Ask D’Mine: The Best Birth Control for FWDs is…

Need help navigating life with diabetes?  Ask D’Mine! That would be our weekly advice column, hosted by veteran type 1, diabetes author and educator Wil Dubois.

This week, Wil’s done some serious homework on a women-specific issue: Birth Control. But don’t fear, men, this isn’t just a post for those Females With Diabetes (FWDs). There’s something in it for everyone. So, don’t be afraid to read on! (Or print out and read later — this one’s a doozy!)

{Got your own questions? Email us at AskDMine@diabetesmine.com}

Kathleen, type 2 from Texas, asks: What do you think of Mirena as a birth control option for diabetics, especially those on insulin?

Wil@Ask D’Mine answers: Seriously? The new-style intrauterine device (IUD) that’s implanted into the wall of the uterus? You know I’m a man, right? And as such, I only have the vaguest of idea of where the uterus is in the first place.

But even though I’m out of my league, and out of my gender, your question piqued my interest. I mean, come on, sex and diabetes—what more could I want to totally make my day? So I read up on Mirena, then I started calling all the female diabetes docs I know. They told me that there’s no nationwide standard recommendation for birth control for female diabetes patients, and no one agrees on what’s best.

It turns out that the entire subject of birth control for FWDs is more complex than you’d think. In fact, birth control options for any female are more complex than I had realized, so we’re going to devote today’s entire column to the subject. Not just Mirena, but the full spectrum of options for my diabetic sisters.

Mirena and Garden Variety IUDs

But since you asked about Mirena, we’ll start there. It’s an IUD, a small plastic device that looks a bit like a boat anchor. I should make some sort of joke about sailors and sex, or anchors away at this point, but I’m still trying to figure out where the uterus is.

Oh yes, and speaking of the uterus, that’s where an IUD goes. IUDs, which come in two flavors, are inserted by a doc into the wall of the uterus. And like an anchor, an IUD has a little string that threads down through the cervix (man alert: not the same as the clitoris), and into the vagina.

You know what guys? Please review this road map to the female reproductive system before going on. It will save us all a lot of time.

A traditional IUD (not to be confused with an IED) is clad in copper and can be left in place to prevent pregnancy for up to ten years. How on earth does that work? Copper is toxic to sperm. It kills the little swimmers. Penny for your thoughts? Well, it’s actually a little more complicated than that, but that explanation will have to do for today.

Mirena, on the other hand, is a hormonal IUD. It’s loaded with levonorgestrel, a progestin hormone that’s also used in the “morning after pill,” some birth control pills, and the now-off-the-market Norplant.  Oh, yes, and Mirena is only good for five years, half the lifespan of a copper IUD. If you were paying out-of-pocket it would cost you around $600, not including the doctor’s visit. That’s about the same price as a copper IUD like ParaGard, but of course, Mirena only lasts half as long as the traditional copper—so it would cost twice as much if you used it long-term

But is Mirena, or any IUD, a good choice for an FWD?

First, that depends on your control, because IUDs aren’t recommended for women who get any sort of pelvic infections easily, and we all know that high blood sugar almost guarantees a wide assortment of “down there” infections in ladies with diabetes. So for IUDs in general, Kathleen, I don’t think that insulin use comes into play at all. If an FWD’s A1C is excellent, regardless of her diabetes therapy, an IUD would probably be fine.

What about the Mirena IUD? My first thought was it would probably be OK, but then I got two emails. Both from health care providers who work with FWDs extensively. Neither want to be quoted by name, but they both tell me that they’ve seen break-through bleeding, blood sugar changes, acne, personality changes such as depression and mood swings, and weight gain on their patients who tried Mirena. One of the two told me she found these effects in most of her patients who tried it, and the other said “it does have an effect on many women, perhaps not all, but quite a few.” They both prefer traditional copper IUDs for their FWDs. One added “Every OB we’re talked with acts like ‘Oh that doesn’t happen,’ with Mirena, but after seeing and talking to the patients I disagree.”

Meanwhile, diabetes doesn’t exist in a vacuum, and Mirena has other contraindications to consider as well, like large fibroids, breast cancer, abnormal Pap smear, liver disease, heart disease, and high blood pressure. So ultimately the choice of any kind of birth control Rx needs to be made by the doc and the patient together.

And just what are the choices?

Patches and Plan B

There are pills, more formally known as “oral contraceptives.” There are condoms, more informally known as “rubbers.” There are diaphragms. And rings. And injections. And foams. And patches. And the rhythm method. And abstinence. Yeah, right. And the ethically controversial Plan B.

To help us wade through all of this, I emailed Dr. Kathleen Colleran, a practicing endo, clinical researcher, and professor with the University of New Mexico School of  Medicine. Dr. C is one of those overworked people without much time to spare, so I’ve learned to keep my communications with her simple. I asked her to list her favorite top two birth control methods for both type 1s and type 2s. Dr. C felt there was no difference in her recommendations between the two flavors of diabetes, so she gave us her top three birth control choices for all FWDs: condoms, rings, then pills. In that order.

