Glycaemic control and plasma lipoproteins in menopausal women with Type 2 diabetes treated with oral and transdermal combined hormone replacement therapy

Effects of Transdermal 17β-Estradiol + Norethisterone Acetate on Cardiovascular Disease Risk Factors in Postmenopausal Women: A Meta-analysis of Data From Randomized, Controlled Trials

PURPOSE

To date, no study has demonstrated the role of transdermal 17β-estradiol + norethisterone acetate on all of the risk factors for cardiovascular disease in postmenopausal women. To overcome this knowledge gap, a systematic review and meta-analysis were conducted to determine the effects of this combination treatment on BMI, body weight, waist/hip ratio, fibrinogen, factor VII, lipoprotein(a), fasting blood sugar, insulin, HbA1c, TG, LDL-C, HDL-C, and TC in postmenopausal women.

METHODS

PubMed/Medline, SCOPUS, Web of Science, Embase, and Google Scholar were searched for relevant articles published between the inception of each database and April 6, 2023. The sample size and mean (SD) were used to calculate overall effect size using a random-effects model.

FINDINGS

A total of 10 articles with 14 arms were included in the meta-analysis. On pooled analysis of effect size, fibrinogen (weighted mean difference [WMD], -0.18 g/L; 95% CI, -0.25 to -0.10), factor VII (WMD, -9.58; 95% CI, -12.51 to -6.64), LDL-C (WMD, -13.09 mg/dL; 95% CI, -18.48 to -7.71), and TC (WMD, -12.61 mg/dL; 95% CI, -18.11 to -7.12) were significantly affected with the use of transdermal 17β-estradiol + norethisterone acetate (all, P < 0.001), but effects on lipoprotein(a), TG, HDL-C, fasting blood sugar, insulin, HbA1c, BMI, body weight, and waist/hip ratio were not significant.

IMPLICATIONS

Based on the findings from the present systematic review and meta-analysis, it was concluded that transdermal administration of 17β-estradiol + norethisterone acetate had beneficial impacts on fibrinogen, factor VII, LDL-C, and TC, suggesting a possible application in the reduction of cardiovascular disease risk.

Effect of Postmenopausal Hormone Therapy on Glucose Regulation in Women With Type 1 or Type 2 Diabetes: A Systematic Review and Meta-analysis

BACKGROUND

Blood glucose regulation in women with diabetes may change during and after menopause, which could be attributed, in part, to decreased estrogen levels.

PURPOSE

To determine the effect of postmenopausal hormone therapy (HT) on HbA1c, fasting glucose, postprandial glucose, and use of glucose-lowering drugs in women with type 1 and women with type 2 diabetes.

DATA SOURCES

We conducted a systematic search of MEDLINE, Embase, Scopus, the Cochrane Library, and the ClinicalTrials.gov registry to identify randomized controlled trials (RCTs).

STUDY SELECTION

We selected RCTs on the effect of HT containing estrogen therapy in postmenopausal women (≥12 months since final menstrual period) with type 1 or type 2 diabetes.

DATA EXTRACTION

Data were extracted for the following outcomes: HbA1c, fasting glucose, postprandial glucose, and use of glucose-lowering medication.

DATA SYNTHESIS

Nineteen RCTs were included (12 parallel-group trials and 7 crossover trials), with a total of 1,412 participants, of whom 4.0% had type 1 diabetes. HT reduced HbA1c (mean difference -0.56% [95% CI -0.80, -0.31], -6.08 mmol/mol [95% CI -8.80, -3.36]) and fasting glucose (mean difference -1.15 mmol/L [95% CI -1.78, -0.51]).

LIMITATIONS

Of included studies, 50% were at high risk of bias.

CONCLUSIONS

When postmenopausal HT is considered for menopausal symptoms in women with type 2 diabetes, HT is expected to have a neutral-to-beneficial impact on glucose regulation. Evidence for the effect of postmenopausal HT in women with type 1 diabetes was limited.

