What are suitable contraception options for someone with well-controlled diabetes?

Contraception Options for Women with Well-Controlled Diabetes

Women with well-controlled diabetes can safely use all contraceptive methods available to women without diabetes, as the risk of an unplanned pregnancy outweighs the risk of any given contraception option. 1

General Considerations

• Planning pregnancy is critical for women with diabetes due to the need for preconception glycemic control to prevent congenital malformations and reduce other complications 1
• All women with diabetes of childbearing potential should have family planning options reviewed regularly to ensure effective contraception is maintained 1
• Preconception care should include attainment of glycemic goals (ideally A1C <6.5%) prior to conception 1

Contraceptive Options

Long-Acting Reversible Contraception (LARC)

• Long-acting reversible contraception may be ideal for many women with diabetes 1
• Benefits include:
  • High effectiveness with minimal user error 2
  • Reduced risk of unplanned pregnancy 1
  • No need for daily adherence 2

Intrauterine Devices (IUDs)

• Copper IUDs:

  • Non-hormonal option with efficacy similar to perfect use of combined oral contraceptives 2
  • First-line option for women with history of deep venous thrombosis, pulmonary embolism, or coronary events 2
  • May cause heavier menstrual bleeding 2
  • Safe for use in women with diabetes 3, 2

• Levonorgestrel IUDs:

  • At least as effective as copper IUDs 2
  • Reduces menstrual blood loss; amenorrhea occurs in 35% of women after 2 years 2
  • Potential hormonal side effects (headache, acne, breast tension) 2

Hormonal Contraceptives

• Combined Oral Contraceptives (COCs):

  • Safe and effective option for women with uncomplicated diabetes 4
  • Should be avoided in women with:
    • Cardiovascular risk factors 4
    • Cardiovascular disease 4
    • Severe microvascular complications (nephropathy with proteinuria or active proliferative retinopathy) 4
  • Caution in type 2 diabetes due to frequent association with obesity and vascular risk factors 4
  • May affect carbohydrate metabolism - carefully monitor prediabetic and diabetic women 5

• Progestin-only methods:

  • Good metabolic and vascular safety profile 4
  • Alternative for women who cannot use combined hormonal contraception 4
  • Options include progestin-only pills, implants, and injections 4

Barrier Methods

• May be acceptable and reliable for well-motivated women with diabetes 3
• Options include male and female condoms, diaphragms, cervical caps 6
• Lower effectiveness than hormonal or intrauterine methods, especially with typical use 2
• Provide protection against sexually transmitted infections (unlike other methods) 2

Permanent Methods

• Sterilization (tubal ligation or vasectomy) for those who have completed childbearing 6
• Highly effective, permanent solution 6

Special Considerations

• Preconception planning is essential for women with diabetes who wish to become pregnant 1
• Women should achieve optimal glycemic control before discontinuing contraception 1
• Regular screening for complications that might affect contraceptive choice or pregnancy outcomes should be part of routine care 1
• The risk of unplanned pregnancy generally outweighs the risk of any given contraception option 1

Contraceptive Counseling Algorithm

1. Assess for contraindications to specific methods:

   • Check for cardiovascular risk factors, existing cardiovascular disease, or severe microvascular complications 4
   • Evaluate for hypertension, which may limit options 1, 5

2. Consider effectiveness needs:

   • For women requiring highest effectiveness: recommend LARC methods (IUDs) or permanent methods if childbearing is complete 2
   • For women comfortable with user-dependent methods: offer hormonal options or barrier methods 3

3. Consider patient preferences:

   • Non-hormonal options for those concerned about metabolic effects 6
   • Hormonal options for those seeking benefits like menstrual regulation 2, 4

4. Provide comprehensive education about:

   • Correct use of chosen method 1
   • Importance of preconception care when planning pregnancy 1
   • Signs of complications requiring medical attention 5