Reproductive-age. Contraceptive options for women with diabetes mellitus: An evidence-based guide to safety and patient counseling

Transcription

1 Contraceptive options for women with diabetes mellitus: An evidence-based guide to safety and patient counseling Jane E. D. Broecker, MD Jennifer E. Lykens, OMS IV Reproductive-age women with diabetes mellitus are in one of two categories: those desiring pregnancy or those not desiring pregnancy. For women who desire pregnancy, referral to an obstetrician/gynecologist for preconception counseling is essential, and excellent preconception glycemic control is necessary to decrease the risk of congenital anomalies and fetal loss. For women wishing to postpone pregnancy, a comprehensive contraceptive plan is imperative. April 2011 DOs Against DIABETES 11

2 There is a growing need for careful contraceptive counseling in women with diabetes mellitus. From 1990 to 1998, rates of diabetes mellitus increased 70% in women aged 30 to 39 years. 1 As Figure 1 indicates, an increasing number of Americans are being diagnosed with diabetes mellitus compared with two decades ago. 2 Currently, 1.85 million women of reproductive age (ie, 18 years to 44 years) have diabetes mellitus, and an estimated 500,000 women of this age have undiagnosed diabetes. 1 The comorbidities associated with diabetes mellitus, such as cardiovascular disease, renal impairment, retinopathy and morbid obesity, are becoming more common in women of reproductive age. 1 Therefore, a contraceptive plan is essential for women with diabetes mellitus who are at risk for pregnancy, and counseling of these women must take into account the relative safety of most forms of contraception, as well as the risks associated with pregnancy. Contraceptive counseling for women with diabetes mellitus must be evidencebased and combined with education materials that emphasize current safety data for hormonal contraceptive choices as they apply to such patients. The present evidence-based review of contraceptive use in women with diabetes mellitus includes safety data and key counseling points to assist clinicians in providing appropriate contraceptive choices for this patient population. Using guidelines in U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 (See Figure 2), 3 published by the Centers for Disease Control and Prevention (CDC), the present article explains and outlines current recommendations, taking into account patient risk factors and comorbidities. Contraceptive risks Women with diabetes mellitus need evidence-based contraceptive counseling, but many clinicians may focus on the risks of hormonal contraceptives while neglecting the potential risks of unintended pregnancy in these patients. Although text included in hormonal contraceptive package inserts and patient education resources lists risks related to the products, some of this text is the result of class labeling or legal concerns rather than evidencebased medicine. It is important to keep in mind that women with diabetes mellitus are at significantly higher risk of pregnancy complications than are women without diabetes, and the actual health risks of pregnancy often overshadow the risks of hormonal contraception. To make the best decisions based on each patient s unique medical problems and lifestyle, it is crucial to understand which of the listed risks are evidence-based. Pregnant women with diabetes mellitus are considered at high risk because of the increased maternal morbidity and mortality associated with pregnancy. These risks include preeclampsia and new onset of diabetes-related morbidities, such as nephropathy, retinopathy and worsening of preexisting vascular or renal disease. 4,5 The risks of such maternal complications are greater in patients with long-standing or poorly controlled diabetes mellitus than in other women. Pregnancy-related complications also occur more often in women with diabetes mellitus than in women without diabetes. These complications include higher rates of spontaneous miscarriage, polyhydramnios, pregnancyinduced hypertension, cephalopelvic disproportion and cesarean section. 4 When the risks of pregnancy are compared to the risks of each contraceptive option, it becomes clear that there are many safe and effective contraceptive choices for women with diabetes mellitus even those women who have moderately advanced disease. With regard to fetal or neonatal morbidity and mortality, physicians should be aware that congenital anomalies are eight times more likely in patients with diabetes mellitus (rate of 5.1%-9.8%) than in patients without diabetes. Such anomalies often involve the cardiovascular, renal, skeletal, and central nervous systems. 6,7 Because organogenesis occurs during weeks three to six of gestation, rates of congenital anomalies in women with diabetes who had strict pre-pregnancy glycemic control have been similar to rates in normoglycemic controls. 