Wednesday, May 04, 2005

Type 1 Diabetes and the IUD

Good news for diabetic reproductive-age women: using the progestin-releasing IUD (Mirena) does not adversely affect blood "sugar" levels in women with type 1 diabetes.

Contraceptive options for women with type 1 DM [diabetes mellitus] are limited because of concerns about the effect of hormones on glucose ["sugar"] metabolism and cardiovascular outcomes. However, good contraception and fertility planning is important because of the risk of fetal anomalies when glucose control is suboptimal. IUDs are an appropriate contraceptive device for diabetic women with no contraindications for use, because of excellent efficacy, minimal metabolic effects, and cost-effectiveness. According to WHO, the copper IUD falls into category 1 (no restrictions on use) for women with type 1 DM, whereas the levonorgestrel IUD falls into category 2 (benefits generally outweigh risks) because of the potential effect of levonorgestrel [the hormone in Mirena] on carbohydrate metabolism. According to the authors of the current study, data are lacking on the effect of the levonorgestrel system when compared with the copper IUD on glucose metabolism in women with type 1 DM. They conducted a randomized controlled trial to examine these effects in women with well-controlled type 1 DM and to examine continuation rates of the two devices at one year.


The study's conclusion:

"The levonorgestrel-releasing device had no adverse effect on glucose metabolism, even at the six-week observation when systemic levels of levonorgestrel would have been higher than at later observations," the authors write. "Concern about a potential adverse effect of this contraceptive on glucose control is unwarranted, and its use in women with diabetes should be liberalized. . . . The WHO [World Health Organization] Category 2 rating for use of the levonorgestrel intrauterine system by women with insulin-dependent diabetes mellitus therefore is overly cautious."


One more noteworthy finding:

  • In the levonorgestrel group, hemoglobin levels increased from the baseline of 12.85 g/dL to 13.09 g/dL at 12 months, whereas in the copper IUD group, they decreased from 12.67 g/dL to 12.28 g/dL at 12 months. [low hemoglobin-->anemia]


  • Speaking of Mirena and what it can do for your menstrual management needs, here's a little excerpt from my book:


    Mirena

    The Mirena Intrauterine System (IUS) has a plastic, T-shaped frame that contains 52 milligrams of the progestin levonorgestrel in the vertical arm. The IUD gradually releases a very small amount of hormone every day (20 micrograms) and it can be used for five years. LevoNova is Mirena's counterpart in Scandinavian countries. Mirena has been used in Europe for more than ten years, and in December 2000, it was also finally approved for use in the United States.

    Mirena is especially useful for women with heavy, prolonged, or painful menstrual periods, because it:

  • Significantly reduces the monthly blood loss. Approximately 90% of women who use Mirena have a reduction in their menstrual bleeding. In fact, this type of IUD can be used (off-label) as a possible alternative to hysterectomy (the surgical removal of the uterus) as a treatment for heavy menstrual bleeding. For example, the number of days of bleeding is reduced from seven days, during the first month of use, to two days, during the twelfth month. This is a very important benefit of using this IUD, considering that in the United States about 118,000 hysterectomies are performed annually for this reason alone.

  • Stops monthly bleeding. After one year of using Mirena, up to 50% of women stop having a monthly bleeding episode altogether.

  • Reduces menstrual pain (dysmenorrhea). Because the hormone released by this IUD acts locally, inside the uterus, it greatly reduces the secretion of the substances (prostaglandins) that have a role in causing painful periods.

    ...

  • Reduces the bleeding associated with uterine fibroids. For example, one study found that 95% of women with fibroids who were anemic and who used this method were no longer anemic after one year of use.

    When it comes to menstrual management, the particular disadvantage associated with using Mirena is bleeding and spotting, sometimes heavy, mostly during the first three to six months of use.

    ...

    Currently being developed is Femilis T
    [scroll to bottom of page for picture], a framed hormone-releasing IUD that releases 14 micrograms of the progestin levonorgestrel per day (compared to 20 micrograms for Mirena). The intended lifespan of this brand of IUD is ten years (compared to Mirena's five years). Femilis T will come in two models, one for women who have never had children (nulliparous), and one for those who have already given birth (parous).

    The advantages of this IUD for menstrual management use are that it:

  • Releases less daily hormone and has a longer life span

  • Should be easier to insert and remove

    The device is smaller and more flexible in order to allow for an easy insertion even in the small uteri of women who have never had children. Also, because the arms unfold immediately upon insertion of the IUD into the uterine cavity, the risk of perforation is likely to be reduced. The end result is that this model will likely have fewer troublesome side effects such as disturbed bleeding patterns, including amenorrhea, and hormonal side effects.

    As with any hormone-releasing IUD in general, the main disadvantage is that, if you're interested in active period control, the hormone-releasing IUD wouldn't be your first choice.

    This new type of IUD looks promising for women who suffer from heavy and painful periods, or other period-related medical problems, and who might not be able to tolerate the available IUDs.


    And speaking of being unable to tolerate existing IUD brands, more from the book about frameless IUDs:


    GyneFix [click on this link for a good review of some of the IUD brands available outside the U.S.]

    A frameless IUD, as the name implies, is an IUD that doesn't have the rigid, or semiflexible, plastic frame seen in the framed brands. The frameless IUD currently in use is the GyneFix (and the GyneFix mini), which consists of six (four for the mini) small copper sleeves threaded on a suture strings.

