Diabetes and oral contraception

Differential Effect of 2 Hormonal Contraceptives on the Relative Telomere Length of Youth With Type 1 Diabetes

Context

Adolescents and young women (AYA) with type 1 diabetes (T1D) may require hormonal contraception for an extended period. However, it is unclear what effect hormonal contraception has on telomere length, a marker of the risk for complications.

Objective

To investigate the relative telomere length (RTL) in AYA with T1D (AYA-T1D) and healthy young women (AYA-C) after 18 months of combined oral contraception use (COC) with ethinyl estradiol/desogestrel, or a subdermal etonogestrel implant (IM).

Methods

A nonrandomized prospective study was performed in which 39 AYA-T1D and 40 AYA-C chose the COC or the IM. RTL was measured by monochrome multiplex-quantitative PCR in DNA from peripheral blood mononuclear cells (PBMC). The impact of contraceptives and clinical variables on RTL was assessed using lineal regression analysis.

Results

Longer RTL compared to baseline was observed in AYA-T1D (P < .05) and AYA-C (P  < .01) after using the IM. However, the total of AYA and the AYA-C group treated with COC decreased RTL after 18 months of treatment compared to baseline (P < .05). The type of contraceptive used was determinant for the changes in RTL compared to baseline in all subjects and controls (P ≤ .006). For AYA-T1D, HbA1c levels were not associated with RTL, but the high-sensitivity C-reactive protein was negatively related with the changes in RTL at 18 months compared to baseline (standardized R2 : 0.230, P  = .003).

Conclusion

IM was associated with longer RTL in AYA-T1D and AYA-C. In contrast, a shortening of telomere length in PBMC was observed after using COC.

Management of type 2 diabetes in pregnancy: a narrative review

The prevalence of type 2 diabetes (T2DM) at reproductive age is rising. Women with T2DM have a similarly high risk for pregnancy complications as pregnant women with type 1 diabetes. To reduce adverse pregnancy and neonatal outcomes, such as preeclampsia and preterm delivery, a multi-target approach is necessary. Tight glycemic control together with appropriate gestational weight gain, lifestyle measures, and if necessary, antihypertensive treatment and low-dose aspirin is advised. This narrative review discusses the latest evidence on preconception care, management of diabetes-related complications, lifestyle counselling, recommendations on gestational weight gain, pharmacologic treatment and early postpartum management of T2DM.

Contraception and diabetes: Which modalities should we consider in 2021?

Diabetes affects many women of reproductive age. Choice of contraceptive method is essential in order to combine efficacy and the patient's wishes, while taking into account the potential side effects. In this review, we will discuss the different methods available for women with diabetes, focusing the discussion on their metabolic and general effects. We will not discuss the side effects and contraindications common to all women, whether they have diabetes or not. The objective is to try to identify an algorithm to help in the decision to choose the most suitable contraceptive method for women with type 1 or type 2 diabetes.

Sexual Risk Behaviors of Adolescents with Type 1 Diabetes in Comparison with Their Peers

BACKGROUND

Adolescents with type 1 diabetes mellitus (T1D) may differ from peers regarding sexual risk behaviors.

OBJECTIVES

To explore sexual risk behaviors of adolescents with T1D in comparison with peers.

MATERIALS AND METHODS

The subjects were 174 adolescents, 58 adolescents with T1D (mean ± SD age 16.3 ± 2.0 yrs, disease duration 6.7 ± 3.5 yrs and HbA1c:8.0 ± 1.3%) and 116 without (matched 1:2). Anonymous, self-reported questionnaires were used to evaluate sexual education and behaviors.

RESULTS

Fewer adolescents with T1D than those without had a sexual experience (74.1% vs. 87.4%, p = 0.033), with similar age of sexual debut. Among adolescents with T1D, ≥2 risky behaviors were observed less frequently than adolescents without T1D (8.62% vs. 23.27%, p = NS respectively) and in fewer girls than boys in both adolescents with T1D (0% vs. 18.5%, p = NS) and adolescents without T1D (11% vs. 44%, p = 0.022). Adolescents with T1D with ≥2 risky behaviors were older (p = 0.031), younger at first sexual intercourse (p = 0.031), with higher maternal education (p = 0.039). Early sexual debut was associated with higher maternal education (p = 0.014) and HbA1c (p = 0.049). Most adolescents without T1D with ≥2 risky behaviors were boys and older than peers.

