Menstrual irregularities are more common in adolescents with type 1 diabetes: association with poor glycaemic control and weight gain

Gonadal dysfunction in women with diabetes mellitus

It is well known that both type 1 and type 2 diabetes mellitus (DM) are related to increased risk for cardiovascular (CV) and chronic kidney disease (CKD). However, besides these prominently presented complications, DM has also been associated with reproductive dysfunctions. It seems that these disorders are met in up to 40% of women with DM and consist of delayed menarche, all types of menstrual disorders, such as amenorrhea, oligomenorrhea, menstrual irregularity, as well as menorrhagia, infertility, characteristics of polycystic ovary syndrome (PCOS) and early (or rarely late) menopause. In type 1 DM (T1DM), insulin treatment, although it has reduced the rates of insulinopenic-induced hypogonadotropic hypogonadism, an entity commonly presented in many women with the disease in the past decades, when it is used in excess it can also promote hyperandrogenism. Regarding type 2 DM (T2DM), insulin resistance (IR) and hyperinsulinemia have mainly been implicated in the pathogenesis of reproductive dysfunctions, as insulin can act as gonadotropin on the theca cells of the ovary and can lead to hyperandrogenism and inhibition of proper ovulation. This review aims to detail the reproductive dysfunctions associated with DM and provide scientific data to enlighten the underlying pathogenetic mechanisms.

Alterations in the Menstrual Cycle as a Peculiar Sign of Type 1 Diabetes Mellitus: A Meta-analytic Approach

BACKGROUND

Menstrual irregularities are present in >30% of women with type 1 diabetes mellitus (T1DM). These abnormalities will likely lead to reduced fertility and earlier menopause. T1DM management has changed over time, with even more emphasis on stringent levels of glycemic management. Thus, we investigated whether therapeutic T1DM changes have an influence on the proportion of menstrual disorders in women with T1DM.

METHODS

A meta-analysis was performed that included clinical trials in which menstrual abnormalities in women with T1DM were studied. The literature was checked for studies in which women with T1DM were compared with healthy, age-matched controls. Case-control, cohort, and cross-sectional studies were included. The primary endpoint was rate of menstrual dysfunction.

RESULTS

Menstrual dysfunction was higher in women with T1DM compared with controls (odds ratio 2.08, 95% confidence interval [CI] 1.43 to 3.03, p<0.001), even when sensitivity analysis was performed, considering only studies published after 2000. The age at menarche was higher for women with T1DM compared with controls (mean difference 0.53, 95% CI 0.32 to 0.74 years, p<0.001). The proportion of menstrual abnormalities in T1DM was inversely related to diabetes duration, but was unrelated to both body mass index and glycated hemoglobin.

CONCLUSIONS

The meta-analytic approach used confirmed the correlation between T1DM and menstrual irregularities. T1DM menstrual dysfunction seemed unrelated to change in therapeutic management across years, as well as to glycemic management and body weight. The underlying pathogenetic mechanisms are not fully understood.

Assessment of pubertal onset and disorders of puberty in Indian children and youth with type-1 diabetes

OBJECTIVES

Disorders of pubertal development are enlisted as associated conditions in children and adolescents with type-1 diabetes (T1D). We conducted this study with objective (1) To estimate the median age at onset of puberty and luteinizing hormone (LH) and sex-steroid concentrations in Indian adolescents with T1D and (2) To assess the impact of puberty on glycemic control and insulin resistance (IR).

METHODS

This cross-sectional study included 399 children and youth aged 6-23 years with T1D. Demographic, anthropometric, biochemical and pelvic ultrasound data were collected using standard protocols. IR was calculated using estimated glucose disposal rate and puberty was assessed using Tanner staging.

RESULTS

Median age at onset of thelarche, pubarche and menarche were 11.3, 11.4 and 12.8 years in girls and that of gonadarche and pubarche were 10.6 and 12.7 years for boys. The mean LH and sex-steroid concentrations of subjects with T1D were similar to healthy subjects at each stage of puberty. The cut-offs of LH and sex-steroids derived from healthy Indian children yielded high sensitivity and specificity in determining pubertal onset. The prevalence of precocity, delayed puberty, ovarian cysts and polycystic ovaries was 0.9 , 5.1, 5.1 and 8.6 %, respectively. Glycaemic control and insulin sensitivity was poor in pubertal subjects.

