patterns of contraception in iddm in the uk ra lawrenson, gm leydon, tj williams, rb newson, md...
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Patterns of contraception in IDDM in the UK
RA Lawrenson, GM Leydon, TJ Williams, RB Newson, MD Feher*
Department of Epidemiology and Public Health,
*Department of Clinical Pharmacology
Imperial College School of Medicine
Contraception in women with IDDM
• No UK studies
• No comparative studies
• Important to prevent unwanted pregnancies
• Risks of contraceptive use may have more serious consequencies in women with IDDM
Oral contraceptive use
• Commonest method used in the UK
• Combined oral contraceptives with high doses of oestrogen may increase risk of cardiovascular disease and increase requirement for insulin
• CHD risk may be due to changes in lipids. New generation oral contarceptives (gestodene and desogestrel) seem to increase HDL and decrease LDL
Oral contraceptive use (POPs)
• Progestogen only pills have less risk of cardiovascular problems.
• However they are less effective with 3 pregnancies per 100 women years of use
• Also have the problem of irregular bleeding
Percentage of women by age using combined oral contraceptives for contraception
0
10
20
30
40
50
60
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Percentage of women by age using third generation combined oral contraceptives
0
5
10
15
20
25
30
35
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Percentage of women by age using second generation combined oral contraceptives
0
5
10
15
20
25
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Preferential prescribing of third generation oral contraceptives ?
• Proportion of women with IDDM using a third generation oral contraceptive was 60% compared with 58% in women with no diabetes - OR 1.06 which was not statistically significant.
Percentage of women by age using oral progestogen preparations for contraception
0
2
4
6
8
10
12
14
16
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Percentage of women by age using injectable progestogen preparations for contraception
0
0.5
1
1.5
2
2.5
3
3.5
4
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Percentage of women by age using diannette progestogen preparations for contraception
0
0.5
1
1.5
2
2.5
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Comparison of different hormonal contraception usage in women with IDDM
and women without diabetes in 1994
IDDM No diabetes Crude OR Adjusted OR
All hormonalcontraception
238(25 .4%)
3196(31.96)
0.72(0.62,0.84)
0.74(0.63,0.88)
COC 162(17.3)
2823(28.2)
0.53(0.45,0.63)
0.52(0.43,0.63)
POP 81(8.6)
393(3.9)
2.31(1.80,2.96)
2.11(1.64,2.71)
Dianette 0 129(1.3)
Injectables 12(1.3)
159(1.6)
0.8(0.44,1.45)
0.85(0.47,1.56)
Summary of use of oral contraceptives in women with IDDM
• Women with IDDM are less likely to be prescribed an oral contraceptive
• If they are prescribed an oral contraceptive it is most likely to be a combined oral contraceptive
• Women with IDDM are twice as likely to be prescribed a POP
• There is no evidence of preferential prescribing of third generation COCs to women with IDDM in 1994
IUCD
• IUCD use has been associted with increased risk of pelvic inflammatory disease
• One series in 30 women with diabetes resulted in 11 pregnancies in the first year (contradicted by other studies)
Percentage of women by age using an intra uterine device for contraception
0
1
2
3
4
5
6
7
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
IUCD summary
• 2.9% use in women with IDDM and 2.2% in those with no diabetes - adjusted OR 1.21 (0.80,1.82)
• No evidence that it is being avoided as a method in women with IDDM
Barrier methods
• Under reporting on GP records
• Diaphragm or cap 0.8% in women with IDDM and 0.4 in comparison groupadjusted OR 1.64 (0.72,3.74)
• Condom use 0.3% in IDDM and 0.9% in othersadjusted OR 0.32 (0.10,1.02)
Percentage of women by age with a prescription for condoms
00.20.40.60.8
11.21.41.61.8
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Surgery
• May be under recording of hysterectomy and sterilisation
• No information of vasectomy in partners
• In high risk women with IDDM pregnancy maybe such a risk that sterilisation is recommended (Steel)
Proportion of women by age with a record of sterilisation prior to 1995
0
2
4
6
8
10
12
14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Proportion of women by age with a record of a hysterectomy prior to 1995
0
2
4
6
8
10
12
14
16
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Use of sterilisation
• 5.8% women with IDDM had a record of sterilisation compared with 3.7% of others. adjusted OR 1.32 (0.98,1.79)
• Hysterectomy rate was 3.8% vs 3.7% which after adjustment gave an OR of 0.91 (0.63,1.30)
• Some evidence of an increased use of sterilisation in women with IDDM
Proportion of women by age in whom there is a record of a claim from the GP for
contraceptive services in 1994
05
1015202530354045
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Evidence of a cervical smear in 1992, 1993 or 1994 - women with IDDM and women
with no diabetes
0
10
20
30
40
50
60
70
80
15-19
20-24
25-29
30-34
35-39
40-44
45-49
No diab
IDDM
Proportion of women recorded as being current smokers in 1994 by age
0
5
10
15
20
25
15-19
20-24
25-29
30-34
35-39
40-44
45-49
AGE
% No diabetes
IDDM
Proportion of women recorded as being ex-smokers in 1994 by age
02468
101214161820
15-19
20-24
25-29
30-34
35-39
40-44
45-49
AGE
% No diabetes
IDDM
Smoking
• 20.4% of women with IDDM and 20.2% without were recorded as being current smokers
• More emphasis should be put on this risk factor for women with IDDM
Obesity
• Obese women have an increased risk of CVD and should therefore be less likely to be prescribed combined oral contraceptives
Proportion of women in each BMI category(1 = <20, 2 = 20-25, 3 = 25-30, 4 = 30-35, 5 = 35+)
0
10
20
30
40
50
60
1 2 3 4 5
BMI
% No diabetes
IDDM
Obesity
• The mean BMI of women with IDDM was 26.2 (95% CI 25.4,26.9)
• Mean BMI in women without diabetes was 24.1 (24.0,24.2)
• Differences in the two groups suggest that this should be adjusted for in the analysis
Hypertension
• Record of a diagnosis of hypertension linked to a prescription in 1994
• 17/938 (1.8%) women with IDDM and 54/10,000 (0.5%) women without diabetes were being treated for hyertension
• Not statistically different
Risk of pregnancy by age group IDDM vs no diabetes in 1994
Overall RR 0.77 (.59,1.02)
0
1
2
3
4
5
6
15 20 25 30 35 40
Upper
Point
Lower
Proportion of women with a record of a pregnancy in 1994 by age
02
46
810
1214
16
15-19 25-29 35-39 45-49
AGE
%No diabetes
IDDM
Use of oral contraceptives in women with IDDM from different countries
OC0
10
20
30
40
50
OC
UK
France
Denmark
Germany
NZ
Use of progestogen only pills in women with IDDM from different countries
POP0
5
10
15
20
POP
UK
France
Denmark
Germany
NZ
Use of IUCD in women with IDDM from different countries
IUCD0
5
10
15
20
25
30
35
IUCD
UK
France
Denmark
Germany
NZ
Use of female sterilisation in women with IDDM from different countries
Sterile0
5
10
15
20
25
Sterile
UK
France
Denmark
Germany
NZ
Use of vasectomy in the partners of women with IDDM from different countries
Vasect0
2
4
6
8
10
12
Vasect
UK
France
Denmark
Germany
NZ
Use of barrier methods of contraception in women with IDDM from different countries
Barrier0
5
10
15
20
25
Barrier
UK
France
Denmark
Germany
NZ
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