CONCLUSIONS

Adolescents with T1D and females were more cautious than adolescents without T1D regarding sex. The associations of increased risky behaviors with male gender, older age, younger age at sexual debut and higher maternal education in adolescents with T1D merit further investigation.

Pregnancy and contraception in women with Pre-Gestational diabetes in secondary Care- A questionnaire study

AIMS

To establish the knowledge of women with pre-gestational diabetes about of the risks of diabetes in pregnancy, and investigate their pregnancy plans, contraceptive choices, and preparedness for pregnancy.

METHODS

Women of reproductive age attending diabetes clinics across a single busy metropolitan NHS Trust were invited to fill in a questionnaire about pregnancy and contraception. The electronic health records of those women were also reviewed.

RESULTS

Ninety-six women completed the questionnaire. The majority of respondents (94%) had Type 1 Diabetes. Only 3% of women met the criteria of 'prepared for pregnancy'. Low efficacy contraception was used by 32% of women. Most women were only aware of a few risks to the mother and fetus in pregnancy, though the majority of women were aware of the importance of good glycaemic control before pregnancy. Previous pregnancies, or attendance at pre-conception counselling, did not improve participant knowledge.

CONCLUSIONS

Many women with diabetes of reproductive age are poorly prepared for pregnancy, but many are also using less effective contraceptive methods. These areas should be addressed if the poor pregnancy outcome in women with diabetes are to be improved, possibly through the development of an evidenced-based structured education course to target pre-conception and contraception.

Role of Lipid Management in Women's Health Preventive Care

Managing dyslipidemia over a women's life, including a focus on pregnancy, contraception, and atherosclerotic cardiovascular disease risk prevention can decrease the burden of cardiovascular disease.

Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology

Even though fertility is reduced, conception and delivery are possible in all stages of CKD. While successful planned pregnancies are increasing, an unwanted pregnancy may have long-lasting deleterious effects, hence the importance of birth control, an issue often disregarded in clinical practice. The evidence summarized in this position statement is mainly derived from the overall population, or other patient categories, in the lack of guidelines specifically addressed to CKD. Oestroprogestagents can be used in early, non-proteinuric CKD, excluding SLE and immunologic disorders, at high risk of thromboembolism and hypertension. Conversely, progestin only is generally safe and its main side effect is intramestrual spotting. Non-medicated intrauterine devices are a good alternative; their use needs to be carefully evaluated in patients at a high risk of pelvic infection, even though the degree of risk remains controversial. Barrier methods, relatively efficacious when correctly used, have few risks, and condoms are the only contraceptives that protect against sexually transmitted diseases. Surgical sterilization is rarely used also because of the risks surgery involves; it is not definitely contraindicated, and may be considered in selected cases. Emergency contraception with high-dose progestins or intrauterine devices is not contraindicated but should be avoided whenever possible, even if far preferable to abortion. Surgical abortion is invasive, but experience with medical abortion in CKD is still limited, especially in the late stages of the disease. In summary, personalized contraception is feasible, safe and should be offered to all CKD women of childbearing age who do not want to get pregnant.

Type 2 Diabetes in Pregnancy

Hyperglycemia is common during pregnancy, involving multisystem adaptations. Pregnancy-induced metabolic changes increase insulin resistance. Pregnancy-induced insulin resistance adds to preexisting insulin resistance. Preexisting pancreatic β-cell defect compromises the ability to enhance insulin secretion, leading to hyperglycemia. Women with type 2 DM have similar rates of major congenital malformations, stillbirth, and neonatal mortality, but an even higher risk of perinatal mortality. In utero type 2 DM exposure confers greater risk and reduces time to development of type 2 DM in offspring. Preconception care to improve metabolic control in women with type 2 diabetes is critical.

The Impact of Ethinyl Estradiol on Metformin Action on Prolactin Levels in Women with Hyperprolactinemia

Background Metformin reduced prolactin levels only in women with hyperprolactinemia.

