Menopausal Hormone Therapy and Type 2 Diabetes Prevention: Evidence, Mechanisms, and Clinical Implications

Gallbladder Disease and Risk of Type 2 Diabetes in Postmenopausal Women: A Women's Health Initiative Study

Studies have suggested that adults with gallbladder disease have increased risk of type 2 diabetes. This prospective cohort study assessed the risk of type 2 diabetes in postmenopausal women with gallbladder disease. Data from women enrolled in the Women's Health Initiative from 1993 to 2005, aged 50-79 years (mean = 63.2; standard deviation, 7.2), were analyzed. Cox proportional hazards regression models were used to estimate the risk of type 2 diabetes associated with gallbladder disease. There were 8,896 new cases of type 2 diabetes after 1,025,486 person-years of follow-up. Gallbladder disease was significantly associated with type 2 diabetes (hazard ratio = 1.52; 95% confidence interval (CI): 1.38,1.67). The observed risk of type 2 diabetes in women with both gallbladder disease and central obesity was 37% higher than expected (relative excess risk due to interaction = 0.37, 95% CI: 0.11,0.63) on the additive scale. The hazard ratios for type 2 diabetes associated with gallbladder disease were 1.25 (95% CI: 1.19,1.32) and 1.48 (95% CI: 1.34,1.63) in women with and without central obesity, respectively, on the multiplicative scale. Results of this study support further studies to determine whether interventions in older women with gallbladder disease would reduce type 2 diabetes risk, especially among those with central obesity. Future research should examine the pathophysiological basis of the association between gallbladder disease and type 2 diabetes.

Reproductive Life Span and Severe Hypoglycemia Risk in Postmenopausal Women with Type 2 Diabetes Mellitus

BACKGROUND

Estrogen promotes glucose homeostasis, enhances insulin sensitivity, and maintains counterregulatory responses in recurrent hypoglycemia in women of reproductive age. Postmenopausal women with type 2 diabetes mellitus (T2DM) might be more vulnerable to severe hypoglycemia (SH) events. However, the relationship between reproductive factors and SH occurrence in T2DM remains unelucidated.

METHODS

This study included data on 181,263 women with postmenopausal T2DM who participated in a national health screening program from January 1 to December 31, 2009, obtained using the Korean National Health Insurance System database. Outcome data were obtained until December 31, 2018. Associations between reproductive factors and SH incidence were assessed using Cox proportional hazards models.

RESULTS

During the mean follow-up of 7.9 years, 11,279 (6.22%) postmenopausal women with T2DM experienced SH episodes. A longer reproductive life span (RLS) (≥40 years) was associated with a lower SH risk compared to a shorter RLS (<30 years) (adjusted hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.69 to 0.80; P for trend <0.001) after multivariable adjustment. SH risk decreased with every 5-year increment of RLS (with <30 years as a reference [adjusted HR, 0.91; 95% CI, 0.86 to 0.95; P=0.0001 for 30-34 years], [adjusted HR, 0.80; 95% CI, 0.76 to 0.84; P<0.001 for 35-39 years], [adjusted HR, 0.74; 95% CI, 0.68 to 0.81; P<0.001 for ≥40 years]). The use of hormone replacement therapy (HRT) was associated with a lower SH risk than HRT nonuse.

CONCLUSION

Extended exposure to endogenous ovarian hormone during lifetime may decrease the number of SH events in women with T2DM after menopause.

Dose-Response Relationship of Uric Acid With Fasting Glucose, Insulin, and Insulin Resistance in a United States Cohort of 5,148 Non-diabetic People

Background

There is a limited number of studies on the dose-response relationship between serum uric acid and impaired glucose metabolism in people without diabetes, and no large-scale research exploring the relationship in women without diabetes is based on menopausal status. Consequently, the present study aimed to investigate the above relationship in United States adults without diabetes.

Materials and Methods

Data from 2,498 men and 2,650 women aged ≥20 years were obtained from the National Health and Nutrition Examination Survey 2011-2016 conducted in the United States. Binary logistic regression analysis was applied to evaluate the association between uric acid and impaired glucose metabolism. Restricted cubic spline analysis, sensitivity analysis, and stratified analysis by menopausal status were performed to explore the above relationships.

Results

A positive correlation was found between uric acid and the risk of insulin resistance in all participants (P < 0.05). In binary logistic regression analysis, after adjusting for confounding factors, compared with the lowest quartile of uric acid, the odds ratio (95% confidence intervals) of insulin resistance in the highest quartile was 1.9 (1.1-3.1) and 2.2 (1.2-4.3) in men and women, respectively. A significant positive relationship was also observed between uric acid and impaired fasting glucose and hyperinsulinemia in women, while in men, uric acid was positively associated with the risk of hyperinsulinemia but not impaired fasting glucose. Restricted cubic spline showed that the odds ratios of insulin resistance and hyperinsulinemia increased with elevating uric acid levels in both men and women. When stratified by menopause, the association remained significant in pre-menopausal women aged ≥20, but insignificant in post-menopausal women.

Conclusion

Uric acid was positively associated with the risk of impaired glucose metabolism in a cohort of United States adults, and uric acid increased the risk of insulin resistance in pre-menopausal, but not in post-menopausal women.

Premature and early menopause among US women with or at risk for HIV

OBJECTIVE

Little is known about the prevalence and treatment of premature and early menopause among people with HIV. We described premature and early menopause and subsequent hormonal treatment in a longitudinal cohort of women living with or at risk for HIV in the US.

METHODS

Data from the Women's Interagency HIV Study between 2008 and 2020 were analyzed to describe premature and early menopause among cohort participants under the age of 51.

RESULTS

Of 3,059 eligible women during the study period, 1% (n = 35) underwent premature menopause before age 41, 3% (n = 101) underwent menopause between ages 41 and 46, and 21% (n = 442) underwent menopause between ages 46 and 50, inclusive. Of participants who experienced menopause before age 41, between age 41 and 45, and between ages 46 and 50, 51%, 24%, and 7% (respectively) received either menopausal hormone therapy or hormonal contraception.

CONCLUSION

These findings suggest that disparities in receipt of recommended hormone therapy for premature and early menopause may contribute, in part, to evident health disparities, such as cardiovascular disease, osteoporosis, and overall mortality. They also suggest a substantial need for education among people experiencing early menopause and their providers, with the goal of improving access to hormone therapy based on guidelines to address health disparities and minimize future health consequences.

Dietary regulations for microbiota dysbiosis among post-menopausal women with type 2 diabetes

Type 2 diabetes (T2D) and T2D-associated comorbidities, such as obesity, are serious universally prevalent health issues among post-menopausal women. Menopause is an unavoidable condition characterized by the depletion of estrogen, a gonadotropic hormone responsible for secondary sexual characteristics in women. In addition to sexual dimorphism, estrogen also participates in glucose-lipid homeostasis, and estrogen depletion is associated with insulin resistance in the female body. Estrogen level in the gut also regulates the microbiota composition, and even conjugated estrogen is actively metabolized by the estrobolome to maintain insulin levels. Moreover, post-menopausal gut microbiota is different from the pre-menopausal gut microbiota, as it is less diverse and lacks the mucolytic Akkermansia and short-chain fatty acid (SCFA) producers such as Faecalibacterium and Roseburia. Through various metabolites (SCFAs, secondary bile acid, and serotonin), the gut microbiota plays a significant role in regulating glucose homeostasis, oxidative stress, and T2D-associated pro-inflammatory cytokines (IL-1, IL-6). While gut dysbiosis is common among post-menopausal women, dietary interventions such as probiotics, prebiotics, and synbiotics can ease post-menopausal gut dysbiosis. The objective of this review is to understand the relationship between post-menopausal gut dysbiosis and T2D-associated factors. Additionally, the study also provided dietary recommendations to avoid T2D progression among post-menopausal women.