The effect of 17beta-estradiol plus norethisterone acetate on anthropometric indices: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Little evidence exists on the effect of 17beta-estradiol plus norethisterone acetate on all the anthropometric indices. Hence, this systematic review and meta-analysis of Randomized Controlled Trials was conducted to give an evidence-based report on the effect of 17beta-estradiol plus norethisterone acetate on anthropometric indices.

METHODS

The literature search was executed in databases including PubMed/Medline, Web of Science, Scopus, Embase, and Google Scholar to recognize clinical trials that examined the influence of 17beta-estradiol plus norethisterone acetate on obesity indices from database inception to Jan 2023.

RESULTS

Combined findings were generated from 20 eligible articles. The meta-analysis showed that body weight (Weighted Mean Difference (WMD): -0.47 kg, 95% CI: -1.32, 0.37, p = 0.274), body fat (WMD: 0.16 kg, 95% CI: -1.26, 1.59, p = 0.821), WHR (WMD: 0.001 kg, 95% CI: -0.006, 1.15, p = 0.872), and LBM (WMD: -0.02 kg, 95% CI: -1.19, 1.15, p = 0.970) were not modified in DHEA group compared to the control, but BMI levels were significantly reduced in 17beta-estradiol plus norethisterone acetate group (WMD: -0.15 kg/m2, 95% CI: -0.30, -0.008, p = 0.039). Moreover, based on intervention duration (months), a more significant reduction in BMI was found in trials that were performed on studies with ˃3 months duration (WMD: -0.176 kg/m2) than studies with ≤ 3 months (WMD: 0.05 kg/m2).

CONCLUSION

Administration of 17beta-estradiol plus norethisterone acetate for more than 3 months results in a decrease in BMI, which helps to reduce cardiovascular disease risk.

The influence of 17β-estradiol plus norethisterone acetate treatment on markers of glucose and insulin metabolism in women: a systematic review and meta-analysis of randomized controlled trials

Objective

Despite the fact that some evidence suggests that the administration of 17β-estradiol plus norethisterone acetate influences glucose and insulin metabolism in women, these findings are still contradictory. Thus, we aimed to examine the impact of the co-administration of 17β-estradiol and norethisterone acetate on glycated haemoglobin (HbA1c), fasting glucose, insulin and C-peptide concentrations in females by means of a systematic review and meta-analysis of randomized controlled trials (RCTs).

Methods

We searched four databases (PubMed/MEDLINE, Scopus, Embase, and Web of Science) using specific keywords and word combinations. The random-effects model (DerSimonian and Laird model) was employed to compute the weighted mean difference (WMD) and 95% confidence intervals (CIs) for the variations from baseline of HbA1c, fasting glucose, insulin, and C-peptide concentrations.

Results

In total, 14 RCTs were entered into the quantitative synthesis. The combined administration of 17β-estradiol and norethisterone acetate decreased HbA1c (WMD: -0.65%, 95% CI: -1.15 to -0.15; P=0.011), fasting glucose (WMD: -11.05 mg/dL, 95% CI: -16.6 to -5.5; P<0.001) and insulin (WMD: -1.35 mIU/L, 95% CI: -2.20 to -0.50; P=0.001) levels. C-peptide concentrations' declined only in females diagnosed with overweight/obesity or diabetes.

Conclusion

Evidence to date points out that the administration of 17β-estradiol and norethisterone acetate has a positive impact on glucose metabolism in women by reducing fasting glucose, HbA1c, and insulin values. Future studies need to confirm the potential benefits of this drug combination in the prevention and/or management of cardiometabolic disorders.

The effect of 17β-estradiol plus norethisterone acetate on blood pressure and inflammation markers: A meta-analysis of randomized controlled trials

OBJECTIVE

Several randomized controlled trials (RCTs) have explored the impact of 17β-estradiol plus norethisterone acetate administration on blood pressure and inflammation markers, however, their findings have often been contradictory. Thus, we conducted a systematic review and meta-analysis of RCTs to assess the effects of this drug combination on systolic blood pressure (SBP), diastolic blood pressure (DBP) and C-reactive protein (CRP) concentrations.

