Hormonal Contraception

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Hormonal contraception contains either a progestin compound alone or in conjunction with estrogen. They can be administered orally, intramuscularly, transdermally, and transvaginally. Some IUDs also contain progestin. Estrogen does not affect glucose tolerance (5), but progestins do increase insulin resistance and decrease glucose tolerance in a dose and potency fashion (6-8). Estrogen slightly increases blood pressure (9) by increasing angiotensin production while progestins have no effect. Estrogens produce an increase in clotting factors while progestins have no effect (10-14). Estrogens favorably affect lipid profiles, decreasing LDL-cholesterol and increasing HDL-cholesterol, while progestins produce an opposite effect (15-19). Estrogen increases triglycerides, while progestins have no effect. When estrogens and progestins are combined as in combination oral contraceptives (COC), the lower doses and less androgenic progestins generally produce milder and a more estrogen-dominant effect on carbohydrate and lipid metabolism with no effect on glucose tolerance and favorable changes in serum lipids. Table 1 gives an overview of general metabolic effects on glucose tolerance, serum

Table 1

Metabolic Effects of Hormonal Contraceptive Components

Table 1

Metabolic Effects of Hormonal Contraceptive Components

Oral estrogen

Oral progestin

Progestin intramuscular injections and implants

Glucose tolerance

Neutral

T Insulin resistance,

T Insulin resistance,

T HDL-Chol

T glucose tolerance

Tglucose tolerance

Serum lipids

i HDL-Chol

i Triglyceride

i LDL-Chol

T Triglyceride

T LDL-Chol

Minimal effect on HDL-C and Chol

Blood pressure

Slight T

Neutral

Neutral

Coagulation factors

T Globulins:

Neutral

Neutral

dose-dependent T

T increase; i decrease; HDL High-density lipoprotein; LDL low-density lipoprotein

T increase; i decrease; HDL High-density lipoprotein; LDL low-density lipoprotein lipids, blood pressure, and coagulation factors. In women with diabetes, these metabolic effects become important considerations when comorbidities exist, particularly hypertension or hyperlipidemia. Serum lipids and blood pressure need to be assessed to select the best formulation with the least possible metabolic effect. As a rule the lowest possible dose and potency formulations should be selected.

COC, containing both estrogen and progestin, have been extensively studied for over 40 years. Today's formulations contain lower doses of both ethinyl estradiol (20-35 mg) and various formulations of progestins. They have an excellent safety profile and can be prescribed in healthy women without physical examination, except for a blood pressure measurement. Newer combination methods deliver estrogen plus progestin via injection, transdermally or intravaginally. These methods will be considered similar to COC in risks and benefits, but they lack long-term safety data and have limited metabolic data. These methods offer an advantage of longer duration of coverage, weeks to monthly dosing. Short-term and limited studies in healthy women show a neutral effect on blood pressure, coagulation factors, and lipid metabolism with combination injectable contraception (CIC) (20, 21). Minimal information is available regarding metabolic effects of the transdermal patch (22) or vaginal ring. Data are also limited regarding the newer progestin-only implant containing etonogestrel, and therefore it will be considered together with well-studied levonorgestrel (LVN) implant and injectable depo-medroxyprogesterone acetate (DMPA).

Studies examining contraceptive use in diabetic or prediabetic women are similarly limited and generally retrospective (23), necessitating extrapolation from the vast number of clinical trials and epidemiological studies in healthy women as well as the World Health Organization classification of categories of contraceptive risk (24). Thus, most of the data presented will be a combination of level C evidence, expert opinion, and practitioner experience (Table 2).

The following series of questions will help the provider decide which methods of contraception are best suited to the patient with diabetes.

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Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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