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The various contraceptive methods available and their suitability and contraindications in the case of diabetic patients are reviewed. After briefly discussing tubal sterilization, condoms, diaphragms and spermicides, and IUDs, and their respective safety and effectiveness, the risks and advantages of contraceptive steroids are analyzed in detail. It is concluded that the metabolic effects of estrogen-progestin combinations are more serious in many diabetics, and their use often increases the need for exogenous insulin, as well as the tendency to hyperlipemia, excessive weight gain, and hypertension, which are all factors that aggravate diabetes. The contraindications apply to cases of subclinical diabetes, because the administration of these drugs to genetically predisposed subjects may precipitate the appearance of clinical diabetes. Oral contraceptives should then be used only if IUDs are contraindicated in a specific case and the desire for future pregnancies precludes sterilization. Patients should then be carefully monitored, and the oral contraceptive used contain the smallest possible effective dose of estrogen (preferably ethinyl estradiol) and progestin (preferably other than the nortestosterone type of a 19-nortestosterone derivative in a very low dose).
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PMID:[Choice of a contraceptive method in the diabetic patient]. 121 58

Research and development in contraception has only limited interest in women over 35 years old, so we know little about safety, side effects, and effectiveness of contraceptives in this age group. In addition, clinical trials use healthy women which further limits our knowledge about contraceptives in women who have cardiovascular problems, diabetes, and liver conditions. Research does indicate, however, that women with high blood pressure should not take oral contraceptives (OCs) after the age of 35. It also shows that healthy and nonobese women over 35 who do not smoke and have no family history of cardiovascular disease before age 45 can take OCs with 30 mcg of ethinyl estradiol. Practitioners should provide these women with balanced and up-to-date information on the link between OCs and breast cancer and their apparent protective effect against endometrial cancer. The pregnancy rate for 35-39 year old married women using the diaphragm for at least 5 months stands at 1.1/100 women years. Contrary to popular belief, barrier methods can be harmful, e.g., urinary tract infections are more frequent in women who use the diaphragm than in those who do not. Women older than 35 should consider the condom because of its ability to reduce the risk of acquiring HIV or sexually transmitted diseases. Considerable research exists on women over 35 who use copper releasing IUDs. These IUDs are safe in women who do not have heavy menstrual bleeding. The levonorgestrel releasing IUDs are well tolerated in women over 35 since they reduce the amount and duration of menstrual bleeding. Besides users of these IUDs are less likely to have pelvic inflammatory disease and endometritis than those using copper releasing IUDs. Older women in developing countries often undergo hysterectomy for contraceptive purposes and because of heavy bleeding. Tubal ligation is a significant family planning method for older women in developing countries.
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PMID:Contraception after thirty-five. 131 37

The effectiveness of monophasic and multiphasic oral contraceptives (OCs) depends on their ability to suppress ovulation, change endometrial growth and ovum receptivity, and reduce cervical mucus receptivity to sperm. They are all more than 99% effective, but, depending on the type and dose of hormone components, they have different side effects. The estrogen component (ethinyl estradiol) of most new OCs is between 30 and 35 mcg, which reduces the risk of estrogen side effects, especially thromboembolism and hypertension. The Food and Drug Administration does not recommend use of an OC with an estrogen component for lactating mothers, while the American College of Obstetrics and Gynecology and the American Academy of Pediatrics believe it is fine. Estrogen may protect against coronary artery disease, yet the estrogen component of today's OCs is so low that the progestin component may cancels this beneficial effect. It also prevents breakthrough bleeding. The most frequently used progestins in OCs are norethindrone and norgestrel. They prevent ovum implantation, sperm penetration through the cervical mucus, and ovulation. Progestins, especially norgestrel, increase the risk of coronary artery disease. Other side effects include acne and weight gain. Progestin benefits are reduced menstrual blood loss, pain during menstruation, premenstrual tension, and endometrial cancer risk. The ideal estrogen-progestin balance depends on the individual, but the estrogen component should be between 30 and 35 mcg, and the progestin component should be the lowest possible dose to reduce metabolic side effects. If an OC user with a well stabilized cycle who takes another recently prescribed drug experiences unexpected breakthrough bleeding or spotting, this change may indicate a drug interaction. Absolute and/or possible contraindications of OC use are smoking after age 35, history of breast or endometrial cancer, liver disease or impaired liver function, cardiovascular risk factors, and diabetes mellitus.
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PMID:Benefits and risks of oral contraceptive use. 143 13