METHODS

The Cochrane Library, PubMed/Medline, Scopus, and Google Scholar were searched to identify relevant published RCTs. The pooled mean change and standard deviation (SD) of the outcomes were calculated using the STATA software (version 14) for Statistical Computing.

RESULTS

A total of 18 publications were included in the current meta-analysis. In total, there were 12 RCT arms on SBP, 12 RCT arms on DBP, and 6 RCT arms on CRP levels. The administration of 17β-estradiol plus norethisterone acetate intake increased SBP (WMD: 3.48 mmHg, 95% CI: 0.73, 6.23, P = 0.013), particularly in subjects aged ≥ 60 years (WMD: 5.89 mmHg, 95% CI: 1.71, 10.07, P = 0.006) or with a body mass index (BMI) < 30 kg/m² (WMD: 6.55 mmHg, 95% CI: 2.64, 10.46, P = 0.012), as well as in the RCTs which lasted ≥ 6 months (WMD: 6.47 mmHg, 95% CI: 3.03, 9.90, P < 0.001),when 17β-estradiol dosages were ≥ 2 mg/day (WMD: 4.12 mmHg, 95% CI: 1.03, 7.22, P = 0.009; I² = 99%, P < 0.001) and in RCTs conducted on healthy postmenopausal women (WMD: 4.22 mmHg, 95% CI: 0.43, 8.01, P = 0.02; I² = 94%, P < 0.001). DBP decreased following this drug combination in the RCTs which lasted < 6 months (WMD: -1.42 mmHg, 95% CI: -2.27, -0.57, P = 0.001). CRP concentrations increased following the use of this drug combination (WMD: 1.01 mg/L, 95% CI: 0.62, 1.41, P < 0.001), especially in participants aged < 60 years (WMD: 1.22 mg/L, 95% CI: 0.77, 1.68, P < 0.001) or with a BMI < 30 kg/m² (WMD: 0.97 mg/L, 95% CI: 0.67, 1.27, P < 0.001), as well as in RCTs with a duration of ≥ 6 months (WMD: 1.15 mg/L, 95% CI: 0.57, 1.73, P < 0.001), when 17β-estradiol dosages were ≥ 2 mg/day (WMD: 0.97 mg/L, 95% CI: 0.67, 1.27, P < 0.001; I² = 55%, P = 0.107) and in RCTs conducted on healthy postmenopausal women (WMD: 1.22 mg/L, 95% CI: 0.77, 1.68, P < 0.001; I² = 90%, P < 0.001).

CONCLUSION

The administration of 17β-estradiol plus norethisterone acetate increases SBP and CRP concentrations and, when prescribed for less than 6 months, decreases DBP. However, despite being statistically significant, the impact of this drug combination on SBP and DBP is not clinically relevant as the variation in blood pressure values was low.

The effect of 17β-estradiol plus norethisterone acetate treatment on lipoprotein (a), atherogenic and anti-atherogenic apolipoproteins levels in postmenopausal women: A meta-analysis of randomized controlled trials

BACKGROUND AND AIM

The administration of 17β-estradiol plus norethisterone acetate seems to confer women cardioprotection, however, its impact on lipoprotein (a) and apolipoproteins' concentrations remains unclear. Thus, we conducted a meta-analysis of randomized controlled trials (RCTs) to investigate the effect of 17β-estradiol plus norethisterone acetate treatment on lipoprotein (a) and apolipoproteins' values in females.

METHODS

We systematically searched four databases (PubMed/MEDLINE, Scopus, Embase, and Web of Science) to identify relevant publications published until March 9th, 2022. No language restrictions were applied. The random-effects model (the DerSimonian and Laird methods) was employed to calculate the weighted mean difference (WMD).

