Rybelsus (semaglutide) is an oral GLP-1 receptor agonist licensed in the UK for treating type 2 diabetes mellitus in adults. Women of childbearing potential taking Rybelsus require careful contraceptive counselling, as the medication should be discontinued at least two months before a planned pregnancy. Understanding the relationship between Rybelsus and birth control is essential for safe diabetes management and family planning. This article examines contraceptive recommendations, potential interactions, and integrated care strategies for women taking Rybelsus, drawing on MHRA guidance, NICE recommendations, and current evidence to support informed decision-making about reproductive and metabolic health.

What Is Rybelsus and How Does It Work?

Rybelsus (semaglutide) is an oral medication licensed in the UK for the treatment of type 2 diabetes mellitus in adults. It belongs to a class of drugs known as glucagon-like peptide-1 (GLP-1) receptor agonists. Unlike injectable forms of semaglutide (such as Ozempic), Rybelsus is taken as a tablet, making it the first oral GLP-1 receptor agonist available.

The mechanism of action involves mimicking the naturally occurring hormone GLP-1, which plays several important roles in glucose regulation. Rybelsus works by:

• Stimulating insulin secretion from pancreatic beta cells in a glucose-dependent manner, meaning it only promotes insulin release when blood glucose levels are elevated

• Suppressing glucagon secretion, which reduces glucose production by the liver

• Slowing gastric emptying, which helps moderate the rise in blood glucose after meals

• Reducing appetite, which may contribute to weight loss in some patients

Rybelsus is typically prescribed when diet and exercise alone have not achieved adequate glycaemic control. It can be used as monotherapy when metformin is inappropriate (due to intolerance or contraindications), or in combination with other diabetes medications. The medication is available in three strengths (3 mg, 7 mg, and 14 mg) with a recommended titration schedule: 3 mg once daily for 30 days, then increase to 7 mg; consider 14 mg if additional glycaemic control is needed.

Rybelsus must be taken on an empty stomach with up to 120 mL of water, swallowed whole (not split, crushed or chewed), at least 30 minutes before the first food, drink or other oral medicines of the day.

Common adverse effects include gastrointestinal symptoms such as nausea, vomiting, diarrhoea, and abdominal discomfort, which often improve over time. Serious side effects can include acute pancreatitis (severe, persistent abdominal pain) and gallbladder disease. There is also an increased risk of hypoglycaemia when used with sulfonylureas or insulin. Importantly, Rybelsus is not licensed for weight management.

Rybelsus is not recommended during pregnancy or breastfeeding.

Contraception Recommendations While Taking Rybelsus

Women and people who could become pregnant taking Rybelsus should receive comprehensive counselling about contraception and pregnancy planning. According to current guidance from the Medicines and Healthcare products Regulatory Agency (MHRA) and product literature, semaglutide should be discontinued at least two months before a planned pregnancy due to its long half-life and the lack of adequate human data regarding foetal safety. Semaglutide is not recommended during breastfeeding.

Key contraceptive considerations include:

• Women should use effective contraception throughout treatment with Rybelsus and for at least two months after discontinuation

• All forms of contraception remain appropriate options, including combined hormonal contraceptives, progestogen-only methods, intrauterine devices (IUDs), and barrier methods

• The choice of contraceptive method should be individualised based on the person's medical history, preferences, and any contraindications related to diabetes or its complications

• People with diabetes may have specific considerations when selecting contraception, such as the potential cardiovascular effects of oestrogen-containing methods in those with vascular complications (UK Medical Eligibility Criteria category 3 or 4)

It is essential that healthcare professionals discuss family planning intentions before initiating Rybelsus therapy. If pregnancy is being considered, alternative diabetes management strategies should be explored well in advance. Insulin is the first-line treatment for diabetes during pregnancy, as it does not cross the placental barrier and has an established safety profile. Metformin may be considered in some cases of type 2 diabetes when benefits outweigh risks.

Preconception care for people with diabetes should include taking folic acid 5 mg daily from preconception until 12 weeks of pregnancy, and achieving optimal glycaemic control (ideally HbA1c below 48 mmol/mol) before conception. Pregnancy should be avoided if HbA1c is above 86 mmol/mol due to increased risks of congenital anomalies.

Patients should be advised to contact their GP or diabetes specialist immediately if they suspect they may be pregnant whilst taking Rybelsus, as prompt medication review and adjustment of diabetes management will be necessary to optimise maternal and foetal outcomes.

