Acceptance of weight loss medication in patients with atypical hyperplasia or carcinoma of the endometrium as part of the fertility preservation treatment: A qualitative study

Graphical abstract

Highlights

• •Patients’ understanding of impact of obesity on endometrial cancer is limited.
• •Weight loss medications are acceptable to young patients with endometrial cancer.
• •Comprehensive counselling with clear risk–benefit discussion is needed.

Abstract

Objective

Sustained weight loss in combination with progestin may improve oncologic and fertility outcomes for young patients with endometrial cancer/atypical hyperplasia (EC/AH) desiring fertility-preserving treatment. Weight-loss medications are non-invasive and effective weight management tools; however, their acceptability is unknown in this population. Thus, we conducted a qualitative study to understand the acceptability of weight loss medication in young patients with obesity and EC/AH.

Methods

Purposive sampling was used to recruit patients between 18 and 41 years of age with body mass index (BMI) ≥ 27, and a diagnosis of grade 1 endometrioid EC or AH. Semi-structured interviews were conducted to explore participants’ perception of their weight, its relationship to their EC/AH diagnosis, and their acceptability of weight-loss medication as part of fertility-sparing treatment.

Results

Thirteen interviews were conducted. The median participant age was 37 years (26–40), and the median BMI was 34.8 (28–48). Participants lacked understanding of the relationship between obesity, EC/AH, and infertility. Participants identified the need for honest, early, actionable, and sensitive obesity counselling in the context of EC/AH management. Participants were receptive to the use of weight-loss medication and expressed little worry about associated stigma; however, they were highly concerned about cost, side effects, and sustainable weight loss, and emphasized that addressing these concerns would be essential to increase their comfort.

Conclusions

Weight-loss medication may be an acceptable adjunct to progestin treatment in this population, if preceded by a thorough risk–benefit discussion and early counselling on the role and management of obesity in EC/AH.

1. Introduction

Endometrial cancer (EC) is the fourth most common cancer in biological women in the United States, with incidence rates increasing by approximately 1% per year over the last decade. (Siegel et al., 2025) It is estimated there will be approximately 69 000 new cases in the United States in 2025. (Siegel et al., 2025) Although largely a post-menopausal disease, 3–5% of diagnoses are in individuals younger than 40 and the incidence in this cohort is rising. (Matsuo et al., 2021, Simpson et al., 2014) This trend has been attributed to the rising incidence of obesity, a key risk factor for EC and its precursor atypical hyperplasia (AH). (Simpson et al., 2014, Abarca-Gómez et al., 2017) The current standard of care for EC is a total hysterectomy with bilateral salpingo-oophorectomy, which precludes fertility. (National Comprehensive Cancer Network, 2026) Progestin therapy offers a fertility-sparing alternative; (National Comprehensive Cancer Network, 2026) however, despite high initial response rates (60–80%), recurrence rates of 30–50% are seen at 2 years as progestin therapy does not address the underlying obesity. (Suzuki et al., 2024) Studies demonstrate that high baseline BMI (>25 kg/m²) is associated with lower complete response to progestin therapy and a high post-treatment BMI is associated with EC recurrence. (Park et al., 2017, Dzyubak et al., 2025) Thus, achieving and maintaining a healthy BMI is integral to the success of progestin therapy and maintaining sustained response.