RESULTS

The administration of 17β-estradiol plus norethisterone acetate resulted in a significant decrease of lipoprotein (a) (WMD: -67.59 mg/L, 95 % CI: -106.39 to -28.80; P < 0.001) and apolipoprotein B concentrations (WMD: -3.71 mg/dL, 95 % CI: -6.68 to -0.75; P = 0.014), respectively. No effect of 17β-estradiol plus norethisterone acetate on apolipoprotein AI (WMD: 0.23 mg/dL, 95 % CI: -3.99 to 4.46; P = 0.91) or AII (WMD: 0.21 mg/dL, 95 % CI: -2.24 to 2.68; P = 0.86) concentrations was detected. In the stratified analysis, there was a notable reduction in lipoprotein (a) levels in the RCTs with a duration of ≥6 months (WMD: -73.34 mg/L), in postmenopausal women with a BMI ≥25 kg/m² (WMD: -69.85 mg/L) and in postmenopausal women aged ˂60 years (WMD: -61.93 mg/L).

CONCLUSION

The present meta-analysis of RCTs demonstrates that 17β-estradiol plus norethisterone acetate treatment reduces lipoprotein (a) and apolipoprotein B levels in postmenopausal women.

Eligibility criteria for Menopausal Hormone Therapy (MHT): a position statement from a consortium of scientific societies for the use of MHT in women with medical conditions. MHT Eligibility Criteria Group

This project aims to develop eligibility criteria for menopausal hormone therapy (MHT). The tool should be similar to those already established for contraception A consortium of scientific societies coordinated by the Spanish Menopause Society met to formulate recommendations for the use of MHT by women with medical conditions based on the best available evidence. The project was developed in two phases. As a first step, we conducted 14 systematic reviews and 32 metanalyses on the safety of MHT (in nine areas: age, time of menopause onset, treatment duration, women with thrombotic risk, women with a personal history of cardiovascular disease, women with metabolic syndrome, women with gastrointestinal diseases, survivors of breast cancer or of other cancers, and women who smoke) and on the most relevant pharmacological interactions with MHT. These systematic reviews and metanalyses helped inform a structured process in which a panel of experts defined the eligibility criteria according to a specific framework, which facilitated the discussion and development process. To unify the proposal, the following eligibility criteria have been defined in accordance with the WHO international nomenclature for the different alternatives for MHT (category 1, no restriction on the use of MHT; category 2, the benefits outweigh the risks; category 3, the risks generally outweigh the benefits; category 4, MHT should not be used). Quality was classified as high, moderate, low or very low, based on several factors (including risk of bias, inaccuracy, inconsistency, lack of directionality and publication bias). When no direct evidence was identified, but plausibility, clinical experience or indirect evidence were available, "Expert opinion" was categorized. For the first time, a set of eligibility criteria, based on clinical evidence and developed according to the most rigorous methodological tools, has been defined. This will provide health professionals with a powerful decision-making tool that can be used to manage menopausal symptoms.

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.

Menopause, hormone therapy and diabetes

Over the past three decades, the prevalence of diabetes has increased four-fold. Coupled with the global obesity epidemic and aging of the world's population, a perfect metabolic storm is brewing. The influence of menopause and exogenous estrogen and progestogens must be included in this equation. In this review, criteria for diagnosing diabetes and recommendations for screening are described. The reported effects of menopause on diabetes risk in healthy women are reviewed as well as the relationship between established diabetes and the timing of menopause. The effects of menopausal hormone therapies (MHT) on glucose control in women with diabetes and the effect of MHT on diabetes risk in menopausal women without diabetes are described. Evidence-based strategies to prevent diabetes in midlife women are highlighted. The augmenting effect of diabetes on chronic health concerns of aging women, such as cardiovascular disease, osteoporosis, and cancer, along with current recommendations for screening and prevention are presented. Given the current demographics of today's world, the content of this review may apply to as many as one-third of the average practitioner's postmenopausal patient population.