A brief review of vitamin D as a potential target for the regulation of blood glucose and inflammation in diabetes-associated periodontitis

Diabetes is a metabolic disorder associated with various complications, including periodontitis. The risk of periodontitis is increased in patients with diabetes, while vitamin D deficiency is associated with both diabetes and periodontitis. Thus, there is a need to identify the molecular effects of vitamin D on the regulation of inflammation and glucose in diabetes-associated periodontitis. The Web of Science, Scopus, and PubMed databases were searched for studies of the molecular effects of vitamin D. Molecular effects were reportedly mediated by salivary secretions, interactions of advanced glycation end products (AGEs) with receptors of AGEs (RAGEs), cytokines, and oxidative stress pathways linking diabetes with periodontitis. Vitamin D supplementation attenuates inflammation in diabetes-associated periodontitis by reducing the levels of inflammatory cytokines and numbers of immune cells; it also has antibacterial effects. Vitamin D reduces cytokine levels through regulation of the extracellular signal-related kinase 1/2 and Toll-like receptor 1/2 pathways, along with the suppression of interleukin expression. Glucose homeostasis is altered in diabetes either because of reduced insulin production or decreased insulin sensitivity. These vitamin D-related alterations of glucoregulatory factors may contribute to hyperglycaemia; hyperglycaemia may also lead to alterations of glucoregulatory factors. This review discusses the pathways involved in glucose regulation and effects of vitamin D supplementation on glucose regulation. Further studies are needed to characterise the effects of vitamin D on diabetes-associated periodontitis.

2',3',4'-Trihydroxychalcone changes estrogen receptor α regulation of genes and breast cancer cell proliferation by a reprogramming mechanism

BACKGROUND

Menopausal hormone therapy (MHT) is recommended for only five years to treat vasomotor symptoms and vulvovaginal atrophy because of safety concerns with long-term treatment. We investigated the ability of 2',3',4'-trihydroxychalcone (2',3',4'-THC) to modulate estrogen receptor (ER)-mediated responses in order to find drug candidates that could potentially prevent the adverse effects of long-term MHT treatment.

METHODS

Transfection assays, real time-polymerase chain reaction, and microarrays were used to evaluate the effects of 2',3',4'-THC on gene regulation. Radioligand binding studies were used to determine if 2',3',4'-THC binds to ERα. Cell proliferation was examined in MCF-7 breast cancer cells by using growth curves and flow cytometry. Western blots were used to determine if 2',3',4'-THC alters the E2 activation of the MAPK pathway and degradation of ERα. Chromatin immunoprecipitation was used to measure ERα binding to genes.

RESULTS

The 2',3',4'-THC/E2 combination produced a synergistic activation with ERα on reporter and endogenous genes in human U2OS osteosarcoma cells. Microarrays identified 824 genes that we termed reprogrammed genes because they were not regulated in U2OS-ERα cells unless they were treated with 2',3',4'-THC and E2 at the same time. 2',3',4'-THC blocked the proliferation of MCF-7 cells by preventing the E2-induced activation of MAPK and c-MYC transcription. The antiproliferative mechanism of 2',3',4'-THC differs from selective estrogen receptor modulators (SERMs) because 2',3',4'-THC did not bind to the E2 binding site in ERα like SERMs.

CONCLUSION

Our study suggests that 2',3',4'-THC may represent a new class of ERα modulators that do not act as a direct agonists or antagonists. We consider 2',3',4'-THC to be a reprogramming compound, since it alters the activity of ERα on gene regulation and cell proliferation without competing with E2 for binding to ERα. The addition of a reprogramming drug to estrogens in MHT may offer a new strategy to overcome the adverse proliferative effects of estrogen in MHT by reprogramming ERα as opposed to an antagonist mechanism that involves blocking the binding of estrogen to ERα.

Menopause-associated risk of cardiovascular disease

Cardiovascular disease (CVD) is of major concern in women entering menopause. The changing hormonal milieu predisposes them to increased CVD risk, due to a constellation of risk factors, such as visceral obesity, atherogenic dyslipidemia, dysregulation in glucose homeostasis, non-alcoholic fatty liver disease and arterial hypertension. However, an independent association of menopause per se with increased risk of CVD events has only been proven for early menopause (<45 years). Menopausal hormone therapy (MHT) ameliorates most of the CVD risk factors mentioned above. Transdermal estrogens are the preferable regimen, since they do not increase triglyceride concentrations and they are not associated with increased risk of venous thromboembolic events (VTE). Although administration of MHT should be considered on an individual basis, MHT may reduce CVD morbidity and mortality, if commenced during the early postmenopausal period (<60 years or within ten years since the last menstrual period). In women with premature ovarian insufficiency (POI), MHT should be administered at least until the average age of menopause (50-52 years). MHT is contraindicated in women with a history of VTE and is not currently recommended for the sole purpose of CVD prevention. The risk of breast cancer associated with MHT is generally low and is mainly conferred by the progestogen. Micronized progesterone and dydrogesterone are associated with lower risk compared to other progestogens.

Non-Alcoholic Fatty Liver Disease and the Risk of Diabetes Mellitus by Menopausal Status: A Nationwide Cohort Study

Background: Non-alcoholic fatty liver disease (NAFLD) is regarded as a risk factor for type 2 diabetes mellitus (DM). Menopausal status also influences T2DM risk, where estrogen is presumed to play a protective role by decreasing insulin resistance. As such, we investigated the association between NAFLD and DM risk according to menopausal status. Objectives: We sought to examine the association between NAFLD and DM incidence in pre- and post-menopausal women. Methods: A total of 842,772 pre-menopausal and 1,074,767 post-menopausal women who underwent health examinations between 2009 and 2014 were included from the Korean National Health Insurance Service database. Multivariate Cox proportional hazard analyses were performed to evaluate the association between the risk of DM according to menopausal status and NAFLD, defined by a fatty liver index >60. Results: During the mean follow-up period (7.8 years), DM was diagnosed in 33,461 (4.0%) of pre-menopausal women and 121,102 (9.4%) post-menopausal women. A stronger association between NAFLD and the risk of DM was found in pre-menopausal women (multivariable-adjusted hazard ratio [aHR], 3.60; 95% confidence interval [CI], 3.48−3.71) than in post-menopausal women (aHR, 2.24; 95% CI, 2.21−2.28) (P-interaction < 0.01). Subgroup analyses among women aged 45 to 55 years also showed a stronger association in pre-menopausal (aHR, 3.35; 95% CI, 3.21−3.49) than in post-menopausal women (aHR, 2.83; 95% CI, 2.68−2.98) (P-interaction < 0.01). Conclusions: The association between NAFLD and DM was stronger in pre-menopausal women than in post-menopausal women. This might be due to the protective effect of estrogen, which is possibly in higher production in the peripheral fat tissue of post-menopausal women with NAFLD.

Profile of estetrol, a promising native estrogen for oral contraception and the relief of climacteric symptoms of menopause

INTRODUCTION

Estrogens used in women's healthcare have been associated with increased risks of venous thromboembolism (VTE) and breast cancer. Estetrol (E4), an estrogen produced by the human fetal liver, has recently been approved for the first time as a new estrogenic component of a novel combined oral contraceptive (E4/drospirenone [DRSP]) for over a decade. In phase 3 studies, E4/DRSP showed good contraceptive efficacy, a predictable bleeding pattern, and a favorable safety and tolerability profile.

AREAS COVERED

This narrative review discusses E4's pharmacological characteristics, mode of action, and the results of preclinical and clinical studies for contraception, as well as for menopause and oncology.

EXPERT OPINION

Extensive studies have elucidated the properties of E4 that underlie its favorable safety profile. While classical estrogens (such as estradiol) exert their actions via both activation of nuclear and membrane estrogen receptor α (ERα), E4 presents a specific profile of ERα activation: E4 binds and activates nuclear ERα but does not induce the activation of membrane ERα signaling pathways in specific tissues. E4 has a small effect on normal breast tissue proliferation and minimally affects hepatic parameters. This distinct profile of ERα activation, uncoupling nuclear and membrane activation, is unique.

Menopausal hormone therapy and risk of cardiovascular events in women with prediabetes or type 2 diabetes: A pooled analysis of 2917 postmenopausal women

BACKGROUND AND AIMS

The effect of MHT on cardiovascular disease (CVD) risk among women with prediabetes or type 2 diabetes (PreDM or T2DM) is unclear. We examined the association between ever or early use MHT and CVD risk in postmenopausal women with PreDM or T2DM, and the potential modifying effect of race.

METHODS

2,917 postmenopausal women with PreDM or T2DM were pooled from 3 prospective CVD cohorts (the Atherosclerosis Risk in Communities, the Multi-Ethnic Study of Atherosclerosis, and the Jackson Heart Study). Ever (yes vs no) or early use of MHT (MHT initiated ≤5 vs > 5 years since menopause), and their associations with ischemic stroke, coronary heart disease (CHD), and atherosclerotic cardiovascular disease (ASCVD) were assessed using Cox proportional hazards models.