CONCLUSIONS

The age at onset of puberty, LH, and sex-steroid concentrations in subjects with T1D were like otherwise healthy Indian children with poor glycemic control and IR in pubertal subjects. Although most complications of T1D are associated with poor glycemic control, pubertal disorders were significantly low despite the less-than-optimal glycemic control.

Prevalence of polycystic ovary syndrome and its clinical and hormonal profile in young females with type 1 diabetes mellitus: experience from a teaching institution of India

OBJECTIVE

To investigate the prevalence of polycystic ovary syndrome and its clinical and hormonal profile in females with type 1 diabetes.

MATERIALS AND METHODS

65 T1DM females were evaluated for presence of PCOS by Rotterdam ESHRE/ASRM consensus criteria and compared with age and BMI matched females with PCOS without diabetes and females with T1DM without PCOS.

RESULTS

According to Rotterdam criteria 18/65 (27%) had PCOS. Prevalence of androgen excess, hirsutism, menstrual dysfunction and PCOM was 26%, 3%, 21% and 52%, respectively. Females with T1DM who had PCOS did not differ from females with T1DM without PCOS. When the group of T1DM with PCOS was compared with PCOS females without diabetes, they had significantly lower hirsutism score (median, IQR; 1.5, 0-3 vs. 11.5, 0-16.5, p = 0.04), significantly higher waist hip ratio (0.91, 0.89-0.99 vs. 0.86, 0.80-0.89, p = 0.004) and SHBG (in nmol, 54.4, 38-86.2 vs. 28.3, 20.4-37.4, p = 0.004).

CONCLUSION

Females with T1DM have a high prevalence of menstrual abnormalities, hyperandrogenism and PCOS which is not related to metabolic control, age of onset of diabetes or insulin dose. Polycystic ovary syndrome, hyperandrogenism, type 1 diabetes, menstrual irregularity, hirsutism.

Variability of Glycemic Outcomes and Insulin Requirements Throughout the Menstrual Cycle: A Qualitative Study on Women With Type 1 Diabetes Using an Open-Source Automated Insulin Delivery System

BACKGROUND

The impact of hormone dynamics throughout the menstrual cycle on insulin sensitivity represents a currently under-researched area. Despite therapeutic and technological advances, self-managing insulin therapy remains challenging for women with type 1 diabetes (T1D).

METHODS

To investigate perceived changes in glycemic levels and insulin requirements throughout the menstrual cycle and different phases of life, we performed semi-structured interviews with 12 women with T1D who are using personalized open-source automated insulin delivery (AID) systems. Transcripts were analyzed using thematic analysis with an inductive, hypothesis-generating approach.

RESULTS

Participants reported significant differences between the follicular phase, ovulation, and luteal phase of the menstrual cycle and also during puberty, pregnancy, and menopause. All participants reported increased comfort and safety since using AID, but were still required to manually adjust their therapy according to their cycle. A lack of information and awareness and limited guidance by health care providers were frequently mentioned. Although individual adjustment strategies exist, achieving optimum outcomes was still perceived as challenging.

CONCLUSIONS

This study highlights that scientific evidence, therapeutic options, and professional guidance on female health-related aspects in T1D are insufficient to date. Further efforts are required to better inform people with T1D, as well as for health care professionals, researchers, medical device manufacturers, and regulatory bodies to better address female health needs in therapeutic advances.

SARS-CoV-2 infection and female reproductive health: A narrative review

The COVID-19 pandemic has had a profound global impact, affecting people's physical and mental health, and their social and economic circumstances. Mitigation measures have disproportionately affected women. Studies have reported menstrual cycle and psychological disturbance associated with the pandemic. Pregnancy is a risk factor for severe COVID-19 disease. Reports have also demonstrated associations between COVID-19 infection, vaccination and Long COVID syndrome and reproductive health disturbance. However, studies are limited and there may be significant geographical variation. Also there is bias amongst published studies, and menstrual cycle data was not included in COVID-19 and vaccine trials. Longitudinal population based studies are required. In this review we discuss existing data, along with recommendations for further research required in this area. We also discuss a pragmatic approach to women presenting with reproductive health disturbance in the era of the pandemic, encompassing a multi-system assessment of psychological, reproductive health and lifestyle.

