Diabetics present contraceptive dilemmas
The next patient in your exam room is a 32-year-old woman with type 2 (adult onset) diabetes. While she is obese, she does not smoke, and her chart shows no evidence of hypertension, nephropathy, or retinopathy. What birth control options can you offer her?
With type 2 diabetes becoming more prevalent in young women due to obesity, clinicians will be seeing an increase in similar scenarios, predicts Sarah Freeman, PhD, FNP, clinical professor in the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta and director of its family and women’s health nurse practitioner programs. Freeman will present on care of diabetic women at the October 2003 annual meeting of the Washington, DC-based National Association of Nurse Practitioners in Women’s Health.
The Atlanta-based Centers for Disease Control and Prevention (CDC) classifies diabetes and obesity as "twin epidemics" a 2003 CDC study shows a 61% increase in diagnosed diabetes and a 74% spurt in obesity from 1991 to 2001.1
According to the Washington, DC-based American College of Obstetricians and Gynecologists (ACOG), use of combination OCs by diabetic women should be limited to those who do not smoke; are younger than 35; and are otherwise healthy with no evidence of hypertension, nephropathy, retinopathy, or other vascular diseases.2 This same line of thinking may be extended to the transdermal contraceptive and the contraceptive vaginal ring as well, advises Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Cen-ter/Jacksonville. Kaunitz aided in the development of the 2000 ACOG practice bulletin that reviewed hormonal options for women with coexisting medical conditions.
"In the absence of data suggesting otherwise, it indeed makes sense to treat all combination methods similarly with respect to vascular disease risk factors," he states.
What contraceptive options are available for older diabetic women and those with hypertension, coronary artery disease, nephropathy, retinopathy, peripheral, or other vascular disease?
According to Kaunitz, appropriate contraceptive options include progestin-only methods, such as depot medroxyprogesterone acetate injections (DMPA or Depo-Provera, Pharmacia Corp., Peapack, NJ) and mini-pills, and intrauterine devices, including the ParaGard Intrauterine Copper Contraceptive (also known as the TCu-380A; Ortho-McNeil Pharmaceutical, Raritan, NJ) and the Mirena levonorgestrel intrauterine system (Berlex Laboratories, Montville, NJ).
Barrier methods represent an acceptable option for women with all classes of diabetes, says Freeman. Keep in mind that use of such methods must be correctly and consistently used to achieve the level of efficacy needed for women who may face health risks should an unintended pregnancy occur.
Contraception is key
Effective contraception is an important part of the medical management of diabetic women of reproductive age.3 Although expectant mothers with diabetes can and do have normal, healthy pregnancies and deliveries, they are at greater risk for complications such as preeclampsia, cesarean section, and infections.4 Pregnancy also can aggravate common diabetic complications such as retinopathy and nephropathy.5
Diabetes’ effect on pregnancy outcome also can impact the child. Infants of diabetic women are at higher risk of congenital malformations, premature birth, stillbirth, and abnormally large body size.3 Children of diabetic women also have a higher risk of becoming diabetic during their lives.3
"The stress of pregnancy can make the disease worse; so if you go into pregnancy, you are liable to come out of it with more damage than you went into it with," comments Freeman. "So, if women do not want to become pregnant, it is really important that we give them an effective method of contraception."
For women who have completed their families, sterilization should be discussed as a contraceptive option, says Freeman. Pregnancy can be problematic in diabetic women who already have vascular disease, such as nephropathy or retinopathy.3 If sterilization is chosen, the procedure should be conducted when the diabetic condition is under control; additional medical support may be necessary when sterilizing diabetics with vascular complications.3
Review the options
Early studies demonstrated that high-dose OCs impaired carbohydrate metabolism; however, today’s combined low-dose OCs have little or no impact on carbohydrate metabolism.6 In addition, OCs do not increase a woman’s chance of developing type 1 or type 2 diabetes.7 Women with gestational diabetes also do not appear to be at increased risk of developing type 1 or type 2 diabetes mellitus from combined pill use.8
Intrauterine devices are considered safe for diabetic women, with or without vascular disease.3 As with healthy women, intrauterine devices should be offered to those in monogamous relationships, since those at risk of sexually transmitted infections may be at increased risk for pelvic inflammatory disease following device insertion.3
For women with diabetes who do not have vascular disease, the Geneva-based World Health Organization (WHO) says that with DMPA injections, "the advantages generally outweigh theoretical or proven disadvantages," and the method may be provided.9 The WHO advises caution, however, in providing DMPA to diabetic women with nephropathy, retinopathy, or neuropathy; these women should be carefully monitored for adverse effects, it notes.9
It is important to monitor diabetic patients’ blood pressure, weight, and lipid status, part of what the National Diabetes Education Program terms the "ABCs" (A1C, blood pressure, and cholesterol) throughout the duration of contraceptive use as standard practice in managing the diabetic condition, says Freeman. (See "Teach diabetic patients to know their ABCs'" at the bottom of this article.)