Bariatric surgery has been shown to achieve significant and prolonged weight loss and has demonstrated efficacy in reducing EC incidence rates and decreasing biomarkers of EC carcinogenesis (Anveden et al., 2017, MacKintosh et al., 2019, Modesitt et al., 2015); however, patient uptake remains low. In a qualitative study, 64% of participants with EC/AH were reluctant to try bariatric surgery as part of their treatment due to lack of knowledge, stigma, and fear of surgical risks. (Kim et al., 2023) This hesitancy around bariatric surgery, combined with the advent of highly effective weight-loss medications like Glucagon-like Peptide-1 (GLP-1) receptor agonists, presents a new avenue of investigation. These agents have demonstrated superior weight loss reductions and weight loss maintenance compared to placebo. (Wilding et al., 2021) For example, at one year, tirzepatide, a GLP-1 and Glucose-dependent insulinotropic polypeptide dual agonist, demonstrated dose-dependent weight reduction up to 21% compared to 3.1% in placebo groups, (Jastreboff et al., 2022) with superior weight loss maintenance of 80% vs 16.6% in placebo groups across 52 weeks of continued therapy. (Aronne et al., 2024) However, after weight loss medications are discontinued, weight regain is common with users returning to baseline weight at approximately two years. (West et al., 2026) These agents have also been successful in decreasing LDL-cholesterol, HDL-cholesterol and triglycerides in obese patients (Miranda et al., 2025) and subsequently incidence of death from myocardial infarction and non-fatal stroke in obese patients with cardiovascular disease. (Lincoff et al., 2023) Preliminary evidence suggests that GLP-1 s may also directly inhibit EC proliferation pathways. (Kanda et al., 2018, Hagemann et al., 2025) In Canada, liraglutide and semaglutide have been approved for those with BMI over 30 kg/m² or with BMI over 27 kg/m² and one obesity-related disorder. (Authors et al., 2022) This presents an opportunity for an effective weight loss intervention in individuals with EC/AH who do not meet the cutoff for bariatric surgery (BMI > 35 kg/m²). (Garneau et al., 2022) Maintaining a healthy BMI is integral for the success of progestin treatment in young individuals with EC/AH. Weight-loss medications present a new, non-invasive yet effective option for weight management in this population. Therefore, prior to launching a clinical trial (NCT06073184) to assess the efficacy of adding weight-loss medication to standard progestin therapy, it is critical to understand patients’ acceptability and perception towards weight-loss medication as a treatment.

2. Materials and methods

We conducted a qualitative study using thematic analysis to understand patient perception on weight-loss medication as a fertility-sparing treatment strategy for EC/AH. (Braun and Clarke, 2006) Semi-structured in-depth interviews were conducted due to the sensitive topic. To increase rigor, we followed the Consolidated Criteria for Reporting Qualitative Research. (Tong et al., 2007) Our study was approved by the University Health Network Research Ethics Board (REB # 24-5208).

3. Sampling and recruitment

We implemented a typical case purposive sampling strategy to recruit participants. (Palinkas et al., 2015) Participants were recruited from June 2025 to August 2025 from the Princess Margaret Cancer Centre oncofertility clinic that provides multidisciplinary care for those with EC/AH seeking fertility preservation. (Dzyubak et al., 2025) Patients who met the inclusion criteria were approached during their clinic visit and asked to participate. The inclusion criteria were: 1) Age ≥ 18 and ≤ 41 years old; 2) BMI ≥ 27 kg/m²; 3) EC or AH diagnosis; 4) candidate for fertility sparing management; (Dzyubak et al., 2025) 5) no prior weight-loss medication use; 6) English speaking; 7) able to provide written informed consent. To be a candidate for fertility-sparing treatment, patients must have AH or low-grade endometrioid EC that is limited to the endometrium on MRI with no evidence of extrauterine disease on CT. Recruitment continued until thematic saturation was reached. (Saunders et al., 2018).

3.1. Data collection & analysis

We developed a semi-structured interview guide based on the principles of the Theory of Reasoned Action and Transtheoretical Model, (Reyna, 2008, Prochaska and Velicer, 1997) developed and refined by research staff and a qualitative research expert. Data were analyzed throughout the interview process, and the guide was modified iteratively as findings emerged. Interviews were conducted either in person or via video conferencing following the guide. Participants were asked about 1) their knowledge and perceptions of weight-loss medication, 2) their understanding of the relationship between obesity and EC/AH, 3) their journey with their weight, and 4) their attitudes towards weight-loss medications as a treatment for cancer and fertility.

The research team was entirely female. Although none had lived experience with EC/AH, two team members had extensive experience with this population, supporting prolonged engagement and enhancing credibility. (Nowell et al., 2017) The team’s age and racial composition were similar to participants’, aiding contextual understanding and strengthening interpretive rigour during peer briefing. (Nowell et al., 2017) The interviewer was a female medical trainee not involved in participant care but familiar with the population through prior observerships, further supporting prolonged engagement. (Nowell et al., 2017) She approached the study with an external non-clinical perspective. After each interview, she documented her reactions, impressions, and overall tone of the interview to provide context to the analysis. Initial reflections revealed the use of leading questions during the first two interviews. The interviewer subsequently revised her technique by avoiding immediate follow-ups and returning to open-ended questions. These iterative adjustments and reflections helped identify bias, maintain reflexivity, and ensure interpretations remained grounded in participant experience.