Menstrual Dysfunction in Adolescents with Chronic Illness: A Systematic Review

STUDY OBJECTIVE

Menstrual dysfunction can impact both the physical and emotional health of young people¹. Multiple chronic disease have been associated with menstrual dysfunction in adults², however there is little research in adolescents, despite non adherence and sub-optimal illness control in this group. We aimed to identify the impact chronic illness has on the age of menarche (AAM) and the menstrual cycle in adolescents.

METHODS

Studies were extracted of female adolescents aged 10-19 who had a chronic physical illness. Data included outcomes on age of menarche and/or menstrual cycle quality. Exclusion criteria aimed to exclude diseases where menstrual dysfunction was a known part of the disease pathophysiology i.e. polycystic ovarian syndrome³, or in which medications were used that directly impacted gonadal function⁴. A literature search (to January 2022) was performed on EMBASE, PubMed and Cochrane library databases. Two widely used modified quality analysis tools were used.

RESULTS

Our initial search netted 1451 articles, of which 95 full texts were examined and 43 met inclusion criteria. 27 papers focussed on Type 1 Diabetes (T1D), with 8 papers examining adolescents with cystic fibrosis (CF) and the remaining studying inflammatory bowel disease (IBD), juvenile idiopathic arthritis (JIA), coeliac disease and chronic renal disease. Metanalysis of 933 patients with T1D versus 5244 controls demonstrated a significantly later AAM in T1D (by 0.42 years; p=<0.00001). There was also a significant association between higher HbA1c and insulin dose (IU/kg) and later age of menarche. Eighteen papers reviewed other aspects of menstruation, including dysmenorrhoea, oligomenorrhoea, amenorrhoea and ovulatory function, with variable findings.

CONCLUSION

The majority of studies were small and in single populations. Despite this, there was evidence of delayed menarche and some evidence of irregular menses in those with CF and T1D. Further structured studies are needed to evaluate menstrual dysfunction in adolescents and how it relates to their chronic illness.

Factors Affecting Menstrual Cycle Developmental Trajectory in Adolescents: A Narrative Review

CONTEXT

The time interval between the age at menarche and regulation of menstrual cycles (menstrual cycle developmental trajectory) is considered an indicator of the function of the reproductive system later in life. This study aimed to summarize the factors affecting this trajectory.

EVIDENCE ACQUISITION

A comprehensive literature search in PubMed, Scopus, Google Scholar, and Web of Science was performed to identify studies investigating factors influencing the regularity of the menstrual cycle in adolescents.

RESULTS

The interval between menarche and the onset of the regular menstrual cycle in adolescent girls may vary from several months to several years. Several factors, including genetic, race/ethnicity, intrauterine situation, social factors, geographical factors, lifestyle, and chronic diseases, are considered the predisposing factors for the trajectory.

CONCLUSIONS

Age at menarche and the onset of regular menstrual cycles are directly and indirectly influenced by several genetic, environmental, and lifestyle factors. Understanding these factors may improve our practice in managing irregular menstrual cycles that commonly happen in the first years after menarche.

Obesity, menstrual irregularity and polycystic ovary syndrome in young women with type 1 diabetes: A population-based study

BACKGROUND

Type 1 diabetes (T1D) is associated with reproductive dysfunction, particularly in the setting of poor metabolic control. Improvements in contemporary management ameliorate these problems, albeit at the cost of increased exogenous insulin and rising obesity, with emerging reproductive implications.

OBJECTIVE

To evaluate changes in body mass index (BMI) and the relationship between obesity, menstrual irregularity and polycystic ovary syndrome (PCOS) in young women with T1D, compared with controls.

METHODS

Longitudinal observational study using data from the Australian Longitudinal Study in Women's Health of the cohort born in 1989-95, from 2013 to 2015. Three questionnaires administered at baseline and yearly intervals were used to evaluate self-reported menstrual irregularity, PCOS and BMI.

RESULTS

Overall, 15 926 women were included at baseline (T1D, n = 115; controls, n = 15 811). 61 women with T1D and 8332 controls remained at Year 2. Median BMI was higher in women with type 1 diabetes (25.5 vs 22.9 kg/m² , P < .001), where over half were overweight or obese (54.4% vs 32.9%, P < .001). Median BMI increased by 1.11 and 0.45 kg/m² , in the T1D and control groups, respectively. T1D was independently associated with an increased risk of menstrual irregularity (RR 1.22, 95% CI 1.02-1.46) and PCOS (RR 2.41, 95% CI 1.70-3.42). Obesity conferred a 4-fold increased risk of PCOS, compared to those with normal BMI (RR 3.93, 95% CI 3.51-4.42).