{If you want to hear Dr. C talk some more about diabetes, watch this video. You’ll see a familiar face in the second half.}

Condoms

In number one place, Dr. C likes condoms. Ummm… that might not have been the best choice of words, but you know what I mean. Her reason is that in addition to preventing unwanted pregnancy, they “prevent ugly diseases that have pretty names.” Good point. Of all the assorted types of birth control, only condoms and total abstinence can prevent sexually transmitted diseases.

I think we’re all up to speed on condoms, so I won’t spend too much time on them today. But while I was looking for a good link for those of you who wanted to know more, I actually stumbled on a place called Condom Depot, that has a mind-numbing inventory, featuring, no shit, 25 different brands, each with multiple styles. Not your grandpa’s Trojans. I just have to share some of the current brand names with you: Vibrating Johnny, Bravo, Caution Wear, Impulse, Natural Lamb, Night Light, Paradise, and Vivid.

And don’t forget there’s also a female condom, sometimes called a “femidom,” not to be confused with femdom.

The Ring

In number two place, Dr. C likes the ring, as she feels it is less systemic, meaning fewer body systems are involved in metabolizing the medication. The ring looks like a … ring, and is placed in the vagina. It’s flexible, about two inches in diameter, and is worn for three weeks, removed, and then replaced with a new one after a week off.

On the pharmacologic level, the ring is sorta like the pill, but the hormones are absorbed directly through the wall of the vagina, bypassing the digestive system altogether. It shares the same 99% effectiveness in preventing pregnancy that the pill boasts.

Merck, makers of NuvaRing, warns us that women who already have diabetes complications shouldn’t use their product.

The Pill

In third place, Dr. C likes the oral pill ortho tri-cyclen, as she feels it is less androgenic than other pills. Andro-what? It’s one of those fancy-pants medical terms. It means “to develop male characteristics.” Because if your birth control pill causes you to grow a beard you won’t be getting pregnant, that’s for damn sure.

The American Diabetes Association also favors this kind of pill, which uses synthetic estrogen and norgestimate. But the pill isn’t for every FWD. Like all other hormonal birth control methods, it isn’t recommended for ladies who have high blood pressure, heart disease, blood clots, are over the age of 35, or smoke cigarettes.

Smoking? Really? Yes. Really. Taking the pill and smoking greatly increases your risk of a heart attack. Also be aware of the fact that some women need to increase their insulin dose when on the pill.

Other Options

Well, we’re running out of time today, but just to quickly review the other keep-yourself-NOT-knocked-up options: there’s the patch. It’s another hormonal solution, this time using a transdermal patch — like NicoDerm for quitting smoking. So if you need to quit smoking and need birth control, you could be wearing two patches. It carries the same risks and contraindications that pills do. Hormones can also be injected, but injections seem more likely than pills to cause weight gain, which can increase insulin resistance (and lower self-esteem).

Last up on the hormone front is Plan B, a.k.a. “the morning after pill.” I don’t want to get bogged down in the storm of controversy surrounding the ethics of this approach to birth control, just know that Plan B unleashes a flood of hormones compared to proactive hormone birth control, and there are some reports of blood sugar control issues after taking Plan B.

Getting away from hormones, another birth control option is a diaphragm, and its cousins the sponge and the cervical cap. These are collectively called “barrier” devices, as their function is to create a barrier to prevent the sperm from getting to its destination. Most barriers are used with an spermicidal jell, foam, or tablet. And of course, gels and foams can be used by themselves as well, but are only about 70% effective in preventing pregnancy when used alone.

Barriers are safe and effective for FWDs, but the spermicides have been shown in some women to increase the risk of urinary tract infections, so if your blood sugar is already high, you might not want to risk adding a second risk factor.

Of course you can also use the rhythm method. The theory behind this system is that a woman’s basal temperature will change when she starts ovulating. By tracking basal temperatures, you can, in theory, avoid sex when you’re most fertile. I think that’s where my nephew came from… so enough said about that.

Oh, and I forgot to mention the… umm… withdrawal “method.” What do I think of that? Don’t trust men. Enough said about that, too.

And last, and least effective, is abstinence. It only works when applied 100% of the time, and has been proven time and time again to fail in the face of human nature.

The Ultimate Risk

I wanted to end today’s column with a good joke, a witty play-on words, or a return to the running uterus gag—I love that kind of “circular construction.” But while sex can, and should, be funny and edgy to talk about, birth control for FWDs is a serious topic.

Of course, high blood sugars can be a side effect when talking about the pill. Some FWDs who’ve been on birth control say their basal insulin amounts nearly doubled when going on the pill. So it’s important to recognize that the birth control could be causing insulin resistance, and you’re not doing something wrong like being off in carb counting. Some women also say they need a lot less insulin during the time they’re on placebo pills, so that’s something to keep in mind, too.

Sadly for my D-sisters, most of the forms of female birth control carry some degree of medical risk, and those risks seem to inflate for all FWDs. But it’s the lesser of evils. The largest risk to an FWD’s health is an unplanned pregnancy when her blood sugar control isn’t optimum. A high-blood sugar pregnancy is extraordinarily dangerous.

Both for the mother and for the baby.

Disclaimer: This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.