procedure, although the of sleeve gastrectomies exceeded the of Roux-en-Y gastric bypass surgeries in some European countries [ 911 ].

Figure 1 gives a graphical overview of the sleeve gastrectomy and Roux-en-Y gastric bypass surgical procedures. The aim of this paper is to identify sex-specific aspects in the bariatric treatment of women suffering morbid obesity.

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Based on these aspects, the implications in terms of clinical treatment, recommendations, and key messages for therapeutic practice are worked out. In order to identify current relevant topics, a systematic search was carried out according to the requirements of Cochrane [ 12 ] and PRISMA-P [ 1314 ].

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A systematic literature search including a of medical databases of scientific publications for the last 5 years was performed with several online search engines. An overview of the databases and search engines used is presented in Table 1. Table 2 gives an overview of the of the literature search.

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Due to specific features of the search engines, the search functions differed. The latter always refers to the search term that was mentioned directly before. The literature search included publications from the last 5 years as of the time of writing and was performed in English. Articles published in English or with an English summary or abstract were taken into consideration. Journal literature, which means original research articles, case reports, systematic reviews, and comments as well as abstracts of recently published posters of peer-reviewed journals, was considered in the systematic literature search and checked for eligibility.

All original research articles and systematic reviews were included. Educational papers were included and named as such.

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Comments, corrections, and letters to the editor were taken into consideration too if they referred to a research article or review that met the inclusion criteria and were included in this review. Comments that did not refer to recently published articles and did not offer additional scientific value were excluded. In individual cases, abstracts of recently published posters were included if the survey met the scientific criteria. All studies that focused specifically on the bariatric treatment of women and on sex- or gender-specific aspects were included.

For this systematic literature review, no systematic assessment of potential bias was performed. Rather, this paper aims to consider surveys that might be relevant for clinical practice but do not fit the criteria of a meta-analysis, such as case reports. Therefore, no studies were excluded due to potential bias, such as a limited of cases. If limited evidence was observed, it was named and discussed collectively with the concerning publication. Publications with a clear conflict of interest or insufficient scientific procedures were excluded.

Studies that only dealt with men or children or did not consider sex-specific aspects were excluded. If studies were carried out with a female survey group, e.

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If this was not the case, the surveys were not taken into consideration. As a first step, the records were screened after duplicates were removed. The manuscripts that already stood out in the screening because they did not meet the inclusion criteria were already sorted out at this point.

The detailed reasons are described in Figure 2. In the next step, the screened were verified for full-text eligibility and ased to mainas described above. Articles that did not meet the described inclusion criteria on closer examination were excluded during this process. Articles that were not open access but did not offer an abstract with sufficient information to justify buying the article were excluded. The same was true for articles published in languages other than English and without a meaningful English abstract or summary.

The reasons for exclusion are described in detail. After thorough examination of the selected literature, the social and mental health aspects and eating behavior and disorders were not included in this review paper.

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Although some publications in these fields discuss sex-specific aspects, especially in terms of development and prevalence, there were no resulting sex-specific implications in the treatment. Therefore, the criteria regarding sex-specific aspects according to the definition in the Methods section were not met and the articles did not fit the purpose of this review paper focused on treatment.

In this paper, sex-specific aspects are defined as aspects that are associated with sex-specific divergence, for example due to female anatomy or metabolism. In order to provide an overview and recommendations for therapists, this research only focuses on those aspects that result in sex-specific implications. Based on the publications that were considered for inclusion by screening the of the systematic literature review, the main were developed deductively.

If a publication covered topics of more than one main criterion, it was ased to more than one category. The for each category are presented as follows. All included publications were ased to these. For each category, the are worked out and summarized.

Associated data

The complete literature search with the process of inclusion and development of the main is presented in Table S1. The of the asment of the relevant literature into the listed are presented in Table S2. Additional information concerning the included publications is summarized in Table S3. The literature search and the process of selection of relevant literature are presented in a flow diagram Figure 2 according to the PRISMA guidelines [ 13 ]. An overview of the inclusion criteria and the reasons for exclusion are presented in Table S4 in the Supplementary Materials.

According to the process of category development, which is described in Section 2. The presence of obesity is correlated with sexual and erectile dysfunction. In women, this correlation links obesity to disorders of the female cycle and hormone regulation, which are in turn associated with sexual function.

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Poor self-acceptance of body image, comorbid mental disorders, and difficulties in interpersonal relationships may aggravate the situation [ 15 ]. This instrument was developed as a measure of female sexual dysfunction and contains six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. There is an overall FSFI score, and each domain can be evaluated on its own.

Slight deviations due to language and culturally sensitive validated versions must be considered in this context too [ 161718 ].

Review: sex-specific aspects in the bariatric treatment of severely obese women

In a multicenter study, Steffen et al. One year after bariatric surgery, This betterment persisted in follow-up after five years.

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At this time, The improvement was independent of the type of surgical procedure [ 20 ]. Similar were found by researchers in Brazil. This improvement was found in both overall FSFI score and all included domains. The same authors also found amelioration of several sex positions. As a result, the surveyed women reported adopting a greater variety of sexual positions six months after bariatric surgery [ 21 ]. In contrast, a smaller American survey of women found an improvement in total FSFI scores as well as the arousal, desires, and satisfaction domains within the first three years but no more in the fourth year.