CONCLUSIONS

Obesity is prevalent amongst women with T1D and may be a key contributor to the higher risk of menstrual irregularity and PCOS in this cohort, representing an important opportunity for prevention and intervention.

Diabetes: a metabolic and reproductive disorder in women

Reproductive dysfunction is a common but little studied complication of diabetes. The spectrum of reproductive health problems in diabetes is broad, and encompasses delayed puberty and menarche, menstrual cycle abnormalities, subfertility, adverse pregnancy outcomes, and potentially early menopause. Depending on the age at diagnosis of diabetes, reproductive problems can manifest early on in puberty, emerge later when fertility is desired, or occur during the climacteric period. Historically, women with type 1 diabetes have frequently had amenorrhoea and infertility, due to central hypogonadism. With the intensification of insulin therapy and improved metabolic control, these problems have declined, but do persist. Additional reproductive implications of contemporary diabetes management are now emerging, including polycystic ovary syndrome and hyperandrogenism, which are underpinned by insulin action on the ovary. The sharp rise in type 2 diabetes incidence in youth suggests that more women of reproductive age will encounter diabetes-related reproductive problems in their lifetimes. With an ever increasing number of young women living with diabetes, clinicians need to be aware of and equipped for the challenges of navigating reproductive health concerns across the lifespan.

Ovarian markers and irregular menses among women with type 1 diabetes in the Epidemiology of Diabetes Interventions and Complications study

OBJECTIVE

Women with type 1 diabetes have increased risk of infertility compared to women without diabetes even after adjustment for irregular menses, but aetiologies are incompletely understood. Our aim was to examine the prevalence of abnormalities in ovarian markers consistent with polycystic ovary syndrome in women with type 1 diabetes and associations with irregular menses and diabetes-specific variables.

DESIGN, PATIENTS AND MEASUREMENTS

We conducted a secondary analysis of women in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study (DCCT/EDIC), a randomized trial and observational follow-up of intensive insulin therapy for type 1 diabetes. We included women with anti-Müllerian hormone (AMH) measurements among women not using oral contraceptives (n = 187). Initial AMH and testosterone measures were performed between EDIC years 1 and 4. History of irregular menses was assessed annually.

RESULTS

The median age of women was 35 (interquartile ratio 29, 40) years; 133 (35%) had elevated AMH and 62 (17%) reported irregular menses. Twelve per cent of women had relative elevations in total testosterone. In multivariable models, lower insulin dosages were associated with higher AMH concentrations (P = .0027), but not diabetes duration, glycemic control, body mass index or irregular menses. Neither irregular menses nor diabetes-specific variables were associated with testosterone concentrations.

CONCLUSIONS

Among women with type 1 diabetes in their thirties, abnormalities in ovarian markers are common and not associated with irregular menses and thus may partially account for decreased fecundity in women with type 1 diabetes.

Reproductive disturbances among Saudi adolescent girls and young women with type 1 diabetes mellitus

AIM

To identify reproductive disturbances among adolescent girls and young women with type 1 diabetes mellitus (T1DM) in Saudi Arabia.

METHODS

This cross sectional study was conducted among 102 female with T1DM, (aged 13-29 years) who attended the Diabetes Clinic at Diabetes Treatment Center, Prince Sultan Military Medical City, Saudi Arabia between April 2015 to March 2016. Clinical history, anthropometric characteristics and reproductive disturbance were collected through a questionnaire.

RESULTS

Of 102 patients included in this analysis, 26.5% (27/102) were reported that they experienced an irregular menses. Of these patients, when compared to whose diabetes was diagnosed before menarche (35.4%, 17/48), patients diagnosed with diabetes after menarche (18.5%, 10/54) showed significantly less irregular menses (difference 16.9%, P = 0.04). Similarly, compared to patients diagnosed with diabetes prior to menarche (mean age 12.9 years; n = 48), patients diagnosed with diabetes after menarche (mean age 12.26 years; n = 54) were found to have 0.64 years delay in the age of menarche (P = 0.04). Among the studied patients, 15.7% (16/102) had polycystic ovary syndrome (PCOS). Of these PCOS patients, 37.5% (6/16) had irregular menses, 6.3% (1/16) had Celiac disease, 37.5% (6/16) had Hashimoto thyroiditis and 18.7% (3/16) had acne.

