American Diabetes Association Complete Guide to Diabetes: The Ultimate Home Reference from the Diabetes Experts

CHAPTER 15

Women’s Health

• Specific Risks for Women

• Menstruation

• Menopause

• Sexual Health

• Birth Control

• Pregnancy

Women with diabetes have more opportunities than ever to live healthy and full lives. Perhaps you’ve always dreamed of having children. Perhaps you want a richer sex life. Let’s face it, every woman wants to age gracefully and go through menopause smoothly.

Your diabetes and management of your blood glucose shouldn’t stop you from pursuing your goals. In fact, being more aware of your body, meal plan, and fitness could put you in better touch with your health than other women.

Read on to find tips for dealing with specific women’s issues such as your menstrual cycle, pregnancy, and menopause. In addition, you’ll find out about a few diseases you should have on your radar as a woman with diabetes.

Specific Risks for Women

It’s no surprise that women with diabetes have specific health needs and concerns. After all, pregnancy, menstruation, and menopause are uniquely female circumstances. You’ll want to consider your diabetes and your blood glucose management as you approach these different stages in your life.

Women with diabetes should also be aware of their risk for certain problems such as heart disease, obesity, osteoporosis, and depression. These disorders are common in women with diabetes. The good news is that many of these problems can be prevented or treated effectively.

Heart Disease

You’ve heard that diabetes makes you two to four times more likely to have a heart attack or stroke than someone without diabetes. You also know that cardiovascular disease is the number one killer of men and women with diabetes.

Yet, recent studies are shedding light on how big a problem cardiovascular disease is for women with diabetes—regardless of age or menopause status. Women with diabetes have a 4- to 6-fold increase of coronary artery disease, according to one study. Coronary artery disease can lead to heart attacks, heart failure, and death. This compares with a 2- to 3-fold increase in men with diabetes. In the past, cardiovascular disease was thought of as a “man’s disease.” Now, physicians and patients are realizing that women are at equal or greater risk for cardiovascular disease.

Preventing Heart Disease

It’s important to advocate for your cardiovascular health at your regular checkups. Make sure that your health care provider checks your cholesterol and blood pressure, which are two contributors to cardiovascular health. Ask whether you are meeting the recommended goals for blood pressure and cholesterol as discussed in chapter 14.

Obesity

Women tend to be more overweight than men, so they need to take active steps to reduce and maintain a healthy weight. Obesity is a major risk factor for type 2 diabetes and cardiovascular disease.

Regular physical activity and healthy eating will help you lose weight and prevent obesity. Exercising will also help you lower your blood glucose and increase your insulin sensitivity. If you’re overweight, ask your health care provider about healthy steps that you can take to lose weight and reduce your risk for cardiovascular disease and other diabetes complications.

Osteoporosis

Osteoporosis happens when your bones become weak and brittle, usually because they have lost mass and density. The most common problem is a bone fracture, which can occur even when doing the simplest of tasks.

You’ve probably heard that women, especially post-menopausal women, are at increased risk for osteoporosis. But older women with diabetes have an even higher risk of osteoporosis.

Risk of Fractures

Women with type 1 diabetes have four to five times the risk for fractures than other women, according to one study. In addition, women with type 2 diabetes tend to have more fractures than their nondiabetic counterparts of the same age. TZDS, a diabetes medication, may increase the risk of fractures, so women should discuss these risks with their health care providers.

Preventing and Treating Osteoporosis

Women of all ages should make sure they’re getting the recommended amounts of calcium and vitamin D to promote bone health. You should also exercise regularly. Bone health starts early, so it is important to take healthy steps in your 20s and 30s, but it is never too late to become more active.

Women 65 and older should have a bone density test performed. Your doctor may recommend the test earlier if you have a family history of osteoporosis. Treatments for osteoporosis include prescription medications, such as bisphosphonates, raloxifene, calcitonin, teriparatide, denusomab, and tamoxifen.

Depression

In general, people with diabetes are more likely to experience depression. Women with diabetes are more likely to suffer from depression than men with diabetes, according to one study. Make it a point to bring up any symptoms of depression with your health care team. You can read more about symptoms and treatments for depression in chapter 14.

Menstruation

At first, you think you’re just imagining it. You’re going along and everything seems fine. You’re in good spirits, eating well, getting regular workouts, and your blood glucose levels are on target most of the time. Then, for some unexplained reason, everything seems out of whack. Maybe your blood glucose levels are too high; maybe they’re too low. Then you check the calendar. Oh, yeah—it’s that time of the month.

Research behind Menstruation and Diabetes

If you have trouble keeping your blood glucose levels on target just before your period starts, you are not alone. A survey of 200 women with type 1 diabetes showed that in the week before their periods, 27% had problems with higher-than-normal blood glucose levels and 12% had lower-than-normal blood glucose levels. Another study revealed that among women under the age of 45 who were hospitalized for diabetic ketoacidosis, half were within several days of starting their periods. A survey of more than 400 women revealed that nearly 70% experienced problems with blood glucose levels during their premenstrual period. The problem was more common among women who considered themselves to suffer from the moodiness associated with premenstrual syndrome (PMS).

It’s difficult to pinpoint just how many women have problems with their blood glucose levels before menstruation. Many studies are based on surveys conducted after the fact and do not take physical activity and eating patterns into account.

Menstrual Cycle

A woman’s reproductive system revolves around the monthly task of ovulation—releasing an egg ripe for fertilization. This is true from the time that women begin menstruating until menopause.

Phases of the Menstrual Cycle

• The follicular phase of the menstrual cycle begins the day your period starts and lasts for about 12–14 days, until you ovulate or release the egg.

• During the early part of this stage of the cycle, the female sex hormones estrogen and progesterone are at their lowest levels.

• Another hormone, follicle-stimulating hormone, is produced, which turns on estrogen production. This prepares the ovary to respond to a surge of a second pituitary hormone called luteinizing hormone. The mid-cycle surge of luteinizing hormone causes the ovary to release an egg midway through the cycle.

