Ueda2016 woman’s health & diabetes - lobna el toony

WOMAN’S HEALTH
&
DIABETES
Prof. Lobna Farag El Toony
Head of Internal Medicine Department
Diabetes &Endocrine Unit
Assuit University

Objectives
• How Diabetes Differs for Men and
Women
• Diabetes effects at the age of puberty
• Diabetes during pregnancy
Diabetes and Menopause

Diabetes: A silent killer that hurts
the world's poorest
El País – Planeta Futuro by Álvaro Fuentes translated by Samuel Morgan
24 Nov 2015 - 08:41

How Diabetes Differs for Men and Women
• Women with diabetes have it worse, on average,
than men with diabetes.
• while men with diabetes live 7.5 years less on
average than those who don't have the disease,
among women the difference is even greater:
8.2 years
• The risk for heart disease is six times higher
for women with diabetes than those without .

• Type 2 diabetes is more prevalent
in woman than men, making
prevention and early detection of
particular importance

10
Diabetes has a higher incidence in women, is associated with
hormonal disturbances and is a stronger risk factor in women –
why?
Lundberg et al, Arch Int Med, 1997
10
12
14
16
0
2
4
6
8
Diabetics Risk for MI Lethality from MI MI due to
Diabetes
PCOS
Women
Men
Women with Polyc.ovarian syndr.
Diabetes as risk factor in women and men

12
Sex-related differences in glucose metabolism
0
5
10
15
20
25
30
35
40
45
50
Known D Unkn D IGT IFG all
%ofpopulation
women
men
W Rathmann et al, Diabetologica 2003
Mechanisms?
Fasting glucose
F-GIGT
Women have higher 2 h glucose for
each fasting glucose level
Williams et al., Diab Med. 2003
men
women
Relation between FG and OGT

Stages and Plateaus
Age
0 10 20 30 40 50 60 70 80 90 100
Menarche:
The Beginning
Menopause:
Menses “Pause”
Perimenopause:
Variable
Teen years:
+/- Rough
Fertile Years:
Fairly Predictable

Menarche & Menstrual Cycle
Disturbances in Type 1 Diabetes
• T1DM prior to menarche, particularly before 10
years of age, caused a delay in menarchial age of
approximately 1 year
• Women with younger than age at menarche are
more likely to develop type 2 diabetes, and this
association is only partially explained by higher
adult BMI.athttp://care.diabetesjournals.org/lookup/suppl/doi:10.2337/dc13-0446/-/DC1. ,
2013.
• Persistent menstrual disorders remaining in the
third and forth decade in 30% of those women ,
mainly secondary amenorrhea and
oligomenorrhea.

The Menstrual Cycle And T1DM
• Fluctuations in hormone levels occur through
the menstrual cycle can affect blood sugar
control leading to high blood sugar 3-5 days
before, during or after their periods.
• Premenstrual symptoms (PMS) can be worsened
by poor blood sugar .Food cravings during
PMS are triggered by an increase in
progesterone and can make it more difficult to
control blood sugar
• The extra insulin are needed to overcome insulin
resistance during this with frequent measuring SBG

• 1-Hypothalamic Anovulatory leading to
disruption in hypothalamic pulsetile secretion of
gonadotrophin-releasing hormone (GnRH),
with a lower basal levels of luteinizing
hormone (LH) in Type 1 diabetic patients with
amenorrhea.
Menstrual disturbances in T1DM

Menstrual disturbances in T1DM
• 2-Neuroendocrine control
• Increased central dopaminergic activity , which
in turn inhibits GnRH secretion.
• 3-Polycystic ovary syndrome (PCOS) is
especially prominent among women with the
onset of Type 1 diabetes before menarche.
PCOS prevalence of 31 and 40%
• 4- Young women with spontaneous premature
ovarian failure are at increased risk of
autoimmune hypothyroidism

Correlation between Type 2
Diabetes & Fertility
• Alterations in the length of the menstrual cycle,
and the premature age of onset of menopause
with resultant shortening of the reproductive
period .
• PCOS is a leading cause of infertility due to
insulin resistance and obesity
• Obesity is common in both PCOS and Type 2
diabetes and experience longer times to
conception.
Fertility Issues in Women with Diabetes Women's Healt 2009;

The overlapping relationship between the polycystic ovary syndrome. AES,
Androgen Excess