CONCLUSION

More than one fourth of the study population with T1DM experiencing an irregular menses. Adolescent girls and young women diagnosed with diabetes prior to menarche showed higher menstrual irregularity and a delay in the age of menarche.

Type 1 Diabetes and Polycystic Ovary Syndrome: Systematic Review and Meta-analysis

BACKGROUND

A few small studies have reported increased prevalences of polycystic ovary syndrome (PCOS) and symptoms of androgen excess in women with type 1 diabetes.

PURPOSE

We performed a systematic review and meta-analysis of studies evaluating androgen excess symptoms and PCOS in women with type 1 diabetes.

DATA SOURCES

The Entrez-PubMed and Scopus electronic databases were used.

STUDY SELECTION

We selected studies addressing androgen excess signs, symptoms, and disorders in girls, adolescents, and adult women with type 1 diabetes.

DATA EXTRACTION

The main outcome measures were prevalences of PCOS, hyperandrogenemia, hirsutism, menstrual dysfunction, and polycystic ovarian morphology (PCOM).

DATA SYNTHESIS

Nine primary studies involving 475 adolescent or adult women with type 1 diabetes were included. The prevalences of PCOS and associated traits in women with type 1 diabetes were 24% (95% CI 15-34) for PCOS, 25% (95% CI 17-33) for hyperandrogenemia, 25% (95% CI 16-36) for hirsutism, 24% (95% CI 17-32) for menstrual dysfunction, and 33% (95% CI 24-44) for PCOM. These figures are considerably higher than those reported earlier in the general population without diabetes.

LIMITATIONS

The data collected in the original studies were heterogeneous in age, race, ethnicity, and criteria used for the diagnosis of PCOS; yet, we used a quality-effects model in the meta-analyses to overcome this limitation.

CONCLUSIONS

PCOS and its related traits are frequent findings in women with type 1 diabetes. PCOS may contribute to the subfertility of these women by a mechanism that does not directly depend on glycemic/metabolic control among other negative consequences for their health. Hence, screening for PCOS and androgen excess should be included in current guidelines for the management of type 1 diabetes in women.

MENSTRUAL AND REPRODUCTIVE FUNCTION IN WOMEN WITH TYPE 1 DIABETES

OBJECTIVE

Menstrual irregularities, reproductive abnormalities, and androgen excess are reported to be more prevalent in women with type 1 diabetes (T1D). The objective of this study was to investigate the prevalence of menstrual irregularities, reproductive abnormalities, and androgen excess among women with T1D and their age-matched controls.

METHODS

A survey requesting information regarding menstrual and reproductive histories was administered to all participants. Results were stratified according to age (18 to 40, 40 to 50, and >50 years).

RESULTS

There were no significant differences between women with and without diabetes in age at menarche, cycle length, or androgen excess in any group. Women who self-reported difficulty with glycemic control were more likely to report irregular menses than controls (P = .04). Among women who reported ever being pregnant, there were fewer pregnancies (P = .02) and live births (P = .002) in women with T1D. Women with T1D reported a lower frequency of oral contraceptive use (P = .003), despite being less likely to smoke (P = .016).

CONCLUSION

Menstrual and reproductive abnormalities were not observed more frequently in women with T1D in this study. Subtle but measurable differences in menstrual and reproductive function were confined to the subgroup of women who perceived poor control of their diabetes. Additional prospective studies of T1D and menstrual and reproductive function would be useful.

Insulin-like growth factor 1 mRNA expression in the uterus of streptozotocin-treated diabetic mice