• After egg release, the luteal phase takes over. Luteinizing hormone triggers the ovary to produce estrogen and progesterone. These hormones cause the lining of the uterus to thicken, in preparation for a possible pregnancy.

• If fertilization does not occur, the ovary stops making estrogen and progesterone. The sudden loss of estrogen and progesterone cause the shedding of the uterine lining, and menstruation occurs.

Causes of High Blood Glucose

Some women find that the high levels of estrogen and progesterone about a week or so before menstruation affect their blood glucose levels. Researchers aren’t exactly sure why, but they have some clues.

Insulin works by binding to receptor proteins that sit on the surface of cells. Glucose can then enter the cell. When levels of progesterone and other progestin hormones are high, insulin action within cells is affected. This leads to temporary extra insulin resistance—the cells no longer respond to insulin the way they should. The result is that blood glucose levels may be higher than usual and then drop once menstruation begins.

Causes of Low Blood Glucose

Higher-than-normal estrogen levels may actually increase sensitivity to insulin by improving insulin action. When this occurs, the increased insulin action can lead to blood glucose levels that may be lower than usual before menstruation.

Other Symptoms

Not all women experience changes in blood glucose levels before menstruation. Some studies have shown no differences in blood glucose levels throughout the menstrual cycle. Some women experience bloating, water retention, weight gain, irritability, depression, and food cravings, especially for carbohydrates and fats. If you have a tendency to crave these foods, they could also contribute to high blood glucose levels before your period.

Check Your Records

You can find out for sure if you suspect that your blood glucose levels are affected by your menstrual cycle. Look at your daily blood glucose records over the past few months. Mark the date that your period started for each month. Do you see any pattern? Are your blood glucose levels higher or lower than normal during the week before your period? If you are not recording your blood glucose levels, now may be a good time to start.

Troubleshooting Your Blood Glucose during Menstruation

You can get things back on track if you find your blood glucose levels harder to manage on a monthly basis. Changes in blood glucose levels could be due to normal changes, PMS, or both. Some women find that they need to adjust their insulin dose before their period and again once the period starts.

Think about charting your symptoms along with your glucose levels. It will also help to note how you are feeling throughout the month, not just before your period, to see whether you can detect any sort of pattern.

Here are some specific strategies to try depending on whether you tend to have high or low blood glucose around your period. Try one strategy at a time, so you know which one is the most effective.

Strategies for Highs before Your Period

• If you use insulin, gradually increase your dose. Work with your health care team to add small increments, so that insulin levels are higher the last few days of your cycle, when blood glucose levels normally rise. One to two additional units of insulin may be all it takes. It will take a little trial and error to figure out the right dose for you. As soon as menstruation begins, estrogen and progesterone levels drop. When this happens, return to your usual dose of insulin to lower your risk of hypoglycemia.

• Eat at regular intervals, when possible. This will keep your blood glucose levels from swinging too much. Large blood glucose swings could contribute to some of the emotional and physical symptoms of PMS, which may in turn make variations in blood glucose levels worse.

• Try to avoid eating extra carbohydrates. Keep a handy supply of crunchy veggies—for example, celery, radishes, or cucumbers—and dip them in fat-free salsa.

• Cut back on alcohol, chocolate, and caffeine. They can affect both your blood glucose levels and your mood.

• Be especially careful about your sodium intake, which causes bloating. Use pepper, fresh or powdered garlic, lemon, cayenne pepper, or scallions to add some zing to food.

• Try to be more physically active. Many women find that regular exercise diminishes mood swings, prevents excessive weight gain, and makes it easier to manage blood glucose levels.

Strategies for Lows before Your Period

• If you use insulin, work with your health care team to gradually decrease the amount of insulin you take a few days before your period starts. A decrease of 1 or 2 units of insulin may do the trick.

• Reducing diabetes medications may help, especially if you are concerned about having to take extra food. Ask your provider about the safest way to go about this.

• Try spreading your carbohydrate intake over the course of the day. Multiple small meals can help even out your glucose levels.

• Eat a small amount of carbohydrate before you work out.

If your periods are irregular and your blood glucose swings are unpredictable, try to chart your ovulation to see whether you can tell when your period will occur so you can adjust your treatment plan. If you are taking insulin, you may want to try intensive diabetes management, perhaps with an insulin pump. This may give you the flexibility you need to deal with changes in blood glucose levels on a daily basis.

Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is common in women with diabetes. Roughly 5–10% of American women have PCOS. It can cause abnormal menstrual cycles and is the most common cause of infertility. No one knows exactly what causes PCOS, but some people think there may be a link to insulin.

Symptoms of PCOS

• Abnormal menstrual cycles

• No periods

• Irregular periods

• Heavy or prolonged bleeding

• Painful periods

• Infertility

• Acne

• Facial hair

• Waist measurement greater than 35 inches or a waist bigger than hips (apple shape).

• Acanthosis nigricans: darker patches of skin in neck folds, armpits, folds in the waistline, or groin.

There are treatments for the symptoms of PCOS, so talk to your health care provider if you experience any of the above problems.

Menopause

Menopause is a natural process, not an event. It proceeds slowly, often lasting 8–10 years. It begins when your body slows down its production of estrogen and progesterone, the hormones that set the stage for pregnancy.

Ovulation and menstruation become irregular. Some months you may ovulate and have a period; other months you may not. You may also experience other symptoms, such as vaginal dryness, weight gain, and mood swings—problems that you may initially attribute to your diabetes.

It can begin before you turn 40, but many women continue to menstruate well into their 50s or 60s. The average age for U.S. women having their last period is 51. Your mother’s age at menopause is highly predictive of yours.

Menopause and Blood Glucose

Menopause can throw your diabetes management plan out of balance. That’s because you may have learned to adjust your plan around your normal hormonal fluctuations. The hormones that keep your menstrual cycle going—estrogen and progesterone—can also affect blood glucose levels.

In some women, high levels of progesterone and other progestin hormones may decrease the body’s sensitivity to insulin. High levels of estrogen tend to improve insulin sensitivity. As you start the transition of menopause, you’ll want to pay close attention to the effects it will have on your blood glucose levels.

