Women and
Diabetes- The
Primary Care
Perspective
Sara G. Tariq, M.D., F.A.C.P. Associate Prof, Internal
Goals/Objectives
Highlight issues in Diabetes risk factors/
management specific to women
PCOS
Candidal Infections Sexual Dysfunction Pregnancy
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
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
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
Ms. C
Ob/Gyn- G2P2, had gestational DM with
second child. ROS + blurry vision + fatigue +polydipsia, polyuria + sexual dysfunction
Larger Issues to Consider
With chronic illness comes unique
challenges
Patient engagement through partnership Self-management through education
Larger Issues to Consider
With chronic illness comes unique
challenges
Patient engagement through partnership Self-management through education
HCWs have the easier job- we give info
Patients have to understand, process, and
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?
How to introduce lifestyle
changes
Have all the patient information
Advise in small amounts (2-5 things) Get the patient’s view on your
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
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.
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
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
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)
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
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
Are Diabetic women at increased risk of candidal vaginal infections?
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
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
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
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
Sexual dysfunction
Lack of sexual desire Impaired arousal
Anorgasmia
Pain with sexual activity
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?”
Significantly more women with diabetes
(27%) than women in the control group (15%) reported sexual dysfunction
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-
Is there anything we can
treat?
Prevent progression of hyperglycemia Get HbAIC to goal
What is the PCP’s role in
managing pregnant patients?
Prenatal Pregnancy Post-partum
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%
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
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
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
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
Metformin story
Metformin is known to cross the placenta American Diabetes Association (ADA)
consensus statement advises against oral medications for GDM because of the
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.
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
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