Oct. 18, 2023 – For obese women, on a regular basis life is suffering from landmines. Whether it's concerning the challenges of air travel since the airplane seats are too small, the necessity to protect yourself from the discriminatory gaze of the world, or the good lengths many go to for higher health and the promise of 1 To achieve an extended life – life as an chubby person requires thick skin.
No wonder so many are willing to pay greater than $1,000 a month out of pocket to get drugs like semaglutide (Ozempic and Wegovy) or tirzepatide (Mounjaro). The advantages of those drugs, which belong to a brand new class called GLP-1 receptor agonists, include significant and rapid weight reduction, blood sugar control, and improved quality of life; They are unprecedented in an environment where surgery has long been considered probably the most effective long-term option.
On the opposite hand, the will for rapid weight reduction and higher blood sugar control also comes with unexpected costs. Many women with obesity who take oral contraceptives are unaware that these medications – particularly Mounjaro – can interfere with the absorption and effectiveness of contraception pills, increasing the likelihood of an unwanted pregnancy.
Neel Shah, MD, an endocrinologist and associate professor on the University of Texas Health Science Center at Houston, said he has had several patients turn into unintentionally pregnant.
“It was when Mounjaro came out that we started using it,” he said of the drug, which the FDA approved in 2022 for type 2 diabetes. “It [the warning] was in the package insert, but from a clinical perspective I don’t know if that was what the providers had in mind when they prescribed Mounjaro.”
When asked if he thought we would see a significant increase in the so-called Mounjaro babies, Shah was confident in his answer.
“Absolutely. We'll do it due to the sheer volume [of patients] will increase,” he said.
It's all in your gut
One way medications like Mounjaro work is by delaying the time it takes for food to maneuver from the stomach to the small intestine. Although data continues to be evolving, it’s believed that this process – delayed gastric emptying – may interfere with the absorption of contraception pills.
Shah said one other theory is that vomiting, a typical side effect of all these medications, also interferes with the pills' ability to forestall pregnancy.
And “because of the gastrointestinal tract, it takes a longer time to increase the dose.” [gastrointestinal] unwanted effects,” said Pinar Kodaman, MD, PhD, reproductive endocrinologist and assistant professor of gynecology at Yale School of Medicine in New Haven, CT.
“Initially, the lowest dose may not have large potential effects on absorption and gastric emptying. But as the dose increases, it becomes more common and it can cause diarrhea, which is another condition that can affect medication absorption,” she said.
Unexpected results, additional prevention
Approximately 42% of girls within the United States are obese. 40% of them are between 20 and 39 years old. Although these latest drugs may improve fertility outcomes for girls with obesity (particularly those with polycystic ovary syndrome), or PCOS), just one – Mounjaro – currently carries a warning concerning the effectiveness of the contraception pill on its label. Unfortunately, some physicians look like unaware of this risk or fail to coach their patients about it, and data are unclear as as to if other drugs on this class, corresponding to Ozempic and Wegovy, pose the identical risks.
“So far, it hasn’t been a typical topic that we deliberate on,” Kodaman said. “This is all fairly new, but when we have patients who are taking birth control pills, we check other medications they are taking because some can affect effectiveness and that is something to keep in mind.”
It can be unclear whether other types of contraception – for instance Contraceptive patches released through the skin – could pose similar pregnancy risks. Shah said a few of his patients who had unwanted pregnancies used these patches. This raises much more questions since they release drugs through the skin directly into the bloodstream moderately than through the gastrointestinal tract.
What can women do to make certain they don't get pregnant while taking these medications?
“I really believe that if patients want to protect themselves from unplanned pregnancy, it would not be a bad idea to use condoms as soon as they start taking GLP receptor agonists, as the onset of action is quite rapid,” he told Kodaman also noted that “at the lowest dose, there may not be much potential effect on gastric emptying. But as the dose increases, it becomes much more common or may cause diarrhea.”
Shah said that in his practice, he has “told patients to additionally use a barrier method of contraception for four weeks before starting the first dose and at any dose adjustment.”
Zoobia Chaudhry, an obesity medicine physician and assistant professor of medication on the Johns Hopkins School of Medicine in Baltimore, recommends that “patients simply make sure that the injection and the medications they are taking are at least an hour apart.”
“In most cases, patients take birth control before bed, so if the two are spaced apart, it should be fine,” she said.
Another option is for girls to check with their doctors about other contraceptive options, corresponding to IUDs or implantable rods, where gastric absorption shouldn’t be a difficulty.
“There is very little research on this class of drugs,” said Emily Goodstein, a 40-year-old small business owner in Washington, D.C., who recently switched from Ozempic to Mounjaro. “Being a human living in a larger body is such a terrible experience because of the way the world discriminates against you.”
She appreciates the sense of initiative these latest medications provide. It “opened up a number of opportunities for me to be seen as a full person by the medical establishment,” she said. “I was willing to take the risk knowing I would be taking these medications for the rest of my life.”
In addition to being what Goodstein describes as a guinea pig, she also made sure her primary care doctor knew she wasn't trying or planning to get pregnant again. (She has a 3-year-old child.) Still, her doctor only mentioned probably the most common unwanted effects of those medications, corresponding to nausea, vomiting, and diarrhea, and didn’t mention the danger of pregnancy.
“People really don’t talk about the reproductive effects,” she said, referring to members of a Facebook group concerning the drugs that she belongs to.
Like the patients themselves, many doctors are only starting to become familiar with these energetic ingredients. “Awareness, education, provider engagement and a multidisciplinary team could help patients achieve the goals they have set for themselves,” Shah said.
Clear conversations are key.