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Contraceptive options for women with diabetes mellitus: An evidence-based guide to safety and patient counseling

Jane E. D. Broecker, MD Jennifer E. Lykens, OMS IV

eproductive-age women with Rdiabetes mellitus are in one of two categories: those desiring or those not desiring pregnancy. For women who desire pregnancy, referral to an obstetrician/gynecologist for preconception counseling is essential, and excellent preconception glycemic control is necessary to decrease the risk of congenital anomalies and fetal loss. For women wishing to postpone pregnancy, a comprehensive contraceptive plan is imperative.

April 2011 DOs Against DIABETES AOA Health Watch 11 There is a growing need for careful “U.S. Medical Eligibility Criteria disproportion and cesarean section. 4 contraceptive counseling in women for Contraceptive Use, 2010” (See When the risks of pregnancy are compared with diabetes mellitus. From 1990 Figure 2), 3 published by the Centers to the risks of each contraceptive option, to 1998, rates of diabetes mellitus for Disease Control and Prevention it becomes clear that there are many increased 70% in women aged (CDC), the present article explains safe and effective contraceptive choices 30 to 39 years. 1 As Figure 1 indicates, and outlines current recommendations, for women with diabetes mellitus— an increasing number of Americans taking into account patient risk factors even those women who have moderately are being diagnosed with diabetes and comorbidities. advanced disease. mellitus compared with two decades With regard to fetal or neonatal ago. 2 Currently, 1.85 million women Contraceptive risks morbidity and mortality, physicians of reproductive age (ie, 18 years Women with diabetes mellitus should be aware that congenital to 44 years) have diabetes mellitus, need evidence-based contraceptive anomalies are eight times more likely and an estimated 500,000 women counseling, but many clinicians in patients with diabetes mellitus (rate of this age have undiagnosed diabetes. 1 may focus on the risks of hormonal of 5.1%-9.8%) than in patients without The comorbidities associated with contraceptives while neglecting the diabetes. Such anomalies often involve diabetes mellitus, such as cardiovascular potential risks of the cardiovascular, renal, skeletal, and disease, renal impairment, retinopathy in these patients. Although text included central nervous systems. 6,7 Because and morbid obesity, are becoming more in hormonal contraceptive package organogenesis occurs during weeks common in women of reproductive inserts and patient education resources three to six of gestation, rates of age. 1 Therefore, a contraceptive plan lists risks related to the products, some congenital anomalies in women with is essential for women with diabetes of this text is the result of class labeling diabetes who had strict pre-pregnancy mellitus who are at risk for pregnancy, or legal concerns rather than evidence- glycemic control have been similar and counseling of these women must based medicine. It is important to to rates in normoglycemic controls. 8,9 take into account the relative safety of keep in mind that women with diabetes Other congenital complications most forms of contraception, as well mellitus are at significantly higher risk associated with diabetes mellitus as the risks associated with pregnancy. of pregnancy complications than are include macrosomia, respiratory distress Contraceptive counseling for women women without diabetes, and the syndrome and neonatal hypoglycemia. 9-11 with diabetes mellitus must be evidence- actual health risks of pregnancy often based and combined with education overshadow the risks of hormonal Overview of materials that emphasize current contraception. To make the best contraceptive choices safety data for hormonal contraceptive decisions based on each patient’s When considering contraceptive options choices as they apply to such patients. unique medical problems and lifestyle, for women with diabetes mellitus, The present evidence-based review it is crucial to understand which of assessing both efficacy and safety is of contraceptive use in women with the listed “risks” are evidence-based. important. Efficacy is highest for long- diabetes mellitus includes safety data Pregnant women with diabetes term contraceptive methods, somewhat and key counseling points to assist mellitus are considered at high risk less high for short-term hormonal clinicians in providing appropriate because of the increased maternal therapies (for which daily, weekly, contraceptive choices for this patient morbidity and mortality associated monthly or quarterly dosing may affect population. Using guidelines in with pregnancy. These risks include adherence and, thus, efficacy), and preeclampsia and new onset of lowest for barrier or behavioral methods. diabetes-related morbidities, such The three long-term contraceptives as nephropathy, retinopathy and available in the United States are the worsening of preexisting vascular 10-year Copper T 380A (ParaGard ®; or renal disease. 4,5 The risks of such Duramed Pharmaceuticals Inc, maternal complications are greater Cincinnati, Ohio) in patients with long-standing or (IUD), the five-year - poorly controlled diabetes mellitus releasing intrauterine system than in other women. (LNG-IUS) (Mirena ®; Bayer Pregnancy-related complications HealthCare Pharmaceuticals Inc, also occur more often in women Wayne, New Jersey), and the three- with diabetes mellitus than in women year -releasing subdermal without diabetes. These complications implant (Implanon ®; Merck & Co Inc, include higher rates of spontaneous Whitehouse Station, New Jersey). miscarriage, polyhydramnios, pregnancy- Short-term methods involving estrogen- induced hypertension, cephalopelvic and-progestin combinations include