Effects of non-oral postmenopausal hormone therapy on markers of cardiovascular risk: a systematic review

OBJECTIVE

To review the effects of non-oral administration of postmenopausal hormone therapy (HT) on risk markers for atherosclerotic and venous thromboembolic disease.Non-oral postmenopausal HT appears not to increase venous thromboembolic risk, whereas the effect on coronary heart disease risk is less clear.

DESIGN

Systematic review of literature obtained from MEDLINE, EMBASE, and CENTRAL databases from 1980 until and including April 2006. Terms for "postmenopausal hormone therapy" and for "non-oral administration" were combined in the search.

SETTING

Randomized clinical trials.

PATIENT(S)

Postmenopausal women, both healthy and with established cardiovascular disease or specified cardiovascular risk factors

INTERVENTION(S)

Non-oral HT (e.g., transdermal or intranasal) compared with oral HT or no treatment/placebo.

MAIN OUTCOME MEASURE(S)

Lipoprotein(a), homocysteine, C-reactive protein (CRP), cell adhesion molecules, markers of endothelial dysfunction, coagulation, and fibrinolysis.

RESULT(S)

Seventy-two studies investigating either transdermal or intranasal administration were included. For non-oral HT, decreases in lipoprotein(a), cell adhesion molecules, and factor VII generally were significant, resistance to activated protein C (APCr) was slightly increased, and other markers including CRP and homocysteine did not change. Compared with oral HT, changes in CRP and APCr were smaller, changes in cell adhesion molecules and some fibrinolytic parameters tended to be smaller, whereas changes in other factors including lipoprotein(a) and homocysteine did not differ.

CONCLUSION(S)

Potentially unfavorable changes seen with oral HT on two important markers, CRP and APCr, are substantially smaller with non-oral HT. Non-oral HT has minor effects on the other cardiovascular risk markers studied. Therefore, compared with oral HT, non-oral HT appears be safer with respect to atherosclerotic and venous thromboembolic disease risk.

Meta-analysis: effect of hormone-replacement therapy on components of the metabolic syndrome in postmenopausal women

AIM

To quantify the effects of hormone-replacement therapy (HRT) on components of the metabolic syndrome in postmenopausal women.

METHODS

Comprehensive searches of electronic databases were performed from April 1966 to October 2004. We included randomized controlled trials that were of at least 8 weeks duration and evaluated the effect of HRT on metabolic, inflammatory or thrombotic components. Insulin resistance was calculated by homeostasis model assessment (HOMA-IR). Subgroup analysis evaluated the effects for transdermal and oral treatment and for diabetic and non-diabetic women.

RESULTS

Pooled results of 107 trials showed that HRT reduced abdominal fat [-6.8% (CI, -11.8 to -1.9%)], HOMA-IR [-12.9% (CI, -17.1 to -8.6%)] and new-onset diabetes [relative risk 0.7 (CI, 0.6-0.9)] in women without diabetes. In women with diabetes, HRT reduced fasting glucose [-11.5% (CI, -18.0 to -5.1%)] and HOMA-IR [-35.8% (CI, -51.7 to -19.8%)]. HRT also reduced low-density lipoprotein/high-density lipoprotein cholesterol ratio [-15.7% (CI, -18.0 to -13.5%)], lipoprotein(a) [Lp(a)] [-25.0% [CI, -32.9 to -17.1%)], mean blood pressure [-1.7% (CI, -2.9 to -0.5%)], E-selectin [-17.3% (CI, -22.4 to -12.1%)], fibrinogen [-5.5% (CI, -7.8 to -3.2%)] and plasminogen activator inhibitor-1 [-25.1% (CI, -33.6 to -15.5%)]. Oral agents produced larger beneficial effects than transdermal agents, but increased C-reactive protein (CRP) [37.6% (CI, 17.4-61.3%)] and decreased protein S [-8.6% CI, -13.1 to -4.1%)], while transdermal agents had no effect.

