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Of the contraceptive choices open to a post-partum woman with gestational diabetes, this discussion concentrates on low-dose oral contraceptives. Although gestational diabetes usually clears at delivery, 75% of these women will go on to developed impaired glucose tolerance or overt diabetes, especially if they are obese or if their glucose level had been high. Many elect permanent sterilization, but those requiring reversible contraception usually choose the IUD or the pill. IUDs carry a high risk of infection and are less effective in diabetics. The author compared a low-dose combined pill with 400 mcg norethindrone and 35 mcg ethinyl estradiol (Ovcon 35), and a pill containing levonorgestrel (Triphasil), to barrier contraception in 230 women with recent gestational diabetes. After 6-13 months of use 11-17% of each group had impaired glucose tolerance, and 15-20% of each group had diabetes (n.s.). Insulin levels rose from 28.5 mIU/mL to 59.7 in controls, 32.0 to 71.8 in Ovcon 35 users, and from 40.2 to 85.1 in Triphasil users (p0.05). HDL values rose significantly in the group taking Ovcon, and LDL values fell significantly in all 3 groups. These low-dose pills can be used safely in postpartum gestational diabetic women, as long as they do not smoke, are encouraged to lose weight, and have no sign of cardiovascular disease as evidenced by albuminuria and an ophthalmoscopic exam.
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PMID:Contraceptive options for the gestational diabetic woman. 167 21

The incidence of polycystic ovarian disease (PCOD) varies from 0.6 to 92%, depending on the parameters analysed, PCOD has been reported to appear in association with Cushing's Syndrome, adrenal hyperplasia, hypothyroidism, adrenal and ovarian tumours and some genetic abnormalities. The controversy regarding the pathophysiological mechanism underlying the disease still persists. Critical evaluation of old data, assessment of new findings concerning the possible role of insulin, growth factors and their binding proteins, and extrapolation of neuroendocrinological experiments enabled the construction of a concise hypothesis of the pathophysiology of PCOD. According to this hypothesis, PCOD is a multifactorial disease. The sequence of events finally leading to clinical manifestation of the disease (hyperandrogenism, abnormal luteinizing hormone pulsatility pattern and ovulation disturbances) may originate in different organs or be triggered by different mechanisms. It may stem from the adrenals, the hypothalamus or higher central nervous system centres, or from the ovary itself; it may originate from excess of fat tissue usually combined with hyperinsulinism; or may be the result of a net increase in active growth factors. Each of the above disturbances probably appears early in life, much before the clinical signs of the disease are evident. Predisposing factors such as gestational diabetes of the mother, childhood obesity, borderline adrenal hyperplasia and late menarche have to be looked for as early as possible in order to prevent the late consequences of the disease, such as increased risk of infertility, endometrial and breast cancer and cardiovascular disease.
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PMID:Pathophysiology of polycystic ovarian disease: new insights. 180 58

Although large epidemiologic studies indicated no difference in the frequency of diabetes mellitus in nonusers and everusers of high-dose combination oral contraceptives, other studies had shown an increased risk of impaired glucose tolerance in current users, which is estimated to be roughly twice as frequent as that in nonusers. Women at risk of developing impaired glucose tolerance while receiving high-dose oral contraceptives either had previous gestational diabetes mellitus or were older, obese, or had a positive family history of diabetes mellitus. The tendency to decreased glucose tolerance seems essentially related to the dosage and chemical structure of the progestogen used in oral contraceptives, namely, estrane and particularly gonane progestins. However, increased frequency of impaired glucose tolerance and potentially diabetes mellitus are obviously not linked to the use of the more potent gonane progestins. The use of low-dose oral contraceptives, particularly with reduced progestogen content (such as in the triphasic formulations and last-generation monophasic preparations), is accompanied by a low risk of impaired glucose tolerance, even in previous gestational diabetes mellitus. The mechanism of decreased glucose tolerance in oral contraceptive users is unknown but seems related partially to increased peripheral resistance that is potentially caused by a postreceptor defect in insulin action. Changes in insulin production or metabolic clearance rate are not excluded by recent, sophisticated investigations of carbohydrate metabolism in oral contraceptive users. Impaired glucose tolerance and diabetes mellitus, chronic hyperglycemia, and hyperinsulinemia are believed to increase atherogenic risk either by their direct action or their effects on lipid metabolism. Newer epidemiologic studies now indicate that the incidence of cardiovascular disease in low-dose, low-risk, current oral contraceptive users has been substantially decreased. The use of low-dose oral contraceptives with reduced dosages of better adapted progestogens seems effective in decreasing alterations in carbohydrate metabolism and may thereby contribute to decrease further atherogenic risk in oral contraceptive users.
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PMID:Clinical aspects of the relationship between oral contraceptives, abnormalities in carbohydrate metabolism, and the development of cardiovascular disease. 219 5

