Dr Shivani Sachdev Gour|Contraception in Diabetes.

Contraception in Diabetes.
Diabetes is classified into two categories: Type one (immune and non immune) and Type two (insulin resistance and hyposecretion) According to the journal NATURE more than 9% of Indians have diabetes. Adult onset diabetes (type two) which was predominantly a problem in those over 40 years of age is now being diagnosed in women as young as 25 years of age, giving rise to unique problems. According to a CDC (US) report 90% – 95% women who have diabetes are affected by type two diabetes. The incidence in the Indian population is 2.4% higher than that in the white population. Women are unique as any condition in the reproductive age has to be taken into while planning a pregnancy (as the condition can affect the health of the pregnant women and also the unborn child) and also deciding on contraception.
Contraception is an individual choice and today there are several options available for women with diabetes. The journal of Clinical Obstetrics and Gynaecology has advised that due to the risks to the mother and the baby in an unplanned pregnancy in diabetic women it is essential that an effect method of contraception be chosen

Contraceptive methods need to be effective, safe and also user friendly and keeping this is mind we will discuss various options available
Contraceptive methods are broadly classified as reversible and non reversible
We will discuss the reversible methods first

1 Contraceptive pills: There are over 20 brands of contraceptive pills in the Indian market. The Govt of India NFWP (National Family Welfare Program) started introducing the pill in 1968. Multiple surveys like the Bill Gates UIC Survey have shown that the usage of the pill is less than 5% of women in Indian as compared to the West. This seems to be primarily due to to mis conceptions surrounding its use.

Two types of pills are available: Combined pills and Progesterone only pill (Mini Pill). Most easily available are the combined pill (combination of two hormones estrogen and progesterone)

There are concerns that the pill may adversely effect metabolism of glucose and lipids and worsen diabetic control or increase requirement of insulin and or oral diabetic medication. The Cochrane meta analysis below (the most respected independent publication) looked at 36 studies and concluded that not enough evidence is available the oral contraceptives will not influence glucose and fat metabolism in women with diabetes, they could not reach any definitive conclusion and said that more studies are required http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003990.pub3/abstra...

The general consensus seems to be that women with diabetes with ”vascular involvement” should avoid the pill and those “without vascular involvement” can use it ( CDC from USA level 2 risk – benefits outweigh theoretical or proven risks). So it is best that you consult your doctor and do not use it over the counter or do not self medicate.

Progesterone only pill or mini pill has a lesser effect on metabolism of glucose and lipids and as per CDC USA can be used in women with “diabetes with vascular disease” (Level 2 risk – advantages out weigh theoretical or proven risks)

Figure 2

U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, from the CDC

Adapted from: www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

Guidelines from the U.S. Centers for Disease Control and Prevention (CDC) for assessing

contraceptive safety based on individual patient scenarios. Numbers shown are CDC safety categories:

1 = No restriction for the use of this method.

2 = Advantages of using the method generally outweigh the theoretical or proven risks.

3 = Theoretical or proven risks usually outweigh the advantages of using the method.

4 = Unacceptable health risk.

*Nephropathy, neuropathy, retinopathy or other vascular disease.

Abbreviations: DMPA—depot medroxyprogesterone acetate; LNG-IUS—levonorgestrel-releasing intrauterine system.

Source: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Centers for Disease

Control and Prevention (CDC), Farr S, Folger SG, Paulen M, et al. US Medical Eligibility Criteria for Contraceptive Use, 2010: adapted from

the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition. MMWR Recomm Rep. 2010;59(RR-4):1-86.

Severity Combined Progestin-only Injection Implant LNG IUS Copper T 380A

of disease hormonal pill (DMPA) (Implanon®) (Mirena®) (ParaGard®)

(pill, patch, ring)

Diabetes mellitus 2 2 2 2 2 1

without vascular

disease*

Diabetes mellitus 3/4 2 3 2 2 1

with vascular disease*

OR Duration

Some publications mention that newer pills with norgestinate (a type of progesterone) and synthetic estrogen is best suited to women with diabetes but it our recommendation would be to use pills under supervision.