Menopause can be a very positive time in life for women. They are free from some of their responsibilities and can spend more time taking care of themselves.

Complications of Menopause

Menopause changes the amount of estrogen and progesterone in your body. These hormones have protective effects that can be diminished during menopause. This can put you at risk for heart disease, osteoporosis, and yeast infections. These risks are particularly pertinent for women with diabetes, who already have a greater risk for these problems.

Heart Disease

You will be more sensitive to insulin during menopause. That’s good news. But losing estrogen can increase your insulin resistance. The lack of these hormones can also cause other changes, some of which can affect diabetes complications.

Diabetes increases your risk for heart attack and stroke two to four times above the general population. Women without diabetes are protected against cardiovascular disease until menopause. This is not the case for women with diabetes. Diabetes overrides the protective effect of estrogen. If you have diabetes, your risk for heart attack and heart disease is six times that of a woman without diabetes.

Total cholesterol levels tend to rise and levels of “good,” or HDL, cholesterol tend to drop after menopause. For some women, hormone replacement therapy may increase triglycerides, a common problem in type 2 diabetes. High blood glucose levels can make this situation even worse. Keeping your blood glucose, blood pressure, and cholesterol levels on target can help.

Osteoporosis

Estrogen also helps to maintain strong bones. As estrogen levels fall, your bones can lose some of the minerals that hold them together. This can lead to osteoporosis, a condition in which bones are brittle and easily broken.

Eating calcium-rich foods, taking calcium supplements, and participating in regular weight-bearing exercise, such as walking, can help. Hormone replacement therapy can increase bone density and lower your risk of osteoporosis. Other medications to combat osteoporosis are available.

Yeast Infections

Many women with diabetes find they are more prone to vaginitis and yeast infections once they enter menopause. Yeast and bacteria can irritate the vaginal lining if they grow out of control. They thrive in warm, moist places with a good supply of food (glucose).

Even before menopause, you are more likely to develop yeast infections when your blood glucose levels are high. After menopause, the risk increases. That’s because estrogen normally nourishes and supports the vaginal lining. Without it, yeast and bacteria have an easier time growing. These infections are not related to sexual activity or personal hygiene.


Weight Gain during Menopause

Some women find that they gain weight during menopause. This can increase the need for medications. Many women find that they need to eat less and exercise more to maintain their weight.


Treatments for Menopause

Hormone replacement therapy is a complicated issue. On one hand, estrogen can decrease the risk of osteoporosis and vaginitis and alleviate hot flashes. On the other hand, it can increase the risk of breast and uterine cancer, heart disease, and stroke.

Hormone Replacement Therapy

• The current recommendation is to take the smallest dose of hormone replacements for the least amount of time possible to control symptoms.

• Reevaluate your treatment plan every six months.

• Women with breast cancer, heart disease, or a history of blood clots should avoid hormone replacement therapy.

Whether you decide to use hormone replacement therapy is up to you. Many factors can influence your decision, like whether diseases like cancer, heart disease, and osteoporosis run in your family.

As a woman with diabetes, you need to play an active role in your overall health care throughout menopause and beyond. You have more at stake during this time in your life than women without diabetes. As with other issues related to your sexual health, it’s important that you discuss concerns with your provider and other health care team members.

Important Tests for Women Taking Hormone Replacement Therapy

• Have your A1C tested two to four times a year. This test tells you about your blood glucose levels over the long term.

• Have your cholesterol and triglyceride levels checked as recommended by your provider.

• Have yearly eye exams and kidney function tests.

• Have a yearly mammogram to detect breast cancer.

• Have a yearly Pap smear and gynecologic examination to detect cancer of the cervix, uterus, endometrium, and ovaries.

Sexual Health

Diabetes can affect sexual function and fulfillment for both men and women. The good news is that sexual health is getting more attention, and there is more help available.

If you are having any problems related to sexual issues and you want help, talk to your health care team. If you don’t feel comfortable talking with your provider, perhaps you need to find a health care professional with whom you do feel comfortable discussing personal matters.

Your provider will evaluate your concerns and help you sort out the causes. There are many factors that can result in sexual difficulties, including medications, hormonal changes, problems caused by diabetes, and your emotional health.

Your Sexual Health

• If your sexual problem appears to be due to a physical cause, you may be referred to a gynecologist or urologist.

• If stress or anxiety is contributing to your problem, a visit with a mental health professional may be in order.

• Depression, which is more common among people with diabetes, can also contribute to problems with sexual fulfillment and performance.

Problems with Arousal

Many women with diabetes at one time or another experience some sexual difficulties. In fact, one study showed that 30–40% of women with diabetes reported that they have problems with sexual function, refrain from sexual relations, and are generally not satisfied with sex. But for women, long-term blood glucose levels and diabetes complications don’t appear to have a direct effect on sexual functioning. For most women with diabetes, the problem is caused by lack of arousal.

There is a very strong link between mind and body. If a woman does not feel in the mood for sex, then her body does not respond the way it needs to in order for her to enjoy it. If she is not emotionally ready or interested in sex, then she will be less likely to enjoy it physically.

Common Causes of Lack of Arousal

• Vaginal infections that affect how you feel physically and how sexy you feel

• Bladder infections that can cause painful intercourse

• Hormonal changes due to your menstrual cycle or menopause

• Vaginal dryness

• Lack of sexual desire

• Fear of pregnancy

• Depression and medications used to treat depression

Vaginal Infections

Vaginal infections (yeast infections, vaginitis) are more common among women with diabetes. Blood glucose gives the bacteria an excellent medium in which to grow. These infections do not have anything to do with how clean you are, your age, or sexual activity. Although vaginal infections do not directly affect your sexual health, they can affect how sexy and desirable you feel.

You can buy over-the-counter antifungal products to treat these infections. If the infection does not clear up within a week, contact your health care provider for stronger medicine.