The menstrual cycle of the diabetic woman is irregular, therefore natural methods are not very reliable. Among male contraceptive methods vasectomy has the advantage of simplicity, requiring only local anesthesia. It does not require surgical intervention in the diabetic woman, but the disadvantage is its irreversibility. There have been numerous attempts with steroids, vaccines, and chemical substances, however, there is no contraceptive yet that is effective and harmless. Once the diabetic woman has achieved the desired family size, sterilization is more often used and it is safe. Sterilization should not be performed during cesarean section, especially not during preterm delivery. The route of choice is laparoscopy or the vaginal route. IUDs are not recommended for nulliparous women because of the possibility of tubal inflammation and hence the effect on fertility. Oral contraceptives (OCs) have shown a diabetogenic effect that has not been fully confirmed. This effect is attributed to the progesterone component. The risk of cardiovascular disease increases in diabetic patients during long-term use according to some studies. A 1991 study indicated that low-dose contraceptives used for 6 months by women with gestational diabetes did not provoke changes in the glucose tolerance test and the lipid profile. Similar findings were obtained in 100 women followed up for 5 years who had been implanted subcutaneously with silicone capsules containing 16 mg of levonorgestrel. The contraceptive vaccine could solve all these metabolic problems, however, research is still at the beginning. In sum, for short-term use in nulliparous women low-dose OCs are suitable, while for the long term the IUD or female or male sterilization is recommended.
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PMID:[Contraception for the diabetic woman]. 796 35

In order to assess the clinical consequences of gestational diabetes in the index pregnancy, a group of patients with positive oral glucose challenge test and their matched controls have been closely followed up. No differences in perinatal outcome have been pointed out, except for the higher rate (p < 0.01) among diabetic patients of preterm delivery and pregnancy-induced hypertension. The prevalence of the latter has shown no relationship to maternal obesity. In view of these data, the future risk of cardiovascular disease of this cohort of patients needs to be assessed with a follow-up study.
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PMID:Does gestational diabetes represent an obstetrical risk factor? 805 Jul 27

This study was undertaken to determine whether impaired glucose tolerance and associated risk factors for cardiovascular disease can be improved with 'healthy living' by diet and exercise or with sulphonylurea therapy. Patients were recruited by screening subjects with either a family history of type II diabetes, previous gestational diabetes, or a previously raised plasma glucose (5.6-6.6 mmol/l). Impaired glucose tolerance was defined as hyperglycaemia on two separate tests, an achieved glucose level after a glucose infusion test above the 90th percentile of an age-matched normal population (> 9.3 mmol/l) or a fasting plasma glucose above the 95th percentile (> 5.6 mmol/l). Thirty-seven subjects with impaired glucose tolerance were entered into a randomized, prospective study for 6 months with allocations to healthy living or double blind to sulphonylurea (gliclazide 40 mg twice daily) or placebo tablets. The study took place in an out-patient setting, with three times weekly exercise sessions at a Sports Centre. After 6 months the placebo group showed no change in plasma glucose, cholesterol and blood pressure. The subjects receiving gliclazide showed improved glucose levels (mean fasting plasma glucose levels fell from 5.8 to 5.1 mmol/l, p < 0.05) but no significant change in plasma cholesterol or blood pressure. The healthy living group, after exclusion of four non-compliant subjects, showed no change in glucose levels, but a decreased systolic blood pressure (fall in mean from 124 to 116 mmHg, p < 0.05) and plasma cholesterol levels (fall in mean from 5.2 to 4.5 mmol/l, p < 0.01). with an increase in HDL:LDL ratio (rise in mean from 0.39 to 0.46, p < 0.05). Subjects with impaired glucose tolerance may benefit in different ways from gliclazide and healthy living. The metabolic responses to each therapy may help to decrease the risk of developing diabetes and cardiovascular disease.
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PMID:'Healthy living' and sulphonylurea therapy have different effects on glucose tolerance and risk factors for vascular disease in subjects with impaired glucose tolerance. 832 43

Of the various types of diabetes mellitus, non-insulin-dependent diabetes (NIDDM) is by far the most common and is increasing rapidly in many populations around the world. It is a heterogeneous disorder, characterized by a genetic predisposition and interaction between insulin resistance and decreased pancreatic beta-cell function. There is a strong association between the presence of obesity and low levels of physical exercise and the development of NIDDM. However, NIDDM may also develop in lean individuals and the incidence increases significantly with increasing age. A diagnosis of impaired glucose tolerance or gestational diabetes is a strong predictor for future development of NIDDM and should signal appropriate interventions to prevent or delay the progression to NIDDM. NIDDM is frequently associated with other conditions such as hypertension, hypertriglyceridemia and decreased high-density lipoprotein which are additional risk factors for atherosclerosis and cardiovascular disease. The 'insulin resistance syndrome', which includes obesity, NIDDM, hypertension, hyperinsulinemia and dyslipidemia is a major and increasing cause of morbidity and mortality in many populations. In addition, people with NIDDM and poor glycemic control may develop severe microvascular complications of diabetes, including retinopathy, nephropathy and neuropathy. Appropriate diet, weight control and increased physical activity will increase insulin sensitivity in insulin resistant patients and are effective treatments for patients with NIDDM or may prevent the development of NIDDM in susceptible individuals. If these measures are unsuccessful, then oral hypoglycemic agents or insulin therapy may be required.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:NIDDM--the devastating disease. 852 17