Objective The purpose of this case-control study was to compare metformin action on lactoctrope function between women receiving oral contraceptive pills and women not using hormonal contraception.

Methods The study included two groups of matched women with elevated prolactin levels and new-onset prediabetes or diabetes. The first group consisted of 20 women using oral contraceptive pills for at least 12 months before entering the study, while the second group included 20 patients not using any hormonal contraception. Over the whole study period, all women were treated with metformin (1.7–3 g daily). Circulating levels of glucose, insulin, prolactin, thyrotropin, free thyroid hormones, adrenocorticotropic hormone, gonadotropins and insulin-like growth factor-1 were measured at the beginning and at the end of the study (16 weeks later).

Results Thirty-eight patients completed the study. Metformin reduced plasma glucose levels and improved insulin sensitivity but the latter effect was stronger in women receiving oral contraceptive pills than in women not using any contraception. Although metformin treatment decreased plasma prolactin levels in both study groups, this effect was stronger in women taking oral contraceptive pills. Only in this group of women, metformin increased plasma luteinizing hormone levels. The changes in plasma prolactin correlated with their baseline insulin sensitivity and the effect of metformin on insulin sensitivity. Metformin did not affect plasma levels of thyrotropin, free thyroxine, free triiodothyronine, follicle-stimulating hormone, adrenocorticotropic hormone and insulin-like growth factor-1.

Conclusions The obtained results suggest that the effect of metformin on overactive lactotropes depends on estrogen levels.

Oral contraception in adolescents with type 1 diabetes and its association with cardiovascular risk factors. A multicenter DPV study on 24 011 patients from Germany, Austria or Luxembourg

OBJECTIVE

To investigate differences in cardiovascular risk factors and metabolic control in girls with type 1 diabetes with or without use of oral contraceptives (OC) from the multicenter "diabetes prospective follow-up" (DPV) registry.

METHODS

Twenty-four thousand eleven adolescent girls (13 to < 18 years of age) from Germany, Austria or Luxembourg with type 1 diabetes from the DPV registry were included in this cross-sectional study. Multivariable regression models were applied to compare clinical characteristics (hemoglobin A1c [HbA1_C ], blood pressure, serum lipids, body mass index) and lifestyle factors (smoking, physical inactivity, alcohol consumption) between girls with or without OC use. Confounders: age, diabetes duration and migration background.

STATISTICAL ANALYSIS

SAS 9.4.

RESULTS

In girls with type 1 diabetes and OC use, clinical characteristics and lifestyle factors were less favorable compared to non-users. Differences were most pronounced for the prevalence of dyslipidemia (OC-users: 40.0% vs non-users: 29.4; P < .0001) and the number of smokers (OC-users: 25.9% vs non-users: 12.5%; P < .0001). OC use, sociodemographic characteristics and lifestyle factors explained between 1 and 7% of the population variance in serum lipids and blood pressure. The use of OC explained a small additional proportion in all variables considered (<1%).

CONCLUSIONS

OC use in adolescent girls with type 1 diabetes was associated with a poorer cardiovascular risk profile. Biological risk factors were partly explained by a clustering of sociodemographic and lifestyle factors with a small additional contribution of OC use. Prescription of OC should therefore be combined with a screening for cardiovascular risk factors and targeted education.

Review and Recommendations on Management of Adult Female Thalassemia Patients with Hypogonadism based on Literature Review and Experience of ICET-A Network Specialists

BACKGROUND

Multi-transfused thalassemia major (TM) patients frequently develop severe endocrine complications, mainly due to iron overload, anemia, and chronic liver disease, which require prompt diagnosis, treatment and follow-up by specialists. The most common endocrine complication documented is hypogonadotropic hypogonadism which increases with age and associated comorbidities. It is thus important for physicians to have a clear understanding of the pathophysiology and management of this disorder. Also to be aware of the side effects, contraindications and monitoring of sex steroid therapy. In this paper, practical ICET-A recommendations for the management of hypogonadism in adult females with TM are addressed.