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

Women with gestational diabetes mellitus (GDM) diagnosed in the period 1978-1984 were followed for on average 6 yr after the index pregnancy. Thirty percent had diabetes mellitus at the follow-up examination, and preliminary results indicate that at least another third will develop diabetes during a subsequent pregnancy. Therefore, family planning and contraceptive guidance should follow the lines for women with pregestational diabetes. When low-dose hormonal contraceptives containing ethinyl estradiol and levonorgestrel were given to women with previous GDM, glucose tolerance and lipoprotein levels remained unchanged during a 6-mo treatment. However, insulin response to oral glucose increased significantly after hormonal intake for 6 mo. A triphasic preparation resulted in a significantly lower insulin response than a low-dose monophasic preparation. However, the results indicate that low-dose oral-contraceptive compounds appear to be safe for women with previous GDM when administered for limited periods. At the follow-up examination, we found no increased risk of developing diabetes in women with previous GDM who used oral contraception. We consider the intrauterine contraceptives (IUD) a safe and effective alternative for women with previous GDM. Of 154 women with GDM, 33% chose IUD, 22% a combination-type oral contraceptive, and 16% barrier methods as their first choice of contraception 2 mo postpartum. We conclude that family planning and qualified contraceptive advice are important in women with previous GDM.
Diabetes 1991 Dec
PMID:Preconception counseling and contraception after gestational diabetes. 174 46

We recently found circulating corticosterone (CS) levels to be significantly lower in diabetic female rats as compared with proestrous control animals. This reduction in CS was correlated with the hypoestrogenic state of the diabetic female. It was the purpose of this study to evaluate basal and corticotropin releasing hormone (CRH)-stimulated CS secretion in ovariectomized (OVX) control (C) and streptozotocin-induced diabetic (D) rats given blank, 5 mcg and 20 mcg estradiol (E2) implants to determine if adrenal CS secretion in the diabetic is normalized by E2 treatment. After 3 weeks of diabetes, pituitary-adrenal function was assessed in rats from each group with a CRH stimulation test. The remaining rats were sacrificed for determination of CS, E2, testosterone and fructosamine in serum. Suppressed CS secretion in OVX female diabetic rats was partially restored with E2 therapy. Basal CS levels were significantly higher in 20 mcg E2 treated C and D rats compared with OVX rats. However, C rats had significantly higher basal CS compared with D rats in similarly E2 treated groups. The CS response to CRH stimulation was not different between OVX female diabetic and control rats. Estrogen enhanced the CS response to CRH stimulation in control animals but not in diabetic animals suggesting altered estrogen action at the pituitary level in diabetic animals.
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PMID:Does estradiol treatment normalize the hypothalamic-pituitary-adrenal axis in streptozotocin-induced ovariectomized diabetic female rats? 176 Dec 79

Effective contraceptives contribute to the regulation of births, protect the health of women, reduce maternal and perinatal mortality and gynecological diseases, and prevent abortion-related complications. Complications after abortion average 30%, and among primigravidas the rate reaches 45%. Abortion can result in sterility and in the inability to carry out the pregnancy. Oral contraceptives (OCs) are used by 150 million globally. In new preparations ethinyl estradiol (EE) and levonorgestrel (LNG) are the most common components. In the 2-phase and 3-phase preparations Sequilar, Anteovin, and lipid profile safe Triquilar the gestagen component was reduced 40%. Continuin and Famulen are minipills, and Postinor is a postcoital contraceptive. Absolute contraindications of OCs include thromboembolytic diseases, severe cardiovascular system diseases, liver disorders, cirrhosis, cerebral vascular diseases, grave diabetes, jaundice, and malignant tumors of the mammae and sexual organs. Rigevidon, Triquilar, and Trisiston have high steroid content with minimal side effects. The protective effect of OCs are: 2-3 times lower risk of inflammation of the small pelvis, lower risk of malignant and benign ovarian tumors that lasts even after discontinuation, uterine cancer prevention (antiproliferation effect on the endometrium and inhibition of mitotic activity of the myometrium), and reduced risk of benign breast neoplasms. The finding that estrogen-induced risk of breast cancer increases with longterm contraceptive use in young nulliparas has not been persuasively proven. The optimal duration of uninterrupted OC use is 1-1.5 years. Monophasic estrogen-gestagen preparations include Bisecurin, Non-Ovlon, Ovidon, Rigevidon, Minisiston, and Demulen with low dosages of EE, LNG, norethisterone acetate, and diacetate ethonodiol. Norplant is a subdermal silastic capsule with effectiveness for up to 5 years.
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PMID:[Hormonal contraception]. 178 55

