Contraception for the insulin-dependent diabetic woman: the view from one clinic

Abstract

Experience in a large diabetic clinic has confirmed the suspicion that insulin-dependent diabetic women are at considerably increased risk of thromboembolic disease if they take combined estrogen/progestogen oral contraceptive preparations. The most obvious alternative, an intrauterine device, is associated with an unexpectedly high failure rate, probably because of an unusual metabolic interaction with the diabetic endometrium. In a small group of diabetic women the progestogen-only pill was found to be a successful form of contraception not associated with any side effects except for menstrual irregularities. For most diabetic women the choice of contraceptive should therefore be between a progestogen-only pill and a mechanical method. Female sterilization and injectable progesterone each have their place in particular circumstances. Careful counseling of each patient is essential to ensure the best choice of contraceptive and correct application of the chosen method.

PIP: Experience in a clinic for diabetics is recounted in terms of successful methods of contraception for the insulin-dependent woman. Earlier reports of increased risk to side effects (especially thromboembolic disease) and failure in women with diabetes using combined (estrogen/progestin) oral contraception were confirmed. The failure rate could be lowered by allowing the women to adjust their insulin dose, but the incidence of thrombotic disorder remains high. Of 120 insulin-dependent women taking the combined pill (compared with 156 nonuser diabetics) 6 patients had thrombotic episodes, whereas none of the controls did. The use of IUDs is discouraged among diabetic women because of an extremely high failure rate, probably caused by an unusual metabolic interaction with the diabetic endometrium. In this clinic, a small (n=45) group of women was given progesten-only contraceptives (norethisterone, .35 mg orally) and, of the 29 completing over a year on the preparation, 15 have had fairly regular bleeding and 14 have experienced very irregular cycles. Aside from the menstrual irregularity, the progesten-only pill proved successful; no pregnancies have occurred. This method is the recommended one for diabetic women. Equally successful with proper fitting and instruction were mechanical methods. Sterilization is only indicated when the family is completed or pregnancy is absolutely contraindicated.