FUDiabetes

Birth Control for Hormone Stabilization: A Research Thread

Since I am not satisfied with the information I have received (well, largely NOT received) from my GP, Endo and OB/GYN regarding (1) the safety of various birth control options for diabetics, (2) how cyclical female hormones impact insulin resistance, and (3) how to strategically use hormonal birth control to moderate the effect of cyclical female hormones on blood sugar control, I am starting this thread as a compilation of reputable research and anecdotal evidence since so much of diabetic self-care is generated by story-sharing.

I am not a doctor. I am making no recommendations to anyone.

This thread will be link heavy, but I’ll try to put the high points in each post as much as possible.

Please feel free to chime in, share your knowledge, share your questions, challenge, etc.

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Overview of Hormonal Birth Control Options can be found at this link:

This article is from “American Family Physician” published 9/15/2010. It gives a great chart overview of hormonal birth control options, as well as considerations for prescribing to women with underlying medical conditions.

It also states, “Combined hormonal contraceptives can be used safely in women with a range of medical conditions, including well-controlled hypertension, uncomplicated diabetes, depression, uncomplicated valvular heart disease, migraine headaches without aura, systemic lupus erythematosus without antiphospholipid antibodies, human immunodeficiency virus (HIV) infection, thyroid disease, anemia, and uncomplicated liver disease.”

Based on the cited 2006 recommendations from the American College of Obstetricians and Gynecologists (ACOG), “ACOG recommends that the use of OCPs [oral contraceptive pills] in women with diabetes be limited to women younger than 35 years who do not smoke; are otherwise healthy; and show no evidence of hypertension, nephropathy, retinopathy, or other vascular disease.” *At this time, I am not sure if ACOG has updated this recommendation. A subsequent link will show that the American Diabetes Association might be less restrictive on age…maybe…

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Here is an article that gives a super generic overview of how hormonal contraception works, if you are curious:

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Here is a 2016 study that reviewed commercial insurance claims for contraception among diabetic women while also looking at the occurrence of thromboembolism:

It concluded:
"RESULTS We identified 146,080 women with diabetes who experienced 3,012 thromboembolic events. Only 28% of reproductive-aged women with diabetes had any claims for hormonal contraception, with the majority receiving estrogen-containing oral contraceptives. Rates of thromboembolism were highest among women who used the contraceptive patch (16 per 1,000 woman-years) and lowest among women who used intrauterine (6 per 1,000 woman-years) and subdermal (0 per 163 woman-years) contraceptives. Compared with use of intrauterine contraception, progestin-only injectable contraception was associated with increased risk of thromboembolism (12.5 per 1,000 woman-years; adjusted hazard ratio 4.69 [95% CI 2.51–8.77]).

CONCLUSIONS The absolute risk of thromboembolism among women with type 1 or 2 diabetes using hormonal contraception is low. Highly effective, intrauterine and subdermal contraceptives are excellent options for women with diabetes who hope to avoid the teratogenic effects of hyperglycemia by carefully planning their pregnancies."

HOWEVER, a comment was submitted by Dr. Braillon and published by the ADA that, "We would like to thank Dr. Braillon for his thoughtful letter (1) and for his enthusiasm regarding our work (2). His point is well taken that the incidence of thromboembolism among women with diabetes using the contraceptive patch was greater than 1 per 100 woman-years and would therefore meet the European Union’s definition of a “common” adverse event.

We agree with Dr. Braillon that women with diabetes should be encouraged to consider intrauterine or subdermal contraception and be cautioned about the risk of thromboembolism among women using the contraceptive patch."

So the moral here is that the contraceptive patch needs to be considered with caution for diabetic women.

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Many articles came out reporting on the 2016 study referenced in the links directly above.

It was stated that,
"Women with diabetes often fall through the cracks when it comes to prescription contraception. A new study illuminates the issues and highlights safe options.

The use of contraception to prevent unplanned pregnancies is an important aspect of women’s health. For women with chronic health conditions, family planning has important implications for the health of the mother and of the child. For women with diabetes, pregnancy timing is critical because hyperglycemia increases the risk for birth defects.

However, because of concerns over a potential increase in risk of heart attack or stroke, many physicians have been slow to offer prescription birth control to women with diabetes.