METHODS

In March 2015, the Coordinator of the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A) conducted a two-step survey to assess the attitudes and practices of doctors in the ICET-A network taking care of adult female TM patients with hypogonadism. They were clinically characterized by the absence of pubertal development or discontinuation or regression of the maturation of secondary sex characteristics, and biochemically by persistent low FSH, LH and estradiol levels. Recently a supplementary survey on adult female hypogonadism in TM was undertaken within the ICET-A network.

RESULTS

The completed questionnaires were returned by 16 of 27 specialists (59.2%) following 590 female TM patients over the age of 18 years; 315 patients (53.3%) had hypogonadism, and only 245 (74.6%) were on hormone replacement therapy (HRT). Contraceptive oral pills (COC) were the first treatment choice in 11 centers (68.7%). A wide range of COCs was used with different progestin contents. In general, the patients' compliance to treatment was reported as good in 81.2 % of centers. The frequency of required tests for follow-up HRT, in addition to the regular check-up for thalassemia, was variable in the participating centers.

CONCLUSIONS

Doctors taking care of TM patients should have sound knowledge of the pathophysiology of hypogonadism in adult females with TM. They should know the potential effects of HRT including advantages and disadvantages of estrogen and progestins. Moreover, they should keep in consideration the emotional needs of these patients dreaming of attaining a full pubertal development.

Contraception for women with diabetes: challenges and solutions

Diabetes mellitus (DM), the most common of metabolic disorders, is a global public health concern. Numbers are rising with 383 million adults currently diagnosed with DM and another 175 million as yet undiagnosed. The rise in cases includes increasing numbers of women of a reproductive age whose reproductive health and contraception need careful consideration. Unintended pregnancy with poor glycemic control at the time of conception increases the chance of adverse pregnancy outcomes including stillbirth, congenital abnormalities, and perinatal mortality. In order to minimize complications, safe and effective contraception is paramount for all women with DM. This is a challenge as women have been found to be reticent to ask for advice, appear to lack understanding of risks, and are less likely to be using contraception than women without DM. The World Health Organization has developed Medical Eligibility Criteria to guide contraceptive choice. Women with DM without complications can choose from the full range of contraceptive methods including hormonal contraception as the advantages of use outweigh any risk. Women with diabetic complications may need specialist advice to assess the risk–benefit equation, particularly in respect of hormonal contraception. Women should be aware that there is no restriction to the use of oral and copper intrauterine emergency contraception methods. There is a need for an integrated approach to diabetes and reproductive health with improved communication between women with DM and their health care providers. Women need to be aware of advice and services and should make their own choice of contraception based on their needs and associated risk factors. Practitioners can offer nonjudgmental guidance working in partnership with women. This will enable discussion of risks and benefits of contraceptive methods and provision of advice dedicated to improving overall health and well-being.

The polycystic ovary syndrome: a position statement from the European Society of Endocrinology

Polycystic ovary syndrome (PCOS) is the most common ovarian disorder associated with androgen excess in women, which justifies the growing interest of endocrinologists. Great efforts have been made in the last 2 decades to define the syndrome. The presence of three different definitions for the diagnosis of PCOS reflects the phenotypic heterogeneity of the syndrome. Major criteria are required for the diagnosis, which in turn identifies different phenotypes according to the combination of different criteria. In addition, the relevant impact of metabolic issues, specifically insulin resistance and obesity, on the pathogenesis of PCOS, and the susceptibility to develop earlier than expected glucose intolerance states, including type 2 diabetes, has supported the notion that these aspects should be considered when defining the PCOS phenotype and planning potential therapeutic strategies in an affected subject. This paper offers a critical endocrine and European perspective on the debate on the definition of PCOS and summarises all major aspects related to aetiological factors, including early life events, potentially involved in the development of the disorder. Diagnostic tools of PCOS are also discussed, with emphasis on the laboratory evaluation of androgens and other potential biomarkers of ovarian and metabolic dysfunctions. We have also paid specific attention to the role of obesity, sleep disorders and neuropsychological aspects of PCOS and on the relevant pathogenetic aspects of cardiovascular risk factors. In addition, we have discussed how to target treatment choices based according to the phenotype and individual patient's needs. Finally, we have suggested potential areas of translational and clinical research for the future with specific emphasis on hormonal and metabolic aspects of PCOS.