Urinary Tract Infections

Women with diabetes are also at risk for bladder or urinary tract infections (UTIs) for the same reason. Signs of a bladder infection include feeling like you need to go to the bathroom more often, painful urination, painful intercourse, and blood in the urine.

If you think that you have a bladder infection, call your health care provider right away. These infections usually respond quickly to antibiotics. Some women find that cranberry juice helps treat or prevent these infections. Choose artificially sweetened cranberry juice or purchase a bottle of cranberry pills.

Hormonal Changes

Many women find that during their menstrual cycle, and especially around the time of their period, their blood glucose levels are erratic, and they have less energy for everything, including sex.

During menopause, hormone levels change, and some women find that their blood glucose levels go up and down. Mood changes and hot flashes are also common during this time. Although menopause does not affect sexual desire, some women find that they have vaginal dryness that can make sex painful or uncomfortable. You can buy lubricating gels (e.g., water-soluble jelly) that can help. You can also ask your provider about estrogen creams.

Lack of Sexual Desire

Some women find that they are just too tired. They are coping with busy lives, caring for children and grandchildren, working, and trying to find some time for themselves. Diabetes adds more stress and work to their lives. High blood glucose levels add to feeling tired and run down. Because of nerve changes related to diabetes or simply due to getting older, some women find that they need more stimulation to fully enjoy sex.

Depression is more common among people with diabetes. Depression usually causes people to feel less interested in sex. In addition, some of the medications used to treat depression can affect sexual desire.

Women with either type 1 or type 2 diabetes may feel less desirable or that their bodies are less attractive as they get older and perhaps heavier. Diabetes complications can also cause you to feel less desire, both emotionally and physically.

Tips to Increase Your Desire

• If you have dryness, infections, or are worried about getting pregnant, talk with your diabetes care provider or your gynecologist.

• If you are worried about your blood glucose levels, do a quick blood glucose check before having sex. Knowing that you are not likely to have a reaction can help you relax and enjoy yourself. You may also want to keep something to treat a low glucose nearby so that if you do go low, you won’t have to interrupt things too much. See more about avoiding lows during and after sex in chapter 8.

• If you feel sad and blue or if your sadness is affecting your desire for sex, talk with your provider. There are medicines that will work for depression that do not affect your desire for sex.

• Help set the stage to get into the mood. Take time for yourself and your partner. Let your partner know what will help you feel more romantic and in the mood.

Birth Control

Practicing birth control and safe sex are important for anyone, but especially for women with diabetes. You don’t want to be caught off guard. Instead, you want to plan and prepare for a pregnancy as much as possible to ensure optimal health for you and your baby.

Why It’s Important

Choosing and using an effective form of birth control allows you to plan your pregnancies. This will help you get your blood glucose on target before you become pregnant.

Blood Glucose and Early Pregnancy

• High blood glucose levels can interfere with the early development of a baby, and the baby has a greater chance of a birth defect.

• A baby’s organs are formed in the first six weeks after conception. Most women are not even sure that they are pregnant during this critical time.

• Also, when blood glucose levels are high, the risk of spontaneous miscarriage may double in early pregnancy.

• You increase your chances for a healthy child when you plan your pregnancy and have an A1C level that is as near to normal as possible before you conceive.

• In fact, when blood glucose levels are close to normal, the risk for birth defects is about the same as for women without diabetes.

Types of Birth Control

Women with diabetes have the same birth control options as other women. The pill, intrauterine device (IUD), barrier methods, and spermicides are all ways to reduce the risk of unplanned pregnancy.

The rhythm method, in which women predict ovulation and avoid intercourse during fertile times, is generally not a sufficiently reliable method of birth control for women with diabetes. A tubal ligation may be an option if you are sure you never want to become pregnant, because it is nearly impossible to reverse.

Many birth control methods work by altering hormone concentrations. The methods of birth control that rely on hormones, such as birth control pills and the IUD that releases progesterone, can affect your blood glucose levels. Birth control methods that don’t rely on hormones are not likely to change your blood glucose levels.

Which method you choose will depend on your own personal and family health history and your individual preferences. If you have any special concerns, be sure to bring them up with your health care team.

Oral contraceptives (“the pill”) are the most popular and effective birth control method available. Hormonal methods of birth control prevent pregnancy by preventing ovulation. They are available as pills, patches, vaginal rings, and by injection. Hormonal contraceptives are about 95–99% effective. But whether the pill is right for you depends on many factors.

Types of Birth Control Pills

• Some pills contain estrogen and progesterone.

• Other pills contain only progesterone (called mini pills).

• Another pill is taken for three months straight, and a woman only gets her period four times a year.

Other Types of Hormone Delivery

• The patch contains both estrogen and progesterone. You leave it on for 21 days and then remove it for seven days.

• The vaginal ring is a small circular device that contains estrogen and progesterone. You insert it deep into your vagina and leave it there for 21 days.

• An injection called Depo-Provera contains only progesterone. It is given at your provider’s office every three months. Before committing to any long-lasting method, you may want to try a progesterone-only pill, which you can stop at any time, to see how you respond.

• Progestin implants are surgically implanted beneath the skin and work for several years. The Norplant implant was taken off the market, but other implants are available.

In general, hormonal methods of birth control are safe for women with diabetes. If you are over 35 and smoke or if you have a history of heart disease, stroke, high blood pressure, peripheral blood vessel disease, or blood clots, these methods may be risky for you.

If you’ve found that your insulin sensitivity varies at certain times of the month, being on the pill, patch, ring, or injections may help smooth out your blood glucose levels. By providing a steady dose of hormones, blood glucose swings can be kept to a minimum.

Some women find that oral contraceptives increase insulin resistance. If your blood glucose levels are affected, your insulin or your dose of oral diabetes medication can be adjusted. Taking the lowest possible dose or the mini pill can also help.

Pill Precautions

• Check your blood glucose levels frequently, especially during the first couple of months.

• Some women need to slightly increase their insulin dose. By keeping complete records, you and your health care team can decide whether you need to make changes in food, activity, or diabetes medication.

• Have your A1C, blood pressure, cholesterol, and triglyceride levels checked three months after you go on the pill and then as often as recommended.

