What are suitable contraception methods for patients with diabetes, with and without complications?

Contraception for Patients with Diabetes

Women with well-controlled diabetes without complications can safely use all contraceptive methods available to women without diabetes, while those with vascular complications or nephropathy should avoid combined hormonal contraceptives and use progestin-only or non-hormonal methods instead. 1, 2, 3

Key Principle: Preventing Unplanned Pregnancy is Critical

• The risk of an unplanned pregnancy in women with diabetes outweighs the risk of any currently available contraception option, making effective contraception essential 1, 2
• Unplanned pregnancy in women with diabetes carries significant risks of congenital malformations if glycemic control is not optimized preconception (target A1C <6.5%) 1, 4
• All women with diabetes of childbearing potential should have family planning options reviewed at regular intervals to ensure effective contraception is maintained 1, 2

Contraception for Women WITHOUT Diabetes Complications

First-Line Recommendation: Long-Acting Reversible Contraception (LARC)

• Long-acting reversible contraception may be ideal for women with diabetes and is the preferred option 1, 2
• LARC methods include intrauterine devices (IUDs) and contraceptive implants, which provide highly effective contraception without requiring daily adherence 1

Combined Hormonal Contraceptives (CHCs) - Safe in Uncomplicated Diabetes

• Combined oral contraceptives (estrogen plus progestin) are safe and effective for preconception care in women with uncomplicated diabetes 3
• No consistent evidence shows that combined oral contraceptives significantly worsen glycemic control or accelerate microvascular complications in women with uncomplicated diabetes 3
• Blood pressure measurement is the only essential examination before initiating combined hormonal contraceptives (can be obtained in non-clinical settings like pharmacies) 1
• Glucose screening before contraceptive initiation is not necessary due to low prevalence of undiagnosed diabetes and minimal clinical impact of hormonal contraceptives on glucose metabolism 1

Progestin-Only Methods - Alternative Option

• Progestin-only contraceptives represent safe alternatives with excellent metabolic and vascular safety profiles 3
• These include progestin-only pills, depot medroxyprogesterone acetate injections, and progestin implants 3

Contraception for Women WITH Diabetes Complications

Absolute Contraindications to Combined Hormonal Contraceptives

Combined hormonal contraceptives must be avoided in the following situations: 3

• Nephropathy with proteinuria (>190 mg/24h increases risk of hypertensive disorders; >400 mg/24h increases risk of intrauterine growth retardation) 1, 3
• Active proliferative retinopathy 3
• Cardiovascular disease or established atherosclerosis 1, 3
• Multiple cardiovascular risk factors (hypertension, smoking, obesity) 3
• Hypertension (particularly if uncontrolled or with vascular disease) 1, 3

Recommended Options for Complicated Diabetes

For women with diabetes complications, use: 3

1. Progestin-only contraceptives (pills, injections, implants) - excellent metabolic and vascular safety profile 3
2. Intrauterine devices (copper or levonorgestrel-releasing) - highly effective non-hormonal or progestin-only options 3, 5
3. Barrier methods - safest but less effective, requiring consistent use 5

Special Considerations for Type 2 Diabetes

• Exercise caution when prescribing combined hormonal contraception in type 2 diabetes due to frequent association with obesity and vascular risk factors 3
• These comorbidities increase both thromboembolic and arterial risks with estrogen-containing contraceptives 3
• Progestin-only or non-hormonal methods are preferred in this population 3

Postpartum Contraception

• Contraception planning should be discussed and implemented immediately postpartum for all women with diabetes 1
• This is critical because insulin sensitivity changes dramatically after delivery, and another pregnancy should be carefully planned 1
• The same contraceptive recommendations apply in the postpartum period based on presence or absence of complications 1

History of Gestational Diabetes

• Women with previous gestational diabetes can safely use low-dose combined oral contraceptives (30 mcg ethinyl estradiol with 150 mcg levonorgestrel) without deterioration of glucose metabolism 6
• However, these women should be counseled about their increased lifetime risk of developing type 2 diabetes and the importance of effective contraception until ready for pregnancy 1

Common Pitfalls to Avoid

• Do not delay contraception while waiting for "perfect" glycemic control - the risk of unplanned pregnancy is too high 1, 2
• Do not prescribe combined hormonal contraceptives without assessing for diabetes complications, particularly nephropathy and retinopathy 3
• Do not assume all women with type 2 diabetes are appropriate candidates for combined hormonal contraceptives - assess cardiovascular risk factors carefully 3
• Do not forget to counsel about the critical importance of preconception glycemic optimization (A1C <6.5%) before discontinuing contraception 1, 4