8,9 Other congenital complications associated with diabetes mellitus include macrosomia, respiratory distress syndrome and neonatal hypoglycemia Overview of contraceptive choices When considering contraceptive options for women with diabetes mellitus, assessing both efficacy and safety is important. Efficacy is highest for longterm contraceptive methods, somewhat less high for short-term hormonal therapies (for which daily, weekly, monthly or quarterly dosing may affect adherence and, thus, efficacy), and lowest for barrier or behavioral methods. The three long-term contraceptives available in the United States are the 10-year Copper T 380A (ParaGard ; Duramed Pharmaceuticals Inc, Cincinnati, Ohio) intrauterine device (IUD), the five-year levonorgestrelreleasing intrauterine system (LNG-IUS) (Mirena ; Bayer HealthCare Pharmaceuticals Inc, Wayne, New Jersey), and the threeyear etonogestrel-releasing subdermal implant (Implanon ; Merck & Co Inc, Whitehouse Station, New Jersey). Short-term methods involving estrogenand-progestin combinations include 12 DOs Against DIABETES April 2011

3 Figure 1. Growing Percentage of Americans with a Diagnosis of Diabetes by Age Age years Age years Age over 59 years An increasing number of people in the United States are being diagnosed as having diabetes mellitus today, compared with two decades ago. Among American women, 7.8% were diagnosed as having diabetes in , compared to 5.4% in Diabetes rates have increased most among individuals older than age 59 years. Source: Table 51. Diabetes among adults 20 years of age and over, by sex, age, and race and Hispanic origin: United States, , , and In: National Center for Health Statistics. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD: National Center for Health Statistics; 2010:258. daily oral contraceptives, the monthly vaginal ring (NuvaRing ; Merck & Co Inc) and the weekly contraceptive patch (Ortho Evra ; Ortho-McNeil-Janssen Pharmaceuticals Inc, Raritan, New Jersey). Short-term progestin-only methods include the quarterly depot medroxyprogesterone acetate (DMPA) injection (Depo-Provera ; Pfizer Inc, New York, New York) and daily progestin oral contraceptives. Emergency contraception is another short-term hormonal option. Nonhormonal barrier and behavioral methods include male and female condoms, diaphragms, caps, shields, spermicides, withdrawal, fertility awareness and natural family planning. At the completion of childbearing, elective sterilization may be considered. Long-term methods Contraceptives that do not rely on active participation of the patient have the highest efficacy among contraceptive methods, as well as very high safety ratings for patients with diabetes mellitus, regardless of severity of disease. The Copper T 380A, the LNG-IUS and the subdermal implant offer three excellent choices for patients. Although long-term methods are considered last by many patients and clinicians, the efficacy and safety of these methods warrant their consideration as first-line defense against unintended pregnancy. All three devices are easily placed by a physician or midlevel provider in an office setting. Placement takes just a few minutes and provides long-term reversible contraception with rapid return to baseline fertility after removal. Intrauterine contraception The Copper T 380A and the LNG-IUS are the two IUDs available in the United States. Despite high efficacy, safety and convenience, intrauterine contraception is underutilized in the United States, with only 5.5% of U.S. women using these devices. 12 The Copper T 380A does not contain hormones, while the LNG-IUS does. Thus, these devices have different adverse-effect profiles, expected bleeding patterns and benefits to patients. The duration of action of the Copper T 380A is listed as 10 years. Instead of releasing hormones, this device provides contraceptive efficacy secondary to the effect of copper ions in the uterine environment. It impairs sperm motility, alters the composition of cervical mucus and prevents fertilization. 13 Safe in nulliparous and parous women alike, 14 the Copper T 380A is rated by the CDC as safety category 1 (1=most safe to 4=least safe) for all patients with diabetes mellitus, regardless of severity of disease. Because this IUD can increase menstrual flow and lengthen duration of bleeding, caution is advised for women who have bleeding-related problems, such as heavy periods, anemia, fibroids or anticoagulation. With few contraindications, this method of contraception is safe, effective and easily placed in the office setting. Women who are sensitive to progestin-related adverse effects and who have normal menstrual patterns are typically excellent candidates for the Copper T 380A. The hormone-releasing LNG-IUS is also an excellent contraceptive choice for most women with diabetes mellitus, regardless of the severity of their diabetes or related comorbidities. With a CDC safety classification of category 2 meaning the advantages of using this contraceptive generally outweigh the theoretical or proven risks the LNG-IUS may be considered for almost any patient. Besides having a high safety rating, it also has high efficacy and patient satisfaction. It prevents pregnancy by impairing sperm motility and thickening cervical mucus. 13 With high intrauterine levels, but relatively low systemic levels of levonorgestrel, the LNG-IUS provides a dramatic reduction in menstrual blood loss with relatively few hormone-related adverse effects. 15 This device has indications not only for contraception, April 2011 DOs Against DIABETES 13