Interviews lasted thirty minutes to one hour and they were audio-recorded, transcribed verbatim and verified. Participant recruitment and interviews were conducted until thematic saturation, the point at which no new information, themes or patterns were emerging, was reached. (Saunders et al., 2018) Notes were made after the interview to identify emerging salient themes the questionnaire did not address.

Data analysis was completed using thematic analysis. (Braun and Clarke, 2006) Data were managed using NVivo Data Analysis Software. (Moncada, 2025) Codes were identified then grouped into categories and categories were grouped into themes. Two peer-briefing meetings were held with the research team throughout data analysis. (Nowell et al., 2017) The first, after three interviews, involved reviewing emerging codes and interviewer reflections, leading to the addition of two questions about participants’ previous weight loss conversations and their desires around these conversations. The second meeting, held after the 13th interview, reviewed emerging codes and themes and concluded that thematic saturation had been reached and no further interviews were required. Deductive and inductive reasoning was used to extract themes. Thick descriptions and quotes were used to support thematic interpretations of perceptions, attitudes, and barriers to weight-loss medications. (Nowell et al., 2017).

4. Results

Twenty-six patients were approached and 13 were consented and interviewed. The clinical and demographic characteristics are presented in Table 1. Participant median age was 37 years (26–40), and the median BMI was 34.8 kg/m² (28–48). Of the 13 participants, 4 (31%) had stage IA grade 1 endometrioid EC, and 9 (69%) had AH. Comorbidities included diabetes or prediabetes (N = 7; 54%), hypertension (N = 3; 23%), hypothyroidism (N = 5; 38%), and polycystic ovarian syndrome (N = 4; 31%). Of the 13 participants, 10 (77%) had tried to conceive in the past while 3 (23%) had made no attempts to conceive. All 10 (100%) who had tried to conceive reported a history of infertility. Among these 10 individuals, 6 (60%) patients have yet to conceive, and 4 (40%) patients had successful live births after diagnosis while receiving care through the clinic.

Table 1.

Characteristics of study participants.

Characteristic
Median age (range), years	37 (26–40)
Median BMI (range), kg/m2	34.8 (28–––48)
Overweight (BMI 25.0–––29.9), N	2
Obese (BMI 30 to 39.9), N	7
Severe Obesity (BMI > 40), N	4
Diagnosis
Grade 1 endometrioid endometrial cancer	4 (31%)
Atypical hyperplasia	9 (69%)
Comorbidities
Diabetes/ Pre-Diabetes	7 (54%)
Hypertension	3 (23%)
PCOS	4 (31%)
Hypothyroidism	5 (38%)
Attempted to Conceive	10
No Attempts to Conceive	3
History of infertility in those who attempted to conceive	10 (100%)
Nulliparous	9 (69%)
Live births (of those who attempted to conceive)	4 (40%)

5. Perception towards weight, fertility, and endometrial cancer/atypical hyperplasia (Table 2).

Table 2.

Major Themes and Patient Quotes on Weight, Fertility, and EC/AH diagnosis.

Theme	Number of Interviews	Highlighted Quotations
Perceptions towards weight, fertility, and endometrial cancer/atypical hyperplasia
Participants did not understand the relationship between endometrial cancer/ atypical hyperplasia infertility and obesity	9 (69%)	“I am aware that there is a correlation between obesity and occurrence of my particular type of cancer. The exact mechanism of that, I don't know.” (ID-013) “Wild guess. I don't know. I guess it does. I feel like obesity …would impact anything that you have. I feel like, you know, if, I don't know, it might exasperate the body. It might, I don't know… I don't know directly how it would affect fertility and cancer.” (ID-004)
Participants report lack of explanation from healthcare providers, avoidance of obesity discussions and insufficient obesity counselling.	7 (54%)	“Nobody actually, nobody told me to, you know, okay, you must lower your weight. I mean, no doctors actually told me about like, oh, you must, maybe if you're losing your weight may affect something. If they were saying it, maybe I will take it more seriously… But here I had a misconception, or maybe, oh, they're not saying anything about my weight because maybe it's not the fact” (ID-010) “It's funny, no one has actually said to me that I should lose weight. I have read in a clinical note that we have had that conversation. And I was like, I was there. We did not have that conversation.” (ID-013)“I don't think they specifically mentioned like how weight affects what I have.” (ID-004)“I think, even here they didn’t mention anything about weight loss, like relation to the weight but because I do remember asking our team here about, like, what would have caused it?” (ID-003)

5.1. Participants (N = 9; 69%) did not understand the relationship between EC/AH, infertility and obesity

Participants could identify a general hormonal link and that obesity “would impact anything” in the body (ID-004); however, they struggled to articulate how obesity-led hormonal imbalance contributed to EC/AH and infertility. One participant shared, “I am aware that there is a correlation between obesity and occurrence of my… type of cancer. The exact mechanism of that, I don't know” (ID-0013).