IUD

The IUD is a small T-shaped object that is placed into the uterus by a provider. IUDs prevent sperm from reaching the egg or from implanting in the uterus. One type contains copper, and others contain progesterone. IUDs can remain in place for one, five, or ten years, depending on the type.

IUDs are generally recommended for women who have had one or more children. When properly inserted and retained, IUDs are 95–98% effective in preventing pregnancy.

Diaphragm

The diaphragm is a shallow rubber cup that fits tightly over the cervix, the entrance to the uterus. It prevents sperm from entering the uterus. The diaphragm is coated with spermicidal jelly before you insert it. The diaphragm is put into place just before intercourse and needs to be kept in place for at least 6 hours after intercourse and then removed.

It is 80–94% effective for preventing pregnancy. The effectiveness depends on the user’s ability to place the device correctly, use of spermicidal jelly, and leaving it in place for the full time. Your gynecologist will fit your diaphragm and teach you how to place it properly and check to be sure it is covering the cervix.

Sponge

The sponge contains spermicidal jelly and is placed into the vagina over the cervix to prevent sperm from entering the uterus. It can be inserted up to 24 hours prior to intercourse and needs to be left in place for 6 hours afterward. Sponges are 80–91% effective.

Cervical Cap

The cervical cap is a small, thimble-shaped barrier device that fits tightly over the cervix to prevent sperm from entering the uterus. It is used with spermicidal jelly.

Condom

The condom, a thin sheath that is placed over the penis before intercourse, is a common form of birth control. It prevents the sperm from entering the woman’s vagina. When used correctly and along with a spermicide, the condom is 85–90% effective in preventing pregnancy. The condom should be put on before intercourse and can be removed soon afterward. Condoms also help prevent the spread of several sexually transmitted diseases, including gonorrhea, chlamydia, and AIDS.

Female Condom

The female condom is another barrier method of contraception. It is a larger type of condom that you insert into your vagina up to eight hours before intercourse. You remove it afterward, taking the sperm with it. It can also help protect against sexually transmitted diseases. It is 74–79% effective.

Spermicides

These work by killing sperm and can be purchased without a prescription. There are several types: foam, gel, cream, suppository, or tablet. They can be used alone or to increase the effectiveness of barrier methods. They are 72–90% effective.

Sterilization

If you are sure you never want children or don’t want any more children, you may want to consider surgical or nonsurgical sterilization. With the surgical method, the fallopian tubes are tied off to prevent eggs from reaching the uterus. With the nonsurgical method, tiny spring-like coils are placed into the fallopian tubes. Material embedded into the coils irritates the lining of the tube, causing scar tissue to grow. After about three months, there is enough scar tissue to block the tubes.

Done correctly, these methods are almost 100% effective in preventing pregnancy. In very rare cases, a fertilized egg may reach the uterus, resulting in pregnancy, or may grow outside the uterus, resulting in an ectopic pregnancy. You’ll need to be certain about your decision to be sterilized, because it is nearly impossible to reverse.

Pregnancy

In the past, it was common for women with diabetes who became pregnant to experience serious problems, such as miscarriage, stillbirth, or a baby with birth defects. Today, it is very common for women with diabetes—either type 1 or type 2—to have safe and healthy pregnancies.

Although women with diabetes and their unborn children face additional risks because of diabetes, these can be kept to a minimum through careful blood glucose management, before and during pregnancy, and intensive obstetrical care. For this reason, all women with diabetes need to plan ahead before becoming pregnant.

Before Pregnancy

The first step is to meet with your health care team to consider the specific challenges you may face during your pregnancy. You need a complete evaluation of your overall health and any diabetes complications. It’s important to get a good idea of how much extra work and expense may be involved before you become pregnant.

You may have specific questions for your health care provider. You may be concerned that your baby could develop diabetes. You may be worried for your own health. Your glucose levels may also be an issue.

Baby’s Risk for Type 1 Diabetes

You may have concerns about your child someday developing diabetes. A child born to a parent who has type 1 diabetes is at slightly greater risk of developing type 1 diabetes than children of parents without diabetes. The risk is slightly higher when the father has type 1 diabetes.

Researchers have identified genes that could play a role in type 1 diabetes. However, there is no genetic test for predicting whether your baby will develop type 1 or type 2 diabetes.

• A baby has a 1% risk of developing diabetes if the baby is born to a mother who is age 25 or older and has type 1 diabetes.

• A baby has a 4% risk of developing diabetes if the mother is younger than age 25 when the child is born.

• A baby has a 6% risk of developing diabetes if the father has type 1 diabetes.

• Each of these risks is doubled if the parent with type 1 diabetes developed it before the age of 11.

• If both parents have type 1 diabetes, the risk is not known but is probably somewhat higher.

• A baby born to parents who do not have diabetes has a 0.3% risk of developing the disease.

Baby’s Risk for Type 2 Diabetes

Type 2 diabetes tends to run in families. You can inherit genes that increase the chances you will develop type 2 diabetes. Studies of twins have shown that genetics play a very strong role in the development of type 2 diabetes. However, scientists do not yet have tests that can predict which genes cause diabetes.

Lifestyle also influences the development of type 2 diabetes. Obesity tends to run in families, and families tend to have similar eating and exercise habits.

If you have a family history of type 2 diabetes, it may be difficult to figure out whether your diabetes is due to lifestyle factors or genetic susceptibility. Most likely it is due to both. However, don’t lose heart. Studies show that it is possible to delay or prevent type 2 diabetes by exercising and losing weight.

Ask your provider to refer you to a medical geneticist or genetic counselor if you have concerns about your baby’s risk for diabetes. They are trained to assess the contributions of genetic and environmental factors in causing many diseases, including diabetes. They will know the results of the latest diabetes and genetics studies and studies to prevent diabetes in high-risk individuals.

Pre-Pregnancy Exam

You’ll need a thorough physical exam before you become pregnant to assess any problems that could jeopardize your health or that of your baby.