Estrogen-containing birth control — including oral contraceptives, transdermal patches and vaginal rings — prevent pregnancy by suppressing ovulation. While effective contraceptives, these methods increase women’s risks for heart attacks, strokes and blood clots. Physicians have been especially reluctant to prescribe hormonal birth control to women with diabetes, as adults with diabetes are two to four times more likely to die from heart disease than adults who do not have diabetes.

The results of a recently published study in Diabetes Care showed that the vast majority of diabetic women — 72 percent — did not receive prescription contraception of any kind, despite the importance of pregnancy planning for this population.

‘This was alarming, since women with diabetes become pregnant as often as other women,” said lead author Sarah O’Brien, MD, principal investigator in the Center for Innovation in Pediatric Practice and hematologist at Nationwide Children’s Hospital. “But birth defects occur in pregnancies conceived by women with diabetes more than twice as frequently as in the general population.’"

http://pediatricsnationwide.org/2017/01/24/hormonal-contraception-safer-than-expected-for-women-with-diabetes/?et_rid=533982236&et_cid=6384320&utm_medium=ET-Email&utm_content=http%3A%2F%2Fpediatricsnationwide.org%2F2017%2F01%2F24%2Fhormonal-contraception-safer-than-expected-for-women-with-diabetes%2F&utm_campaign=ResearchNow&utm_source=03-01-2017_Research+Now+-+March+2017

I have not seen a comparison in any of these articles to how many NON-diabetic women have received hormonal birth control prescriptions compared to diabetic women. But I can say from my own experience that I definitely got the deer in the headlights look from my GP, Endo and OB/GYN for how hormonal birth control would impact me as a diabetic.

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Nuvaring is what has been recommended to me by my OB/GYN and CDE. However, I have serious concerns about it and risks for blood clots and strokes.

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@T1Allison, this an outstanding thread. I hope you keep it going! Thanks for sharing your research!

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Thanks so much, @Michel. I really appreciate that.

I just got off the phone for my last retainer consult with my professional CDE. We had a long talk about how under-served diabetic women are when it comes to understanding the interplay of hormones and glycemic control. On the one hand, many doctors still conclude that hormones do not impact insulin resistance in any meaningful way on a large scale. Yet there are all these generic articles that continually cite that “most women state they see higher blood sugar 3-5 days before their…” So which is it? Are we denying the impact of hormones? Or is this so well-studied already that we don’t even have to cite a source?

Anyway…obviously this has tapped into a passion of mine. I hate to see patient care compromised due to prevailing inaccurate narratives. FUD is such a great forum to get the RIGHT conversation started in a meaningful, impactful way. Thanks for everything you do for FUD!

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Here’s what came of my CDE consult today based on her observations of patients (assuming I took accurate notes):
-If you take birth control in such a way as to prevent menstruation altogether, there is still a cycling of hormonally-induced insulin resistance but it is significantly blunted.
-Using hormonal contraception will likely increase your insulin needs (since you are adding insulin-resistant hormones to the mix), but the cyclical fluctuations will be less overall.
-Patients who took progesterone-only birth control pills saw more insulin resistance than those taking combination birth control pills.
-The lower dose birth control will cause less insulin-resistance than higher-dose birth control.

Even if you experience consistent cycles, it is possible that you could see reduced hormone fluctuations (and therefore reduced insulin sensitivity fluctuations) by taking the supplement Vitex Berry. Also mentioned was Evening Primrose Oil.

Again, I’m not a doctor. I’m not making medical recommendations. I’m just trying to compile as much information as I can.

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I can attest to hormonal balance from taking vitex - I took it for years prior to my first pregnancy because of PCOS; it helped immensely with regulating my cycles. Never thought to try it for my blood sugar, hmmmm.

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@Pianoplayer7008, that’s great information! Thanks for sharing!

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Thanks for compiling all this information @T1Allison. I’ve been trying to pay more attention to my basal needs during my hormone cycle since this conversation began on FUD.

I think I may need a little (1 unit/day) more basal just before (and mostly throughout) the 4th week on the NuvaRing (I skip my period, but this is when it’d be). I’ve only had a chance to observe one cycle though. My 4th week will begin again on July 4th, so I’ll take notes around that time. Not sure this month will be a good reference because I’m coming down with a cold that required a substantial basal increase yesterday and today. Hopefully I get better quick so that I’m on track to see if I need to increase again sometime between Sunday-Wednesday.