RESULTS

During a median follow-up of 15 years, 264 stroke, 484 CHD, and 659 ASCVD events were observed. In fully adjusted models, ever use of MHT was associated with reduced risk of stroke (hazard ratio 0.86, 95% CI 0.76-0.98), CHD (0.85, 0.74-0.98), and ASCVD (0.83, 0.73-0.95) in white women with PreDM or T2DM. Early use of MHT was associated with reduced risk of stroke (0.82, 0.72-0.95), CHD (0.85, 0.74-0.98), and ASCVD (0.82, 0.70-0.96) in the white group. No risk reduction with ever or early use of MHT was found for black women with PreDM or T2DM.

CONCLUSIONS

MHT is associated with statistically reduced CVD risk among white but not black women with PreDM or DM. Race is an effect modifier in the association between MHT use and CVD.

Prolonged Islet Allograft Function is Associated With Female Sex in Patients After Islet Transplantation

BACKGROUND

Islet transplantation (ITx) has proved to be effective in preventing severe hypoglycemia and improving metabolic control in selected subjects with type 1 diabetes. Long-term graft function remains a challenge. Estrogens have been shown to protect β cells from metabolic stresses and improve revascularization of transplanted human islets in the mouse. We aimed to evaluate the influence of sex in allograft survival of ITx recipients.

METHODS

We analyzed a retrospective cohort of ITx recipients (n = 56) followed-up for up to 20 years. Allograft failure was defined as a stimulated C-peptide <0.3 ng/mL during a mixed-meal tolerance test. Subjects were divided into recipients of at least 1 female donor (group 1) and recipients of male donors only (group 2).

RESULTS

Group 1 subjects (n = 25) were aged 41.5 ± 8.4 years and group 2 subjects (n = 22) 45.9 ± 7.3 years (P = 0.062). Female recipient frequency was 44.8% (n = 13) in group 1 and 55.2% (n = 16) in group 2 (P = 0.145). Group 2 developed graft failure earlier than group 1 (680 [286-1624] vs 1906 [756-3256] days, P = 0.038). We performed additional analyses on female recipients only from each group (group 1, n = 16; group 2, n = 20). Female recipients in group 1 exhibited prolonged allograft function compared with group 2, after adjustment for confounders (odds ratio, 28.6; 95% CI, 1.3-619.1; P < 0.05).

CONCLUSION

Recipients of islets from at least 1 female donor exhibited prolonged graft survival compared with recipients of islets from exclusively male donors. In addition, female recipients exhibited prolonged survival compared with male recipients following ITx of at least 1 female donor.

A high carbohydrate and soda diet influences metabolic variables in Wistar rats

AIMS

High carbohydrate diet and carbonated soda consumption have individually been associated with metabolic dysfunction, with links to glucose and insulin homeostasis, affecting metabolic variables associated with feeding, satiety and adiposity. Our objective is to determine the combined effect of a high carbohydrate and carbonated soda diet on metabolic variables in male and female Wistar rats.

MATERIALS AND METHODS

Thirty-two female and male weanlings were equally divided into four dietary groups; Control, Soda, High Carbohydrate diet (HCD), and High Carbohydrate diet/Soda (HCD/Soda), and fed ad libitum for fourteen weeks. Bodyweight, thoracic circumference, abdominal circumference and glucose was determined; Insulin, leptin, adiponectin, Tumor Necrotic Factor (TNF)-α, Interleukin (IL)-6 and lipid profile were assayed and used to determine the metabolic effects.

KEY FINDINGS

Soda and HCD/Soda had increased body weight in male rats, while HCD-fed rats were reduced compared to respective controls. Abdominal circumference, total cholesterol and reduced HDL of Soda were elevated in both sexes. Although HCD/Soda groups had elevated abdominal circumference in both sexes, total cholesterol and reduced high-density lipoprotein (HDL) were both reduced in females. Insulin and malondialdehyde (MDA) concentrations in Soda-fed rats was significantly reduced, however, MDA was elevated in both sexes in HCD and HCD/Soda fed rats. Female HCD and HCD/Soda groups had a significant increase in glutathione (GSH) concentration and a significant reduction in catalase. TNF-α was increased in both Soda and HCD/Soda groups.

SIGNIFICANCE

The results of this study suggest that HCD and Soda consumption results in alteration in phenotype and variables impacting metabolism.

The glycolytic process in endothelial cells and its implications

Endothelial cells play an obligatory role in regulating local vascular tone and maintaining homeostasis in vascular biology. Cell metabolism, converting food to energy in organisms, is the primary self-sustaining mechanism for cell proliferation and reproduction, structure maintenance, and fight-or-flight responses to stimuli. Four major metabolic processes take place in the energy-producing process, including glycolysis, oxidative phosphorylation, glutamine metabolism, and fatty acid oxidation. Among them, glycolysis is the primary energy-producing mechanism in endothelial cells. The present review focused on glycolysis in endothelial cells under both physiological and pathological conditions. Since the switches among metabolic processes precede the functional changes and disease developments, some prophylactic and/or therapeutic strategies concerning the role of glycolysis in cardiovascular disease are discussed.

Duodenal microbiome changes in postmenopausal women

Objective:

Hormone therapy (HT) is used to treat menopause-related conditions and symptoms. The small intestine plays key roles in metabolic and endocrine function, but the effects of HT on the small intestinal microbiome are unknown. Here, we characterize duodenal microbiome differences, and the effects of HT, in postmenopausal women.

Methods:

Female participants undergoing esophagogastroduodenoscopy who were postmenopausal and taking HT (HT+), postmenopausal but not taking HT (HT−), or of reproductive age and not taking exogenous hormones (RA), were identified and matched for body mass index (±3 kg/m²). DNAs were isolated from duodenal aspirates obtained during upper endoscopy. V3 and V4 libraries were used for 16S rRNA sequencing. Serum hormone levels were analyzed by Luminex FlexMap.

Results:

The core duodenal microbiome was different in HT− participants (n = 12) when compared with RA participants (n = 10), but more similar in HT+ (n = 13) and RA participants. HT− participants had increased Proteobacteria taxa, leading to greater microbial dysbiosis compared with HT+ participants, and had decreased prevalence of Bacteroidetes, which was associated with higher fasting glucose levels, lower duodenal microbial diversity, and lower testosterone levels. HT+ participants had significantly higher estradiol (P = 0.04) and progesterone (P = 0.04), and lower fasting glucose (P = 0.03), than HT− participants, and had increased relative abundance of Prevotella (P = 0.01), and decreased Escherichia (P = 1.12E-7), Klebsiella (P = 5.93E-7), and Lactobacillus (P = 0.02), all associated with lower cardiovascular disease risks.

Conclusions:

These findings support previous studies suggesting that HT may have beneficial effects following menopause, and although preliminary, may also support a beneficial effect of HT on the duodenal microbiome.

Estradiol overcomes adiponectin-resistance in diabetic mice by regulating skeletal muscle adiponectin receptor 1 expression

Adiponectin and insulin resistance creates a vicious cycle that exacerbates type 2 diabetes. Earlier, we observed that female leptin receptor-deficient BLKS mice (BKS-db/db) were more sensitive to an adiponectin mimetic GTDF than males, which led us to explore if E2 plays a crucial role in modulation of adiponectin-sensitivity. Male but not female BKS-db/db mice were resistant to metabolic effects of globular adiponectin treatment. Male BKS-db/db displayed reduced skeletal muscle AdipoR1 protein expression, which was consequent to elevated polypyrimidine tract binding protein 1 (PTB) and miR-221. E2 treatment in male BKS-db/db, and ovariectomized BALB/c mice rescued AdipoR1 protein expression via downregulation of PTB and miR-221, and also directly increased AdipoR1 mRNA by its classical nuclear receptors. Estrogen receptor regulation via dietary or pharmacological interventions may improve adiponectin resistance and consequently ameliorate insulin resistance in type 2 diabetes.

Body composition and cardiometabolic health across the menopause transition

Every year, 2 million women reach menopause in the United States, and they may spend 40% or more of their life in a postmenopausal state. In the years immediately preceding menopause-known as the menopause transition (or perimenopause)-changes in hormones and body composition increase a woman's overall cardiometabolic risk. In this narrative review, we summarize the changes in weight, body composition, and body fat distribution, as well as the changes in energy intake, energy expenditure, and other cardiometabolic risk factors (lipid profile, glucose metabolism, sleep health, and vascular function), that occur during the menopause transition. We also discuss the benefits of lifestyle interventions in women in the earlier stages of menopause before these detrimental changes occur. Finally, we discuss how to include perimenopausal women in research studies so that women across the life-span are adequately represented.