5.2. Participants (N = 7, 54%) reported lack of explanation from healthcare providers, avoidance of obesity discussions, and insufficient obesity counselling

One participant recounted that during her diagnosis discussion, the team did not “specifically mention how weight affects what I have,” and that at subsequent appointments there was “not a whole lot of conversation” (ID-004). Participants also described avoidance of obesity discussions; as one participant described, “both my family doctor and other healthcare professionals have talked around it without actually saying it” (ID-013). When discussions did occur, they were too general, brief and ineffective. One participant noted that their family doctor only mentioned weight in relation to their high blood pressure, encouraging general changes to her “diet” and “lifestyle” (ID-006). Another participant recalled her weight being “mentioned… but not very often and not in a way that I fully digest or understood” (ID-004). Another participant described past weight loss conversations as “nothing too heavy,” typically limited to unhelpful repetitive reminders to stay active (ID-001).

6. Participants desire honest (n = 8; 62%), early (n = 7; 54%), actionable (n = 7; 54%) and sensitive (n = 8; 62%) obesity discussions (Table 3)

Table 3.

Major Themes and Patient Quotes on Weight Loss Counselling.

Theme	Number of Interviews	Highlighted Quotations
Participants desire, honest, early, actionable, sensitive, obesity discussions
Honest	8 (62%)	“It's not news to me-- I own a mirror, like I own a scale. It's one of these things where you, it's not like the person doesn't know, right?… Like at some just you're the medical professional, you're not here to hug me, you're here to tell me how to take care of my health. The particular point of this conversation is to tell me about a risk factor that you want me to address. You might as well just pull the band-aid off, like in my view.” (ID-13)“You can't tiptoe around it or ignore it. You do have to be honest and truthful and that this is what can cause that.” (ID-006)
Early	7 (54%)	“If people knew…that should be something that we should be told a long time ago…If I had known that this was gonna happen to me … [it’s] just one more thing say okay or you know [obesity] causes heart problems, but like I had no idea it could cause this. So, I feel like it would be good information to know for sure.” (ID-006)“Ideally like at like the very first stage, like as soon as things are…Because I would say start me off like when I was told that, okay, you have PCOS, you can manage it by managing your weight. That would be an ideal time.” (ID-008) “Yeah, that would've been great to know yesterday… but like if that was happening at like regular gyn visits or family doctor visits or like you know anybody in their 20 s or 30 s that might be considering having a kid, knowing that weight loss medication might make that fertility easier on you, that would be a much better time to introduce it.(ID-011)“Maybe just address it in the beginning. Like, we're not just trying to get your attention. We just want to give you all the information.” (ID-007)
Actionable	7 (54%)	“So as a patient, if I am told by the doctor, okay, these are the simple steps you need to take in order to get to the like, you know your goal, that would I think something that can break the ice and that can probably not offend me as much, to tell me that okay this is something that we're on the same page and we're working on towards a healthier better me.” (ID-008)“I would want information, but I would also want actionable information.” (ID-011) “It seems like to look at it and be okay, I want you to lose 40 lb. If you tell me that, you tell me to go do it myself. I tell you right now, would be exactly in the same position five years from now. But if you actually have something you want me to read or look at in terms of a strategy about how to do that, I may actually be capable of actioning that. If it's incremental.” (ID-013) “So, I feel like maybe if there's some more guidance in the sense of if doctors could provide you to go to a nutritional program or speak to a nutritionist or maybe provide this kind of other resources to help educate yourself and help guide you a little bit more.” (ID-012).
Sensitive	8 (62%)	“And I feel like, obviously with a gentle tone, like, and, you know, and keeping like, if you put yourself in your patient's shoes, how like obviously they're scared, emotions are on high, especially when you get like the diagnosis.” (ID-012)“I feel it's not even too far to be, ‘I wanna be really clear that you did not do this to yourself and this is not your fault that you're in this situation. And acknowledging that it can be easy to blame yourself for this problem, but that it's a confluence of factors that cause this and you're not responsible for any one of them,’ that can take some of the blame away.” (ID-011)