    Using a frameless IUD has several advantages over using the regular, framed IUD--better tolerated, less likelihood of expulsion. In addition, when it comes to the menstrual period, this type of IUD doesn't increase period bleeding and reduces cramping. When you use an inert (no copper, no hormone) IUD, like the Lippes Loop, your menstrual blood loss could be about twice (70-80 milliliters) that of a normal period due to the inert frame. With a copper IUD, like one of the copper T series, the amount of excess bleeding is less (50-60 milliliters). In contrast, GyneFix, particularly the GyneFix mini, does not increase your menstrual blood loss (compared to the period prior to IUD use). Of course, a hormone-releasing IUD like Mirena actually decreases the amount of monthly blood loss. But, because Mirena has a frame, that in itself can cause spotting and cramping compared to a frameless IUD like GyneFix.

    So developing a frameless, hormone-releasing IUD would be very helpful, because it would combine the best features of GyneFix (no frame, less cramping) and Mirena (hormone-releasing, less bleeding). Enter FibroPlant.

    FibroPlant consists of a small rod (about 3 centimeters long), which houses the hormone and the conventional anchoring system used for frameless IUDs. The progestin levonorgestrel is released at a rate of 14 micrograms per day, for a period of three years. A version designed to last a minimum of five years is also under development.

    The advantages of this type of IUD for menstrual management are:

  • Reduced incidence of cramping and pain. Because FibroPlant doesn't have a frame and it's shorter than the original frameless one (GyneFix), it tends to adapt very well to uterine cavities of various sizes and shapes. This greatly minimizes the discomfort/cramping and expulsion seen with the use of the framed IUDs. ...

  • Significantly reduced amount of bleeding. In women with regular but heavy menstrual bleeding and anemia, this method significantly reduces the amount of blood lost. For example, the reduction of menstrual blood loss is at least 80% and it occurs as early as one month after insertion.

  • Fewer disturbances in the bleeding pattern. Because of the reduced dose of hormone released by this type of IUD, fewer women experience breakthrough spotting or bleeding, and complete absence of monthly bleeding. Of course, some users might consider this a disadvantages. However, if you're a woman who wants or needs to use menstrual management, but prefers to have a monthly episode of bleeding, this is clearly an advantage for you.

    The main disadvantage of the frameless hormone-releasing IUD is that you won't be able to use it for active menstrual management.

    The frameless hormone-releasing IUD will be particularly useful for women who have tried to use an IUD but were unable to tolerate other types of IUD in the past. It will also help women with heavy or painful periods, and those with uterine fibroids.


    [Sorry, I don't know how to reproduce the book's typesetting; I just typed the text in, and I'm all typed out for now. To check the references used, do a "Search inside" at Amazon, starting on page 230.]

  • 10 Comments:

    At 10:51 PM, Blogger margie said...

    So can a nulliparous woman get a Mirena?

     
    At 1:30 AM, Blogger ema said...

    Yes. [Ideal scenario: patient, and her partner are monogamous, and the Ob/Gyn is versed in, and comfortable with inserting IUDs in nullips.]

     
    At 11:43 AM, Anonymous missmeridian said...

    This is off-topic, but... I've been hearing things about episiotomies and the "husband stitch" - could you do a post sometime outlining the pros/cons? Thanks!

     
    At 6:54 AM, Anonymous Anonymous said...

    this is very informative. I have been having pro-longed and heavy periods. my ob/gyn had given me 3 options. the IUD, endometrial ablation, or a hysterectomy. I'm leaning more towards the IUD even though I have had a tubal ligation. This post was very informative. Thank you.

     
    At 4:53 PM, Anonymous Anonymous said...

    woo hoo I got my Mirena a couple days ago :-)

    So they say that nulliparous women have a higher chance of expelling it in the first year. Then today I read your post on how everyone should have a Plan B script on hand. Even IUD people? How do you know if it's getting expelled? Does it just fall out?

     
    At 12:13 AM, Anonymous Anonymous said...

    Can either of these IUDs cause weight gain? I have had two children and easily lost all of the weight that I had gained each time. After my second son was born I got an IUD and I have gained almost all of the weight back, more than 30 lbs! I work out and control portions but it's been 2 years and I just don't know what else could be causing this.
    Any information would be appreciated.

     
    At 11:39 PM, Anonymous Anonymous said...

    I'm 35, history of PCOS, endometriosis, depression, systemic vasculitis and very irregular light periods (equating to a sneeze every 6 months) - cramping is not an issue. BCP's in the past regulated me fine, but due to the vasculitis, we had to stop it a year ago.

    I'm being encouraged to try the Mirena IUD - however, I'm concerned about the potential side-effects - particularly the depression and weight gain since I'm very prone to both.

    Any recent resources you can recommend I read to weigh the Pros/Cons?

     
    At 10:52 PM, Anonymous Anonymous said...

    Is GyneFix close to gaining FDA approval?

     
    At 4:54 PM, Anonymous Anonymous said...

    I just hosted my site on diabetes.I passionately
    reads different l blogs on diabetes to get latest information on diabetes and other topics. Can I publsih some information on my site.
    I am working with a non profit group for diabetes prevention in rural india. Please vist my site and mailto: alta@vsnl.net.

     
    At 6:52 AM, Anonymous Anonymous said...

    Refer to Diabetes for
    useful information

     

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