The Use of ERE-Luc Reporter Mice to Monitor Estrogen Receptor Transcriptional Activity in a Spatio-Temporal Dimension

In spite of the fact that women spend 1/3 of their lives in postmenopause, the search for appropriate therapies able to counteract the derangements associated with the menopause still represents a sort of sought after the "Holy Grail."Nowadays, the combination of estrogens and selective estrogen receptor modulators (SERMs), a class of compounds with a mixed agonist/antagonistic activity on the estrogen receptor (ER) in various tissues, represents the most promising approach to improve postmenopausal women's health, by preserving the benefits while avoiding the side effects of estrogen-based therapy.Given their complex mechanisms of action, the evaluation of SERM activity in combination with conjugated estrogens (CE) requires a multifactorial analysis that takes into account the multifaceted and dynamic effects of these compounds in target tissues, even in relation to the physiological/pathological status.To accomplish such a goal, we took advantage of the ERE-Luc model, a reporter mouse that allows the monitoring of ER transcriptional activity in a spatio-temporal dimension. Cluster analyses performed on in vivo/ex vivo bioluminescence (BLI) data and ex vivo luciferase activity enabled to sustain the combination of CE plus bazedoxifene (TSEC, tissue-selective estrogen complex) as a valuable option for the pharmacological treatment of the postmenopause.

Gender Differences in the Context of Obstructive Sleep Apnea and Metabolic Diseases

The relationship between obstructive sleep apnea (OSA) and endocrine and metabolic disease is unequivocal. OSA, which is characterized by intermittent hypoxia and sleep fragmentation, leads to and exacerbates obesity, metabolic syndrome, and type 2 diabetes (T2D) as well as endocrine disturbances, such as hypothyroidism and Cushing syndrome, among others. However, this relationship is bidirectional with endocrine and metabolic diseases being considered major risk factors for the development of OSA. For example, polycystic ovary syndrome (PCOS), one of the most common endocrine disorders in women of reproductive age, is significantly associated with OSA in adult patients. Several factors have been postulated to contribute to or be critical in the genesis of dysmetabolic states in OSA including the increase in sympathetic activation, the deregulation of the hypothalamus-pituitary axis, the generation of reactive oxygen species (ROS), insulin resistance, alteration in adipokines levels, and inflammation of the adipose tissue. However, probably the alterations in the hypothalamus-pituitary axis and the altered secretion of hormones from the peripheral endocrine glands could play a major role in the gender differences in the link between OSA-dysmetabolism. In fact, normal sleep is also different between men and women due to the physiologic differences between genders, with sex hormones such as progesterone, androgens, and estrogens, being also connected with breathing pathologies. Moreover, it is very well known that OSA is more prevalent among men than women, however the prevalence in women increases after menopause. At the same time, the step-rise in obesity and its comorbidities goes along with mounting evidence of clinically important sex and gender differences. Metabolic and cardiovascular diseases, seen as a men's illness for decades, presently are more common in women than in men and obesity has a higher association with insulin-resistance-related risk factors in women than in men. In this way, in the present manuscript, we will review the major findings on the overall mechanisms that connect OSA and dysmetabolism giving special attention to the specific regulation of this relationship in each gender. We will also detail the gender-specific effects of hormone replacement therapies on metabolic control and sleep apnea.

Yacon-based product improves intestinal hypertrophy and modulates the production of glucagon-like peptide-1 in postmenopausal experimental model

AIMS

The progressive decline in estrogen level puts postmenopausal women at a higher risk of developing cardiometabolic diseases. Thus, we evaluated the potential beneficial effects of yacon-based product (YBP) on glycemic profile and intestinal health of postmenopausal rats.

METHODS

Eighty Wistar rats were randomized into 4 ovariectomized (OVX) groups or 4 celiotomized groups treated with a standard diet (SD) or diet supplemented with YBP at 6% of fructooligosaccharide (FOS)/inulin.

KEY FINDINGS

The continued consumption of YBP at 6% of FOS/inulin did not generate liver damage and gastrointestinal disorders. Rats fed with YBP displayed higher food consumption, but this did not increase the body weight gain, abdominal circumference and body fat percentual of OVX rats. Furthermore, we also found that the FOS/inulin fermentation present in the YBP resulted in cecum, ileum and colon crypts hypertrophy and increased the lactic acid levels in the cecal content. We observed an increase of glucagon-like peptide-1 (GLP-1) immunoreactive cells and there was no change in the glucose and insulin plasma levels of YBP-fed OVX rats.

SIGNIFICANCE

Our findings indicated that YBP when consumed previously and after the menopausal period has important effects on the morphology and function of intestinal mucous of rats and has potential to modulate indirectly the glycemic and insulinemic profiles, weight gain and body fat percentual in the hypoestrogenic period through metabolites produced in the fermentation process.

The Relationship Between Psychosocial Factors and Adherence to Treatment in Men, Premenopausal and Menopausal Women with Type 2 Diabetes Mellitus

Introduction

Type 2 Diabetes Mellitus (T2DM) is a chronic disease that begins in adulthood, and is caused by multiple factors. The onset of menopause involves changes that predispose women to the development of T2DM, which can worsen if the adherence to treatment is inadequate due to psychosocial factors or medications. The present study aims to describe the psychosocial factors that may affect adherence to treatment among men and premenopausal and menopausal women with T2DM.

Methods

This was a cross-sectional study of 96 patients with T2DM, who were divided into three groups: 1) men (n=32); 2) premenopausal women (n=32); and 3) menopausal women (n=32). Somatometric and metabolic control data were obtained. Adherence to treatment and psychosocial factors were evaluated: social support, belief in conventional medicine, disease denial, and depressive symptoms.

Results

Adherence to medication had a negative correlation with depressive symptoms in men (p <0.001) and menopausal women (p <0.021). Dietary adherence had a positive correlation with belief in conventional medicine in men (p <0.037) and premenopausal women (p <0.029).

Conclusion

Medication adherence in men and menopausal women was correlated with fewer depressive symptoms. Adherence to diet in men and premenopausal women was correlated with greater belief in conventional medicine. The results show the diversity of psychosocial factors among the groups that must be addressed in order to improve adherence.

Menopausal hormone therapy in women with medical conditions

Hormone therapy is the most effective treatment for menopause-related symptoms. Current evidence supports its use in young healthy postmenopausal women under the age of 60 years, and within 10 years of menopause, with benefits typically outweighing risks. However, decision making is more complex in the more common clinical scenario of a symptomatic woman with one or more chronic medical conditions that potentially alter the risk-benefit balance of hormone therapy use. In this review, we present the evidence relating to the use of hormone therapy in women with chronic medical conditions such as obesity, hypertension, dyslipidemia, diabetes, venous thromboembolism, and autoimmune diseases. We discuss the differences between oral and transdermal routes of administration of estrogen and the situations when one route might be preferred over another. We also review evidence regarding the effect of different progestogens, when available.

Acute estradiol and progesterone therapy in hospitalised adults to reduce COVID-19 severity: a randomised control trial

INTRODUCTION

As of November 2021, COVID-19 has killed more than 5 million people globally, including over 750 000 in the USA. Apart from corticosteroids, most available therapeutic options are at best marginally efficient in reducing disease severity and are extremely expensive. The systematic investigation of clinically approved drugs is a priority to determine what does mitigate disease severity. Oestradiol (E2) and progesterone (P4) produce a state of anti-inflammatory immune responses and immune tolerance, and enhanced antibody production. The goal of this trial is to evaluate the efficacy of a short E2 and P4 therapy, in addition to standard of care (SOC), in mitigating disease severity in COVID-19 hospitalised patients.

METHODS AND ANALYSIS

Phase 2, randomised, double blind, placebo-controlled, single-centre trial. Patients hospitalised for confirmed COVID-19, with scores 3-5 on the 9-point WHO ordinal scale are randomised between two arms: (1) Oestradiol cypionate intramuscular (IM) and micronised progesterone oral (PO), in addition to SOC, and (2) placebo, in addition to SOC. The primary outcome is the proportion of patients improving to scores 1 or 2 on the WHO scale through day 28. Secondary outcomes include length of hospital stay, duration of mechanical ventilation, cause of death, readmission rates, change in inflammatory biomarkers between admission and occurrence of primary endpoint, and adverse events. Study sample size will be up to 120 participants. The trial is currently recruiting subjects.