Participants communicated that healthcare providers cannot “tiptoe” or “ignore” weight discussions, and they “have to be honest and truthful” (ID-006). Participants acknowledged the difficulty of discussing weight with patients but urged that “if you actually want the patient to do something about it, you have to be clear” (ID-013). Participants explained that honesty empowers them to act on their weight: “the more [I] know, the more likely I am to do things” (ID-008). Participants wanted to know about the impact of obesity on fertility and cancer early in their diagnosis. One participant felt that weight in the context of EC/AH “requires consistent support, conversation” and to “start it early” so that “whatever [lifestyle changes] we do early, can set us up” to be successful throughout treatment (ID-001). Participants identified the first few appointments as the ideal time to discuss obesity but not during their initial consultation to avoid “overwhelming” (ID-007) the patient or stirring feelings of “blame” (ID-013). Participants urged for actionable advice with weight loss. Participants emphasized wanting “simple” (ID-008), “concrete” and “incremental” advice on nutrition and exercise instead of general statements such as “eat better” and “exercise” (ID-013), also suggesting physicians should provide referrals to nutritionists for individualized support (ID-012). Participants stressed the need for sensitivity when discussing the topic of obesity. Participants desired empathy, encouraging physicians to put themselves in their “patient’s shoes” utilizing a “warm and understanding” tone as patients are often scared after receiving an EC/AH diagnosis (ID-012). Participants uniformly stressed the importance of avoiding blame. One participant suggested: “It’s not even too far [for physicians to say] ‘I wanna be really clear that you did not do this to yourself and this is not your fault that you're in this situation… but that it's a confluence of factors that cause this and you're not responsible for any one of them,’ that can take some of the blame away” (ID-011).

7. Participant perception towards weight loss medication as part of treatment for endometrial cancer/atypical hyperplasia (Table 4)

Table 4.

Major Themes and Patient Quotes on Weight Loss Medications.

Theme	Number of Interviews	Highlighted Quotations
Participants were receptive to the use of Weight Loss Medications, but were highly concerned about affordability, side effects, and sustainability of weight loss
Participants were open to trying weight loss medications	10 (76%)	“I think one of the things really, I guess, is like try Ozempic. Low dose, I guess. I would love to try that and see where it goes.” (ID-005)“It doesn’t matter, I feel like what I do, the scale never moves. So, I think at this rate it would be helpful.” (ID-002)“If I could come to a place of near 100% comfort that it would help in a way that it wouldn't harm me, then I would try it. I would try it.” (ID-001) “So, thinking of like, all right, fool me once, give me hyperplasia because of my obesity. All right, you get one for free. And now it's like, I don't wanna die of hypertension or diabetes or I don't even know what else because I stayed this way. So I am considering like I'm thinking about the GLP 1 s. I'm thinking about it.” (ID-011)
No fear of stigma	12 (92%)	“I usually don't get influenced by what other people say or do. If it's something that's helping me or something that's helping others, I'm okay with it, and if somebody says something to me, I don't really take it personally. They're not aware of what's going on.” (ID-008)“Me, personally? No. Because I feel like, now I’m like, I have, first of all I have cancer and this is what I'm trying to do to get rid of cancer.” (ID-006) “Q: And do you think that this stigma, like you said, you would experience from some family members, some people in your life, would stop you from taking the weight loss medication? ID-011: No, it would just stop me from telling them.” “There's definitely judgment, but I wouldn't mind the judgment if it's beneficial for me, yeah.” ID-003
Cost	13 (100%)	“The monthly, I think more than a couple hundred and I would start questioning whether this was really worth it.” (ID-013)“But if it is expensive I probably wouldn't want it.” (ID-004) “I don’t know, ‘cause like I also take Synthroid and Metformin and if I had to pay out of pocket for all it adds up, right?… When you have a kid and, like, the way the economy is right now, like, our grocery bill, you know, like, weekly, how much it costs to feed our family now, it feels like it’s out of hand.” ID-002 “Like is it covered under a drug plan? That might make it more cost-effective. Yeah, I don't want it to be another bill.” (ID-001)
Fear of Acute Side Effects	11 (84%)	“So I know that, this is from what I've heard, is that it can make you really nauseous. So I don't want to be nauseous all the time. So if that's something that if this medication I'm thinking, yes it's got good results, but you're constantly uncomfortable and it's affecting your day-to-day, I probably wouldn't want to take that.” (ID-006)“But in terms of like discomfort or like nausea or constipation like I can handle that, so I'm not, I just don't want anything that's gonna like greatly impact my ability to continue to be a functioning person.” (ID-011)I think that if I don’t do well on it, if it makes me feel really sick and I’m unable to cope with that and it affects my daily life, that would be a reason that I would stop. (ID-002)
Fear of Long-term Side Effects	9 (69%)	“Like, I don't know if it's going to cause, pancreatic issues or, you know, things, anything really that all of a sudden, you're like, oh, if I had known. I'm not really sure, like anything severe. What if it increases your risk for cancers or I think diabetes. I don’t know. If there’s anything really that would be major that you’re like irreversible, I guess. Damages.” (ID-006)“I don't want to do something that's going to cause other problems later on down the line…If later on down the line it does continue to affect, you know, a woman's fertility. If it affects fertility, immunity, causes damages to like tissues or organs or dependence.” (ID-001) “If they were more transparent with everything. It would make it a little easier like if they were more transparent about what could go wrong, what will go right. Instead of just kind of blanketing it all, be like here you take this once a week and you'll lose weight. I don't feel like we're really transparent with our drugs before we give them to our patients.” (ID-009)“What's the impact on that chain for somebody who did not have the on-label use, right? So that's my thinking, is well…is this actually something that could potentially mess up a balance or have long-term effects on some part of you?” (ID-013)
Desire for sustainable weight loss	8 (62%)	“How do I take them, like how do I get the other aspects of losing weight into shape? Like basically I'm gonna take them and like I have to eat food still, how do I do that right? Like what are the supports that I need to put in place to be the most successful on them in terms of eating and maintaining muscle mass.” (ID-011)“Yeah there has to be an exit strategy. Like what was the point of doing this if I'm gonna go right backwards?” (ID-001) “I probably wouldn't, no, because then guess what, you might even be back to, okay, first of all, you might be probably back to square one with the weight you started at, right? Or even worse off, like you might not even gain more weight than what you lost, right? (WLM Q-012)