"Blood pressure is the one that is most critical to deal with, especially since we are getting more evidence that uncontrolled blood pressure may not be a good choice with hormonal contraception,"10 states Freeman. Are you looking for information on contraception and coexisting medical conditions? Please send your topic suggestions to Rebecca Bowers, Editor, Contraceptive Technology Update, P.O. Box 740056, Atlanta, GA 30374. Fax: (404) 262-5447. Or e-mail Joy Daughtery Dickinson, Senior Managing Editor, at [email protected].]
References
1. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003; 289:76-79.
2. Kaunitz AM. The use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin No. 18: Clinical Management Guidelines for Obstetrician-Gynecologists; 2000.
3. Rivera R. Diabetic women need effective contraception. Network 1999; 19:9-10.
4. National Center for Chronic Disease Prevention and Health Promotion. Diabetes and Women’s Health Across the Life Stages: A Public Health Perspective; 2001. Accessed at: www.cdc.gov/diabetes/pubs/women/index.htm#2.
5. Wysocki S, Schnare SM. Current Advances In Oral Contraceptives. Accessed at: www.npwh.org/Oral-Contraception/.
6. Contraception for women with diabetes. Contraception Report 2000; 11:10-14.
7. Hannaford PC, Kay CR. Oral contraceptives and diabetes mellitus. BMJ 1989; 299:1,315-1,316.
8. Kjos SL, Shoupe D, Douyan S, et al. Effect of low-dose oral contraceptives on carbohydrate and lipid metabolism in women with recent gestational diabetes: Results of a controlled, randomized, prospective study. Am J Obstet Gynecol 1990: 163:1,822-1,827.
9. World Health Organization, Department of Reproductive Health and Research. Medical Eligibility Criteria for Contraceptive Use. Second ed.; 2000. Accessed at www.who.int/reproductive-health/publications/RHR_00_2_medical_eligibility_criteria_ second_edition/rhr_00_2_acknowledgments.html.
10. Lubianca JN, Faccin CS, Fuchs FD. Oral contraceptives: a risk factor for uncontrolled blood pressure among hypertensive women. Contraception 2003; 67:19-24.
Resources
For more information on diabetes, review information at the National Diabetes Education Program web site, www.ndep.nih.gov. The web site, a joint program of the Bethesda, MD-based National Institutes of Health and the Atlanta-based Centers for Disease Control and Prevention, offers several patient education materials that may be ordered or freely printed using documents posted in Adobe Acrobat Portable Document Format. Those with multicultural populations may be especially interested in the brochure, "Take Care of Your Heart. Manage Your Diabetes," which is available in 15 Asian American and Pacific Islander languages, as well as Spanish. Order forms may be printed from the web site, then mailed to National Diabetes Education Program, One Diabetes Way, Bethesda, MD 20892-3600, or faxed to (301) 907-8906.
Teach diabetic patients to know their ABCs’
• A is for A1C.
The A1C test — short for hemoglobin A1C — measures your average blood glucose (sugar) over the last three months.
Suggested target: below 7.
• B is for blood pressure.
High blood pressure makes your heart work too hard.
Suggested target: below 130/80.
• C is for cholesterol.
Bad cholesterol, or low-density lipoprotein (LDL), builds up and clogs your arteries.
Suggested LDL target: below 100.
Source: Adapted from National Diabetes Education Program. Be Smart About Your Heart. Control the ABCs of Diabetes: A1C, Blood Pressure, and Cholesterol. November 2001. Accessed at: www.ndep.nih.gov.
The next patient in your exam room is a 32-year-old woman with type 2 (adult onset) diabetes. While she is obese, she does not smoke, and her chart shows no evidence of hypertension, nephropathy, or retinopathy. What birth control options can you offer her?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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