CONCLUSIONS

HRT reduces abdominal obesity, insulin resistance, new-onset diabetes, lipids, blood pressure, adhesion molecules and procoagulant factors in women without diabetes and reduced insulin resistance and fasting glucose in women with diabetes. Oral agents adversely affected CRP and protein S, while transdermal agents had no effects.

Effects of intranasal estradiol treatment on serum paraoxonase and lipids in healthy, postmenopausal women

BACKGROUND/AIMS

Serum lipid concentrations worsen after the menopause because of estrogen deficiency, leading to an increased atherogenic pattern. It is known that serum paraoxonase (PON1) activity prevents the development of atherosclerosis. The aim of this cross-sectional study was to observe the effects of intranasal 17beta-estradiol (300 microg/day) on serum PON1 and lipid levels in healthy postmenopausal women.

METHODS

48 healthy, postmenopausal women were enrolled into this cross-sectional study. 28 subjects without an intact uterus and ovaries were using single-dose (300 microg/day) intranasal 17beta-estradiol and 20 subjects with spontaneous natural menopause were not on any hormone therapy. Body mass index (BMI), blood pressure, serum follicle-stimulating hormone, estradiol, fasting glucose, insulin, lipid fractions and PON1 levels were measured. Homeostasis model assessment (HOMA-R) was used to estimate insulin resistance.

RESULTS

The higher estradiol, high-density lipoprotein and salt-stimulated paraoxonase (SSP) levels were observed in intranasal 17beta-estradiol users in comparison with non-users. There were no statistically significant differences in BMI, blood pressures, other lipid fractions, basal paraoxonase, arylesterase, fasting glucose and insulin levels, HOMA-R between the groups. SSP was inversely associated with fasting insulin levels and HOMA-R.

CONCLUSION

These observations may suggest that intranasal 17beta-estradiol does not have harmful effects on the PON1 activity and lipid metabolism.

Influence of hormone replacement therapy in postmenopausal women with type 2 diabetes and hyperlipidemia on lipid and glucose metabolism

Introduction. Hormone replacement therapy (HRT) is less frequently prescribed to postmenopausal women with diabetes type 2 who have poor lipid status despite well known favorable effect of HRT on lipid levels. Objective. The aim of this study was to assess the effect of oral HRT in postmenopausal women with type 2 diabetes and hyperlipidemia. Method. Continuously combined HRT, estradiol 2mg + norethisterone acetate 1mg was given to 30 women with diabetes type 2 and hyperlipidemia and two control groups of postmenopausal women (30 with hyperlipidemia only and 30 healthy women) over a 6-month period. Total cholesterol (t- HOL), triglycerides, LDL-cholesterol, HDL-cholesterol, glycosylated hemoglobin A1c (HbA1c) were evaluated in 3-month intervals. Fasting and postprandial glucose levels were evaluated monthly. Results. HRT significantly decreased levels of t-HOL (?2 Friedman=11.712; p<0.01) and LDL-c (?2 Friedman=10.403; p<0.01) in postmenopausal women with type 2 diabetes. However, the effect was more pronounced in two control groups. Triglycerides (?2 Friedman=5.400; p?0.05) and HDL-c (?2 Friedman=1.113; p>0.05) did not change in postmenopausal women with type 2 diabetes. Six month of oral HRT significantly decreased HbA1c (F=44.693; p<0.01). Fasting and postprandial glycemia was decreased but not significantly (?2 Friedman=6.527; p>0.05). Conclusion. Six-month application of HRT is effective in lowering the lipid levels and HbA1c in postmenopausal women with type 2 diabetes. However, target lipid levels were not achieved.