7.1. Most participants (N = 10; 76%) were open to trying weight-loss medications

Participant willingness ranged from eager, to “hesitantly optimistic” (ID-001) and “curious” (ID-007). Health and fertility emerged as the strongest motivators, as participants agreed they would be “way more inclined” to use weight-loss medications, if they knew it could treat their cancer (ID-011). One participant shared: “Weight loss itself is very important regardless of whether you have the condition… if I didn’t have cancer, I would still be looking to lose the weight” (ID-008). One participant explained, “Anything that has the word ‘fertility’ and ‘help’ in it, I would do it,” further elaborating that: “another thing that scares me a lot is that I might be able to get pregnant and then [not] carry out a full term…because in that, diabetes matters, weight matters, insulin resistance matters… so I would want to start on weight loss to make sure that I am providing the best possible conditions for the pregnancy to be full term” (ID-008). Notably, a participant opposed to weight-loss medications indicated that framing these medications as a cancer treatment “means something different” and would make the intervention acceptable to them (ID-004). Most (N = 12; 92%) were not worried about societal stigma, as they were “doing it to better [their] health, both mental and physical” (ID-009).

Three participants (23%) were not open to weight-loss medications. One participant, whose hesitancy stemmed from mistrust of the healthcare system, stated that they would be more open if doctors were “more transparent with everything… what could go wrong, what would go right instead of just kind of blanketing it all” (ID-009). Other participants preferred lifestyle modification as their initial strategy. One participant explained, “I just feel like, is there something that I can do just without having to take something? Can my body like do what it needs to do on its own?” (ID-012). All three participants positioned weight-loss medications as a “last resort” (ID-012) only for extreme circumstances such as being “dangerously obese” (ID-009), only after they have “tried everything 100% and nothing is working” (ID-012), and if they are at a point where “a doctor literally comes up to me and says, we're desperate for you to lose weight” (ID-004).