Pre-Pregnancy Checkup

• An assessment of any complications, such as high blood pressure, heart disease, and kidney, nerve, and eye damage. If you have any of these complications, they need to be treated before you try to conceive. Even kidney transplant recipients who are otherwise healthy have had babies.

• Your A1C level will be measured.

• If you have type 1 diabetes, your thyroid function will be measured.

• In addition, your exam will include a review of all the medications, herbs, and supplements you are taking to make sure they are compatible with a safe pregnancy.

Diabetes Complications and Pregnancy

In rare cases, diabetes-related problems may be so serious that it’s safer to avoid pregnancy. For example, you’ll need to think carefully about pregnancy if you have untreated high blood pressure, cardiovascular disease, kidney failure, or crippling gastrointestinal neuropathy. Pregnancy can make these conditions worse.

Heart Disease. Your doctor may recommend an electrocardiogram if you have any signs of heart disease, such as chest pain during exertion.

Neuropathy. Signs of nerve damage will also be checked. If the nerves that control heart rate or blood pressure have been damaged, this can affect how you will respond to the physical stresses of pregnancy. Neuropathy can also affect how well your body nourishes you and your growing baby, so tell your provider if you have had persistent problems with nausea, vomiting, or diarrhea.

Kidney Disease. Your pre-pregnancy exam will also include an evaluation of your kidneys. In women with high blood glucose levels and untreated kidney disease, kidney function can worsen during pregnancy. Fortunately, pregnancy does not appear to have long-lasting effects on kidney function. If you have kidney problems, you need to be prepared for a potentially more difficult pregnancy. This can include problems with edema (swelling) and high blood pressure.

Retinopathy. You will also be referred to an ophthalmologist, who will examine your eyes, especially the retina—the part of your eye that senses visual images. Your pupils will be dilated so that the back of the retina can be checked for damage caused by diabetes. Untreated diabetic retinopathy may get worse during pregnancy and should be treated and stable before you become pregnant. You will continue to get your eyes examined throughout the pregnancy.


ACE Inhibitors, Statins, and Pregnancy

You will need to change your medication if you have been taking ACE inhibitors or ARBs for kidney disease or high blood pressure. Taking these drugs during pregnancy can cause kidney problems for the baby. Likewise, if you take a statin to treat your cholesterol levels, you will also need to discontinue those before becoming pregnant.


Ideal Pregnancy Health Care Team

• Diabetes care provider

• Obstetrician experienced in treating pregnancy complicated by diabetes

• Pediatrician experienced in the care of infants of mothers with diabetes

• Registered dietitian

• Diabetes nurse educator experienced in teaching women how to intensively manage their diabetes

Managing Your Blood Glucose before Pregnancy

Birth defects occur in 1–2% of all babies born to women without diabetes. These problems include abnormalities of the central nervous system, heart, and kidneys.

Women with diabetes have a higher risk of birth defects in their babies, but they can lower the risk to the same level as mothers without diabetes by keeping blood glucose levels on target. This means keeping blood glucose levels as close to normal as possible before and during the first trimester of your pregnancy. Keep in mind that pregnant women without diabetes have lower blood glucose levels than non-pregnant women.

Why is well-controlled blood glucose important before conception? Because you want your blood glucose levels to be as favorable to your developing baby as possible. All of the baby’s major organs are formed during the first 6–8 weeks of pregnancy, which may be before you know you’re pregnant.

Planning ahead of time will ensure that you find a diabetes management plan that will work for you. This takes some trial and error as well as patience. It may take too long if you wait until you are pregnant.


Research behind Tight Control and Pregnancy

In several studies, women who had an A1C that was 1% above normal levels before conception lowered their baby’s risk of birth defects to 1–2%, the same as women without diabetes. Normal A1C is less than 7%. Babies of mothers who began intensive diabetes management after conceiving were more likely to have birth defects.


Tips for Pre-Pregnancy Blood Glucose Management

• Before you become pregnant, you probably will intensify your daily diabetes care.

• If you have type 1 diabetes, you will begin or fine-tune your plan by using several insulin injections each day or switching to insulin pump therapy.

• If you have type 2 diabetes, using oral diabetes medicines may not be recommended.

• You will probably need to begin insulin therapy. Many women with type 2 diabetes find that they need to use insulin during pregnancy.


A1C before Pregnancy

Your A1C level will be measured frequently. It is recommended that your 

A1C level be as close to normal as possible before you stop using birth control.


Health Care Expenses

Having a baby is a major financial investment for any parent. Your pregnancy will include the added expenses involved in tight blood glucose management. It used to be worse. Before self-monitoring of blood glucose, a woman could easily spend half of her pregnancy in the hospital. Now the major expenses are fetal monitoring and blood glucose monitoring instead of hospitalizations.

Before you conceive, check with your insurance company to find out what is covered. Your insurance plan may cover more during your pregnancy if you have the appropriate documentation.

Extra Expenses and Doctor Visits

• You will need to see both your obstetrician and your diabetes health care provider frequently—perhaps every week or every 2 weeks for most of your pregnancy. You will learn to make adjustments to insulin doses based on blood glucose values. This requires time, practice, and lots of support from your health care team.

• Your health care should include nutrition counseling with a registered dietitian and diabetes educator. You will likely learn how to count carbohydrates and adjust insulin doses.

• You’ll need to check blood glucose values often to make sure you are within your target ranges. Many pregnant women do seven or more checks each day. Test strips are the big expense in monitoring.

• You may need to do ketone monitoring each day. This will protect you against surprise ketoacidosis as well as starvation ketosis, which can occur after a low blood glucose value, when carbohydrate intake is very limited, or when calorie intake is lower than needed. This means buying ketone strips.

• If you treat your type 2 diabetes with oral diabetes medications, you may need to switch to insulin before you become pregnant. This means paying for insulin pens or syringes and insulin, plus training from an educator on how to give insulin and to adjust your dose.

During Pregnancy

Your pregnancy is one of the most important times to take good care of yourself and your diabetes. You’ll want to create the healthiest environment possible for your growing baby. Women with diabetes can deliver perfectly healthy babies with the right care, planning, and management.