Hormonal contraception in women with diabetes mellitus: special considerations

Contraception is an important issue for women with diabetes mellitus as unplanned pregnancy can present major maternal and perinatal complications. The rising incidence of diabetes worldwide means increasing thought needs to be given to contraceptive options for these women. This article reviews current evidence and recommends best practice for prescribing hormonal contraceptives in women with diabetes. Women with diabetes have the same choice of contraceptives as the general population, but the potential metabolic effects of hormonal methods need to be considered in relation to an individual's diabetic profile and their need for effective contraception. Currently, there appear to be wide variations in the way that professionals evaluate the risk-benefit equation, and significant differences in prescribing practice have been identified. The World Health Organization (WHO) has established medical eligibility criteria to assist in assessing such risks. Cardiovascular disease is a major concern, and for women with diabetes who have macrovascular or microvascular complications, nonhormonal methods are recommended. Studies of young women with diabetes and no vascular changes who are taking low-dose combined oral contraceptives (COCs) have been reassuring, although larger long-term studies are needed. There is little evidence that any changes in glycemic control caused by COCs are of clinical relevance. While low-dose COCs appear to cause minimal change in the lipid profile and may even be beneficial in this respect, there are some concerns in relation to progestogen only pills and injectable contraceptives in certain women. There is little evidence of best practice for the follow-up of women with diabetes prescribed hormonal contraception. It is generally agreed that blood pressure, weight, and body mass index measurements should be ascertained, and blood glucose levels and baseline lipid profiles assessed as relevant. Research on hormonal contraception has been carried out in healthy populations; more studies are needed in women with diabetes and women who have increased risks of cardiovascular disease.

Impact of hormone replacement therapy on microvascular function in healthy and Type 2 diabetic postmenopausal women

AIMS

Hormone replacement therapy (HRT) has been previously reported to modulate vascular function and cardiovascular risk. Its impact on the macrocirculation has previously been explored, however, little data is available on its impact on the microcirculation. This study aimed to determine the impact of HRT on microvascular function in healthy and Type 2 diabetic postmenopausal women (n=20 and 17, respectively).

METHODS

Microvascular function was assessed by skin maximum hyperaemia, skin hyperaemic response to iontophoretically applied acetylcholine (endothelial-dependent vasodilator) and sodium nitroprusside (endothelial-independent vasodilator), capillary pressure and the microvascular filtration capacity. Microvascular assessments were carried out at baseline and repeated following 6 months' oral hormone replacement therapy (1 mg oestradiol/0.5 mg norethisterone or 1 mg unopposed oestradiol for hysterectomized women).

RESULTS

Following 6 months' therapy there were no significant changes in microvascular assessments in the healthy women. In the diabetic women there was a reduction in the skin hyperaemic response to acetylcholine [median pretreatment peak response: 1.95 (25th, 75th centiles: 1.54, 2.30) V vs. post-treatment peak response: 1.53 (1.30, 1.91) V (P=0.011, Wilcoxon's signed rank test)] and sodium nitroprusside [median peak response 1.59 (1.37, 1.99) vs. 1.35 (0.92, 1.63) V (P=0.011)] with HRT, but no other changes.

CONCLUSION

These data suggests that HRT does not affect microvascular function in healthy women, but adversely affects it in diabetic women. These findings may help to explain why HRT fails to provide the predicted cardiovascular protection, and raises the possibility that HRT influences microangiopathy progression in diabetic women.

The effects of hormone replacement therapy combined with vitamins C and E on antioxidants levels and lipid profiles in postmenopausal women with Type 2 diabetes

BACKGROUND

Recent studies have demonstrated that oxidative modification of low-density lipoprotein (LDL) involving the formation of lipid peroxides (MDA), exerts several biological effects that may contribute to the onset and progression of cardiovascular diseases in postmenopausal women with Type 2 diabetes (DPMW). Therefore, the aim of our study was to evaluate the effect of hormone replacement therapy (HRT), vitamin C and E (VCE) treatments on lipid profiles, glucose and MDA levels as well as antioxidant vitamins and enzymes in plasma and red blood cells (RBC) in diabetic or non-diabetic postmenopausal women (PMW).

METHODS

Oral HRT and VCE supplementation for 6 weeks were compared with HRT treatment in 40 non-diabetic PMW and 40 DPMW.