7.2. Participants stressed the need for more information on cost, side effects and whether sustainable weight loss could be achieved

All participants (100%) expressed that cost was a major concern and most were willing to spend between $50 to $200 a month. One participant explained, “the way the economy is right now… I feel like I’m just constantly spending money” (ID-002). Participants were worried about weight loss medication being “another bill” and expressed the desire for “drug plan” coverage (ID-001). Health priorities were a key consideration in participants’ willingness to pay for weight-loss medications. One participant explained that “you have to weigh the importance of it in your life” and added “I also know how much fertility meds cost too,” (ID-006) underscoring the complex evaluation of weight loss in relation to fertility goals. Another participant highlighted the confluence of factors that go into affordability explaining that: “If I'm paying for it out of pocket how much does it cost, how long am I gonna be on it? Are the cost of these drugs projected to go down… if it's one of those where it was… $400 a month and you're gonna have to pay 400 bucks out of pocket for the rest of your life, weighing the like, is that worth it?” (ID-011).

Eleven participants (84%) were concerned about acute medication side effects. As one participant said, “I don't want to be nauseous all the time, so if that's something that …I'm thinking, ‘yes it's got good results’, but you're constantly uncomfortable and it's affecting your day-to-day, I probably wouldn't want to take that” (ID-006).

Long-term side effects emerged as a serious concern for nine (69%) participants. One participant explained that long term, she doesn’t “know what this kind of stuff could do, like, I don't know if it's going to cause… pancreatic issues or, you know… anything really that all of a sudden you're like, ‘oh, if I had known’” with the fear of “anything really that would be major… like irreversible” (ID-006). Participants desired honesty about the known side effects stating, “I'd have to be explicitly told…like don't mince words with me: ‘Using this long-term, here is the worst that could happen, here's what is likely to happen, and here's what most people experience” (ID-001).

Eight participants (62%) expressed a desire for sustainable weight loss. Participants expressed that regaining the weight on a weight loss medication would deter them from using them. “You might be probably back to square one with the weight you started at, right? Or even worse off, like you might even gain more weight than what you lost, right?… I would be really hesitant to want to take these drugs, because then that not only physically takes a toll but mentally” (ID-012). Participants desired proper counselling and support to maintain the drug-induced weight loss after stopping the medication, explaining that “there has to be an exit strategy” and questioning “what was the point of doing this if I'm gonna go right backwards?” (ID-001). Another participant wondered, “How do I get the other aspects of losing weight into shape? … Like what are the supports that I need to put in place to be the most successful on them in terms of eating and maintaining muscle mass?” (ID-011).

8. Discussion

Our study reveals that participants have limited understanding of the relationship between obesity, EC/AH, and infertility, and feel that they have not received effective counselling from healthcare providers. Participants identified the need for honest, early, actionable, and sensitive obesity counselling throughout their EC/AH management. Weight-loss medications are an acceptable weight loss strategy for this population, with cancer, health and fertility serving as major motivators. Notably, stigma was not a deterrent. However, concerns regarding cost, side effects, and long-term sustainability need to be addressed to increase participant comfort.

The acceptability of weight-loss medications represents a central finding of this study. Among participants who accepted pharmacotherapy, 90% (9/10) had obesity- related comorbidities and 80% (8/10), had a history of infertility (Table 1). Many described lifelong struggles with weight management despite repeated lifestyle attempts. This cumulative burden, combined with the urgency of cancer treatment and fertility preservation appears to contribute to heightened receptivity. Similar patterns are emerging in diabetic populations where patients demonstrate greater willingness to initiate weight-loss medications if their intention is to treat diabetes. (Hooker et al., 2025) Framing weight-loss medications as a medically indicated intervention aligned with patient health priorities is critical to acceptability. Participant concerns mirrored those reported in the general population about weight-loss medications including cost, side effects, and sustainability. (Donnan et al., 2022, Naveed et al., 2025) Transparent communication about the benefits, limitations, and evolving evidence base of weight-loss medications is essential. Clear discussion of long-term weight expectations and financial considerations will be critical to informed decision making and sustained adherence.

Interestingly, although stigma surrounding weight-loss medications was acknowledged, it was rarely perceived as a barrier. Framing weight-loss medications as part of cancer and fertility treatment appeared to legitimize its use and mitigate internalized stigma. This contrasts with literature on bariatric surgery in EC/AH populations, where invasiveness and perceived external stigma have been identified as major barriers to uptake. (Kim et al., 2023) Despite demonstrated efficacy, bariatric surgery rates in EC/AH have declined since 2008, (Suzuki et al., 2024) potentially reflecting concerns regarding surgical risk and social perception. Notably, the median BMI of our cohort was 34.8 kg/m² meaning most of our patients fall exactly into a critical treatment gap where they may not meet the criteria for bariatric surgery. If stigma and invasiveness are less prohibitive, weight-loss medications may achieve greater uptake especially for this young population of patients.