Diabetic complications and
fertility
• Diabetic microvascular or cardiovascular
complications is associated with particularly low
fertility that is improved after glycemic control

Diabetes in Pregnancy: 2
Categories
Pregestational diabetes Gestational diabetes
Pregnancy in
pre-existing diabetes
• Type 1 diabetes
• Type 2 diabetes
Diabetes diagnosed in
pregnancy

Dysglycemia in Pregnancy can
Result in Adverse Pregnancy
Outcome
• Elevated glucose levels can have
adverse effects on the fetus
– 1st trimester  ↑ fetal malformations
– 2nd and 3rd trimester: ↑ risk of macrosomia and
metabolic complications

Risk of Fetal Anomaly Relative to
Periconceptional A1C
Guerin A et al. Diabetes Care 2007;30:1-6.
Glycemic control pre-conception = essential

We Currently Intervene Too Late
4 5 6 7 8 9 10 11 12
Central Nervous SystemCentral Nervous System
HeartHeart
ArmsArms
EyesEyes
LegsLegs
TeethTeeth
PalatePalate
External genitaliaExternal genitalia
EarEar
Missed Period Mean Entry into Prenatal Care
Critical Periods of Fetal DevelopmentCritical Periods of Fetal Development

Diabetes in Pregnancy:
Consider Phases
Pregestational diabetes Gestational diabetes
1. Preconception counseling 1. Screening
2. Glycemic control during
pregnancy
2. Glycemic control during
pregnancy
3. Management in labour 3. Management in labour
4. Postpartum considerations 4. Postpartum considerations

Diabetes in Pregnancy:
Avoiding Complications
• Advances in diagnosis and treatment have dramatically
reduced morbidity and mortality in both mothers and infants1,2Preconception care
• Renal impairment, cardiac disease, neuropathy3
Careful evaluations
at each visit
• 1st trimester through 1st year postpartum
• Examine active lesions more frequently1
Regular
ophthalmologic exams
• Target: systolic BP 110-129 mmHg; diastolic BP 65-79 mmHg
• Lifestyle changes, behavior therapy, and pregnancy-safe
medications (ACE inhibitors and ARBs contraindicated in
pregnancy)3
Hypertension
management
1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Jovanovic L, et al. Diabetes Care.
2011;34(1):53-54.
3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 4. ADA. Diabetes Care.

Insulin Delivery Throughout Pregnancy
Calculating Daily Insulin Dose for Pregnancy
With Preexisting Diabetes
Gestational
week
4–12
12–24
24–38
38–42
0.7 U
0.8 U
0.9 U
1.0 U
Insulin dose
Multiplied by
current
pregnant
weight in kg
Jovanovic L. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY:
Marcel Dekker Inc; 2002:139-151

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Postpartum care for pre-existing diabetes
1. Adjust insulin  at risk of hypoglycemia
2. Encourage women to breastfeed
3. Metformin and glyburide may be used during breast-
feeding  no long term data but appears safe
4. Screen for postpartum thyroiditis in T1DM 
check TSH at 6-8 weeks postpartum

•“Half of the women
diagnosed with GDM will
develop diabetes in the
next 15 to 20 years” (Pacaud
& Dunbar, 2001, p. 1)

Gestational Diabetes Care
In Upper Egypt

Gestational Diabetes (GDM)
Diagnosis
• Universal screening for GDM @ 24-28 weeks
Gestational Age (GA)
• Screen earlier if risk factors for GDM:
Previous GDM BMI ≥30 kg/m2
Prediabetes Polycystic ovarian
syndrome
High risk population
(Aboriginal, Hispanic,
South Asian, Asian, African)
Current fetal macrosomia
or polyhydramnios
Age ≥35 years History of macrosomic
infant
Corticosteroid use Acanthosis nigricans

Screening and Diagnostic Criteria for GDM:
Glucose
Level
Reference Diagnostic Test -- Glucose Tolerance Test:
Cut points in Milligrams per deciliter (mg/dL)
Screening
National Diabetes
Data Group*
100 g
American Diabetes
Association*
100 g/75 g
World Health
Organization †
75 g
Glucose Challenge
Test
50 g
Fasting 105 95 >126 --
1hour 190 180 -- 130/140
2 hours 165 155
> 140 --
3 hours 145 140 -- --
* Two or more criteria must be met or exceeded for a positive diagnosis.
† One or more criteria must be met or exceeded for a positive diagnosis.
-- Indicates glucose levels not used for the test indicated.