4 Figure 2 U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, from the CDC Adapted from: Severity Combined Progestin-only Injection Implant LNG IUS Copper T 380A of disease hormonal pill (DMPA) (Implanon ) (Mirena ) (ParaGard ) (pill, patch, ring) Diabetes mellitus without vascular disease* Diabetes mellitus 3/ with vascular disease* OR Duration >20 years 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. but also for the treatment of patients with heavy menstrual bleeding. The LNG-IUS does not change metabolic parameters. A study comparing the LNG-IUS with the Copper T 380A showed no differences in daily insulin requirement, glycosylated hemoglobin levels, or fasting blood sugar levels after 12 months of use. 16 Despite the benefits and efficacy of the LNG-IUS and Copper T 380A, these devices are underutilized in the United States because of a variety of factors. Many patients and clinicians are concerned that these devices may not be safe for teenagers or for women who have never given birth. Data from previous decades suggesting higher rates of pelvic inflammatory disease with the use of older types of IUDs are not easily forgotten. There are, however, excellent recent data on the safety and efficacy of the LNG-IUS and Copper T 380A in teens and nulliparous women. 14,17,18 The physician should be prepared to discuss evidence-based safety recommendations regarding the LNG-IUS for women with diabetes mellitus, women at increased risk of thrombophilia and young or nulliparous patients. The patient education materials provided by Bayer HealthCare Pharmaceuticals Inc, the manufacturer of the LNG-IUS, uses language that may lead patients to question the safety of the device. For example, both the Mirena educational brochure and the Web site instruct patients to tell your health care provider if you...have diabetes...[or if you] have problems with blood clotting Furthermore, the patient education information states, Mirena is recommended for women who have had at least one child. Nevertheless, evidence-based research does indicate the safety of the LNG-IUS for women with diabetes mellitus, women at risk of thrombophilia and young or nulliparous women. Subdermal implant The etonogestrel-releasing implant is safe (CDC safety category 2) for women with diabetes mellitus, and it provides the highest efficacy of any reversible contraceptive. 20 This 4-cm subdermal implant releases etonogestrel, a progestin, to prevent pregnancy for as long as three years. 21 With low systemic levels of progestin, contraceptive efficacy is achieved through two mechanisms: ovulation inhibition and thickening of the cervical mucus. In a study of metabolic effects of the subdermal implant in women with diabetes mellitus, there was a statistically significant reduction of total serum cholesterol, no change in low-density lipoprotein cholesterol (LDL-C) level, and no change in the ratio of highdensity lipoprotein cholesterol (HDL-C) to total cholesterol. 22 Carbohydrate metabolism was unchanged over the two-year study period, and no aggravation of vascular lesions was noted. 14 DOs Against DIABETES April 2011

5 With appropriate patient selection, continuation rates of implant use are high. Bleeding irregularity is the main reason for discontinuation in U.S. women. 21 Minimal weight gain (ie, 3 pounds after two years of use), changes in acne, and mood alterations are among the adverse effects that lead to implant discontinuation for some women. The ideal patient for the subdermal implant would be a woman who desires the highest contraceptive efficacy and a simple method of insertion and who would be tolerant of irregular bleeding patterns. Estrogen-and-progestin combination pills and other methods The most widely prescribed forms of contraception in the United States are those containing both estrogen and progestin. 23 These hormonal therapies include oral contraceptive pills, vaginal rings and patches. Combination therapies contain a range of ethinyl estradiol doses and varying types of progestins, which prevent pregnancy by blocking the luteinizing hormone surge (which would otherwise trigger ovulation) and by thickening cervical mucus. All combination contraceptives have similar efficacy and continuity data, with a 0.3% failure rate with perfect use in the first year and an 8.7% failure rate with typical use in the first year. 24 However, only approximately 68% of patients continue combination contraceptive use one year after starting the therapy. 