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Women and Diabetes- The Primary Care Perspective. Sara G. Tariq, M.D., F.A.C.P. Associate Prof, Internal Medicine

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(1)

Women and

Diabetes- The

Primary Care

Perspective

Sara G. Tariq, M.D., F.A.C.P. Associate Prof, Internal

(2)
(3)
(4)

Goals/Objectives

 Highlight issues in Diabetes risk factors/

management specific to women

 PCOS

 Candidal Infections  Sexual Dysfunction  Pregnancy

(5)
(6)

We know how big DM is!

 Estimated 7% of US population is diabetic  Twice that many have pre-diabetes

 21% of those over 60 have diabetes

 45% of new diagnoses are being made in

(7)

Ms. C

 35-year-old woman who presents to your

clinic to establish care. She has recently been diagnosed with DM after being

seen in the ED two weeks ago with blurry vision, deemed secondary to

hyperglycemia. They started her on

Metformin and told her to follow up with her PCP. Labs from the ED show BS in 350 range, HbAIC 12%, BMP normal, CBC

(8)

Ms. C

 PMHx- PCOS

 PSHx- C-section X 2

 Fam Hx- Mother had breast cancer , father had DM  Meds- Metformin 500 mg daily

 All- NKDA

 Soc Hx- Her mother lives with her, currently divorced. Works in IT, more than 50 hours/week. Supports both kids on her own. No T/E/D. Has little knowledge about DM, less time to manage it. Currently “sort of dating” a gentleman- sexually active, using appropriate

(9)

Ms. C

 Ob/Gyn- G2P2, had gestational DM with

second child.  ROS  + blurry vision  + fatigue  +polydipsia, polyuria  + sexual dysfunction

(10)
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Larger Issues to Consider

 With chronic illness comes unique

challenges

 Patient engagement through partnership  Self-management through education

(12)

Larger Issues to Consider

 With chronic illness comes unique

challenges

 Patient engagement through partnership  Self-management through education

(13)

 HCWs have the easier job- we give info

 Patients have to understand, process, and

(14)

Issues to consider for Ms. C

 What overall approach should one take in

managing patients with DM?

 How strong is the PCOS-Diabetes

connection?

 What is the role of DM with sexual

dysfunction?

(15)
(16)
(17)

How to introduce lifestyle

changes

 Have all the patient information

 Advise in small amounts (2-5 things)  Get the patient’s view on your

(18)

How to introduce lifestyle

changes?

You must have all the info

 Take a detailed diet history  What does their day look like?

Discuss 2 concepts (no more than 5)

 “It is going to be really important for you to

cut down on the amount of fast food you eat.”

 “Starting exercise will lower your blood

(19)

Motivational Interviewing

How confident (on 1-10 scale) are you

that you can:

 Start exercising for 30 minutes- 3 times per

week?

 Prepare your lunches 4 days/week?

What would help you be more confident?

Miller, W.R. and Rollnick, S. Motivational Interviewing: Preparing People to Change, 2nd ed. NY: Guilford Press, 2002.

(20)
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Role of Polycystic Ovarian

Syndrome

 PCOS

 Cause of both menstrual irregularity and

androgen excess

 Frequently associated with obesity  Most common cause of infertility  One of the most common

endocrinopathies in women of reproductive age

(22)

PCOS and DM Connection

 The risk of type 2 diabetes is increased in

PCOS

 In a study of 122 obese women with

PCOS, 45 percent had either impaired glucose tolerance (35 percent) or type 2 diabetes mellitus (10 percent) by age 40

(23)

PCOS and DM connection

 Up to 85% of women with PCOS are

overweight or obese compared with age-matched controls

 Insulin resistance is present in both lean

and obese women with PCOS (30 and 70 percent, respectively)

(24)

How should we screen for DM

in pts with PCOS?

 A two-hour oral glucose tolerance test (OGTT; with

measurement of fasting and two-hour glucose) in all women with PCOS at initial diagnosis.

 If this is not feasible, a fasting glucose should be

obtained together with a measurement of the hemoglobin A1C

 Patients with impaired glucose tolerance should

be screened annually for development of type 2 diabetes.

American Association of Clinical Endocrinologists Position Statement on Metabolic and Cardiovascular Consequences of PCOS

(25)
(26)

The bottom line…

 Undiagnosed diabetes can cause

progressive microvascular damage.

 At the time of diagnosis, approximately 20

percent of newly diagnosed patients with Type 2 diabetes have diabetic

retinopathy and 10 percent have nephropathy

(27)

Are Diabetic women at increased risk of candidal vaginal infections?

(28)

Pathophysiology- Candida

 Increased glucose levels in genital tissues

enhance yeast adhesion and growth.