12 AOA Health Watch DOs Against DIABETES April 2011 Figure 1. with only 5.5% of U.S. women using 12 Growing Percentage of Americans these devices. The Copper T 380A does not contain hormones, while the with a Diagnosis of Diabetes by Age LNG-IUS does. Thus, these devices 30 have different adverse-effect profiles, expected bleeding patterns and benefits 16.9 to patients. 25 The duration of action of the Copper 15.1 T 380A is listed as 10 years. Instead of 20 releasing hormones, this device provides 12.8 contraceptive efficacy secondary to 15 the effect of copper ions in the uterine environment. It impairs sperm motility, 10 alters the composition of cervical 8.3 13 6.6 mucus and prevents fertilization. 15.5 Safe in nulliparous and parous 5 women alike, 14 the Copper T 380A is 1.1 1.7 1.7 rated by the CDC as safety category 1 0 1988-1994 1999-2002 2003-2006 (1=most safe to 4=least safe) for all patients with diabetes mellitus, regardless Age 20-39 years Age 40-59 years Age over 59 years of severity of disease. Because this IUD can increase menstrual flow and lengthen An increasing number of people in the United States are being diagnosed as having duration of bleeding, caution is advised diabetes mellitus today, compared with two decades ago. Among American women, for women who have bleeding-related 7.8% were diagnosed as having diabetes in 2003-2006, compared to 5.4% in 1988-1994. problems, such as heavy periods, Diabetes rates have increased most among individuals older than age 59 years. anemia, fibroids or anticoagulatio n. Source: Table 51. Diabetes among adults 20 years of age and over, by sex, age, and race and Hispanic origin: With few contraindications, this method United States, 1988-1994, 1999-2002, and 2003-2006. In: National Center for Health Statistics. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD: National Center for Health Statistics; 2010:258. of contraception is safe, effective and easily placed in the office setting. Women who are sensitive to progestin-related daily oral contraceptives, the monthly methods, as well as very high safety adverse effects and who have normal vaginal ring (NuvaRing ®; Merck & Co ratings for patients with diabetes menstrual patterns are typically excellent Inc) and the weekly mellitus, regardless of severity of candidates for the Copper T 380A. (Ortho Evra ®; Ortho-McNeil-Janssen disease. The Copper T 380A, the The hormone-releasing LNG-IUS Pharmaceuticals Inc, Raritan, New LNG-IUS and the subdermal implant is also an excellent contraceptive choice Jersey). Short-term progestin-only offer three excellent choices for for most women with diabetes mellitus, methods include the quarterly depot patients. Although long-term methods regardless of the severity of their medroxyprogesterone acetate (DMPA) are considered last by many patients diabetes or related comorbidities. injection (Depo-Provera ®; Pfizer Inc, and clinicians, the efficacy and safety With a CDC safety classification of New York, New York) and daily of these methods warrant their category 2—meaning the advantages progestin oral contraceptives. consideration as first-line defense of using this contraceptive generally is another against unintended pregnancy. All outweigh the theoretical or proven short-term hormonal option. three devices are easily placed by a risks—the LNG-IUS may be considered Nonhormonal barrier and behavioral physician or midlevel provider in an for almost any patient. Besides having methods include male and female office setting. Placement takes just a high safety rating, it also has high , diaphragms, caps, shields, a few minutes and provides long-term efficacy and patient satisfaction. It , withdrawal, reversible contraception with rapid prevents pregnancy by impairing sperm awareness and natural . return to baseline fertility after removal. motility and thickening cervical mucus. 13 At the completion of childbearing, With high intrauterine levels, elective may be considered. Intrauterine contraception but relatively low systemic levels of The Copper T 380A and the LNG-IUS levonorgestrel, the LNG-IUS provides Long-term methods are the two IUDs available in the United a dramatic reduction in menstrual blood Contraceptives that do not rely on States. Despite high efficacy, safety and loss with relatively few hormone-related active participation of the patient have convenience, intrauterine contraception adverse effects. 15 This device has the highest efficacy among contraceptive is underutilized in the United States, indications not only for contraception,