24 Because pills must be taken daily, patches must be changed weekly, and rings must be changed monthly, a patient s ability to adhere to each regimen must be carefully assessed. Estrogen-containing contraceptives are preferred by many women because these methods offer such noncontraceptive benefits as improvement in acne, reduction in dysmenorrhea, decreased menstrual flow, and suppression of ovarian cysts. For women with diabetes mellitus who have no subsequent vascular disease, the advantages of combination contraceptive methods generally outweigh any theoretical or proven risks associated with these options. However, because estrogen increases the risk of clotting, caution must be used when prescribing combination contraceptive methods for women with diabetes in whom vascular co-morbidities have developed. In patients who have evidence of end-organ damage or who have had diabetes mellitus for more than 20 years, combination therapy is usually not recommended unless other contraceptive options are not available or acceptable. Figure 2 shows CDC guidelines for assessing contraceptive safety based on individual patient scenarios. As with any clinical decision, both clinical guidelines and individualized risk stratification must be considered when initiating a new contraceptive. Because diabetes mellitus is often diagnosed in the context of metabolic syndrome, it is important to consider the effects of combination estrogen-andprogestin therapy on both carbohydrate and lipid metabolism. However, with careful monitoring and appropriate counseling of patients, physicians should feel confident in prescribing combination therapy to women with diabetes mellitus. Studies of women with type 1 diabetes mellitus (T1DM) who used oral contraceptives have shown no change in levels of glycosylated hemoglobin or degree of nephropathy and retinopathy, compared to women with T1DM who did not use oral contraceptives. These findings suggest that these mediations did not accelerate vascular disease in the patients. 25 Discussing diabetes, pregnancy and birth control with women Birth control options for women with diabetes Choosing a safe and effective birth control method can be particularly confusing when patients are concerned about risks related to diabetes control. Following are some questions to review with your patients before making a decision about birth control: 1. How long until you want to become pregnant? Months, one year, five or more years? 2. What birth control methods have you used in the past? What were the pros and cons? 3. How frequently do you want to have to take or change your birth control? 4. Do you have any other risk factors that would limit your options? For example: smoking and over age 35 history of heart attack, stroke or blood clots migraine with visual changes uncontrolled high blood pressure liver or gallbladder diseases Some birth control options for patients to consider: Combined Hormonal: oral contraceptive pills Ortho-Evra TM, patch NuvaRing, vaginal ring Three-year implant (Implanon ) Intrauterine Device (IUD): Mirena, progesterone only Copper T 380A, no hormones Barrier Methods: Condoms/diaphragms Behavioral Methods Natural Family Planning Withdrawal Sterilization Tubal ligation/essure /Adiana Vasectomy April 2011 DOs Against DIABETES 15

6 Elevations in lipid levels, including total cholesterol, HDL-C and triglycerides, have been noted in patients using oral contraceptives. 26 In addition, oral contraceptives are associated with decreased insulin sensitivity. 26 These metabolic effects seem to vary depending on the progestin component included in the pill. Levonorgestrel has been associated with decreased insulin sensitivity However, pills containing drospirenone, desogestrel or gestodene tend to be metabolically neutral in terms of carbohydrate metabolism. 30,31 Despite these trends in lipid alterations, it is still considered safe to use combination contraceptives in patients with lipid dysfunction in the absence of more severe comorbidities because the benefits of contraception outweigh the risks. Once combination contraceptive therapy is determined to be a safe option for a patient with diabetes mellitus, the physician and patient must select which formulation is best pills, vaginal rings or patches. This decision should be driven by both patient preference and patient lifestyle, with some consideration given to the potential metabolic effects based on route of administration. Intravaginal ring NuvaRing is a vaginal ring containing etonorgestrel (an active form of desogestrel) as the progestin component, along with ethinyl estradiol. The steroid hormones in the ring are absorbed directly through the vaginal mucosa, minimizing first-pass metabolism through the liver and causing 30% to 40% less hormone exposure than from oral administration. The advantage of this local hormone administration is that fewer systemic effects have been