Findings are presented from the 1993 European Society of Contraception Oral Contraceptive Survey conducted in 12 member countries among 102 physicians. Findings are considered suggestive because of the low response rate of 25% to the mailed questionnaire to 400 physicians. The aim is to determine the prescribing practices of oral contraceptives. Over 50% of physicians prescribed the following modern, low-dose combined formulations: Marvelon, Mercilon, Minulet, Gynera, Cilest, and Femodene. 66% of physicians prescribed monophasic pills containing 20-30 mcg of ethinyl estradiol and low doses of desogestrel, gestodene, levonorgestrel, or norgestimate. 58% preferred oral pills because of their tolerability. Other desirable features were the cost, hormonal content, and other factors. 94% prescribed oral pills for women aged over 40 years who were healthy and did not smoke. 75% would not prescribe oral pills to women who were over the age of 35 years and who smoked. Over 50% of physicians recommended mammograms for women aged over 35 years who used oral pills. 45% routinely performed lipoprotein screening of oral pill users. 8% did so only for patients aged over 30 years. 42 physicians out of the 102 responding had a protocol based on the total cholesterol level. 61% prescribed oral pills for women with non-insulin-dependent diabetes. The majority prescribed oral pills for women with insulin-dependent diabetes. 38% of physicians who prescribed oral pills for women with diabetes prescribed very-low-dose monophasic oral contraceptives. 85% prescribed oral pills for women with gestational diabetes. 42% were concerned about patient risk of cardiovascular disease. The study revealed a range of practices among physicians.
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PMID:European Society of Contraception oral contraceptives survey update: birth control methods in "Europe of the 12". 857 53

Health plan "report cards," that is, published summaries of health plan performance, are a new way to help consumers select a health plan on the basis of cost and quality. The Health Plan Employer Data and Information Set (HEDIS) includes a set of health plan performance measures, standardized definitions, and methods for data collection. HEDIS is used as the basis for many report card initiatives and is the preferred tool of the managed care industry for measuring health plan performance. Nevertheless, the current list of HEDIS performance measures omits many health services, including medical nutrition therapy. Nutrition measures have the potential for wide appeal among health care stakeholders (ie, payers, consumers, and providers). Four measures related to medical nutrition therapy are proposed for managed care report cards: staffing for nutrition services and medical nutrition therapy for high cholesterol level, gestational diabetes, and cardiovascular disease. Barriers to adopting medical nutrition therapy measures in HEDIS include the need to address technical issues before considering new measures and competition from other potential measures. Steps to create support for medical nutrition therapy measures in HEDIS should focus on influencing representatives of health plans and employers to include these measures. The involvement of registered dietitians in the dynamic process of health plan evaluation is an important extension of ongoing efforts for strategic positioning in the managed care market.
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PMID:Nutrition measures for managed care report cards. 859 39

Insulin resistance appears to be central to obesity, NIDDM, hyperlipidemia, and cardiovascular disease. While obese women with abdominal (android) fat distribution are more insulin resistant than those with peripheral (gynecoid) obesity, in nonobese women, the relationship between abdominal fat and insulin resistance is unknown. By measuring regional adiposity with dual-energy X-ray absorptiometry and insulin sensitivity by euglycemic-hyperinsulinemic clamp in 22 healthy women, with a mean +/- SE body BMI of 26.7 +/- 0.9 kg/m2 and differing risk factors for NIDDM, we found a strong negative relationship between central abdominal (intra-abdominal plus abdominal subcutaneous) fat and whole-body insulin sensitivity (r = -0.89, P < 0.0001) and nonoxidative glucose disposal (r = -0.77, P < 0.001), independent of total adiposity, family history of NIDDM, and past gestational diabetes. There was a large variation in insulin sensitivity, with a similar variation in central fat, even in those whose BMI was <25 kg/m2. Abdominal fat had a significantly stronger relationship with insulin sensitivity than peripheral nonabdominal fat (r2 = 0.79 vs. 0.44), and higher levels were associated with increased fasting nonesterified fatty acids, lipid oxidation, and hepatic glucose output. Because 79% of the variance in insulin sensitivity in this heterogeneous population was accounted for by central fat, abdominal adiposity appears to be a strong marker and may be a major determinant of insulin resistance in women.
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PMID:Abdominal fat and insulin resistance in normal and overweight women: Direct measurements reveal a strong relationship in subjects at both low and high risk of NIDDM. 862 Oct 15


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