April 2011 DOs Against DIABETES AOA Health Watch 13 Figure 2 U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, from the CDC Adapted from: www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

Severity Combined Progestin-only Injection Implant LNG IUS Copper T 380A of disease hormonal pill (DMPA) (Implanon ®) (Mirena ®) (ParaGard ®) (pill, patch, ring)

Diabetes mellitus 222221 without vascular disease*

Diabetes mellitus 3/4 23221 with vascular disease* OR Duration >20 years

Guidelines from the U.S. Centers for Disease Control and Prevention (CDC) for assessing contraceptive safety based on individual patient scenarios. Numbers shown are CDC safety categories: 1 = No restriction for the use of this method. 2 = Advantages of using the method generally outweigh the theoretical or proven risks. 3 = Theoretical or proven risks usually outweigh the advantages of using the method. 4 = Unacceptable health risk. *Nephropathy, neuropathy, retinopathy or other vascular disease. Abbreviations: DMPA—depot medroxyprogesterone acetate; LNG-IUS—levonorgestrel-releasing intrauterine system. Source: Division of , National Center for Chronic Disease Prevention and Health Promotion; Centers for Disease Control and Prevention (CDC), Farr S, Folger SG, Paulen M, et al. US Medical Eligibility Criteria for Contraceptive Use, 2010: adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition. MMWR Recomm Rep. 2010;59(RR-4):1-86. but also for the treatment of patients to discuss evidence-based safety Subdermal implant with . The recommendations regarding the The etonogestrel-releasing implant LNG-IUS does not change metabolic LNG-IUS for women with diabetes is safe (CDC safety category 2) for parameters. A study comparing the mellitus, women at increased risk women with diabetes mellitus, and it LNG-IUS with the Copper T 380A of thrombophilia and young or provides the highest efficacy of any showed no differences in daily insulin nulliparous patients. reversible contraceptive. 20 This 4-cm requirement, glycosylated hemoglobin The patient education materials subdermal implant releases etonogestrel, levels, or fasting blood sugar levels after provided by Bayer HealthCare a progestin, to prevent pregnancy for 12 months of use. 16 Pharmaceuticals Inc, the manufacturer as long as three years. 21 With low Despite the benefits and efficacy of the LNG-IUS, uses language that systemic levels of progestin, contraceptive of the LNG-IUS and Copper T 380A, may lead patients to question the safety efficacy is achieved through two these devices are underutilized in the of the device. For example, both the mechanisms: inhibition United States because of a variety of Mirena ® educational brochure and the and thickening of the cervical mucus . factors. Many patients and clinicians Web site instruct patients to “tell your In a study of metabolic effects of are concerned that these devices may health care provider if you ...have the subdermal implant in women with not be safe for teenagers or for women diabetes...[or if you] have problems diabetes mellitus, there was a statistically who have never given birth. Data from with blood clotting...” 19 Furthermore, significant reduction of total serum previous decades suggesting higher rates the patient education information states, cholesterol, no change in low-density of pelvic inflammatory disease with the “Mirena ® is recommended for women lipoprotein cholesterol (LDL-C) level, use of older types of IUDs are not easily who have had at least one child.” and no change in the ratio of high- forgotten. There are, however, excellent Nevertheless, evidence-based research density lipoprotein cholesterol (HDL-C) recent data on the safety and efficacy does indicate the safety of the LNG-IUS to total cholesterol. 22 Carbohydrate of the LNG-IUS and Copper T 380A for women with diabetes mellitus, metabolism was unchanged over the in teens and nulliparous women. 14,17,18 women at risk of thrombophilia and two-year study period, and no aggravation The physician should be prepared young or nulliparous women. of vascular lesions was noted.