Managing Diabetes and Contraception Together

The intersection of diabetes management and contraceptive choice requires careful clinical consideration to optimise both glycaemic control and reproductive health. Women with type 2 diabetes face unique challenges when selecting appropriate contraception, and healthcare professionals should provide evidence-based guidance tailored to individual circumstances.

Contraceptive options for women with diabetes:

• Long-acting reversible contraception (LARC) methods, including the copper IUD, levonorgestrel intrauterine system (LNG-IUS), and progestogen-only implant, are generally considered first-line options due to their high efficacy and lack of user-dependent failure, as recommended by NICE guidance

• Progestogen-only pills are suitable for most women with diabetes and do not carry the cardiovascular risks associated with oestrogen

• Combined hormonal contraceptives (containing both oestrogen and progestogen) require careful risk assessment, particularly in women with diabetic complications such as retinopathy, nephropathy, or cardiovascular disease, as oestrogen may increase thrombotic risk (UKMEC category 3 or 4)

• Injectable progestogens (DMPA) may require caution in diabetes with vascular disease (UKMEC category 3)

• Barrier methods remain appropriate but have higher typical-use failure rates

According to NICE guidance on diabetes management, women with diabetes should receive preconception counselling and be supported to achieve optimal glycaemic control (ideally HbA1c below 48 mmol/mol) before conception to reduce the risk of congenital anomalies and pregnancy complications. Pregnancy should be avoided if HbA1c is above 86 mmol/mol, and folic acid 5 mg daily is recommended from preconception until 12 weeks of pregnancy.

When prescribing Rybelsus, clinicians should review the patient's current contraceptive method and ensure it provides adequate protection throughout treatment. Regular diabetes reviews provide opportunities to reassess contraceptive needs and discuss any changes in family planning intentions. Integrated care involving diabetes specialists, GPs, and sexual health services can help ensure comprehensive management of both conditions, supporting women to make informed decisions about their reproductive and metabolic health.

Does Rybelsus Affect Birth Control Effectiveness?

A common concern among patients and healthcare professionals is whether Rybelsus might reduce the effectiveness of hormonal contraception. Based on current evidence and pharmacological understanding, there is no official link or established mechanism by which Rybelsus would directly interfere with the efficacy of birth control methods.

Pharmacological considerations:

Rybelsus does not induce or inhibit hepatic cytochrome P450 enzymes, which are responsible for metabolising many hormonal contraceptives. Unlike some medications (such as certain anticonvulsants or rifampicin) that can accelerate the breakdown of contraceptive hormones and reduce their effectiveness, semaglutide does not affect these metabolic pathways. The Rybelsus Summary of Product Characteristics confirms that drug interaction studies with ethinylestradiol/levonorgestrel showed no clinically relevant effect on contraceptive exposure.

However, one theoretical consideration relates to Rybelsus's effect on gastric emptying. Because the medication slows the movement of food through the stomach, there has been speculation about whether this might affect the absorption of oral contraceptives. Current evidence suggests this is unlikely to be clinically significant, particularly as:

• Oral contraceptives are absorbed primarily in the small intestine, not the stomach

• The delay in gastric emptying does not prevent eventual absorption

• No formal drug interaction studies have identified reduced contraceptive efficacy

Important administration advice: Take Rybelsus first thing in the morning on an empty stomach with up to 120 mL of water, then wait at least 30 minutes before taking any other oral medicines, including oral contraceptives. This timing ensures optimal absorption of semaglutide without affecting other medications.

Patients experiencing severe gastrointestinal side effects from Rybelsus, particularly persistent vomiting or diarrhoea, should be advised that these symptoms could potentially affect the absorption of oral contraceptives. In such cases, additional barrier contraception should be used until symptoms resolve, following Faculty of Sexual and Reproductive Healthcare guidance. Non-oral contraceptive methods (IUD, LNG-IUS, implant, injection) are not affected by gastrointestinal upset and may be more suitable for those with recurrent symptoms.

Women taking Rybelsus can be reassured that their chosen method of contraception should continue to provide effective pregnancy prevention when used correctly. Patients should report any suspected side effects via the MHRA Yellow Card scheme and discuss any concerns with their healthcare provider for individualised assessment and advice.

Frequently Asked Questions