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 Morgan24 Nov 2015 - 08:41

http://www.euractiv.com/content-providers/el-pais-planeta-futuro

http://www.euractiv.com/authors/alvaro-fuentes

http://www.euractiv.com/authors/samuel-morgan

Act Now ……

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 toDiabetes

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%

of

po

pu

lati

on

women

men

W Rathmann et al, Diabetologica 2003

Mechanisms?

Fasting glucoseF-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.

http://care.diabetesjournals.org/lookup/suppl/doi:10.2337/dc13-0446/-/DC1

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

during that time .

• 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 12Central 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, neuropathy3Careful 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.

2013;36(suppl 1):S11-S66.

Insulin Delivery Throughout PregnancyCalculating 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

DysfunctionsFor 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

o Treat the underlying

Women:

• Arousal Disorder

oLovegra

oLadygra

http://www.genericviagra123.com/shop/generic-priligy.aspx

http://www.genericviagra123.com/shop/lovegra.aspx

“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.

LOBNA

Thank you

http://images.google.ps/imgres?imgurl=http://i.ehow.com/images/GlobalPhoto/Articles/4857339/Diabetespregnancyhealthy-ojas.com-main_Full.jpg&imgrefurl=http://www.ehow.com/how_4857339_manage-diabetes-during-pregnancy.html&usg=__6P1P5wZQXzOn-Mk7qacY3UMLG9c=&h=402&w=400&sz=18&hl=ar&start=5&tbnid=ySG982CETONZtM:&tbnh=124&tbnw=123&prev=/images%3Fq%3DDiabetes%2B%2526pregnancy%26gbv%3D2%26hl%3Dar%26sa%3DG

http://images.google.ps/imgres?imgurl=http://i.ehow.com/images/GlobalPhoto/Articles/4857339/Diabetespregnancyhealthy-ojas.com-main_Full.jpg&imgrefurl=http://www.ehow.com/how_4857339_manage-diabetes-during-pregnancy.html&usg=__6P1P5wZQXzOn-Mk7qacY3UMLG9c=&h=402&w=400&sz=18&hl=ar&start=5&tbnid=ySG982CETONZtM:&tbnh=124&tbnw=123&prev=/images%3Fq%3DDiabetes%2B%2526pregnancy%26gbv%3D2%26hl%3Dar%26sa%3DG

ueda2016 woman’s health & diabetes - lobna el toony

Health & Medicine