14 AOA Health Watch DOs Against DIABETES April 2011 With appropriate patient selection, disease, the advantages of combination when initiating a new contraceptive. continuation rates of implant use contraceptive methods generally Because diabetes mellitus is often are high. Bleeding irregularity is the outweigh any theoretical or proven diagnosed in the context of metabolic main reason for discontinuation in risks associated with these options. syndrome, it is important to consider U.S. women. 21 Minimal weight gain However, because estrogen increases the effects of combination estrogen-and- (ie, Ͻ3 pounds after two years of use), the risk of clotting, caution must be progestin therapy on both carbohydrate changes in acne, and mood alterations used when prescribing combination and lipid metabolism. However, with are among the adverse effects that contraceptive methods for women careful monitoring and appropriate lead to implant discontinuation for with diabetes in whom vascular counseling of patients, physicians some women. The ideal patient for the co-morbidities have developed. should feel confident in prescribing subdermal implant would be a woman In patients who have evidence of combination therapy to women with who desires the highest contraceptive end-organ damage or who have had diabetes mellitus. Studies of women efficacy and a simple method of diabetes mellitus for more than 20 years, with type 1 diabetes mellitus (T1DM) insertion and who would be tolerant combination therapy is usually not who used oral contraceptives have of irregular bleeding patterns. recommended unless other contraceptive shown no change in levels of options are not available or acceptable. glycosylated hemoglobin or degree Estrogen-and-progestin Figure 2 shows CDC guidelines for of nephropathy and retinopathy, combination pills assessing contraceptive safety based compared to women with T1DM and other methods on individual patient scenarios. who did not use oral contraceptives. The most widely prescribed forms As with any clinical decision, both These findings suggest that these of contraception in the United States clinical guidelines and individualized mediations did not accelerate are those containing both estrogen and risk stratification must be considered vascular disease in the patients. 25 progestin. 23 These hormonal therapies include oral contraceptive pills, vaginal rings and patches. Combination Discussing diabetes, pregnancy therapies contain a range of ethinyl estradiol doses and varying types of and with women progestins, which prevent pregnancy Birth control options for Some birth control options by blocking the luteinizing hormone women with diabetes for patients to consider : surge (which would otherwise Choosing a safe and effective birth control Combined Hormonal: trigger ovulation) and by thickening method can be particularly confusing Ⅲ oral contraceptive pills cervical mucus. when patients are concerned about risks Ⅲ Ortho-Evra TM , patch All combination contraceptives related to diabetes control. Ⅲ NuvaRing ®, vaginal ring have similar efficacy and continuity Following are some questions to review Ⅲ Three-year implant (Implanon®) data, with a 0.3% failure rate with with your patients before making a perfect use in the first year and an decision about birth control: Intrauterine Device (IUD): 8.7% failure rate with typical use Ⅲ Mirena ®, progesterone only 1. How long until you want in the first year. 24 However, only Ⅲ Copper T 380A, no hormones approximately 68% of patients continue to become pregnant? combination contraceptive use one Months, one year, five or more years? Barrier Methods: year after starting the therapy. 24 2. What birth control methods have you Ⅲ Condoms/diaphragms Because pills must be taken daily, used in the past? patches must be changed weekly, Behavioral Methods and rings must be changed monthly, What were the pros and cons? Ⅲ Natural Family Planning a patient’s ability to adhere to each 3. How frequently do you want to have to Ⅲ Withdrawal regimen must be carefully assessed. take or change your birth control? Estrogen-containing contraceptives Sterilization 4. Do you have any other risk factors that are preferred by many women Ⅲ / ®/Adiana ® would limit your options? For example: because these methods offer such Ⅲ Ⅲ smoking and over age 35 noncontraceptive benefits as Ⅲ history of heart attack, improvement in acne, reduction in stroke or blood clots , decreased menstrual Ⅲ migraine with visual changes flow, and suppression of ovarian cysts. Ⅲ uncontrolled high blood pressure For women with diabetes mellitus Ⅲ liver or gallbladder diseases who have no subsequent vascular