ETHICS AND DISSEMINATION

The sponsor of this study is the Center of Excellence in Sex-Based Biology & Medicine at Tulane University, New Orleans, Louisiana, USA. Ethical approval was obtained from the Tulane institutional review board on 14 May 2021. The study was reviewed by the US Food and Drug Administration and granted Investigational New Drug #152 499. Results of the study will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04865029; Pre-results.

Outcomes between prediabetes and type 2 diabetes mellitus in older adults with acute myocardial infarction in the era of newer-generation drug-eluting stents: a retrospective observational study

Background

The comparative clinical outcomes between prediabetes and type 2 diabetes mellitus (T2DM) in older adults with AMI in the era of newer-generation drug-eluting stents (DES) are limited. We investigated the 2-year clinical outcomes of these patients.

Methods

A total of 5492 AMI patients aged ≥65 years were classified into three groups according to their glycemic status: normoglycemia (group A: 1193), prediabetes (group B: 1696), and T2DM (group C: 2603). The primary outcome was the occurrence of major adverse cardiac events (MACE), defined as all-cause death, recurrent myocardial infarction (Re-MI), and any repeat revascularization. The secondary outcome was stent thrombosis (ST).

Results

The primary and secondary outcomes cumulative incidences were similar between the prediabetes and T2DM groups. In both the prediabetes and T2DM groups, the cumulative incidences of MACE (adjusted hazard ratio [aHR]: 1.373; p = 0.020 and aHR: 1.479; p = 0.002, respectively) and all-cause death or MI (aHR: 1.436; p = 0.022 and aHR: 1.647; p = 0.001, respectively) were significantly higher than those in the normoglycemia group. Additionally, the cumulative incidence of all-cause death in the T2DM group was significantly higher than that in the normoglycemia group (aHR, 1.666; p = 0.003).

Conclusions

In this retrospective study, despite the 2-year clinical outcomes of the patients with prediabetes and T2DM in the older adults were worse than those in the normoglycemia group; they were similar between the prediabetes and T2DM groups. Hence, comparable treatment strategies should be strengthened between prediabetes and T2DM in older adults with AMI.

Trial registration

Retrospectively registered.

Body Composition and Biological Functioning in Polish Perimenopausal Women with Type 2 Diabetes

BACKGROUND AND OBJECTIVES

The aim was to compare body composition and levels of biochemical blood parameters and identify relationships between biochemical parameters and body composition of women with type 2 diabetes and healthy ones, both in perimenopausal period (172 women aged between 45 and 65 come from the West Pomeranian Voivodeship, Poland).

MATERIALS AND METHODS

The study consisted of an interview, body composition analysis with Jawon Medical IOI-353 (Yuseong, South Korea) analyser and venous blood biochemical analysis (lipid profile, levels of glucose, insulin, CRP, glycated haemoglobin).

RESULTS

The vast majority of body composition measurements varied between study and control groups in a statistically significant way (p < 0.05) except protein and soft lean mass of the torso. Statistically significant differences between the two groups have been observed in case of all biochemical parameters (p < 0.001).

CONCLUSIONS

Body composition of women suffering from type 2 diabetes significantly varied from body composition of healthy women. Results of the first group were characterised by higher values, especially in case of general parameters, abdominal area, content of adipose tissue and soft tissues. Relationship between body composition and biochemical results may be observed, especially in level of triglycerides, CRP and insulin. Higher concentrations of these parameters were associated with increased values of majority of body composition measurements regardless of type 2 diabetes incidence.

Menopause and cardiometabolic diseases: What we (don't) know and why it matters

This narrative review discusses the current understanding, knowledge gaps and challenges in expanding our knowledge of the association between menopause and the reproductive aging process and cardiometabolic disease (CMD) in women, with a focus on type 2 diabetes and cardiovascular disease. The physiological changes that occur at different stages of the reproductive life span, as well as type of menopause and timing, are factors widely associated with CMD risk; however, the underlying mechanisms remain either unclear or insufficiently studied. Decreased ovarian estrogen production and relative androgen excess around menopause onset are the most studied factors linking menopause and cardiometabolic health; nevertheless, the evidence is not persuasive and other hypotheses might explain the changes in CMD risk during menopausal transition. In this context, hormone therapy has been widely adopted in the treatment and prevention of CMD, although uncertainty regarding its cardiometabolic effects has raised the need to optimize therapeutic modalities. Mechanisms such as the "iron overload theory" and new "omics" platforms could provide new insights into potential pathways underlying the association between menopause and cardiometabolic health, such as the DNA damage response. Although it has been widely reported that environmental and lifestyle factors affect both menopause and cardiometabolic health, there is little evidence on the role of these exposures in menopause-associated CMD risk.

Ovarian insufficiency impairs glucose-stimulated insulin secretion through activation of hypothalamic de novo ceramide synthesis

Oestrogens regulate body weight through their action on hypothalamus to modulate food intake and energy expenditure. Hypothalamic de novo ceramide synthesis plays a central role on obesity induced by oestrogen deficiency. Depletion in oestrogens is also known to be associated with glucose intolerance, which favours type 2 diabetes (T2D). However, the implication of hypothalamic ceramide in the regulation of glucose homeostasis by oestrogen is unknown. Here, we studied glucose homeostasis and insulin secretion in ovariectomized (OVX) female rats. OVX induces body weight gain associated with a hypothalamic inflammation and impaired glucose homeostasis. Genetic blockade of ceramide synthesis in the ventromedial nucleus of the hypothalamus (VMH) reverses hypothalamic inflammation and partly restored glucose tolerance induced by OVX. Furthermore, glucose-stimulated insulin secretion (GSIS) is increased in OVX rats due to a raise of insulin secretion second phase, a characteristic of early stage of T2D. In contrast, GSIS from isolated islets of OVX rats is totally blunted. Inhibition of ceramide synthesis in the VMH restores GSIS from isolated OVX islets and represses the second phase of insulin secretion. Stimulation of oestrogen receptor α (ERα) by oestradiol (E2) down-regulates ceramide synthesis in hypothalamic neuronal GT1-7 cells but no in microglial SIM-A9 cells. In contrast, genetic inactivation of ERα in VMH upregulates ceramide synthesis. These results indicate that hypothalamic neuronal de novo ceramide synthesis triggers the OVX-dependent impairment of glucose homeostasis which is partly mediated by a dysregulation of GSIS.

Nonalcoholic fatty liver disease increases the risk of diabetes in young adults: A nationwide population-based study in Korea

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of diabetes but has been rarely investigated in young adults. In this study, we investigated the relationship between NAFLD and incident diabetes risk in young adults using nationwide Korean population data.

METHODS

This population-based cohort study from the Korean National Health Insurance Service included adults aged 20 through 39 years who underwent a health examination from 2009 to 2012. NAFLD was defined as a fatty liver index (FLI) ≥60 in the absence of alcohol consumption of ≥30 g/day. Newly diagnosed diabetes during follow-up was identified using claims data. Cox regression was used to calculate the hazard ratio for incident diabetes after adjusting for classical confounders.

FINDINGS

Among the 5,254,786 participants, 9.3% had an FLI ≥60. During the median follow-up of 8.6 years, 91,885 cases of incident diabetes occurred. In multivariable analysis, the risk of incident diabetes was significantly higher in the NAFLD group than the control group (adjusted hazard ratio = 4.97, 95% confidence interval, 4.90-5.05). Stratified analyses showed higher associations in those who were ≥30 years, male, obese, smokers, alcohol consumers, and did not regularly exercise (all P < 0.001).

CONCLUSIONS

NAFLD is associated with a five-fold increased risk of incident diabetes in young adults. These results suggest an independent high risk for incident diabetes in young adults and underscore the importance of paying early attention to patients who develop NAFLD before middle age.

Beyond the X Factor: Relevance of Sex Hormones in NAFLD Pathophysiology

Non-alcoholic fatty liver disease (NAFLD) is a major health issue worldwide, being frequently associated with obesity, unbalanced dietary regimens, and reduced physical activity. Despite their greater adiposity and reduced physical activity, women show a lower risk of developing NAFLD in comparison to men, likely a consequence of a sex-specific regulation of liver metabolism. In the liver, sex differences in the uptake, synthesis, oxidation, deposition, and mobilization of lipids, as well as in the regulation of inflammation, are associated with differences in NAFLD prevalence and progression between men and women. Given the major role of sex hormones in driving hepatic sexual dimorphism, this review will focus on the role of sex hormones and their signaling in the regulation of hepatic metabolism and in the molecular mechanisms triggering NAFLD development and progression.

