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Contraception in diabetes

Dr Bharti Kalra, MD Gyn


(PGIMS),
Cert Diab (Newcastle)
To freedom of speech and worship
and freedom from want
and fear,
(Pr Roosevelt)
a fifth one,
‘freedom from
the
tyranny of excessive fertility,
Sir should
Dugal be
Baird, 1965
added.
TALKING ABOUT
CONTRACEPTION
IS AS
IMPORTANT
AS TALKING
ABOUT ANY
OTHER
ASPECT OF
HEALTH
Talking about contraception

• An embarrasssment?
• A wastage of time?
• Of no importance?

• Not part of pre-pregnancy


counselling
• Not part of obstetrics
• Not part of gynaecology
• Not part of diabetology
AN EMBARRASSMENT ?

• Talking about contraception.

• Treating STD.

• Handling unplanned pregnancy.

• Coping with congenital malformation.


Talk plan

• What is contraception?
• The need for contraception
• Options in general’
• Options in diabetes
• Non-hormonal benefits of
contraception
• Implementation
• Counselling
• Conclusion
VOLUNTARY CONTROL OF
FERTILITY
TYPE I & II DM

Poor glycemic control at conception and


during embryogenesis is associated with up to
25 % increased risk of major congenital
malformation.
Ideal contraceptive

• No need for male cooperation


• Non-coital related
• Non-bedroom related
• Reversible
• Effective
• Safe
• Cost
• Private/Non-intruding
Options: NON-HORMONAL

• Coitus interruptus
• Periodic abstinence
• Condoms –Male Female
• Vaginal spermicides –Today
• Vaginal barriers Diaphragm
• Cervical cap
• IUCD CuT
• Multiload
Options: HORMONAL

• Combined Ocs
• Progestin only - Pills
- Implant

- IUCD
- Injectable
• Antiprogesterone (RU486) –under
trial
Options: PERMANENT

• Vasectomy
• Tubectomy
PEARL INDEX
No method 85

Fertility awareness 25

Withdrawal 17

Male Condoms 14

Progestin-only OCPs 5

Combination OCPs 0.5

IUD 0.8

Transdermal patch 0.7

Tubal ligation 0.55

Depo – Provera 0.3

Vasectomy 0.15
CONDOM

• MALE
Partner participation
STD prevention
• FEMALE
Polyurethane
Sensation preserved
Can be inserted prior to event
STD prevention
IUCDs

• Copper based
– CuT
– Multiload
• Progesterone based
– Mirena
• Silver based
– Silver lily
IUCDs
•Lack metabolic effects

•S/E theoretical increased risk of


salpingitis but practically negligible
(Apgar B, Am Ac F Physic, 1995)

•Mechanically - recommended if it is
essential to avoid pregnancy.
IUCDs

• Copper T 200.

• 103 diabetes vs. 119 normal.

• Comparable effectiveness, expulsion


rate, removal for bleeding and pain,
continuation rate, infection rate.
(Trafford Diabetes, 2006)
OCs

• Diabetes is not a
contraindication.
• Yet, women with diabetes are
less likely to receive Ocs.
OCs

• High estrogen
– Mala D
• Low estrogen
– Femilon
– Crisanta, Janya, Yasmin
• No estrogen
– Cerazette
OCs

• HIGH ESTROGEN OCs


impair insulin secretion.

lead to IGT.

reduce insulin receptors.

• CURRENT LOW DOSE OCs


no effect on carbohydrate
metabolism.
OCs

Triphasic pill with low progestin dose decreases


insulin sensitivity more than combined pill in both
normal women and those with previous GDM.
PROGESTOGENS
↓ HDL.
↑ LDL, triglycerides.
↑ vascular disease.
↑ risk of monilial vaginitis.
EFFECT ON TREATMENT

• Monitor blood glucose frequently.

• Be alert.

• Be prepared to change insulin/ OHA dose.

• Look for any evidence of contraindication


or complication
CONTRA INDICATIONS (OCP)
In Diabetes
Age > 35 yrs .
smoking ≥ 20 cigarettes / day
Duration of DM > 20 yrs.

DM with microvascular complications –


neuropathy
retinopathy
H/O DVT, pulm. embolism.
H/O CVA , IHD.

Hypertension BP ≥ 160/100 or with vascular disease


.
POPs
Omission is more likely to result in pregnancy.

S/E irregular menses


injectables and implants are suitable
for those in whom compliance is an
issue.

Deterioration of glycemic control may occur.

Norgestimate and desogestrel are lipid-


neutral
IMPLANTS/INJECTABLES

• No extensive research in women with


diabetes.
EMERGENCY CONTRACEPTION

• Safe in diabetes

• Yuzpe regime: not used often

• Progesterone-only pills: ipill , Pill72

levo-norgestrel
1.5 mg
• Mifepristone

• CuT
NON –CONTRACEPTIVE BENEFITS

• ↓ premenstrual syndrome , benign breast


disease
• ↓ blood loss , anemia, dysmenorrhoea
• ↓ Acne, hirsutism
• ↓ PID , ectopic pregnancy
• ↓ Malignancy: endometrium, ovary, colorectal,
lung

( breast, cervical, hepatocellular CA


Issues in Unplanned pregnancy

Obstetric – Missed abortion


- Cong . Malformation: NTD, CHD
- IUGR / macrosomia
Diabetes
- worsening of BG control
- complications
Alternatives to
contraception
• Unplanned and unwanted pregnancy
• Unplanned expenses
• Unplanned health problems
• Unplanned stress
Contraceptive goals
• Spacing
• Long term method
• Preservation of fertility?
• Emergency contraception
• Treatment of comorbid conditions

• Every woman is dynamic: goals will


change with time
Men in contraception
• Sociocultural, religious issues
• Men should be involved in
counselling

• TAKE THE LEAD


• TALK TO ALL MEN WITH DIABETES
• TALK TO ALL SPOUSES OF WOMEN
WITH DIABETES
Communication
• WATER method (bharti hospital)

• Welcome
• Ask
• Tell
• Explain
• Return
Benefits of communication
• Successful use
• Long term use
• Satisfaction
• Acceptance of side effects
• Further spread in community
OPTIONS IN DIABETES

Diabetes in

< 35 yrs; uncomplicated COCPs

Coronary artery disease or PVD. IUD

End stage renal disease Diaphragm

Retinopathy
Progestin Implants

Proliferative retinopathy DMPA,POPs


CONCLUSION
Contraceptive guidance
needs to be emphasized and
implemented as a part of
pre-pregnancy counselling
by general practitioners and
diabetologists, as well as
gynaecologists