Authors: Faria Afsana ( Assistant Professor, Department of Endocrinology, BIRDEM (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders), Dhaka, Bangladesh. )
Contraception for women with diabetes mellitus is an important issue mainly as the pregnancy outcome depends on glycaemic control before conception among women with diabetes. Type of diabetes as type 1 or type 2 Diabetes, women with history of gestational diabetes and breast feeding diabetic mothers may be a consideration in selecting a contraceptive .On the other hand presence of diabetic complications is a significant determinant. Different methods of contraception as oral, injectable, implant, intrauterine devices are available. Patient\\\'s choice and health issues both should be considered while prescribing a contraceptive to a woman with diabetes. Emergency contraception is sometimes required in situations where there is chance of contraceptive failure. This review article highlights different contraceptive methods, their use and limitations and will guide to make a rational choice for a woman with diabetes.
Keywords: Contraception, Diabetes mellitus, Gestational diabetes mellitus.
With the rising incidence if Diabetes, the prevalence of the metabolic disorder among women of reproductive age, is also increasing. Their reproductive health and contraception need careful consideration as unintended pregnancy with poor glycaemic control at the time of conception increases the risk of adverse pregnancy outcomes including stillbirth, congenital abnormalities, and perinatal mortality. In order to minimize complications, safe and effective contraception is of great importance for all women with DM.1 Contraception for women with diabetes mellitus is an important factor as the pregnancy outcome depends on glycaemic control starting from before conception to delivery. This has made planning of future pregnancy mandatory for patients with diabetes mellitus. Patients are advised for contraception until optimization of metabolic control has been achieved or until complete and contemporary treatment of the diabetes complications has been fulfilled.2 Choice of contraception depe ds on the aim: short lasting contraception aiming on future pregnancy planning or long lasting contraception targetting family planning 2 In women with diabetes mellitus it is extremely important to take into consideration the type of the diabetes, its duration,degree of metabolic compensation, presence of diabetic complications, body-mass index of the woman and presence of risk factors for cardiovascular diseases.2 In women with type I diabetes mellitus it is possible to use hormonal contraception depending on patient\\\'s request or on medical indications. This is considered only in cases when diabetes has less than 15 years duration and microangiopathic complications and other vascular risk factors are absent.2 It is important to advise contraception keeping in view the insulin requirement, its dosage correction and acquiring of strict metabolic control and maintaining body weight. Different suitable options may be offered to the woman with diabetes and the patient\\\'s choice should be considered in selecting the proper method. For this purpose each and every method with its challenges should be discussed individually. When the combined preparations are contraindicated, progestagenic oral hormonal contraception can be considered if gynaecological contraindications are absent and there is no risk for menstrual disturbances. In women with type 2 diabetes mellitus, combined hormonal contraceptives should be avoided as they could provoke clinical manifestation and deteriorate progress of diabetes mellitus.2
Contraception may be planned according to different diabetes related status of women in the reproductive age; Women with preexisting Diabetes, women with history of GDM and breast feeding diabetic women. Choice of contraception may depend on different stages of reproductive age; requiring temporary contraception i.e women having future pregnancy planning and women having completed their family and not planning a further pregnancy. Contraceptive method may vary according to the above mentioned criteria.
Overview of Contraceptives
Combined hormonal contraception (CHC) methods including combined contraceptive pills, transdermal contraceptive patches, combined vaginal rings, and combined injectable contraception are available. The advances in preparation of these oral combined contraceptive methods overrule the previously documented risks associated with these options. However, as the estrogen component of these combined contraceptive preparations increases the risk of thromboembolic manifestations, caution must be taken while prescribing these agents for women with diabetes having vascular co-morbidities. In diabetic patients with advanced complications or who have had diabetes mellitus for a long duration, combination contraceptive is usually the least recommended option and should only be considered if other contraceptive options are difficult to accept.3 On the other hand progesterone-only pill (POP) is considered as a safe contraceptive method for diabetic women of different ages irrespective of presence of complications and duration of diabetes. This safety factor makes POP an appropriate choice for women with diabetes, hypertension and or cardiovascular co morbidities. POP usually does not interfere with lactation, so it can be easily an option of choice for breastfeeding women during the postpartum period and even throughout the period of lactation. While POP is safe, to get it\\\'s efficacy it should be taken consistently daily , and it\\\'s failure rate will be increased if there is any disruption in it\\\'s regular schedule.3 ACOG (American College of Obstetrics and Gynecology) recommends the use of OCPs in women with diabetes younger than 35 years who do not smoke; are otherwise healthy; and show no evidence of hypertension, nephropathy, retinopathy, or other vascular disease. 