Contraception for women with diabetes
Empowering women to choose the right contraception can make a huge difference to their lives – and to their experience of pregnancy should they choose that later down the line. This year’s Diabetes UK Professional Conference highlighted the importance of providing good contraceptive advice to women with diabetes.
As part of a session on women’s health, an extremely useful presentation was given by Dr Edward Mullins, clinical lecturer at Imperial College London and locum obstetrician – it was aimed at giving participants the confidence to bring up contraception in clinic when they see diabetes patients and raise awareness of where to signpost women for reliable information.
Some 33% of pregnancies are unplanned and this can have a significant impact on the lives of women and their partners. The benefit of contraception for all women is being able to control their lives and give them time and space for wanted pregnancy. For women with diabetes, it enables them to optimise glycaemia and their general health prior to conception. The best possible glycaemic control lowers chances of miscarriage and complications.
The Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists (FSRH) offers excellent information on contraception and also provides the UK Medical Eligibility Criteria, which is the safety guidance for contraception. It has four categories that assess whether benefit outweighs risk for women with various health conditions, including diabetes. The categories are:
- Category 1: A condition for which there is no restriction for the use of the method
- Category 2: A condition where the advantages of the method generally outweigh the theoretical or proven risks
- Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method; the provision of a method requires expert clinical judgment and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable
- Category 4: A condition which represents an unacceptable health risk if the method is used
For contraception in women with diabetes, all methods fall into category 1 or 2. The only exception is combined hormonal contraception (CHC) – for women with diabetes who also have nephropathy/retinopathy/neuropathy, or other vascular disease, it falls into category 3. The guidance can be found here: https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/.
Long-acting reversible contraceptives
Dr Mullins highlighted long acting reversible contraception (LARC) as extremely reliable methods of contraception for women with diabetes – there are four: Mirena (hormonal coil), the copper coil, subdermal implant and Depo-Provera (injectable). The statistics here were enlightening. Using LARC, the percentage of women who would become pregnant in a year is extremely low – for example, with the progestogen-only implant, it’s 0.05% for both perfect use and typical use, compared with the male condom, which is 2% for perfect use but 18% with typical use. For CHC, it’s 0.3% with perfect use, but 9% with typical use.
LARCs are more than 20 times as effective in preventing pregnancy than pills or barrier methods, and they’re cost-effective. Importantly, they are all either category 1 or 2 for women with diabetes or history of gestational diabetes.
He pointed out that, of course, a full menu of choice should be offered to women and they should not be pushed into choosing one over another. As a sidenote, emergency contraception is safe for all women with diabetes.
For CPD, Dr Mullins recommended the free resource of e-Learning for Healthcare, which has a contraceptive choices module. You can register with your GMC number and it takes about two hours to complete.
For patients and their partners, Sexwise [https://www.sexwise.org.uk/] is an excellent resource. Run by Public Health England, it covers all the different forms of contraception and their risks/benefits. For planning a pregnancy when you have diabetes, reliable sources such as Diabetes UK provide valuable information.
When women with diabetes were surveyed about contraception, the most popular options deemed suitable were condoms and pills, closely followed by the coil. Only 33% could recall having a conversation about contraception with a medical professional in the past 12 months, which is low.
He highlighted another survey on general awareness of contraceptive methods and, again, condoms and the pill came very high, whereas the much more effective LARC were low down. Health professionals can make a real difference by raising awareness of these.
With regard to the effect of contraception on glycaemia, Dr Mullins said there have been several small studies on combined oral contraceptives in insulin-dependent women. In general, no differences were found in fasting plasma glucose, insulin requirement, HbA1c and various other measures. When Cochrane reviewed this, it found that there is not enough evidence to prove that hormonal contraceptives do not influence glucose and fat metabolism in women with diabetes.
He summarised other research, such as a study looking at long-acting injectable progestogen and risk of type 2 diabetes in Latino women who’d had gestational diabetes. A cumulative difference in the rate of diabetes was seen, but he pointed out that in this and another study, there were serious confounding factors.
Dr Mullins does a lot of work on improving access to contraception. In the UK, access can be complicated because the system is fragmented between local authorities, primary care and secondary care. Systems such as making contraception universally available to all women who’ve just had a baby are making steps towards equity.
The views expressed in this article are those of the author, Dr Eleanor D Kennedy.