In a close review of participants who declined weight-loss medication, they did not differ substantially in BMI, comorbidity burden, or fertility history. They all viewed weight-loss medications as a last resort, which was shaped by personal experiences and treatment philosophies rather than societal stigma. These findings suggest that acceptability is not only shaped by clinical characteristics or societal perceptions but lived experiences and belief systems. Effective counselling will therefore require individualized discussions that acknowledge these experiences and reframe obesity as a chronic condition that requires early and effective intervention.

Participants’ obesity counselling experiences were consistent with prior literature demonstrating limited patient understanding of the obesity-EC/AH relationship due to limited or absent provider discussion. (Wilkinson et al., 2020, Tagai et al., 2023) There are, however, well- established education models in chronic conditions that we can model after to improve quality of obesity counselling. For example, diabetes self-management education models endorse early initiation of counselling, sustained longitudinal support, personalized incremental interventions, and interprofessional team collaboration ultimately improving glycemic control and health outcomes. (Sherifali et al., 2018) Applying similarly structured multidisciplinary frameworks to weight management in EC/AH may therefore enhance patient engagement and clinical outcomes. However, implementation will require system-level support. Obstetricians and gynecologists report barriers in providing weight-loss counselling including lack of time, insufficient referral pathways and lack of educational resources. (Huepenbecker et al., 2019) Meaningful improvement in obesity counselling in EC/AH will likely require integrated care pathways rather than isolated provider effort.

Patient perceptions of obesity in EC/AH are well documented in the literature. (Wilkinson et al., 2020, Kailasam et al., 2024, Gorzelitz et al., 2025) However, our study centres on a distinct and growing population: young, nulliparous individuals with EC/AH for whom fertility is a central motivation, unlike traditional post-menopausal cohorts. We provide actionable guidance for provider counselling including timing of counselling initiation and scripting to reduce blame. Furthermore, our study is the first to describe the specific facilitators and barriers to weight-loss medication use in this population. As weight-loss medications become increasingly integrated into obesity management, understanding these determinants is essential to ensuring patient-centred adoption within EC/AH care models.

Our findings highlight the need for early and comprehensive weight management counselling for young individuals diagnosed with EC/AH. Given participants’ desire for comprehensive counselling, incorporating allied healthcare professionals into weight management discussions or the development of a concurrent weight management program may be essential to ensure patient-centered support. Weight management counselling should be initiated after the initial appointment to avoid overwhelming patients and stirring feelings of blame but should still occur early in their care timeline and repeated throughout their treatment trajectory. As long-term sustainability data emerges on weight-loss medications, efforts should be made to communicate these findings in a clear and accessible manner to support informed patient decision-making.

Our study is limited by the small single-centre sample size and the fact that participants’ experiences may reflect institutional norms, patient–provider relationships, and access to care specific to this environment. Furthermore, we did not collect ethnic data, which means the impact of cultural and demographic attitudes, which often have a large impact on perceptions towards weight, was not analyzed. However, our study sample consisted of participants at different stages of treatment and family building journeys, which provides varied perspectives. Conducted at a tertiary urban centre within a single-payer healthcare system, the study captured experiences in a socioeconomically and ethnically diverse city with broad access to specialty care, further enriching the diversity of experiences represented. Our findings are critical in shaping weight management counselling in EC/AH and guiding patient-centered clinical trial design when evaluating the impact of weight-loss medication in this patient population.

In conclusion, our study highlights that weight-loss medications are acceptable to individuals with EC/AH and obesity, especially if combined with an honest and thorough risk–benefit discussion with healthcare providers. Our findings reiterate the need for comprehensive, early, empathetic, and longitudinal weight management support in this population focused on achieving the best health and fertility outcomes.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Oluwanifemi O. Adeoye: Writing – review & editing, Writing – original draft, Project administration, Formal analysis, Data curation. Dionne Gesink: Writing – review & editing, Investigation, Formal analysis, Data curation. Oleksandra Dzyubak: . Sarah E. Ferguson: Writing – review & editing, Supervision, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization. Soyoun Rachel Kim: Writing – review & editing, Supervision, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.