April 2011 DOs Against DIABETES AOA Health Watch 15 Elevations in lipid levels, including contraceptive method for women stroke; ischemic heart disease or venous total cholesterol, HDL-C and with diabetes mellitus who have no thromboembolism; migraine with aura; triglycerides, have been noted in vascular disease and who prefer monthly and current breast cancer or history patients using oral contraceptives. 26 administration, the benefits of an of breast cancer with active disease In addition, oral contraceptives are estrogen-containing contraceptive and within the previous five years. 23 associated with decreased insulin a method they can control themselves. sensitivity. 26 These metabolic effects Progestin-only seem to vary depending on the progestin Transdermal contraception methods component included in the pill. Ortho Evra TM is a contraceptive skin Depot medroxyprogesterone acetate Levonorgestrel has been associated patch that delivers 0.15 mg daily of (DMPA) is an injectable progestin-only with decreased insulin sensitivity. 27-29 norelgestromin and 20 mcg daily contraceptive that is administered every However, pills containing drospirenone, of ethinyl estradiol transdermally. three months by intramuscular injection. desogestrel or gestodene tend to be With hormone exposure similar to Although highly effective in preventing metabolically neutral in terms of doses found in 35 mcg combination pregnancy, DMPA has adversely affected carbohydrate metabolism. 30,31 Despite pills, this method typically has such carbohydrate and lipid metabolism. these trends in lipid alterations, it is adverse effects as nausea and breast Use of DMPA causes only minimal still considered safe to use combination tenderness. 32 The patch is changed changes in glucose tolerance, but its contraceptives in patients with lipid once weekly for three weeks. It is effects on lipid metabolism include dysfunction in the absence of more then removed to allow for a one-week increases in LDL-C and decreases severe comorbidities because the withdrawal bleed before placing in HDL-C. 35 Because of the adverse benefits of contraception outweigh the next patch. lipid effects of DMPA, this form of the risks. One consideration of patch use contraception has a CDC safety rating Once combination contraceptive for patients with diabetes mellitus is of category 3, meaning that risks therapy is determined to be a safe that in clinical trials, women weighing outweigh benefits in individuals option for a patient with diabetes more than 90 kg had a greater failure with vascular disease or other mellitus, the physician and patient rate than women with weight less than longstanding illness. must select which formulation is best— 90 kg. 33 Concern regarding increased pills, vaginal rings or patches. This risk of thrombophilia is another Progestin-only pills decision should be driven by both consideration. One study showed the According to CDC guidelines, progestin- patient preference and patient lifestyle, patch resulting in a more than two-fold only pills (Micronor ® [norethindrone]; with some consideration given to increased relative risk of venous Ortho-McNeil-Janssen Pharmaceuticals the potential metabolic effects based thromboembolism in patients without Inc, Raritan, New Jersey) have a safety on route of administration. diabetes, compared to use of a 35 mcg classification of category 2 for all norgestimate oral contraceptive. 34 patients with diabetes mellitus—with Intravaginal ring This risk was lower than the risk of or without vascular disease. This safety NuvaRing ® is a vaginal ring containing venous thromboembolism associated rating makes the pills an appropriate etonorgestrel (an active form of with pregnancy. choice for individuals who have diabetes desogestrel) as the progestin component, The contraceptive patch is appropriate with hypertension or vascular disease. along with ethinyl estradiol. The steroid for women with diabetes mellitus who Because this contraceptive method hormones in the ring are absorbed have no vascular disease and who have does not interfere with lactation, directly through the vaginal mucosa, a normal body mass index and a strong it is often chosen for minimizing first-pass metabolism desire for the benefits of an estrogen- women during the immediate through the liver and causing 30% to containing contraceptive via weekly . 40% less hormone exposure than from transdermal administration. While progestin-only pills are safe, oral administration. The advantage of When making recommendations adherence with this contraceptive option this local hormone administration is regarding estrogen-containing requires consistent daily dosing, and that fewer systemic effects have been contraceptives, it should be kept nonadherance results in significantly noted in women with diabetes mellitus. in mind that the American Congress decreased efficacy. Unlike use of oral contraceptives, use of Obstetricians and Gynecologists of the vaginal ring has resulted in no guidelines for contraceptive use 23 Emergency statistically significant change in total emphasize that the following risk contraceptive options cholesterol or HDL-C levels—though factors outweigh the benefits of Safe to use for patients with diabetes a continued elevation in triglyceride combination therapies: smoking and mellitus, emergency contraceptive levels has been noted with the ring. 26 age greater than 35 years; uncontrolled options (Plan B One-Step TM [Teva The vaginal ring is an excellent hypertension; personal history of Women’s Health Inc, Woodcliff Lake,