4 Long-acting reversible contraceptives (LARC) have high efficacy, which makes it a preferable option for women with diabetes Mellitus. These long acting methods include copper elucidated intrauterine device (IUD), different i trauterine system (IUS), injectable contraceptives and progestogen-only subdermal implants. These IUD devices can cause menorrhagia and or polymenorrhea so caution should be taken for women who have bleeding-related disorders, such as heavy periods, anaemia, fibroids and on antiplatelet or anticoagulant treatment. With a few specific contraindications, this method of contraception is a better option with high efficacy and easily placed in the outpatient setting. Women for whom the POP is contraindicated, develop adverse events after using and who have normal menstrual cycle are typically excellent candidates for IUDs. The ideal candidate for the sub dermal implant would be a woman with diabetes who desires the highest contraceptive efficacy, a simple method and who can cope with irregular bleeding patterns.3 A Cochrane review5 focused on different explanations and evidences from randomized controlled trials regarding hormonal vs nonhormonal contraceptive methods among diabetic women. Results from several such studies inferred that there was very little evidence of adverse events of hormonal contraceptives on glycaemic control and diabetic complications. Although the quality of the data was not so conclusive, it identified that POP and IUD are not contraindicated in women of reproductive age having diabetes, whereas the Combined hormonal contraceptive was identified as having very little effect on glycaemic variability. Barrier methods include a range of contraceptives including diaphragms, cervical caps, as well as male and female condoms. Some involve using spermicide; however, there appear to be no studies contraindicating the use of spermicide from a diabetes perspective. These options usually have the highest failure rates as these are person-dependent, with efficacy rates depending on patient adherence and acceptability. Often some couples do not accept the use of barrier method, which decrease it\\\'s efficacy as with contraceptive methods. According to a survey, a male and female condom, is 98% and 95% effective with proper use respectively. On the other hand a diaphragm with spermicide has an effectivity of 92%-96%.6 Male and female permanent sterilization methods require an operative procedure; however, strict glycaemic control is mandatory prior to the surgery otherwise there is a risk of postoperative infection and profound co morbidities. Emergency contraceptive pills are often required for different reasons including incorrect use of contraceptives and following sexual abuse. These pills should be made accessible to women with increased risk of accidental conception. In perspective of diabetes there is no contraindications to prescribe emergency progestogen-only contraceptive pills within the recommended time period or to the use of the IUD within 5 days of unprotected intercourse or no more than 5 days after ovulation, when the menstrual cycle is regular helping the exact ovulation day calculation.7
Choices of Contraceptive Method
The World health organization (WHO) compares and contrasts the different methods of contraception among different group of diabetic populations (Table)
WHO (World Health Organization) Recommendation of Contraception8,9
WHO give following recommendation for women with diabetes:
1. Hormonal contraception is safe in women with diabetes without any micro or macrovascular complications.
2. Copper Intrauterine device is safe in both type 1 and type 2 Diabetic.
3. Emergency contraceptive is safe for all diabetics to prevent unintended pregnancy.
4. Injectable contraceptive is not contraindicated in healthy diabetic women.
5. Male and female sterilization remains an option.
6. Effective preconception contraception must be provided to all women till the achievement of glycemic target suitable for pregnancy.
On the other hand experts from Joslin Diabetes Center recommend to suggest family planning / contraceptive issues as follows. Depo-Provera and progestin-only oral contraceptives are less preferred in patients who have had gestational diabetes, as they can accelerate the development of type 2 diabetes. In patients with pre-existing diabetes, Depo-Provera may worsen glycaemic control. The intrauterine device (IUD) is preferred because it is a metabolically neutral and highly effective form of contraception.10
Incidence of DM in women of reproductive age is rising. Effective contraception is required in order to prevent unintended pregnancy and thus preventing adverse maternal and foetal outcomes. Thus Contraceptive choices need to be individualized for women at different stages of reproductive age. Women without complications have multiple choices for contraception and those with complications may need specialist advice. The risk benefit ratio should be clearly judged while prescribing a particular method.
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3.Broecker JED, Lykens JE. Contraceptive options for women with diabetes mellitus: an evidence-based guide to safety and patient counseling. AOA Health Watch, Dos against diabetes 2011; part 13.
4.ACOG Committee on Practice Bulletins-Gynecology. ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol 2006; 107: 1453-72.
5.Visser J, Snel M, Van Vilet HA. Hormonal versus non-hormonal contraceptives in women with diabetes mellitus type 1 and 2. Cochrane Database Syst Rev 2013: CD003990.
6.Robinson A, Nwolise C, Shawe J. Contraception for women with diabetes: challenges and solutions. Open Access Journal of Contraception. 2016; 7: 11-18.
7.Faculty of Sexual and Reproductive Health Care. Combined hormonal contraception. London: FSRH; 2011 (updated 2012). (Accessed August 19, 2015). Available from URL: http://www.fsrh.org/pdfs/CEUGuidanceCombinedHormonalContraception.pdf.
8.World Health Organization. Medical eligibility criteria wheel for contraceptive use; Geneva: WHO; 2015. (Accessed August 19, 2015). Available from URL: http://www.who.int/reproductivehealth/ publications/family_planning/mec-wheel-5th/en/.
9.National Institute for Health and Care Excellence. Guidance on long-acting reversible contraception (update). London: NICE; 2014. (Accessed August 19, 2015). Available from URL: http://www.nice.org.uk/CG30.
10.Joslin Diabetes Center and Joslin Clinic. Guideline for detection and management of diabetes in pregnancy 9/10/2010: Revised 06-15-11. (Accessed August 19, 2015). Available from URL: http://www.joslin.org/Preg_guideline_5_10_11_%282%29-0615-11.pdf.