When adolescents with diabetes meet their first boy or girlfriend, parents need to talk with them not only about contraception but also about the effects intimate activity will have on their diabetes. It helps if the parents are already well informed, and that the son or daughter has done previous reading on the subject. 

It is often difficult for parents to talk with their teenagers about sexuality, especially as teenagers often regard any kind of advice from their parents as an intrusion into their privacy and just another lecture. Having diabetes doesn’t make it any easier either. Maybe the son or daughter already has a low self-image and doesn’t want to hear anything to do with the fact that their special metabolic situation may lead to an increased risk for certain vascular conditions. Also, practical questions such as where to put the pump or how sex affects blood sugar levels are rather intimidating. Nevertheless: Teenagers with diabetes must find out what goes on in their bodies, and what contraceptive methods are suitable for them, in order to prevent an unwanted pregnancy or sexually transmitted disease. Although it is the parents’ responsibility to ensure this, if such discussions lead to undue tension within the family, a gynaecologist or diabetologist may be the best alternative, especially for girls. Many gynaecology clinics enable these issues to be discussed in a comfortable environment. Often the boyfriend can also come along and benefit from information on, for instance, the use of condoms.

Openness as a basis
Puberty is a phase in which many physical and psychological changes are taking place. Even teenagers without diabetes are rarely at complete ease with their bodies. To have a chronic condition, whereby one is constantly dependent on such things as pumps and meters, doesn’t necessarily help to strengthen an already fragile self-image. Nevertheless, teenagers must have the courage to explain to their partners about their diabetes right from the start. Those who hold it secret carry around with them a tremendous burden, and deny their partners the chance to be involved. One can even let the partner come to the outpatient clinic to witness closely what goes on in treating diabetes. 

What to look out for
Sexual activity uses up many calories not only through intensive physical activity but also through the secretion of endorphins (mood-enhancing hormones), speeding up the metabolism. This can lower blood sugar levels! Those who have pumps can certainly remove them in times of bodily intimacy, but need to replace them afterwards and check their blood sugar. They may need to reduce the basal insulin rate for a couple of hours. Those who inject insulin may need to take in a few extra carbohydrate exchanges after sexual activity, just like they would after sport. With practice, one will soon be able to obtain a good feel for the body’s metabolic needs.
 
Which contraceptive method to use
In choosing the most appropriate method of contraception, one must take into consideration how often and with whom one is intimate. If sex takes place only occasionally, a condom and perhaps an additional diaphragm may be sufficient. However, the diaphragm needs to be inserted properly, which requires a high level of familiarity with one’s own body. If sex takes place frequently, it may be better to go on the pill. Does the pill raise the risk of cardiovascular diseases—already high in diabetics? With the modern type pills, girls need not worry about this as long as they don’t smoke and keep their weight within normal range. Smoking and overweight damage the arteries. On the other hand, the pill, provides no protection against sexually transmitted diseases. If there are changes in sexual partners, a condom should always be used. 

What the experts recommend
Germany’s associations of gynaecology and obstetrics and of paediatric diabetology have produced joint recommendations for the use of the hormonal pill in adolescents with diabetes (recently updated in May, 2008). The experts suggest using a modern type pill, with an oestrogen dose of less than 0.05 mg, combined with a low dosage of progestogen (combination pill). Preparations containing low-dose progestogen only, with no oestrogen (minipill), are also recommended. None of these types of pills have any influence on sugar and fat metabolism.  

Studies and alternatives
There are no conclusive studies to date as to whether the long-term use of the contraceptive pill has any influence on the appearance of late diabetes complications. Retrospective studies have shown no negative effects when individual risk profiles are taken into account.
Intra-uterine devices (IUDs) offer a good alternative for those women who are unable to take the pill regularly, or are forbidden to take oestrogen orally. Disadvantage: There exists a small risk for uterine infection that may cause gestational problems later.
After unprotected sex, women can take the so-called ‘morning after’ pill. This can, however, cause nausea and consequently affect insulin demand for a few days.

Diabetes and maternity
Of course, women with diabetes can have children. A diabetic pregnancy, however, must be well planned in advance. The metabolism must be brought under optimal control to minimize the risk of foetal disorders, and any diabetes-related complications detected and treated. Pregnancy is not recommended in women with already severe complications, or on dialysis. In any case, close supervision by an internistic diabetologist, or gynaecologist/pre-natal specialist, with experience in diabetes is essential.

 
Claudia Nestoris MD
Kinderkrankenhaus auf der Bult
Hannover
E-mail: nestoris(at)hka(dot)de