16 AOA Health Watch DOs Against DIABETES April 2011 New Jersey] and ellaOne [HRA Pharma, Paris, France]) prevent ovulation and are indicated for emergency pregnancy prevention. Containing the progestin levonorgestrel, Plan B One-Step TM is available over the counter for women older than age 17 years. It is available by prescription for younger women. This pill prevents 85% of expected when taken within 72 hours of unprotected sexual intercourse. 36 EllaOne, containing the progesterone receptor , is a newer form of emergency contraception. It is more effective than Sterilization address contraceptive choices with the levonorgestrel option and provides For women who have completed their patients who have diabetes pregnancy prevention for five days childbearing or who are confident mellitus, because use of an appropriate (ie, 120 hours) after unprotected that they will never desire pregnancy, contraceptive results in lower risks sexual intercourse. 37,38 surgical sterilization is an excellent of morbidity and mortality compared With both emergency contraceptive option. However, sterilization with the risks of pregnancy. options, the risks of unintended procedures do not offer any of the The safety guidelines established pregnancy outweigh any actual or noncontraceptive benefits of some by the CDC can help physicians feel theoretical risks of the medications. of the hormonal methods previously confident about their ability to provide Patients should be educated on how outlined. safe contraceptive choices for women to obtain emergency contraceptives, A woman may choose from three with diabetes mellitus, even those and prescriptions for these pills methods of surgical sterilization: patients who have advanced disease. should be provided to patients using minimally invasive tubal occlusion Patients with diabetes mellitus should short-term or barrier methods. (Essure ® [Conceptus Inc, Mountain be counseled about all contraceptive View, California] or Adiana ® [Hologic options, including such long-term Barrier methods and Inc, Bedford, Massachusetts]); methods as IUDs and subdermal natural family planning laparoscopic tubal ligation (clips, implants as first-line recommendations. Condoms with , diaphragms, rings, or cautery); or tubal ligation at and natural family planning can be the time of cesarean section or other References effective contraceptive methods laparotomy. Efficacy is high for all three 1. Centers for Disease Control and Prevention. when used consistently and correctly. Diabetes & Women’s Health Across the Life sterilization procedures, with the Stages: A Public Health Perspective. Atlanta, GA: However, these methods typically minimally invasive options of tubal Centers for Disease Control and Prevention; 2001. have the highest failure rates because occlusion offering the benefits of fast http://www.cdc.gov/diabetes/pubs/pdf/ they are user-dependent, with efficacy recovery time, minimal surgical risk, womenshort.pdf. Accessed December 13, 2010. rates depending on patient adherence and exceptionally high efficacy rates. 2. Table 51. Diabetes among adults 20 years of age to recommended use. These methods Vasectomy for the male partner is and over, by sex, age, and race and Hispanic origin: may be considered for women who a surgical sterilization option for any United States, 1988-1994, 1999-2002, and 2003- have spiritual beliefs that preclude 2006. In: National Center for Health Statistics. couple in a life-long relationship. Health, United States, 2009: With Special Feature the use of other methods of Of course, vasectomy has the on Medical Technology. Hyattsville, MD: National contraception, for women planning drawback of providing no individual Center for Health Statistics; 2010:258. pregnancy within the next six contraception for the woman should http://www.cdc.gov/nchs/data/hus/hus09.pdf. months, or-rarely-for women she have a change of partner. Accessed December 13, 2010. with contraindications to every 3. Division of Reproductive Health, National other method. Final notes Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control Women choosing these methods Contraceptive counseling is essential and Prevention. US Medical Eligibility Criteria should be informed about emergency for women with diabetes mellitus. for Contraceptive Use, 2010: adapted from the contraceptive methods. For those Yet, these patients are less likely to World Health Organization Medical Eligibility women who desire a highly effective receive such counseling than are women Criteria for Contraceptive Use, 4th edition. MMWR Recomm Rep. 2010;59(RR-4):1-86. contraceptive without hormones, the 40 without diabetes, because physicians http://www.cdc.gov/mmwr/preview/mmwrhtml/ Copper T 380A, previously discussed, are often focused on the management rr5904a1.htm?s_cid=rr5904a1_e. is the best method. 39 of the diabetes. Physicians need to Accessed December 14, 2010.

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Broecker, MD, is an assistant professor of and gynecology at Ohio heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116(3):625-632. University College of Osteopathic Medicine. Affiliated with O’Bleness Memorial Hospital, she is a practicing physician seeing both obstetric and gynecologic patients and specializes 16. Rogovskaya S, Rivera R, Grimes DA, et al. in pediatric and adolescent gynecology. She has a special interest in contraception counseling. Effect of a levonorgestrel intrauterine system on women with type 1 diabetes: a randomized trial. Dr. Broecker is a fellow of the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2005;105(4):811-815. She can be reached at [email protected]. 17. Yen S, Saah T, Hillard PJ. IUDs and adolescents: an under-utilized opportunity for pregnancy Jennifer E. Lykens, OMS IV, is a fourth year medical student at Ohio University College prevention. J Pediatr Adolesc Gynecol. of Medicine in Athens, OH. She plans to begin her career as a resident in obstetrics and 2010;23(3):123-128. gynecology at TriHealth (Good Samaritan/Bethesda North) in Cincinnati, Ohio in July 2011.

18 AOA Health Watch DOs Against DIABETES April 2011