Pre-Pregnancy BMI Recommended range
of total weight gain
(Kg)
Recommended range
of total weight gain
(lb)
BMI <18.5 12.5 – 18.0 28 – 40
BMI 18.5 - 24.9 11.5 – 16.0 25 – 35
BMI 25.0 - 29.9 7.0 – 11.5 15 – 23
BMI > or = 30 5.0 – 9.0 11 – 20
Recommended rate of weight gain and total weight gain for singleton
Pregnancies according to pre-pregnancy BMI
IOM Guidelines for Gestational Weight Gain
Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Consensus Report. May
2009. The National Academies Press. Washington, DC.

What About Insulin Analogues and Oral
Agents Among Patients with GDM?
• May use rapid-acting analog insulin for postprandial
glucose control – no difference in perinatal outcomes
• May use glyburide or metformin for women who
are non-adherent to or who refuse insulin
– Likely safe BUT it is OFF-Label  no long-term data, need
discussion with patient

Postpartum GDM Management Checklist
1. Encourage Breastfeeding
2. 75g OGTT between 6 weeks - 6 months
postpartum to detect prediabetes or diabetes
3. Discuss increased long-term risk of diabetes –
Importance of returning to pre-pregnancy weight

Menopause

A young women is a gift of nature,
An old woman is a work of art

Perimenopause – 6 months
• This person does not feel well!
• Her partner is hanging out with his/her friends a lot lately!
• And she’s thinking about selling her kids.
Hormones are out of balance.

Effect Of Menopause
Risk of
• Fracture
• Heart
Disease
Menopausal Symptoms
Estrogen &
Progesterone
level

70
Inflammation
Women with android obesity
WHR of 0.86 or higher
Enhanced lipid peroxidation
Persistent platelet activation
More likely to have:
Metabolic syndrome
Heart/blood vessel disease
Systemic inflammation
Hypponen et al. Am J Clin Nutr 2007;85:860-868.
Davi et al. JAMA 2002;288:2008-2014.

72
Interaction of hyperglycaemia and diabetes with
CAD is sex dependent
0
1
2
3
4
5
6
F, Diab M, Diab F, HyGly M, HyGly
Pan, Am J Epidem, 1986, Chicago H S
Increase in Relative Risik for death from CAD in female and male patients with
diabetes and Hyperglycemia

73
Incidence of CAD and HF in Diabetics
 Diabetic men
 CAD - 24.9% per 1000 person-years
 HF – 7.75% per 1000 person-years
 Diabetic women
 CAD – 17% per 1000 person-years
 HF – 11.5% per 1000 person-years
Beuters et al. Cardiovascular Diabetology 2003;1:1-16.

Diabetes and menopause:
What to expect
• Changes in blood sugar level
• Weight gain :This can increase the need for insulin or oral
diabetes medication.
• Infections urinary and vaginal infections.
• Sleep problems
• Additional health problems: Atherosclerosis which leads
to stroke and heart attack
• .Osteoporosis
•
• Sexual problems

Medications for Sexual
Dysfunctions
For Men:
• ED
o Generic Viagra (Sildenafil
Citrate)
o Generic Cialis (Tadalafil)
o Generic Levitra
(Vardenafil)
• PE
o Generic Priligy
(Dapoxetine)
o Duloxetine
o Fluoxetine
• Loss of libido
Women:
• Arousal Disorder
oLovegra
oLadygra

“Growing Old is Natural
But
Feeling Old is Not

Take Home Message
• At all stages of life, women’s bodies
present obstacles for managing
diabetes. Challenges may occur
because:
• The fluctuating hormones associated
with the menstrual cycle, childbearing,
and menopause make it more difficult to
maintain proper blood glucose levels.

Take Home Message
• Diabetes can cause difficulties during
pregnancy such as a miscarriage or a baby
born with birth defects. In addition to fertility
disorders .
• Older Women with diabetes are also more
likely to have a heart attack, and at a younger
age, with decreased life expectancy more
than men . Vaginal and UTI Infection ,
• Sleep disorders, sexual dysfunctions that
exaggerate menopausal syndromes .

Take Home Message
• Fortunately , all these stages in women 's
life can pass safely by increasing in the
awareness , frequent monitoring of BG and
follow up to reach target glycemic control
that delay or even prevent diabetes
complications in women.

Ueda2016 woman’s health & diabetes - lobna el toony

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