Incident Type 2 Diabetes Risk of Selective Estrogen Receptor Modulators in Female Patients with Breast Cancer

Accumulating evidence indicates a link between diabetes and cancer. Selective estrogen receptor modulators (SERMs) may increase diabetes risk via antiestrogen effects. This study investigated incident diabetes risk of SERM treatment and its effects on metastatic cancer and death prevention in breast cancer survivors. This retrospective cohort study included female patients with early-stage breast cancer, treated with or without SERMs, between 2008 and 2020 in a tertiary care hospital in Korea. Four propensity score-matched comparison pairs were designed: SERM use versus non-use, long-term use (≥1500 days) versus non-use, tamoxifen use versus non-use, and toremifene use versus non-use; then, logistic regression analysis was performed for risk analysis. SERMs in general were not associated with an elevated risk of diabetes; however, when used for ≥1500 days, SERMs—especially toremifene—substantially increased diabetes risk in breast cancer patients (OR 1.63, p = 0.048). Meanwhile, long-term SERM treatment was effective at preventing metastatic cancer (OR 0.20, p < 0.001) and death (OR 0.13, p < 0.001). SERM treatment, albeit generally safe and effective, may increase diabetes risk with its long-term use in women with breast cancer. Further studies are required to verify the association between toremifene treatment and incident diabetes.

Effects of menopausal hormone therapy on cardiovascular diseases and type 2 diabetes in middle-aged postmenopausal women: analysis of the Korea National Health Insurance Service Database

OBJECTIVE

Although menopausal hormone therapy (MHT) is the most effective treatment for menopausal symptoms, menopausal women hesitate to start MHT due to concerns about adverse events. Recently, however, it has been recommended to use it for appropriate patients who have been evaluated for baseline diseases, age, and timing of initiation. We aimed to investigate the association of MHT with cardiovascular diseases (CVDs) and type 2 diabetes among middle-aged postmenopausal women in Korea.

METHODS

Data were collected from the National Health Insurance Service database in Korea from 2002 to 2016. A total of 58,060 postmenopausal women (including 8,013 [13.8%] MHT users and 50,047 [86.2%] nonusers) were included. The time-dependent Cox regression model with a 1-year latency period was used to evaluate the hazard ratio (HR) and 95% confidence interval (CI) of the associations of MHT with CVDs and type 2 diabetes outcomes. Subgroup analyses by regimen type and cumulative duration were conducted.

RESULTS

In the multivariate-adjusted model, MHT was not significantly associated with CVDs (HR = 1.085, 95% CI: 0.899-1.310) or type 2 diabetes (HR = 1.104, 95% CI: 0.998-1.221). Differential effects were not observed by regimen type, cumulative duration, and years since menopause subgroups. Sensitivity analyses also did not show adverse events by MHT on CVDs and type 2 diabetes.

CONCLUSIONS

Although protective effects of MHT against CVDs or type 2 diabetes were not observed among postmenopausal women who had screened underlying diseases, our results may contribute to reducing the current concerns about the use of MHT for middle-aged postmenopausal women in Korea.

Sex differences in the association between suicide attempts and glucose disturbances in first-episode and drug naive patients with major depressive disorder

BACKGROUND

Glucose metabolism is related to depression, but the relationship between blood glucose and suicide attempts in patients with major depressive disorder (MDD) remains unclear. This large-scale sample explores the relationship between suicide attempts and fasting blood glucose, in addition to sex differences in first-episode and drug naive (FEDN) MDD patients.

METHODS

1718 FEDN MDD patients diagnosed for the first time were recruited, and their demographic data, clinical data, and blood glucose indicators were collected. 17-item Hamilton Depression Rating Scale (HAMD), 14-item Hamilton Anxiety Rating Scale (HAMA), and positive subscale of the Positive and Negative Syndrome Scale (PANSS) were used to assess their depression, anxiety and psychotic symptoms, respectively.

RESULTS

The depression, anxiety, psychotic symptoms and blood sugar levels of the suicide attempt group were higher than those of the non-suicide attempt group. Correlation analysis showed that blood glucose was significantly associated with suicide attempts in male and female patients. While binary logistic regression showed that blood glucose levels were significantly associated with suicide attempts in male patients, it showed that suicide attempts were not significantly associated with blood glucose levels in female patients.

LIMITATIONS

The main limitations are cross-sectional design and inability to control selection bias.

CONCLUSIONS

In male MDD patients, fasting blood glucose level is a potential biomarker of suicide attempt, which deserves attention to avoid suicide risk. However, in female patients, fasting blood glucose has no significant correlation to suicide attempts.

Gut and vaginal microbiomes on steroids: implications for women's health

This review discusses the interactions of steroids with the gut and vaginal microbiomes within each life phase of adult women and the implications for women's health. Each phase of a woman's life is characterized by distinct hormonal states which drive overall physiology of both host and commensal microbes. These host-microbiome interactions underlie disease pathology in disorders that affect women across their lifetime, including bacterial vaginosis, gestational diabetes, polycystic ovary syndrome (PCOS), anxiety, depression, and obesity. Although many associations between host health and microbiome composition are well defined, the mechanistic role of the microbiome in women's health outcomes is largely unknown. This review addresses potential mechanisms by which the microbiota influences women's health and highlights gaps in current knowledge.

Sex hormone-binding globulin: biomarker and hepatokine?

Over the past decade, there have been important breakthroughs in our understanding of the regulation and function of sex hormone-binding globulin (SHBG). A recent genome-wide association and Mendelian randomization study has provided new insights at the population level. Thorough study of genetic variants affecting serum SHBG has identified de novo lipogenesis as one of the mechanistic links between the metabolic syndrome and reduced serum SHBG levels in humans. Furthermore, careful deduction of the Mendelian randomization results suggests a direct, causal role for SHBG in the pathogenesis of type 2 diabetes, as a hepatokine, in women. These findings prompt the development of SHBG-raising therapies as a means to prevent or treat disorders such as type 2 diabetes and polycystic ovary syndrome.

Cardiometabolic health in premature ovarian insufficiency

Premature ovarian insufficiency (POI) is an increasing public health problem with a prevalence now approaching 4%. POI results in adverse effects on the skeleton and central nervous system as well as disturbances of metabolic and cardiological factors that predispose to a major increased risk of cardiovascular disease (CVD). This article reviews the effects of the premature loss of ovarian function on lipids and lipoproteins, glucose and insulin metabolism, body composition, hemostasis and blood pressure, together with effects on the development of metabolic syndrome and diabetes mellitus. The article examines the effects of POI on vascular endothelial function and inflammation that result in arterial disease, and reviews the effects of hormone replacement therapy (HRT) on these various metabolic processes and on cardiovascular outcomes. It is essential that women with POI receive hormonal treatment to help prevent the development of CVD, and that this treatment is continued at least until the normal age of menopause. It appears that HRT has a more favorable effect than the combined oral contraceptive, but larger clinical trials are needed to establish the optimal treatment. Other therapeutic measures may need to be added to correct existing metabolic abnormalities and, in particular, attention to lifestyle factors such as diet and exercise must be encouraged.

Sex-specific expression mechanism of hepatic estrogen inactivating enzyme and transporters in diabetic women

Circulating estrogens levels significantly decrease in menopause and levels off in postmenopausal women. Accordingly, the liver represses levels of enzymes and membrane transporters, thereby decreasing capability of inactivating and excreting estrogens. Women increasingly develop type 2 diabetes during or after menopause. Estrogens are known to promote liver diseases in these women. Here, we have found that the estrogen inactivating sulfotransferase (SULT1E1) and an ATP-binding cassette subfamily G member 2 (ABCG2), a gene encoding breast cancer resistance protein that exports sulfated estrogens, increased their expression levels in diabetic women but not men. For the sulfotransferase gene, phosphorylated nuclear receptors ERα and RORα, at Ser212 and Ser100, respectively, bind their response elements to activate the SULT1E1 promoter in women. This coordinated increase in estrogen inactivation and excretion, and the phosphorylated nuclear receptor-mediated gene activation could be a defense mechanism against toxicities of estrogens through inactivation and excretion in the livers of women.