RESULTS

In the 40 postmenopausal women (PMW) and 20 postmenopausal women with DPMW who received oral HRT and 20 DPMW who received HRT plus VCE, there was a significant fall in MDA, total cholesterol, LDL-cholesterol and triglyceride values. Glycated haemoglobin (HbA1c) in the DPMW was significantly improved with oral HRT and VCE although no significant change in white blood cell counts, vitamin A and HDL values occurred. Additionally, a fall in plasma glucose, HbA1c and platelet values also occurred in the PMW and DPMW groups by oral HRT and VCE treatments. There was a significant increase in plasma vitamin E and beta-carotene concentrations, catalase, glutathione peroxidase and reduced glutathione levels in RBC and plasma in DPMW by treatments with HRT and/or VCE.

CONCLUSIONS

Daily VCE and HRT administrations both in PMW and DPMW seem to produce significant improvement in antioxidants concentrations, and the metabolic control of lipids and glucose. The HRT and VCE supplementations may strengthen the antioxidant defense system due to reducing blood glucose and lipid metabolites, and they may play a role in preventing cardiovascular diseases in postmenopausal women with Type 2 diabetes.

Sex hormones, insulin sensitivity, and diabetes mellitus

Sex differences and the role of gonadal hormones in modulating insulin sensitivity and glucose tolerance are of increasing interest and importance because of the increasing prevalence of type 2 diabetes mellitus and the metabolic abnormalities associated with aging. Body composition is closely associated with insulin sensitivity, and increased body fat, particularly in the visceral compartment, is a risk factor for developing type 2 diabetes mellitus. Sex differences in body composition and/or insulin sensitivity are evident in humans throughout the lifespan. Ovarian hormones influence insulin sensitivity across the menstrual cycle, during pregnancy, and in the menopausal transition. Similarly, estrogens and progestins used for contraception and hormone replacement therapy affect glucoregulation. Nonhuman primates and humans have similar life histories and reproductive characteristics. As a result, nonhuman primates provide a valuable model for investigating factors related to insulin sensitivity. Studies of nonhuman primates have contributed significantly to our understanding of sex differences and the influence of sex steroids in this context. This brief review surveys present knowledge of the sex differences in body composition, insulin sensitivity, and risk for development of type 2 diabetes mellitus derived from studies in humans and nonhuman primates. The influences of endogenous and exogenous gonadal steroids are emphasized.

Estrogen therapy and risk of cardiovascular events among women with type 2 diabetes

OBJECTIVE

To evaluate the association between estrogen therapy and cardiovascular disease risk among women with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A retrospective, case-cohort study was conducted among 6017 women aged 45-80 years with type 2 diabetes from 1 January 1986 to 31 December 1992 at the Group Health Cooperative in Washington state. Cardiovascular outcomes, including nonfatal myocardial infarction (n = 215), coronary revascularization (n = 253), and cardiovascular deaths (n = 229), were ascertained through 31 December 1998. Use of estrogen and progestin was derived from automated pharmacy records and modeled as a time-dependent variable. Median follow-up was 6.8 years. Multivariable-adjusted relative risk (RR) and 95% CI were calculated using Cox proportional hazard models for case-cohort analyses.

RESULTS

Current use of estrogen with (RR 0.43, 95% CI 0.22-0.85) or without (0.48, 0.30-0.78) progestin was associated with a decreased risk of cardiovascular events compared with never having used estrogen. Risk of cardiovascular events associated with a first episode of estrogen use (with or without progestin) of <25 months' duration (1.12, 0.49-2.54), first episode of use >or=25 months' duration (0.32, 0.06-1.70), and current use that was not the first episode of use (0.42, 0.42-0.67) indicated that recent initiation was not associated with an increase or decrease in risk.

CONCLUSIONS

These results show an association of estrogen therapy, with or without progestin, with decreased risk of cardiovascular events among women with type 2 diabetes. This association should be further investigated in large randomized, controlled trials.