Identify Contraceptive Considerations For Female Patients Who Have Diabetes

What should clinicians keep in mind when providing family planning for women with diabetes? Not only are these women at increased risk of macrovascular complications, microvascular complications, and metabolic syndrome, but the reproductive health implications they face include effects on fertility, vaginitis, urinary tract infections, maternal risks, and neonatal risks, says Eleanor Bimla Schwarz, MD, MS, professor of medicine at the University of California, Davis.

Schwarz and other clinicians recently presented information on diabetes management through online webinars hosted by the Association of Reproductive Health Professionals. [To access the webinars and earn continuing education credit, go to the organization’s website for the events, “Managing Diabetes: Increasing Provider Understanding of Reproductive Health Implications” (http://bit.ly/1Ylz0K1) and select the individual presentations.]

According to the CDC, 29.1 million people or 9.3% of the U.S. population have diabetes. Of this number, 21 million are diagnosed, and 8.1 million are undiagnosed.¹ These numbers mean that 27.8% of people with diabetes are undiagnosed, Schwarz notes. For women ages 18-79 years, age-adjusted incidence of diagnosed diabetes has increased since the 1980s; in 1980, the age-adjusted incidence rate was 3.5, while in 2014, it was 6.5.²

The prevalence of diabetes varies in different racial and ethnic groups, with American Indians and Alaskan Natives having the highest prevalence: more than twice that of non-Hispanic whites.¹ “The groups with a higher prevalence of diabetes are often the same groups that struggle with family planning, in part because of difficulty with access to family planning services,” notes Schwarz.

According to the CDC, women are at high risk for diabetes if they are overweight (body mass index of 25 kg/m² or greater) and have one or more of the following risk factors:

• low physical activity (less than 150 minutes of moderate-intensity activity, such as walking, per week);
• family history of type 2 diabetes;
• high-risk race/ethnicity (African American, American Indian or Alaska Native, Asian American, Hispanic or Latino, Native Hawaiian or Pacific Islander);
• have had a baby weighing nine pounds or more, or were diagnosed with gestational diabetes;
• high blood pressure (140/90 mmHg or higher);
• high cholesterol (240 mg/dL or higher);
• history of polycystic ovarian syndrome.³

Diabetes has been associated with menstrual abnormalities, such as oligomenorrhea (defined as infrequent menstruation, cycle length more than 35 days) and secondary amenorrhea (defined as absence of menstruation for six months or more in a woman who previously menstruated), says Schwarz. Better glycemic control and management to prevent diabetic complications can improve these irregularities and increase fertility rates similar to the general population, she notes.

Hyperglycemia damages the tissues of the body, especially the vascular tree; this statement is true for Type 1 and Type 2 diabetes, says Schwarz. The complications due to vascular effects often are divided into macrovascular, affecting the larger vessels, and microvascular, affecting the smaller vessels and capillaries. The macrovascular complications are caused by the buildup of atherosclerosis and include heart disease, peripheral artery disease, and stroke.

The most common cause of death among people with diabetes is cardiovascular disease. The risk of stroke is up to 400% higher in adults with diabetes compared with adults who don’t have the disease.⁴

What Are Options?

In talking with women with diabetes about contraception, look at the most effective forms of birth control, which are the intrauterine device and the contraceptive implant, for those women who cannot risk pregnancy due to their disease, says Lori Gawron, MD, assistant professor at the Salt Lake City-based University of Utah.

Diabetic women are candidates for a contraceptive that contains estrogen. Check the US Medical Eligibility Criteria for Contraceptive Use (US MEC) for guidance, notes Gawron.⁵ For women with a history of gestational diabetes, combination pills, the contraceptive patch, and the vaginal ring are classified as Category 1 (no restrictions for use), while for women with Type 1 or Type 2 diabetes with no evidence of vascular disease, these medications fall into Category 2, in which the chosen method generally can be used, with follow-up as needed.

For women with diabetes and complications (nephropathy, retinopathy, neuropathy, or other vascular disease) or diabetes of more than 20 years’ duration, use of estrogen-containing methods falls in Category 3 (usually not recommended; clinical judgment and continuing access to clinical services are required for use) or Category 4 (should not be used), depending on the severity of the condition.

REFERENCES

1. 1. Centers for Disease Control and Prevention. 2014 National Diabetes Statistics Report. Accessed at http://1.usa.gov/1Dtcela.
2. Centers for Disease Control and Prevention. Age-Adjusted Incidence of Diagnosed Diabetes per 1,000 Population Aged 18-79 Years, by Sex, United States, 1980-2014. Accessed at http://1.usa.gov/1Yk0Cz1.
3. CDC. Women at High Risk of Diabetes. Fact sheet. Accessed at http://1.usa.gov/24JYz7s.
4. Fowler MJ. Microvascular and macrovascular complications of diabetes. Clinical Diabetes 2008; 26(2):77-82.
5. CDC. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-86.