Oral Contraception & Diabetes John Eden, Australia    - Biography English - 2006-11-18

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The diabetic woman should always plan her pregnancy. Pregnancy may aggravate renal disease, retinopathy and coronary artery disease associated with diabetes. Pregnancy complications such as hypertension, polyhydramnios and urinary infection are significantly more common amongst women with diabetes. The diabetic woman’s baby is also increased risk of most pregnancy complications. Excellent blood glucose control at conception and during pregnancy can help reduce the incidence of these complications. Thus, it is apparent that the sexually active, reproductive age, diabetic woman needs access to reliable safe contraception.

Cardiovascular disease is a major concern for women with diabetes who have vascular complications and these women probably should not take the contraceptive pill. Studies of young women with diabetes without vascular changes have been reassuring, although larger long-term studies are needed. Low dose contraceptive pills appear to cause minimum change in the lipid profile and sometimes can even be beneficial. Oral contraceptives probably should not be used by women who have diabetic nephropathy as the oral contraceptives appear to activate the angiotensin system in such affected women although there are conflicting studies.

Teenage diabetics present special clinical dilemmas. Puberty aggravates insulin resistance. Most find that their menstrual cycle has little impact on glucose control but there is a subgroup who finds that the luteal phase tends to be associated with worse glucose control. Modern oral contraceptives do not appear to have much impact on blood glucose control.

The levonorgestrel emergency oral contraceptive is 89% effective when used correctly within 72 hours after unprotected sex and because of its short duration of action is probably safe for diabetic women to use. Certainly the real risk of unplanned pregnancy will greatly outweigh any theoretical hazards of this medication. Long acting injectable progestins such as Depot Provera are probably best avoided as they may aggravate insulin resistance. The diabetic woman who develops a complication or side effect whilst on this medication usually find that the effect lasts three to four months.

The levonorgestrel intrauterine system (Mirena device) offers considerable advantages over other hormonal contraceptives for diabetic women. The impact of the progestin is targeted on the endometrium but blood levels of levonorgestrel are much lower, even than the “mini-Pill”. When compared to a standard copper containing IUD, the Mirena device had no apparent effects on glycaemic control for in women with type 1 diabetes. After insertion of the Mirena device there is often a month or two of irregular bleeding but after that, menstrual loss is substantially reduced and the device offers excellent contraception.

For most reproductive age diabetics, a low dose combined contraceptive pill is probably safe, although the Mirena device is probably safer. Whatever hormonal contraceptive method is chosen it would seem prudent to regularly review glycaemic control and check the lipid profile more regularly during the first three or four months of therapy. Women who have evidence of vascular disease or renal disease probably should not take the combined oral contraceptive pill.




Learning objectives

After viewing this presentation the participant will be able to discuss: - Selecting the correct contraceptive method for a diabetic patient
- Menstrual control and the diabetic women
- The interaction between contraceptive methods and diabetic complications