Managing Your Blood Glucose

The first step is to choose blood glucose targets for your pregnancy. Talk to your health care team about how to personalize blood glucose target ranges to your health and your lifestyle.

Sample Target Blood Glucose Ranges during Pregnancy

• Before meals: 60–99 mg/dl

• One hour after meals: 100–129 mg/dl

• A1C less than 6%

In the first trimester, targets are designed to help you minimize the risk of birth defects or miscarriage. In the second and third trimesters, the targets will help prevent your baby from growing too large. If you have trouble staying in the target range, or if you have frequent or severe hypoglycemia, talk to your health care team about revising your treatment plan or your targets.

Insulin during Pregnancy

• Women with type 2 diabetes usually need to use insulin during pregnancy.

• Many women with gestational diabetes need to use insulin.

• Women who use insulin will find that they need to increase their insulin dose over the course of the pregnancy to reach these targets.

• You may also need to make adjustments in the kind of insulin you take and how often you inject.

• Usually, the amount of insulin you take increases with each trimester. Some women need to increase their insulin dose by as much as two or three times, especially in the last trimester.

You’ll probably need more insulin throughout your pregnancy because the hormones of pregnancy, which increase in effect over time, create more and more insulin resistance. This does not mean that your diabetes is getting worse. You and your provider need to decide together when and how to make any changes in your insulin schedule or dose.

Monitoring Your Blood Glucose

You will probably need to check your blood glucose levels several times each day. If you take insulin, you may monitor before and after meals and at bedtime. If you have type 2 or gestational diabetes and are managing it through meal planning and regular exercise, you will need to check more frequently than usual.


Hypoglycemia Unawareness during Pregnancy

Some women develop hypoglycemia unawareness during pregnancy (chapter 8), and your early-warning signs of hypoglycemia may change. You may have less shaking and sweating and more rapid development of drowsiness or confusion.


When to Monitor

• Once before each meal

• 1–2 hours after each meal

• At bedtime

• During the middle of the night, around 2 a.m.

If you take insulin and keep your blood glucose levels near normal, you are more likely to have episodes of low blood glucose. During pregnancy, blood glucose of 70 mg/dl or lower is considered hypoglycemia.

Monitoring frequently helps you know whether you are close to being low. There is no evidence that hypoglycemia is dangerous for the baby. But, a hypoglycemic episode can be dangerous for the mother-to-be.

In addition to checking before and after physical activity, always check your blood glucose before you drive. Be prepared for severe low blood glucose by carrying a glucagon kit and training several people (whom you see daily) how to use it (chapter 8).


Ketone Testing

Checking your urine for ketones each morning may be recommended. It will help you know if you are getting the carbohydrates and insulin you need.


Food, Physical Activity, and Exercise

You may need to change your eating habits during pregnancy to help stay on target. You will also want to make sure that you are eating foods that provide adequate nutrition for you and your baby. You will probably want to visit your dietitian even before you become pregnant. In general, choose nutritious foods that are part of any healthy eating plan.

Eating five or six small meals a day may help your efforts to stabilize your blood glucose. Women with gestational diabetes may be able to manage their blood glucose levels more effectively by limiting their carbohydrate intake to 35–40% of calories.

Eating small meals may also help with “morning sickness,” which is often worse when your stomach is empty. Morning sickness is not limited to mornings, and nausea can occur day or night, often accompanied by vomiting.

If you have morning sickness, there are some dietary steps you can take to feel better. It can help to keep some starch, such as Melba toast, rice or popcorn cakes, or saltines or other low-fat crackers, close at hand to eat if you become nauseated. Some women find it helpful to eat a small snack at bedtime or before they get up in the morning to prevent morning sickness.

Help with Nausea

• Eat dry crackers or toast before rising.

• Eat small meals every 2 1/2–3 hours.

• Avoid caffeine.

• Avoid fatty and high-sodium foods.

• Drink fluids between meals, not with meals.

• Take prenatal vitamins after dinner or at bedtime.

• Always carry food with you.

• Talk with your health care team. They may have helpful suggestions. Also tell them about any herbs or supplements you may be using. These may make nausea worse.

It is important to maintain physical activity during pregnancy, as long as your overall health permits it. Being fit prepares you for the physical stress of labor and delivery and the busy days that follow. It is usually safe to continue with any exercise you were doing regularly before pregnancy. But pregnancy is not the time to take up any new, strenuous activities (see chapter 11).

Common Weight Goals for Pregnancy

If your pre-pregnancy weight is…

Then gain…

Underweight (BMI less than 18.5 kg/m2)  

28–40 lb

Normal (BMI 18.5–24.9 kg/m2

25–35 lb

Overweight (BMI 25–29.9 kg/m2)

15–25 lb

Obese (BMI 30 kg/m2 or higher)

11–20 lb

Doctor Visits

You’ll need more frequent visits to your obstetrician, perhaps every two weeks for the first part of your pregnancy and weekly during the last month. The reason for these visits is to make sure that your baby is developing as expected and that you stay in good health.

Common Tests during Pregnancy

• You will be screened for neural tube defects early in pregnancy (around weeks 15–18) by measuring the concentration of alpha-fetoprotein in your blood.

• You’ll need an ultrasound test early in your pregnancy (to show when your baby was conceived) and several more throughout your pregnancy to follow the baby’s growth.

• A fetal echocardiogram may be done around the middle of your pregnancy.

• Other monitoring includes counting your baby’s movements for an hour each day and fetal movement and heart rate monitoring during the last 6–12 weeks of pregnancy. These tests help ensure your baby’s well-being and will assist your health care team in deciding when to deliver your baby.

Birth

In the past, babies born to women with diabetes tended to be large. This problem, called macrosomia, was the baby’s response to the extra amounts of glucose in the mother’s blood. To reduce the risk of delivery problems or stillbirth, these babies were usually delivered by inducing labor or by cesarean section (C-section) before or during the 37th week of a 40-week pregnancy.