 Vaginal epithelial cells bind to Candida

albicans with greater propensity in

diabetic patients than in nondiabetic patients

(29)

Candida risk factors..

 Candida infection associated with

 Older age

 Type 1 diabetes (3x more likely than DMII)  Abnormal HbA1c level

 Recent antibiotic use within two weeks

(30)

Treatment

 In RCTs, oral and topical meds achieved

comparable clinical cure rates (>90%)

 Patients consistently reported a preference

for the convenience of oral treatment, even though oral meds take 1-2 days longer to relieve symptoms

Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database Syst Rev. 2001

(31)

Should recurrent yeast

infections = screening for DM?

No current guidelines to screen patients with recurrent vulvovaginal candiasis (more than 4

per year) for Diabetes

May raise red flag to screen for DM in woman who has recurrent yeast infections

(32)
(33)

Sexual dysfunction

 Lack of sexual desire  Impaired arousal

 Anorgasmia

 Pain with sexual activity

(34)

What is the role of DM in

sexual dysfunction?

 Women rarely bring up their sexual problems

 Sexual health reflects overall health and QOL

 How many doctors ask about sexual health as part

of history or ROS?

 Only 35 percent of primary care physicians report that they often or always take a sexual history

 “Do you have any concerns about your sex life or sexual health?”

(35)

 Significantly more women with diabetes

(27%) than women in the control group (15%) reported sexual dysfunction

(36)

What is the role of DM in

sexual dysfunction?

 Autonomic neuropathy– anorgasmia,

difficulty with arousal

 Decreased vaginal lubrication, resulting in

vaginal dryness

 Decreased or no desire for sexual activity-

(37)

Is there anything we can

treat?

 Prevent progression of hyperglycemia  Get HbAIC to goal

(38)

What is the PCP’s role in

managing pregnant patients?

 Prenatal  Pregnancy  Post-partum

(39)

Prenatal Issues in Diabetics

 Women who are in poor glycemic control during the period

of fetal organogenesis, which is nearly complete by seven weeks post-conception:

 High incidence of spontaneous abortion  Fetuses with congenital anomalies

 Get HbAIC to goal BEFORE attempting to get pregnant  Preconception AIC goal : < 6%

(40)

Gestational Diabetes

 Hyperglycemia with onset or first

recognition during Pregnancy

 Characterized by accelerated growth of the

fetus

 A rise in blood levels of several diabetogenic

hormones– that induce insulin resistance

 Food ingestion results in higher and more

(41)

Fetal Risks

 Macrosomia - shoulder dystocia and related

complications

 LGA children or those born to obese mother

have a 7% risk of developing IGT at 7-11 yrs age

 There is increasing evidence that infants

exposed to diabetes in utero have an

increased incidence of childhood obesity and diabetes

(42)

Maternal Risks

 Increased risk of C-section

 Pre-eclampsia- partly due to insulin resistance  Recurrence risk of GDM is 30-50%

 30-60% lifetime risk in developing IFG, IGT or

type 2 diabetes

Am J Obstet Gynecol. 2010;202(3):255.e1. CDA CPG 2008

(43)

Management of Gestational

Diabetes

 Strive to achieve glycemic targets  Receive nutrition counseling from an

Registered Dietitian

 Encourage physical activity

 If BG targets are not reached within 2

weeks of diet then insulin therapy should be started

(44)

Metformin story

 Metformin is known to cross the placenta  American Diabetes Association (ADA)

consensus statement advises against oral medications for GDM because of the

(45)

The Metformin Story: MiG Trial

 751 women were randomized to receive either metformin

or insulin

 There was no significant difference in the composite fetal

outcome between the two groups although preterm birth was found to be increased in the metformin group.

 Women in the metformin group had less weight gain

compared with women in the insulin group

 ACOG has endorsed the use of oral anti-hyperglycemic

agents during pregnancy in the United States

Rowan et al. Moore MP; N Engl J Med 2008;358:2003–2015 Obstet Gynecol. 2013;122:406.

(46)

Post-partum risk

 Most women with GDM are

normoglycemic after delivery.

 They are at high risk for recurrent GDM,

impaired glucose tolerance and overt diabetes over five years

 Responsibility of the MD to check screen

(47)

5% take home

 What overall approach should one take in managing

patients with DM?

 Long-term relationship

 Patient’s daily life

 How strong is the PCOS-Diabetes connection?

 Strong enough that PCOS patients need yearly screening for DM

 What is the role of DM with sexual dysfunction?

 Multifactorial- getting AIC to goal is central to improving this

 Pregnancy issues

 You must get her AIC to less than 6% for optimal pregnancy

outcomes

 GDM – Oral meds remain somewhat contraversial

(48)

References

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