METABOLIC EFFECTS
Pharmacologic doses of contraceptive hormones have widespread metabolic effects, but many of these are merely alterations in laboratory values without clinical significance. Nevertheless, some laboratory test alterations may reflect clinically significant metabolic changes. For example, changes in coagulation factors may predispose certain women to intravascular clotting, and changes in renin and angiotensin may affect blood pressure in a few users. Many of the metabolic alterations associated with steroid contraceptive use are attributable to the estrogenic component of the combination pill. These effects would not be expected with the use of progestin-only contraception. In contrast, the metabolic alterations caused by progestins, which would be expected in progestin-only contraceptive users, may be altered by the concomitant use of estrogen.4 For example, the estrogen in combined oral contraceptives (COCs) raises triglycerides and high-density lipoprotein (HDL), whereas most progestins have the opposite effects.
CARBOHYDRATE METABOLISM
Combined Oral Contraception.
Early studies with high-dose COCs showed impairment of glucose tolerance and increased insulin resistance. However, multiple studies of low-dose COCs have not shown a clinically significant impact of COCs on carbohydrate metabolism.5,6 Even women with a history of gestational diabetes have not been found to be at additional
risk of developing diabetes due to COC use.7,8 The small increase in insulin resistance seen with low-dose COC use may alter glucose metabolism in some women with overt diabetes mellitus; however, this effect has not been consistent among individual patients. Also, the use of COCs has not been found to increase the risk of development of nephropathy or retinopathy in patients with type 1 diabetes mellitus.9 Current consensus opinion is that healthy diabetic women with no end-organ complications of diabetes mellitus may safely use low-dose COC.
risk of developing diabetes due to COC use.7,8 The small increase in insulin resistance seen with low-dose COC use may alter glucose metabolism in some women with overt diabetes mellitus; however, this effect has not been consistent among individual patients. Also, the use of COCs has not been found to increase the risk of development of nephropathy or retinopathy in patients with type 1 diabetes mellitus.9 Current consensus opinion is that healthy diabetic women with no end-organ complications of diabetes mellitus may safely use low-dose COC.
The changes observed in carbohydrate metabolism with oral contraceptive use (increased insulin resistance and decreased glucose tolerance) are believed to be attributable almost entirely to the progestin component of combination pills, and are dose related. Ethinyl estradiol administered alone, even in high doses, does not cause glucose tolerance deterioration or abnormal insulin responses.
Progestin-Only Contraceptives.
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