Now, because more women are able to manage their diabetes more intensively and better tests are available to monitor the baby’s health, most women can deliver close to their due date.

Macrosomia is less common now, but sometimes the baby is too large or the woman’s pelvis is too small for a safe vaginal delivery. Trying to deliver a too-large baby vaginally can result in shoulder damage or respiratory distress for the baby. In this case, a C-section is performed.

What to Expect during Birth

Your blood pressure will be checked frequently throughout your pregnancy. High blood pressure can be a sign of preeclampsia, a serious condition that occurs more often in women with diabetes. Preeclampsia may also lead to early delivery, often by C-section.

Labor is work, and usually you will not be able to eat. You will probably get an intravenous catheter so that fluids or calories can be given as needed. Your blood glucose levels will be monitored frequently during labor. You can be given insulin either as injections or intravenously. Many women don’t need insulin during active labor.

After Delivery

Once you deliver your baby, both you and the baby will be watched closely in the hospital. It’s a time of celebration and recovery. You’ll have new challenges in managing your diabetes with a little one to nurture and feed. Taking care of yourself—and your diabetes—is one of the most important things that you can do to take care of your new baby.

Baby’s Health

Your baby will be closely watched after birth. He or she is at risk for hypoglycemia and will have frequent blood glucose monitoring during the first 24 hours after birth. Hypoglycemia occurs because the baby has been producing enough insulin to cover the high glucose levels in the uterus. This does not mean your baby has diabetes.

Jaundice is also common and may require therapy with lights. If your baby was delivered early or is very large for his or her age, your baby will also be evaluated for respiratory problems. It is not unusual for these babies to be in an intensive care nursery for a short time so that they can be watched very closely.

Mother’s Health

If you have type 1 diabetes, you may require less insulin for the first few days after delivery. Your health care provider may check for postpartum thyroiditis. If you have type 2 diabetes, you may not need insulin at all during this time. Your insulin needs will gradually go back to your pre-pregnancy level in about 2–6 weeks. If you had gestational diabetes, your blood glucose levels will most likely return to normal after delivery (see chapter 5).

The postpartum period may be one of unpredictable swings in blood glucose. Your hormones and body chemistry are in flux. You are recovering from a major physical challenge. You are probably exhausted from caring for your baby, too. If you find that keeping your blood glucose on target poses a greater challenge, try not to get too discouraged.

If you find that you feel overwhelmed by trying to care for a new baby and diabetes or if you are feeling depressed, contact your health care team. They can help you find support or make a referral for evaluation or counseling. It’s not a sign of weakness if you need help at this time. Your baby needs a healthy mother!

Don’t forget that you can become pregnant again soon after you give birth. Even if you have not had a period, you can still ovulate. Breast-feeding does not necessarily prevent you from becoming pregnant. So, before you resume having intercourse, be sure you are using effective birth control.

Although virtually every aspect of your life may seem turned on its head after the birth of a new baby, the four basic management tools remain the same: insulin or other diabetes medication (oral diabetes medications cannot be used while you are breast-feeding), blood glucose monitoring, meal planning, and physical activity.

Working out may be the last thing you are thinking about after the baby is born. But as soon as you feel well enough and you have your doctor’s okay, taking your baby along on a daily walk can help you feel better and more relaxed.

Highs and Lows

Hormonal changes, emotional shifts, irregular sleep patterns, and fatigue may hide or change your symptoms of high or low blood glucose. You may find it hard to tell the difference between “after-baby” blues, such as unexplained crying or moodiness, and low or high blood glucose. Fatigue, feeling spacey, weakness, or forgetfulness can be caused by both high and low blood glucose and by lack of sleep. If you’re not sure, play it safe and check your blood glucose.

Avoiding Lows

• Check often.

• If you feel hypoglycemia coming on, treat it right away, regardless of whether you can check.

• Keep items such as glucose tablets, hard candy, or regular soda handy in several rooms.

• Make sure that those around you know how to spot your signs of low blood glucose; teach them what you want them to do if you don’t seem like yourself.

• Keep a glucagon kit on hand, and be sure that your family members know how and when to use it.

If you have had hypoglycemia unawareness in the past, be vigilant not to let your blood glucose get too low when you are alone with your baby. Get help with middle-of-the-night feedings, or make it a habit to eat a snack then. Take care to check before you get into the car to drive. Don’t nap or sleep on an empty stomach. Remember that your best protection is still frequent blood glucose monitoring and regular snacks and meals.

Having a new baby can affect your diabetes care habits, especially if you have to care for other children. You may find that your baby’s unpredictable schedule and your own erratic sleep patterns make it difficult for you to eat or snack when needed. Using multiple injections may make your life easier and give you more flexibility. Although it is tempting to put your infant’s needs before your own, taking care of yourself is important for both you and your baby.

Breast-Feeding

The ideal food for your baby is your own breast milk. Some studies have shown that breast-feeding may help protect your baby from developing type 2 diabetes later in life. You will need to take in about 300 additional calories per day while breast-feeding, so you may want to schedule another visit with your dietitian. Your hunger level may change, and you may need some help with balancing your meals and your baby’s meals with your insulin doses.

The extra energy your body uses to make breast milk can cause your blood glucose levels to become erratic. Throughout the time you breast-feed, continue checking your blood glucose level often.

Tips for Breast-Feeding and Blood Glucose Management

• Keep a source of fast-acting carbohydrate, such as glucose tablets or orange juice, handy when breast-feeding.

• When your baby is ready to nurse during the day, eat your own snack or meal, plus a glass of water or low-fat milk, while you feed your infant. It helps to have the snack or meal portion ready so you don’t have to prepare your food while the baby is waiting to be fed. This provides your body with fluids and helps prevent low blood glucose.

• During nighttime feedings, have a snack yourself. Otherwise, you might have a low blood glucose reaction, especially if you have been up several times in the night.

Listen to Your Body

As a woman, you have so many possibilities in life. Having diabetes should not stop you from pursuing them. One of the most important things that you can do for your health is to listen to your body. Listening to your body will help you take care of yourself and communicate with your health care team.



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