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Contraceptive risk assessment during tirzepatide treatment and bariatric surgery — DFSRH MCQ

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HardRisk AssessmentContraceptive risk assessment during tirzepatide treatment and bariatric surgeryDFSRH

A 31-year-old woman with a BMI of 44 kg/m² is preparing for laparoscopic Roux-en-Y gastric bypass in 5 weeks. Postoperative pharmacological thromboprophylaxis and a period of reduced mobility are anticipated. She wishes to avoid pregnancy for at least 18 months after surgery. She currently uses a combined oral contraceptive containing ethinylestradiol 30 micrograms with levonorgestrel. Six days ago, she started weekly tirzepatide for weight management; dose escalation is planned every 4 weeks. She has used condoms consistently for the past 4 weeks, and a high-sensitivity urine pregnancy test is negative today. She declines intrauterine contraception and depot medroxyprogesterone acetate but would accept an etonogestrel implant. She has no personal or family history of venous thromboembolism and no other medical contraindication to progestogen-only contraception. Which is the most appropriate contraceptive plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Stop the combined oral contraceptive, insert an etonogestrel implant now, use condoms for 7 days and continue the implant perioperatively

The implant addresses three linked risks. First, combined hormonal contraception should be stopped at least 4 weeks before major surgery or an expected period of limited mobility; elective surgery in 5 weeks provides time to remove this avoidable oestrogen-related thrombotic risk. Her BMI of 44 kg/m² further strengthens the case against continued CHC. Second, tirzepatide can clinically significantly reduce oral contraceptive exposure, particularly after initiation and dose escalation. Third, oral contraceptive effectiveness may be unreliable after malabsorptive bariatric surgery, whereas a non-oral implant bypasses gastrointestinal absorption and provides highly effective contraception during the period when pregnancy should be avoided. As insertion is after day 5 of the cycle without established reliable hormonal cover, condoms are used for 7 days. A is inappropriate because thromboprophylaxis is not a substitute for stopping CHC when advance discontinuation before elective surgery is possible. B avoids gastrointestinal absorption but retains oestrogen during a high-risk perioperative period. C removes oestrogen but remains an oral method exposed to tirzepatide-related and postoperative absorption concerns. E correctly stops CHC before surgery but leaves her dependent on a user-dependent method and then reintroduces an oral oestrogen-containing method despite persistent obesity and altered gastrointestinal anatomy.

Reference: FSRH Statement: Glucagon-like peptide-1 agonists and oral contraception (January 2025) — https://www.fsrh.org/Common/Uploaded%20files/documents/CEU-statement-GLP-1-agonists-and-contraception.pdf FSRH Guideline: Overweight, Obesity and Contraception (April 2019) — https://www.fsrh.org/Common/Uploaded%20files/documents/1overweight-obesity-and-contraception-guideline-april-2019.pdf FSRH Guideline: Progestogen-only Implant (February 2021) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-progestogen-only-implants.pdf