noted in women with diabetes mellitus. Unlike use of oral contraceptives, use of the vaginal ring has resulted in no statistically significant change in total cholesterol or HDL-C levels though a continued elevation in triglyceride levels has been noted with the ring. 26 The vaginal ring is an excellent contraceptive method for women with diabetes mellitus who have no vascular disease and who prefer monthly administration, the benefits of an estrogen-containing contraceptive and a method they can control themselves. Transdermal contraception Ortho Evra TM is a contraceptive skin patch that delivers 0.15 mg daily of norelgestromin and 20 mcg daily of ethinyl estradiol transdermally. With hormone exposure similar to doses found in 35 mcg combination pills, this method typically has such adverse effects as nausea and breast tenderness. 32 The patch is changed once weekly for three weeks. It is then removed to allow for a one-week withdrawal bleed before placing the next patch. One consideration of patch use for patients with diabetes mellitus is that in clinical trials, women weighing more than 90 kg had a greater failure rate than women with weight less than 90 kg. 33 Concern regarding increased risk of thrombophilia is another consideration. One study showed the patch resulting in a more than two-fold increased relative risk of venous thromboembolism in patients without diabetes, compared to use of a 35 mcg norgestimate oral contraceptive. 34 This risk was lower than the risk of venous thromboembolism associated with pregnancy. The contraceptive patch is appropriate for women with diabetes mellitus who have no vascular disease and who have a normal body mass index and a strong desire for the benefits of an estrogencontaining contraceptive via weekly transdermal administration. When making recommendations regarding estrogen-containing contraceptives, it should be kept in mind that the American Congress of Obstetricians and Gynecologists guidelines for contraceptive use 23 emphasize that the following risk factors outweigh the benefits of combination therapies: smoking and age greater than 35 years; uncontrolled hypertension; personal history of stroke; ischemic heart disease or venous thromboembolism; migraine with aura; and current breast cancer or history of breast cancer with active disease within the previous five years. 23 Progestin-only methods Depot medroxyprogesterone acetate (DMPA) is an injectable progestin-only contraceptive that is administered every three months by intramuscular injection. Although highly effective in preventing pregnancy, DMPA has adversely affected carbohydrate and lipid metabolism. Use of DMPA causes only minimal changes in glucose tolerance, but its effects on lipid metabolism include increases in LDL-C and decreases in HDL-C. 35 Because of the adverse lipid effects of DMPA, this form of contraception has a CDC safety rating of category 3, meaning that risks outweigh benefits in individuals with vascular disease or other longstanding illness. Progestin-only pills According to CDC guidelines, progestinonly pills (Micronor [norethindrone]; Ortho-McNeil-Janssen Pharmaceuticals Inc, Raritan, New Jersey) have a safety classification of category 2 for all patients with diabetes mellitus with or without vascular disease. This safety rating makes the pills an appropriate choice for individuals who have diabetes with hypertension or vascular disease. Because this contraceptive method does not interfere with lactation, it is often chosen for breastfeeding women during the immediate postpartum period. While progestin-only pills are safe, adherence with this contraceptive option requires consistent daily dosing, and nonadherance results in significantly decreased efficacy. Emergency contraceptive options Safe to use for patients with diabetes mellitus, emergency contraceptive options (Plan B One-Step TM [Teva Women s Health Inc, Woodcliff Lake, 16 DOs Against DIABETES April 2011

7 New Jersey] and ellaone [HRA Pharma, Paris, France]) prevent ovulation and are indicated for emergency pregnancy prevention. Containing the progestin levonorgestrel, Plan B One-Step TM is available over the counter for women older than age 17 years. It is available by prescription for younger women. This pill prevents 85% of expected pregnancies when taken within 72 hours of unprotected sexual intercourse. 36 EllaOne, containing the progesterone receptor ulipristal acetate, is a newer form of emergency contraception. It is more effective than the levonorgestrel option and provides pregnancy prevention for five days (ie, 120 hours) after unprotected sexual intercourse. 