Again, can’t thank you enough for your comments and research on the subject :slight_smile:. I don’t think my basal needs change dramatically, but I’m sure it’d help me keep things on track if I could predictably add that 1 unit for a week every month.

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@Katers87, I’m so glad that it’s been helpful! My temp basal settings also change based on site degradation, etc, so I try to keep my vision as “big picture” as possible on my overall trends.

On Lantus and Nuvaring, I remember stair-stepping up 11/12/13 units each cycle. I will look for those binders again, but I am pretty sure I tossed them. I was 3 weeks on Nuvaring, 1 week without.

On Lantus and no Nuvaring (when trying for kiddo #2 for a year), my Lantus needs were 11/12/13/14/15/16 each cycle. Couple that with individual variations each day and it was tough. I have to imagine losing the birth control stability was the biggest cause in the change I saw in my bg control and insulin needs.

I’ll be interested to see what your observations are. Your input has been very beneficial in pointing me in different directions for researching. :grinning:

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I was planning on starting on Nuvaring in a week and following my basal needs closely in order to compare whether or not it moderated my basal need fluctuations through my cycle. I have talked to my GP, my OB/GYN, my endo, my CDE and they all green-lighted this move. My OB/GYN was adamant that Nuvaring is absolutely safe and would be very helpful for me. She also was not terribly concerned about revisiting my patient history to verify this as a good medical choice. When I further discussed my personal concerns about my candidacy for using Nuvaring with my CDE, though, my CDE agreed it sounded like a bad idea in my case.

After researching Nuvaring further, I have concluded it is not safe for me to go back on it. Here’s why:

  1. Nuvaring’s website states this warning in part (with my emphasis): “Do not use NuvaRing if you smoke cigarettes and are over age 35. Smoking increases your risk of serious heart and blood vessel problems from combination hormonal contraceptives (CHCs) including heart attack, blood clots, or stroke which can be fatal. This risk increases with age and the number of cigarettes smoked.The use of a CHC, like NuvaRing, is associated with increased risks of several serious side effects, including blood clots, stroke, or heart attack. NuvaRing is not for women with a history of these conditions or any condition that makes your blood more likely to clot. The risk of getting blood clots may be greater with the type of progestin in NuvaRing than with some other progestins in certain low-dose birth control pills. The risk of blood clots is highest when you first start using CHCs and when you restart the same or different CHC after not using it for a month or more. NuvaRing is also not for women with high blood pressure that medicine can’t control; diabetes with kidney, eye, nerve, or blood vessel damage; certain kinds of severe migraine headaches; liver disease or liver tumors; take any Hepatitis C drug combination containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, as this may increase levels of the liver enzyme “alanine aminotransferase” (ALT) in the blood; unexplained vaginal bleeding; breast cancer or any cancer that is sensitive to female hormones; or if you are or may be pregnant.”

**Note that much of this verbiage is a result of the lawsuits against Merck due to blood clot occurrence. The warning pops up on the website and you have to close it to get to the rest of the website.

If I went back on Nuvaring, it would be my third time using it in the course of 12 years…so I would be at an increased risk of clots based on that fact alone.

  1. Nuvaring goes on to warn : “The most common side effects reported by users of NuvaRing are… headache (including migraine)…”

I’ll come back to this one in #3.

  1. This is included in Nuvaring’s list of Who Should Not Use Nuvaring: “Have certain kinds of severe migraine headaches with aura, numbness, weakness, or changes in vision, or have any migraine headaches if you are over age 35”

I have had two episodes of complex migraines with aura. My husband remembered tonight that both of those occurred while I was using Nuvaring. My first complex migraine presented like a stroke in 2009 and I was taken by ambulance to the hospital. I had facial numbness, aura, and I believe the correct term is “aphasia”. I could understand everything people at work said to me. I responded back to them, and I could understand my thoughts in my own head, but I was saying phonetically similar words with completely different meanings. No one had any clue what I was trying to say, and I didn’t know I was misspeaking until I heard it come out of my own mouth. I tried to send one email before I left for the hospital, but the letters on the keyboard made no sense to me. I didn’t recognize any of them. I tried for 20 minutes to type “I’ll keep you in the loop.” but when I came back into the office the next day I checked my sent folder to see what I said, and the closest I got was “I’ll check you in the look.” Terrifying…especially as a T1D who needs to be able to interpret numbers and dose medicine on a regular basis. It was diagnosed as a complex migraine and that was that.