The best methods of contraception for women with insulin-dependent diabetes mellitus and gestational diabetes are discussed, with results of clinical trials in both types of patients. Women with IDDM require effective contraception since there are serious risks both to the mother and the fetus in case of unplanned pregnancy. For women reliable enough to use them consistently, barrier methods are satisfactory. IUDs are the choice for most diabetic women. In a trial of copper-T 200 IUDs in 103 diabetics compared to 119 normal controls, the effectiveness, expulsion rate, removals for bleeding and pain, and continuation rates were comparable. It was noted that there were no added infections in the diabetic group, who have an increased risk for infection generally. Oral contraceptives may worsen glucose tolerance, due to the effect of the progestogen decreasing diabetes, except in women with history of gestational diabetes. The authors found that a triphasic pill, with lower progestin dose, decreased insulin sensitivity more than did a combined pill, in both normal women and in those with previous gestational diabetes. Since natural estrogens, as used in estrogen replacement therapy in climacteric women, do not affect glucose tolerance as much as synthetic alkylated estrogens (i.e., ethinyl estradiol), the authors tried a combination of 4 mg estradiol, 2 mg estriol and 3 mg norethisterone for contraception in diabetic women. This experimental combination was compared with a low dose ethinyl estradiol-norethisterone monophasic, a progestin only pill, and an ethinyl estradiol-levonorgestrel triphasic. There were no differences among the groups in fasting plasma glucose, 24-hour insulin requirements, HbA1C levels, LDL, or free fatty acids. VLDL and HDL cholesterol and total cholesterol decreased in the natural estrogen group. There was a small, significant increase in LDL, VLDL and total cholesterol in the combined group. The authors also have preliminary results of a trial of a low-dose monophasic with ethinyl estradiol and gestodene, showing no adverse effects on glycemic control in IDDM patients. Thus low dose progestin, triphasic and natural estrogen-progestagen combination oral contraceptives can be recommended as safe to diabetics.
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PMID:Contraception for women with diabetes: an update. 195 24

Predisposing factors to cervical cancer development are age, smoking, socioeconomical status, parity, and number of sex partners. Long-term oral contraceptive (OC) use and less than 50 mg estrogen dose have been weakly linked to increased cancer risk. Regular examination and switching to other contraception in case of cervical intraepithelial neoplasia is recommended. Estrogen in sequential pills (Ovacon) increases the risks of uterine cancer by affecting the mucosa. Predisposing factors are: absence of pregnancy (nulliparity), postmenopause, hypertension, and diabetes. Parity reduces the risk. The risk is reduced in combined pills and after use of 1 year. Protection is offered by the progesterone component for 10-20 years after cessation of use. Ovarian cancer is prevented by parity and OC use even 10 years later. High estrogen levels inducing frequent ovulation damage the ovaries. Promoting factors are: old age, avoidance of breast feeding, and overweight. Breast cancer promoters are 1st pregnancy in older age, early menarche, and no pregnancy at all. OC use under age 25 and before 1st pregnancy are significant risk factors. High progesterone levels are associated with increased mitotic activity in the breast. Rare benign fibrocysts can develop into breast cancer. OC use is connected to hepatoma development mainly estrogen-induced. Liver cancer was found twice as high in OC users. Hepatoma often ruptures causing hemorrhage. 8% of liver tumors are malignant with a survival rate of 50% of patients to 4.8 years. The possible association of OCs to skin melanoma and hypophysial tumors could not be confirmed. OCs regulate menstruation, reduce bleeding, protect against uterine and ovarian cancer, but cervical and breast cancers have been influenced by them.
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PMID:[The contraceptive pill and cancer]. 207 68

The clinical use of estrogens and progestogens for menopausal women is reviewed, discussing the indications, results of studies on effectiveness of various agents o each target organ, contraindications, risk-benefit ratio, and types of drug preparations available and used in European countries. The indications for menopausal hormone replacement are primarily to prevent myocardial infarction and osteoporosis, and also to treat early menopause, urogenital atrophy, and severe skin, mucous membrane and psychic disorders. Mechanisms of action of estrogens and progestins, and anticipated results are detailed for each of the indications. Contraindications typical of oral contraceptives usually do not apply for hormone replacement. For example, only severe acute liver disease, current thromboembolism, endometrial cancer other than I, and breast cancer within 3-5 years of primary treatment are contraindications. Neither cervical, ovarian or vulvar cancer, diabetes, varicose veins, hypertension, nor history of liver disease or thromboembolism are contraindications: in some cases progestins or transdermal estrogens are recommended. Estrogen side effects suggest overdosage. Progesterone or its derivatives rather than oral contraceptive progestins are prescribed. There is a clear benefit, comparing cost of medication to that of treating consequences of estrogen deficiency. The preparations currently used in Europe include oral micronized estradiol, conjugated estrogens, transdermal patches, local vaginal estrogens, and injectable estradiol esters for those who cannot tolerate oral or transdermal agents. Preparations should contain progesterone unless the woman has had a hysterectomy. Combinations designed to avoid withdrawal bleeding are available.
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PMID:Clinical use of oestrogens and progestogens. 221 69


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