37,38 With both emergency contraceptive options, the risks of unintended pregnancy outweigh any actual or theoretical risks of the medications. Patients should be educated on how to obtain emergency contraceptives, and prescriptions for these pills should be provided to patients using short-term or barrier methods. Barrier methods and natural family planning Condoms with spermicide, diaphragms, and natural family planning can be effective contraceptive methods when used consistently and correctly. However, these methods typically have the highest failure rates because they are user-dependent, with efficacy rates depending on patient adherence to recommended use. These methods may be considered for women who have spiritual beliefs that preclude the use of other methods of contraception, for women planning pregnancy within the next six months, or-rarely-for women with contraindications to every other method. Women choosing these methods should be informed about emergency contraceptive methods. For those women who desire a highly effective contraceptive without hormones, the Copper T 380A, previously discussed, is the best method. 39 Sterilization For women who have completed childbearing or who are confident that they will never desire pregnancy, surgical sterilization is an excellent option. However, sterilization procedures do not offer any of the noncontraceptive benefits of some of the hormonal methods previously outlined. A woman may choose from three methods of surgical sterilization: minimally invasive tubal occlusion (Essure [Conceptus Inc, Mountain View, California] or Adiana [Hologic Inc, Bedford, Massachusetts]); laparoscopic tubal ligation (clips, rings, or cautery); or tubal ligation at the time of cesarean section or other laparotomy. Efficacy is high for all three sterilization procedures, with the minimally invasive options of tubal occlusion offering the benefits of fast recovery time, minimal surgical risk, and exceptionally high efficacy rates. Vasectomy for the male partner is a surgical sterilization option for any couple in a life-long relationship. Of course, vasectomy has the drawback of providing no individual contraception for the woman should she have a change of partner. Final notes Contraceptive counseling is essential for women with diabetes mellitus. Yet, these patients are less likely to receive such counseling than are women without diabetes, 40 because physicians are often focused on the management of the diabetes. Physicians need to address contraceptive choices with their patients who have diabetes mellitus, because use of an appropriate contraceptive results in lower risks of morbidity and mortality compared with the risks of pregnancy. The safety guidelines established by the CDC can help physicians feel confident about their ability to provide safe contraceptive choices for women with diabetes mellitus, even those patients who have advanced disease. Patients with diabetes mellitus should be counseled about all contraceptive options, including such long-term methods as IUDs and subdermal implants as first-line recommendations. References 1. Centers for Disease Control and Prevention. Diabetes & Women s Health Across the Life Stages: A Public Health Perspective. Atlanta, GA: Centers for Disease Control and Prevention; womenshort.pdf. Accessed December 13, Table 51. Diabetes among adults 20 years of age and over, by sex, age, and race and Hispanic origin: United States, , , and In: National Center for Health Statistics. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD: National Center for Health Statistics; 2010: Accessed December 13, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. 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): rr5904a1.htm?s_cid=rr5904a1_e. Accessed December 14, April 2011 DOs Against DIABETES 17

8 4. Yogev Y, Xenakis EM, Langer O. The association between preeclampsia and the severity of gestational diabetes: the impact of glycemic control. Am J Obstet Gynecol. 2004;191(5): Hopp H, Vollert W, Ebert A, Weitzel H, Glockner E, Jahrig D. Diabetic retinopathy and nephropathy: complications in pregnancy and labor [article in German]. Geburtshilfe Frauenheilkd. 1995;55(5): Becerra JE, Khoury MJ, Cordero JF, Erickson JD. Diabetes mellitus during pregnancy and the risks for specific birth defects: a population-based case-control study. Pediatrics. 1990;85(1): de Valk HW, van Nieuwaal NH, Visser GH. Pregnancy outcome in type 2 diabetes mellitus: a retrospective analysis from the Netherlands. Rev Diabet Stud. 2006;3(3): Fuhrmann K, Reiher H, Semmler K, Fischer F, Fischer M, Glockner E. Prevention of congenital malformations in infants of insulin-dependent diabetic mothers. Diabetes Care. 1983;6(3): Alam M, Raza SJ, Sherali AR, Akhtar AS. Neonatal complications in infants born to diabetic mothers. J Coll Physicians Surg Pak. 2006;16(3): Ehrenberg HM, Durnwald CP, Catalano P, Mercer BM. The influence of obesity and diabetes on the risk of cesarean delivery. Am J Obstet Gynecol. 2004;191(3): Landon MB, Gabbe SG, Piana R, Mennuti MT, Main EK. Neonatal morbidity in pregnancy complicated by diabetes mellitus: predictive value of maternal glycemic profiles. Am J Obstet Gynecol. 1987;156(5): Guttmacher Institute. Facts on contraceptive use in the United States. contr_use.pdf. Published June Accessed December 13, Ortiz ME, Croxatto HB. Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action. Contraception. 2007;75(suppl 6):S16-S Lyus R, Lohr P, Prager S; Board of the Society of Family Planning. Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women. Contraception. 2010;81(5): Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116(3): Rogovskaya S, Rivera R, Grimes DA, et al. Effect of a levonorgestrel intrauterine system on women with type 1 diabetes: a randomized trial. Obstet Gynecol. 2005;105(4): Yen S, Saah T, Hillard PJ. IUDs and adolescents: an under-utilized opportunity for pregnancy prevention. J Pediatr Adolesc Gynecol. 2010;23(3): Suhonen S, Haukkamaa M, Jakobsson T, Rauramo I. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception. 2004;69(5): Safety considerations with Mirena. Bayer Healthcare Pharmaceuticals-Mirena Web site. with_mirena.jsp. Accessed December 14, Graesslin O, Korver T. The contraceptive efficacy of Implanon: a review of clinical trials and marketing experience. Eur J Contracept Reprod Health Care. 2008;13(suppl 1): Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM. Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials. Fertil Steril. 2009;91(5): Vicente L, Mendonca D, Dingle M, Duarte R, Boavida JM. Etonogestrel implant in women with diabetes mellitus. Eur J Contracept Reprod Health Care. 2008;13(4): Mosher WD, Martinez GM, Chandra A, Abma JC, Willson SJ. Use of contraception and use of family planning services in the United States: Adv Data. 2004;350: Hatcher RA, Trussell J, Stewart FH, et al. Contraceptive Technology. 18th rev ed. New York, NY: Ardent Media; Garg SK, Chase HP, Marshall G, Hoops SL, Holmes DL, Jackson WE. Oral contraceptives and renal and retinal complications in young women with insulin dependent diabetes mellitus. JAMA. 1994;271(41): Cagnacci A, Ferrari S, Tirelli A, Zanin R, Volpe A. Route of administration of contraceptives containing desogestrel/etonorgestrel and insulin sensitivity: a prospective randomized study. Contraception. 2009;80(1): Godsland IF, Walton C, Felton C, Proudler A, Patel A, Wynn V. Insulin resistance, secretion, and metabolism in users of oral contraceptives. J Clin Endocrinol Metab. 1992;74(1): Kasdorf G, Kalkhohh RK. Prospective studies of insulin sensitivity in normal women receiving oral contraceptive agents. J Clin Endocrinol Metab. 1988;66(4): Skouby SO, Andersen O, Saurbrey N, Kuhl C. Oral contraception and insulin sensitivity: in vivo assessment in normal women and women with previous gestational diabetes. J Clin Endocrinol Metab. 1987;64(3): Gaspard U, Scheen A, Endrikat J, et al. A randomized study over 13 cycles to assess the influence of oral contraceptives containing ethinylestradiol combined with drospirenone or desogestrel on carbohydrate metabolism. Contraception. 2003;67(6): Klipping C, Marr J. Effects of two combined oral contraceptives containing ethinyl estradiol 20 ug combined with either drospirenone or desogestrel on lipids, hemostatic parameters and carbohydrate metabolism. Contraception. 2005;71(6): Burkman RT. Transdermal hormonal contraception: benefits and risks. Am J Obstet Gynecol. 2007;197(2):134.e1-134.e Zieman M, Guillebaud J, Weisberg E, Shangold GA, Fisher AC, Creasy GW. Contraceptive efficacy and cycle control with the Ortho Evra/Evra transdermal system: the analysis of pooled data. Fertil Steril. 2002;77(2 suppl 2):S13-S Cole JA, Norman H, Doherty M, Walker AM. Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users. Obstet Gynecol. 2007;109 (2 pt 1): Westhoff C. Depot medroxyprogesterone acetate contraception: metabolic parameters and mood changes. J Reprod Med. 1996;41(suppl 5): Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet. 1998;352(9126): Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714): Russo JA, Creinin MD. Ulipristal acetate for emergency contraception. Drugs Today (Barc). 2010;46(9): Visser J, Snel M, Van Vliet HA. Hormonal versus non-hormonal contraceptives in women with diabetes mellitus type 1 and 2. Cochrane Database Syst Rev. October 18, 2006;(4):CD Schwarz EB, Maselli J, Gonzales R. Contraceptive counseling of diabetic women of reproductive age. Obstet Gynecol. 2006;107(5): HW Jane E. D. Broecker, MD, is an assistant professor of obstetrics and gynecology at Ohio University College of Osteopathic Medicine. Affiliated with O Bleness Memorial Hospital, she is a practicing physician seeing both obstetric and gynecologic patients and specializes in pediatric and adolescent gynecology. She has a special interest in contraception counseling. Dr. Broecker is a fellow of the American College of Obstetricians and Gynecologists. She can be reached at broeckerj@yahoo.com. Jennifer E. Lykens, OMS IV, is a fourth year medical student at Ohio University College of Medicine in Athens, OH. She plans to begin her career as a resident in obstetrics and gynecology at TriHealth (Good Samaritan/Bethesda North) in Cincinnati, Ohio in July DOs Against DIABETES April 2011