Hormonal contraception in women with diabetes mellitus: special considerations

Contraception is an important issue for women with diabetes mellitus as unplanned pregnancy can present major maternal and perinatal complications. The rising incidence of diabetes worldwide means increasing thought needs to be given to contraceptive options for these women. This article reviews current evidence and recommends best practice for prescribing hormonal contraceptives in women with diabetes. Women with diabetes have the same choice of contraceptives as the general population, but the potential metabolic effects of hormonal methods need to be considered in relation to an individual's diabetic profile and their need for effective contraception. Currently, there appear to be wide variations in the way that professionals evaluate the risk-benefit equation, and significant differences in prescribing practice have been identified. The World Health Organization (WHO) has established medical eligibility criteria to assist in assessing such risks. Cardiovascular disease is a major concern, and for women with diabetes who have macrovascular or microvascular complications, nonhormonal methods are recommended. Studies of young women with diabetes and no vascular changes who are taking low-dose combined oral contraceptives (COCs) have been reassuring, although larger long-term studies are needed. There is little evidence that any changes in glycemic control caused by COCs are of clinical relevance. While low-dose COCs appear to cause minimal change in the lipid profile and may even be beneficial in this respect, there are some concerns in relation to progestogen only pills and injectable contraceptives in certain women. There is little evidence of best practice for the follow-up of women with diabetes prescribed hormonal contraception. It is generally agreed that blood pressure, weight, and body mass index measurements should be ascertained, and blood glucose levels and baseline lipid profiles assessed as relevant. Research on hormonal contraception has been carried out in healthy populations; more studies are needed in women with diabetes and women who have increased risks of cardiovascular disease.