My second complex migraine occurred during my second time using Nuvaring, in 2011. I got the aura, then I started to lose my ability to read and speak clearly but it never went all the way unintelligible. I saw a neurologist. He said some people just get complex migraines and they pass.

I have not had a complex migraine since 2011. I have not been back on Nuvaring since I stopped using it in late 2011. These are both objectively true statements…but I obviously cannot conclude definitive causality.

What I can conclude is that I am not a contender for using Nuvaring in an attempt for blood sugar stabilization. I will either consider a combination birth control pill for hormone regulation/insulin resistance experimentation…or stay birth control free and continue to try to hone my self-monitoring and hopefully develop more helpful information for other reproductive age T1D women when it comes to tracking hormones and insulin resistance.

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I checked my records and I only kept all of my “initial diagnosis” binders and pregnancy binders. Bummer. I really wanted to verify what I was remembering for my Nuvaring-MDI days and non-Nuvaring MDI days. But I do think my recollection is pretty close to accurate.

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Thanks for taking a look!

Bummer about the Nuvaring. Those migraines sound scary though. I’d definitely avoid it as well if I had the past experience you described.

Do you know if the implants (Nexplanon) have similar side effects? I had a friend (non-D) who had one of those and absolutely loved it.

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I’m scrapping everything that I originally wrote here.

Nexplanon uses only progestin. Nuvaring uses both estrogen and progestin. They both use the same third-generation progestin (etonogestrel). Nuvaring’s website has stiffer warnings about blood clots and headaches than Nexplanon’s, but it seems those warnings were a result of all the litigation from patient death and injury.

Historically, estrogen is the more effective birth control hormone but comes with known health risks (cardiovascular problems, for one). Older versions of progestins tended to cause more unwelcome side effects (hair growth/acne/etc). The newer progestins attempt to minimize those side effects. It is the third generation progestins (in Nuvaring and Nexplanon) that have a statistically significant increase in clots/stroke/etc. It’s not clear from what I’m reading if the increase in clot risk is when etonogestrel is used on its own (like in Nexplanon) or in the combination with estrogen (like in Nuvaring).

Both Nexplanon and Nuvaring appear to be owned by Merck.

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Here is a Fantastic article that seems to make some big picture sense to me.

"Although they [newer progestins] successfully limit side effects,
these newer progestins may lead to an increased risk of blood
clots, though the data are mixed, she says.

Typically, blood clot risk has been associated with the
estrogen component of birth control pills. Estrogen receptors
in the liver are involved in the production of blood clotting
factors. Ethinyl estradiol is much more potent than natural
estradiol, and it remains in the body far longer, so it hyperactivates
the liver pathway, creating conditions that promote
blood clotting."

It goes on to talk about how estrogen doses have also been steadily lowered in birth control to also address their portion of the risk of blood clots:

“To decrease the risks of blood clots and other side effects, the
dose of estrogen analogues in birth control pills has been
gradually dropping over time, says Thomas D. Kimble of
CONRAD, a nonprofit organization that conducts reproductive
health research. “Formulations containing more than 50 μg
of estrogen have not been available in the U.S. since 1988”, he
says. For women who already have an increased risk of blood
clots, birth control pills without ethinyl estradiol may, for now,
be safer than combination pills, Blithe says, though effectiveness
is a concern with these options. A possibly better choice, she
says, would be to consider long-acting estrogen-free methods,
such as intrauterine devices, which do not carry any increased
risk of blood clots.”

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You are doing a great service with this thread. Great job!

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I appreciate you saying so, @Chris. My husband making the conclusion last night that the only two migraines I’ve ever had in my life were while I was taking Nuvaring is quite sobering. Getting deeper into the research (and politics of big pharma) shows me how lucky I was.

Thanks, again!

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