Single-cell RNA Sequencing Reveals Sexually Dimorphic Transcriptome and Type 2 Diabetes Genes in Mouse Islet β Cells

Type 2 diabetes (T2D) is characterized by the malfunction of pancreatic β cells. Susceptibility and pathogenesis of T2D can be affected by multiple factors, including sex differences. However, the mechanisms underlying sex differences in T2D susceptibility and pathogenesis remain unclear. Using single-cell RNA sequencing (scRNA-seq), we demonstrate the presence of sexually dimorphic transcriptomes in mouse β cells. Using a high-fat diet-induced T2D mouse model, we identified sex-dependent T2D altered genes, suggesting sex-based differences in the pathological mechanisms of T2D. Furthermore, based on islet transplantation experiments, we found that compared to mice with sex-matched islet transplants, sex-mismatched islet transplants in healthy mice showed down-regulation of genes involved in the longevity regulating pathway of β cells. Moreover, the diabetic mice with sex-mismatched islet transplants showed impaired glucose tolerance. These data suggest sexual dimorphism in T2D pathogenicity, indicating that sex should be considered when treating T2D. We hope that our findings could provide new insights for the development of precision medicine in T2D.

Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists

Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman’s risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).

Sex differences in soluble prorenin receptor in patients with type 2 diabetes

BACKGROUND

The soluble prorenin receptor (sPRR), a member of the renin-angiotensin system (RAS), is elevated in plasma of patients with preeclampsia, hypertension, chronic kidney disease (CKD), and type 2 diabetes. Our goal was to examine the relationship between sPRR and RAS activation to define whether sexual dimorphisms in sPRR might explain sex disparities in renal outcomes in patients with type 2 diabetes.

METHODS

Two hundred sixty-nine participants were included in the study (mean age, 48 ± 16 years; 42% men, 58% women), including 173 controls and 96 subjects with type 2 diabetes. In plasma and urine, we measured sPRR, plasma renin activity (PRA), and prorenin. In the urine, we also measured angiotensinogen along with other biomarkers of renal dysfunction.

RESULTS

Plasma sPRR and PRA were significantly higher in women with type 2 diabetes compared to men. In these women, plasma sPRR was positively correlated with PRA, age, and body mass index (BMI). In contrast, in men the sPRR in urine but not in plasma positively correlated with eGFR in urine, but negatively correlated with urine renin activity, plasma glucose, age, and BMI.

CONCLUSIONS

In patients with type 2 diabetes, sPRR contributes to RAS stimulation in a sex-dependent fashion. In diabetic women, increased plasma sPRR parallels the activation of systemic RAS; while in diabetic men, decreased sPRR in urine matches intrarenal RAS stimulation. sPRR might be a potential indicator of intrarenal RAS activation and renal dysfunction in men and women with type 2 diabetes.

Clinical trials with plants in diabetes mellitus therapy: a systematic review

INTRODUCTION

The chronic metabolic disorder diabetes mellitus is a fast-growing global problem with huge social, health, and economic consequences, having one of the highest morbidities and mortality rates. Prolonged use of many available medications can produce undesirable side effects. Thus, plants appear as an important source of bioactive resources for the discovery of new treatments for diabetes.

AREAS COVERED

In this sense, this systematic review focused on clinical trials involving plants of National List of Medicinal Plants of Interest to the Unified Health System (RENISUS) (or compounds) with antidiabetic properties. We analyzed indexed studies in PubMed following the reporting guidelines of PRISMA.

EXPERT OPINION

Of the 51 clinical trials found, Curcuma longa, Glycine max, Zingiber officinale, Punica granatum, Aloe vera, Momordica charantia are the species with the greatest amount of clinical trials and the attenuation of insulin resistance, decreased fasting blood glucose and glycosylated hemoglobin levels are some of the main mechanisms by which these plants exert hypoglycemic effects. Thus, we speculate that the Clinical Pharmacology should explore the field of plant-based compounds that will keep concentrating the attention of researchers, and therefore, we gathered studies in advanced stages that highlight the role of plants in the diabetes therapy.

Perils of prolonged ovarian suppression and hypoestrogenism in the treatment of breast cancer: Is the risk of treatment worse than the risk of recurrence?

Premenopausal breast cancer is usually estrogen receptor positive, and hence, prolonged ovarian suppression by medical or surgical means to prevent recurrence has become standard of management to improve disease-free survival. Ten-year adjuvant tamoxifen therapy is associated with 3.5% fewer recurrences compared to five years. The SOFT trial demonstrated small but statistically significant incremental improvements in long-term disease-free survival by the addition of gonadotropin-releasing hormone analog treatment (triptorelin) to an aromatase inhibitor (exemestane). Profound hypoestrogenism in the premenopausal age group may not be well tolerated due to a host of bothersome side effects (primarily vasomotor symptoms, musculoskeletal complaints, genitourinary syndrome of menopause, and mood disorders). Prolonged hypoestrogenism in younger women is associated with premature development of cardiovascular disease, bone loss, cognitive decline, and all-cause mortality. This paper explores multi-system consequences of prolonged hypoestrogenism in premenopausal women derived from studies of women with and without breast cancer. Pretreatment counseling in estrogen receptor positive breast cancer should emphasize the benefit of prolonged estrogen suppression on breast cancer recurrence and established risks of lifelong hypoestrogenism on quality of life and all-cause mortality. Future genomic research may help identify the best candidates for extended ovarian suppression to avoid treating many women when only a minority benefit.

miR-10b-5p Rescues Diabetes and Gastrointestinal Dysmotility

BACKGROUND & AIMS

Interstitial cells of Cajal (ICCs) and pancreatic β cells require receptor tyrosine kinase (KIT) to develop and function properly. Degeneration of ICCs is linked to diabetic gastroparesis. The mechanisms linking diabetes and gastroparesis are unclear, but may involve microRNA (miRNA)-mediated post-transcriptional gene silencing in KIT⁺ cells.

METHODS

We performed miRNA-sequencing analysis from isolated ICCs in diabetic mice and plasma from patients with idiopathic and diabetic gastroparesis. miR-10b-5p target genes were identified and validated in mouse and human cell lines. For loss-of-function studies, we used KIT⁺ cell-restricted mir-10b knockout mice and KIT⁺ cell depletion mice. For gain-of-function studies, a synthetic miR-10b-5p mimic was injected in multiple diabetic mouse models. We compared the efficacy of miR-10b-5p mimic treatment vs antidiabetic and prokinetic medicines.

RESULTS

miR-10b-5p is highly expressed in ICCs from healthy mice, but drastically depleted in ICCs from diabetic mice. A conditional knockout of mir-10b in KIT⁺ cells or depletion of KIT⁺ cells in mice leads to degeneration of β cells and ICCs, resulting in diabetes and gastroparesis. miR-10b-5p targets the transcription factor Krüppel-like factor 11 (KLF11), which negatively regulates KIT expression. The miR-10b-5p mimic or Klf11 small interfering RNAs injected into mir-10b knockout mice, diet-induced diabetic mice, and TALLYHO polygenic diabetic mice rescue the diabetes and gastroparesis phenotype for an extended period of time. Furthermore, the miR-10b-5p mimic is more effective in improving glucose homoeostasis and gastrointestinal motility compared with common antidiabetic and prokinetic medications.

CONCLUSIONS

miR-10b-5p is a key regulator in diabetes and gastrointestinal dysmotility via the KLF11-KIT pathway. Restoration of miR-10b-5p may provide therapeutic benefits for these disorders.

Applying latent class analysis to risk stratification of incident diabetes among Chinese adults

OBJECTIVE

To use latent class analysis to identify unobservable subpopulations amongst the heterogeneous population and explore the relationship between subpopulations and incident diabetes among Chinese adults.

METHODS

The retrospective study included 32,312 Chinese adults without diabetes at baseline. Latent class indicators included demographic and clinical variables. The outcome was incident diabetes. The relationship between latent class and outcome was evaluated with Cox proportional hazard regression analysis.

RESULTS

After screening, the two-class latent class model best fits the population. Participants in class 2 are characterized by higher age, body mass index, systolic and diastolic blood pressure, fasting plasma glucose, total cholesterol, triglyceride, low-density lipoprotein cholesterol, serum creatinine, serum urea nitrogen, alanine aminotransferase, and a higher proportion of males, ever/current smokers and drinkers, but lower high-density lipoprotein cholesterol and a lower proportion of family history of diabetes. The risk of diabetes in class 2 was 5.451 times (HR: 6.451, 95%CI: 4.179-9.960, P < 0.00001) and 5.264 times (HR: 6.264, 95%CI: 4.680-8.385, P < 0.00001) higher than that in class 1 during 3-year and 5-year follow-up, respectively.

CONCLUSIONS

We used latent class analysis to identify two distinct subpopulations with differential risk of diabetes during 3-year and 5-year follow-up.

