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Contraception in Women with Diabetes

5/1/2017 - Jane S. Limmer, MD

Mentor:  Todd Jenkins, MD

Editor:  Pamela D. Berens, MD

The prevalence of diabetes mellitus is increasing worldwide, including among women of childbearing age, with an additional 150 million adult cases projected by 2030. Diabetes poses significant risks to pregnant women and developing fetuses. These risks can be minimized through effective contraception and appropriate preconception care. According to the 2016 U.S. Medical Eligibility Criteria (MEC) for Contraceptive Use, only non-hormonal birth control methods such as barrier methods and the Copper IUD can be used without restriction (MEC Category 1) in women with diabetes. Diabetes is an independent risk factor for micro- and macrovascular disease, and contraceptives that do not further raise these risks are preferred. At the same time, the risks of unplanned pregnancies, particularly in the setting of poor glycemic control, must be weighed against the risks of the contraceptive.

There is no indication for diabetes screening prior to the initiation of any form of contraception. Concern has been raised about the impact of hormonal contraception on glucose metabolism; however, no short or long-term effects have been proven. After detailed review of the diabetic patient’s medical history, hormonal contraceptive methods can be considered.  Combined hormonal contraceptives (CHC) do not increase the risk of developing diabetes, even in patients with a history of gestational diabetes. CHC are safe and effective for women with diabetes not complicated by vascular disease (MEC Category 2). CHC can be prescribed in women with insulin-dependent diabetes unless they have severe microvascular disease such as retinopathy, nephropathy, and neuropathy, or the duration of disease is greater than 20 years. Estrogen-containing contraceptives are contraindicated in diabetic women with persistent hypertriglyceridemia or uncontrolled hypertension. Women with diabetes should have lipid and blood pressure screening prior to and after the initiation of CHC. CHC increase the risk of stroke and myocardial infarction in diabetic women. And CHC are not recommended for diabetic women who have any additional cardiovascular risk factors, such as tobacco use. Women with type 2 diabetes frequently have obesity and other associated cardiovascular risk factors which may affect the decision to prescribe CHCs.

Progesterone-only contraceptive methods, including pills, injections, implants, and the levonorgestrel IUD (LNG-IUD), are generally considered safe for women with diabetes. These methods have minimal impact on glucose metabolism, lipids, and thrombotic markers. An important exception to this is depot medroxyprogesterone acetate (DMPA). The risks of DMPA in diabetics with vascular disease or diabetes duration > 20 years are thought to outweigh the benefits, due to decreased HDL levels in women who use DMPA. DMPA use under these circumstances is MEC category 3, and is generally not recommended.

Sterilization is an option for diabetic patients who have completed childbearing. Surgical complications can be reduced by optimizing glycemic control at the time of the procedure. Obese diabetic patients may benefit from endometrial suppression from hormonal contraception or the LNG-IUD, and should be advised on these benefits as part of sterilization counseling. 

 

Condition Sub-Condition Cu-IUD LNG-IUD Implant DMPA POP CHC
    I C I C I C I C I C I C
Diabetes a) History of gestational disease 1 1 1 1 1 1*
b) Non-vascular disease            
 i) Non-insulin dependent 1 2 2 2 2 2
 ii) Insulin dependent 1 2 2 2 2 2
c) Nephropathy/retinopathy/neuropathy‡ 1 2 2 3 2 3/4*
d) Other vascular disease or diabetes of >20 years’ duration‡ 1 2 2 3 2 3/4*

1=no restriction for the use of the contraceptive method; 2=Advantages of using the method generally outweigh the theoretical or proven risks; 3=theoretical or proven risks usually outweigh the advantages of the method; 4=unacceptable health risk if the contraceptive method is used.*

 

Further Reading:

Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65.

Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65.

Gourdy, Pierre. Diabetes and Oral Contraception. Best Practice & Research Clinical Endocrinology & Metabolism27 (2013):67-76.

Initial Approval:  January 2017

 

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