Emergency contraceptive pills like the I pill are progesterone only pills and have the same safety profile as CDC grade 2 above. These do not protect from Sexually transmitted infection and are not recommended routinely only in an emergency.

Smoking increases the risk of complications in women with diabetes who use the birth control pill and it is not recommended in smokers. Risks include increase in blood pressure, thromboembolism (clots in blood vessels which can cause problems like stroke), increase cardiovascular disorders, increase angiotension production by the liver ( As per the German Pharmaceutical Manual).

2. Injectable progesterone: This is available as a quarterly injection and is not used commonly as cycles get very irregular and unpredictable. It is an effective contraceptive and level two risk for diabetes so can be used if the woman does not mind the cycle irregularity. The advantage is that it is more convenient than taking a daily tablet which some may forget.

3. Vaginal Rings with progesterone or Intrauterine devices with progesterone: these are generally recommended for women who have had a child and now want to wait for a few years before deciding on the next pregnancy. IUD with progesterone is expensive at Rs 8000 approximately and lasts for 5 years. The menstrual cycle may get irregular for 3 – 4 months after use but after 4 months most women will have a very scanty flow or no flow and no other side effect. Published literature suggests that this is safe for women with diabetes with little effect on carbohydrate metabolism.

5. Implants: These are small plastic rods which contain progesterone and are implanted beneath the skin. This procedure is done under local anesthetic. They are generally effective for 5 years. Irregular menstrual cycles are the most common side effects, these are not commonly used in India. Safety profile for diabetics is grade 2 CDC. Removal of the implants can be difficult sometimes and requires a procedure under anesthetic.

4. Non Hormone Intrauterine contraceptive device: Traditionally this was not recommended for women with diabetes due to the risk of infection but as per new recommendations this is safe and can be used for contraception and efficacy is for 5 to 7 years depending on which brand is used. According to the European Journal of Contraception and Reproductive Health Care the copper IUD is a useful option in women with vascular disease, proiferative retinopathy and nephropathy ( eye and kidney complications of diabetes)

5. Dos and Donts with the pill

Have your blood glucose ( A1C) blood cholesterol, lipids checked every three months while on the pill

Have your blood pressure monitored every three months

Urine exam to check for albuminuria are a must at 3 to 6 month intervals

Eye examination to check for retinopathy are a must as above

Weight loss in case of overweight is extremely important

Smokers advised to join support groups to reduce and quit

Do not self medicate

Barrier Methods: Like the condom or vaginal diaphragm. Most attractive advantage is avoiding the risk of sexually transmitted diseases like HIV and HPV (which can cause cancer of the cervix in women) and also avoids the use of any hormones which could affect diabetes control. It is also effec Many find it cumbersome and inconvenient. Data from the Govt of India National Family Health Survey NFHS – 2 show that only 3% of couples use this method regularly.

Non Reversible methods: Like sterilisation: Are ideally suited to those who have completed their family. It has an extremely low failure rate and avoids and side effects of medications. It is usually done by a small keyhole surgical procedure under general anaesthesia. Hospital admission is required for half a day and recovery is quick with return to work in 3 days. Cost is approx Rs 30,000 in a private set up. As per the NFHS – 2 data 32% of women use this which makes it the most popular form of contraception in India today.

Methods like vaginal washing/ douching after intercourse, spermicide creams and rhythm method (avoid intercourse during ovulation) are extremely unreliable with high failure rate and so not recommended

Conclusion: Diabetes is a very common problem in the Indian sub continent and effective contraception is extremely important as an unplanned pregnancy poses risks to both maternal and fetal wellbeing. Several safe options are available and its best to have an in depth discussion with your doctor before you decide on what suits your individual circumstance best. Regular monitoring and check ups are mandatory and will go a long way in ensuring a good outcome. Life style modifications are a part and parcel of living with diabetes and can optimise outcomes.

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