Gonadal hormonal factors before menopause and incident type 2 diabetes in women: A 22-year follow-up of 83 799 women from the E3N cohort study

BACKGROUND

In many populations the incidence of type 2 diabetes is higher in men than in women. This may be explained by exposure to female gonadal hormones, but so far, there is no consensus on their role over the life course in type 2 diabetes etiology.

METHODS

Data are from 83 799 French women from the E3N (Etude Épidémiologique de Femmes de la Mutuelle Générale de l'Education Nationale) cohort study, followed for 22 years. Multivariable Cox models including classical risk factors were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) between gonadal hormonal factors and incident type 2 diabetes.

RESULTS

Older age at menarche, more menstrual cycles, older age at menopause, longer duration of exposure to gonadal hormones and breastfeeding were inversely associated with incident type 2 diabetes cases (n = 4806). While a longer duration of menstrual cycles (HR = 1.23 [95% CI: 1.07-1.41] comparing ≥32 vs ≤24 days) and use of contraceptive pills (HR = 1.33 [1.25-1.42]) were associated with a greater risk of type 2 diabetes.

CONCLUSIONS

In women, a longer exposure to endogenous gonadal hormones with a later menopause as well as breastfeeding were associated with a lower risk of developing type 2 diabetes, independently of classical diabetes risk factors. In contrast, the use of contraceptive agents was associated with incident diabetes, but the influence of each type of contraception and of exposure duration remain to be investigated.

Risks, Benefits, and Treatment Modalities of Menopausal Hormone Therapy: Current Concepts

Menopausal hormone therapy (HT) prescribing practices have evolved over the last few decades guided by the changing understanding of the treatment's risks and benefits. Since the Women's Health Initiative (WHI) trial results in 2002, including post-intervention analysis and cumulative 18-year follow up, it has become clear that the risks of HT are low for healthy women less than age 60 or within ten years from menopause. For those who are experiencing bothersome vasomotor symptoms, the benefits are likely to outweigh the risks in view of HT's efficacy for symptom management. HT also has a role in preventing osteoporosis in appropriate candidates for treatment. A comprehensive overview of the types, routes, and formulations of currently available HT, as well as HT's benefits and risks by outcomes of interest are provided to facilitate clinical decision making.

Sexual hormones and diabetes: The impact of estradiol in pancreatic β cell

Diabetes is one of the most prevalent metabolic diseases and its incidence is increasing throughout the world. Data from World Health Organization (WHO) point-out that diabetes is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation and estimated 1.6 million deaths were directly caused by it in 2016. Population studies show that the incidence of this disease increases in women after menopause, when the production of estrogen is decreasing in them. Knowing the impact that estrogenic signaling has on insulin-secreting β cells is key to prevention and design of new therapeutic targets. This chapter explores the role of estrogen and their receptors in the regulation of insulin secretion and biosynthesis, proliferation, regeneration and survival in pancreatic β cells. In addition, delves into the genetic animal models developed and its application for the specific study of the different estrogen signaling pathways. Finally, discusses the impact of menopause and hormone replacement therapy on pancreatic β cell function.

Liraglutide improves lipid and carbohydrate metabolism of ovariectomized rats

Considering that post-menopausal women and ovariectomized rodents develop obesity associated with increased visceral fat, this study was developed to investigate if liraglutide, a glucagon-like peptide 1 (GLP1) analogue, could improve the metabolism of estrogen (E2) deficient females. Wistar rats were ovariectomized (OVX), and subdivided in four groups: sham saline, sham liraglutide, OVX saline, and OVX liraglutide. After sixty days, metabolic parameters of blood, heart, liver, brown (BAT) and white adipose tissue (WAT) visceral depots, and, heart oxidative homeostasis, were evaluated. Castration increased the animals' body weight, the relative weight of the WAT depots, hepatic triglycerides and cardiac glycogen content. Liraglutide treatment reversed these effects, decreased WAT depots weight and increased glucose oxidation and lipogenesis in BAT and WAT. In addition, liraglutide enhanced adrenalin (A) lipolytic effect. These results indicate that liraglutide may be a promising treatment to restore lipid homeostasis and prevent weight gain associated with E2 deficiency.

CD45RO-CD8+ T cell-derived exosomes restrict estrogen-driven endometrial cancer development via the ERβ/miR-765/PLP2/Notch axis

Rationale: Estrogen-dependent cancers (e.g., breast, endometrial, and ovarian cancers) are among the leading causes of morbidity and mortality in women worldwide. Recently, exosomes released by tumor-infiltrating CD8⁺ T cells have been under the spotlight in the field of cancer immunotherapy. Our study aims at elucidating the underlying mechanisms of the crosstalk between estrogen signaling and CD8⁺ T cells, and possible intervention values in uterine corpus endometrial cancer (UCEC).

Methods: Micro RNA-seq was conducted to screen differentially expressed micro RNA in UCEC. Bioinformatic analysis was processed to predict the target of miR-765. RNA silencing or overexpressing and pharmacologic inhibitors were used to assess the functions of ERβ/miR-765/PLP2/Notch axis in UCEC cell proliferation and invasion in vivo and in vitro. In vivo imaging was performed to evaluate the metastasis of tumor in mice. Combined fluorescent in situ hybridization for miR-765 and immunofluorescent labeling for CD8 was carried out to prove the co-localization between miR-765 and CD8⁺ T cells. Exosomes derived from CD45RO^-CD8⁺ T cells were isolated to detect the regulatory effects on UCEC.

Results: miR-765 is characterized as the most downregulated miRNA in UCEC, and there is a negative correlation between miR-765 and Proteolipid protein 2 (PLP2) in UCEC lesion. Estrogen significantly down-regulates miR-765 level, and facilitates the development of UCEC by estrogen receptor (ER) β. Mechanistically, this process is mediated through the miRNAs (e.g., miR-3584-5p, miR-7-5p, miR-150-5p, and miR-124-3p) cluster-controlled regulation of the PLP2, which further regulates Ki-67 and multiple epithelial-mesenchymal transition (EMT)-related molecules (e.g, E-cadherin and Vimentin) in a Notch signaling pathway-dependent manner. Interestingly, the selective ER degrader Fulvestrant alleviates estrogen-mediated miR-765/PLP2 expression regulation and UCEC development in ERβ-dependent and -independent manners. Additionally, CD45RO^-CD8⁺ T cell-derived exosomes release more miR-765 than that from CD45RO⁺CD8⁺ T cells. In therapeutic studies, these exosomes limit estrogen-driven disease development via regulation of the miR-765/PLP2 axis.

Conclusions: This observation reveals novel molecular mechanisms underlying estrogen signaling and CD8⁺ T cell-released exosomes in UCEC development, and provides a potential therapeutic strategy for UCEC patients with aberrant ERβ/miR-765/PLP2/Notch signaling axis.

ESRα Promoter Methylation May Modify the Association Between Lipid Metabolism and Type 2 Diabetes in Chinese Farmers

Objective: This study is aimed to explore the potential association among the estrogen receptor alpha (ESRα) promoter methylation, lipid metabolism and the risk of type 2 diabetes mellitus (T2DM). Methods: A total of 1143 rural residents were recruited randomly from Henan Province, China. The circulating methylation levels in ESRα promoter region were determined by quantitative methylation-specific polymerase chain reaction. Serum high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglyceride (TG), total cholesterol (TC) and fasting plasma-glucose (FPG) were measured. Results: The ESRα promoter methylation levels were negatively associated with HDL-C levels whether gender stratification was performed (P < 0.05) and positively correlated with LDL-C in men (P < 0.05). Each unit standard deviation (SD) increment in TG was associated with a 43% increase (95% CI: 1.25, 1.64) in the risks of T2DM in all participants, a 36% increase (95% CI: 1.13, 1.64) in the risks of T2DM in men and a 49% increase (95% CI: 1.21, 1.83) in the risks of T2DM in women. Furthermore, each SD increment in HDL-C was associated with a reduction of 25% (OR = 0.75, 95% CI: 0.58, 0.97) in the risks of T2DM in men, and the risk of T2DM in men may be more susceptible to HDL-C than that in women (P for interaction < 0.05). Additionally, we found that the risk of T2DM in participants with lower methylation levels (≤4.07%) were more susceptible to HDL-C (P for interaction < 0.05). Conclusions: These findings suggested that lipid metabolism was associated with ESRα promoter methylation levels and the risk of T2DM. Besides, the levels of ESRα promoter methylation and gender can modify the association of HDL-C and T2DM.