Reproductive functions decline with the onset of diabetes in female mice. Diabetic mice have smaller uteri with an underdeveloped endometrium, suggesting diminished estrogen-induced growth. We aimed to clarify the changes in the estrous cycle and in insulin-like growth factor 1 (IGF1) expression in the uteri of streptozotocin (STZ)-treated diabetic mice, because IGF1 is one of the main growth factors involved in estrogen-induced uterine growth. ICR female mice were intraperitoneally administered STZ (10 mg/100 g BW), and blood glucose levels were determined. Mice with blood glucose levels > 200 mg/dl were classified as diabetic mice. The onset of diabetes was associated with acyclic estrous cycles. Diabetes was also induced with STZ in ovariectomized mice. Uterine Igf1 mRNA levels were reduced in ovariectomized STZ-treated diabetic mice. Estrogen is known to stimulate Igf1 mRNA expression in the uterus, but estrogen action was abolished in the uteri of STZ-treated diabetic mice. mRNA expressions of estrogen receptor α (ERα) and steroid hormone receptor coactivators (SRC-1/Ncoa1, SRC-2/Ncoa2, SRC-3/Ncoa3 and CBP/p300/Crebbp) were reduced in the uteri of ovariectomized STZ-treated diabetic mice. The present study demonstrates that diabetes induces a decline in female reproductive functions in mice. Igf1 expression in ovariectomized diabetic female mice was decreased, and decreased responsiveness to estrogen in the uteri of diabetic mice is probably associated with a reduction in ERα and steroid receptor coactivator mRNA expression.

Female reproduction and type 1 diabetes: from mechanisms to clinical findings

BACKGROUND

The functional reproductive alterations seen in women with type 1 diabetes (T1D) have changed as therapy has improved. Historically, patients with T1D and insufficient metabolic control exhibited a high prevalence of amenorrhea, hypogonadism and infertility. This paper reviews the impact of diabetes on the reproductive axis of female T1D patients treated with modern insulin therapy, with special attention to the mechanisms by which diabetes disrupts hypothalamic-pituitary-ovarian function, as documented mainly by animal model studies.

METHODS

A comprehensive MEDLINE search of articles published from 1966 to 2012 was performed. Animal model studies on experimental diabetes and human studies on T1D were examined and cross-referenced with terms that referred to different aspects of the gonadotropic axis, gonadotrophins and gonadal steroids.

RESULTS

Recent studies have shown that women with T1D still display delayed puberty and menarche, menstrual irregularities (especially oligomenorrhoea), mild hyperandrogenism, polycystic ovarian syndrome, fewer live born children and possibly earlier menopause. Animal models have helped us to decipher the underlying basis of these conditions and have highlighted the variable contributions of defective leptin, insulin and kisspeptin signalling to the mechanisms of perturbed reproduction in T1D.

CONCLUSIONS

Despite improvements in insulin therapy, T1D patients still suffer many reproductive problems that warrant specific diagnoses and therapeutic management. Similar to other states of metabolic stress, T1D represents a challenge to the correct functioning of the reproductive axis.

Contraception, and pregnancy in adolescents with type 1 diabetes: a review

Adolescence is a critical period for girls with type 1 diabetes mellitus (T1D). Reproductive issues, such as menstrual abnormalities, risk of an unplanned pregnancy, and contraception, should be addressed during this phase of life. This paper reviews several reproductive issues that are important in the care of adolescents, including pubertal development, menstrual abnormalities, ovulatory function, reproductive problems, the effects of hyperglycemia, contraception, and treatment of an unplanned pregnancy. A review of the literature was conducted. A MEDLINE search January 1966 to March 2011 was performed using the following MESH terms: puberty, menarche, ovary, polycystic ovary syndrome, menstruation, contraception, contraception-barrier, contraceptives-oral-hormonal, sex education, family planning services, and pregnancy in adolescence. This literature search was cross-referenced with an additional search on diabetes mellitus-type 1, diabetes complications, and pregnancy in diabetes. All published studies were searched regardless of the language of origin. Bibliographies were reviewed to extract additional relevant sources.

High prevalence of hirsutism and menstrual disorders in obese adolescent girls and adolescent girls with type 1 diabetes mellitus despite different hormonal profiles

OBJECTIVES

To compare the pubertal development, the hormonal profiles and the prevalence of hirsutism and menstrual disorders in obese adolescent girls and adolescent girls with type 1 diabetes mellitus (T1DM).

METHODS

Data were collected from 96 obese adolescent girls and 78 adolescent girls with T1DM at Tanner stage IV or V, whose ages ranged between 11.9 and 17.9 years.

RESULTS

High prevalence of hirsutism and menstrual disorder was found in the obese adolescent girls (36.5 and 42% respectively) and the adolescent girls with T1DM (21 and 44% respectively). The obese girls were significantly younger at pubarche, thelarche and menarche than the girls with T1DM. Hirsutism in the obese girls and those with T1DM was associated with hyperandrogenaemia and a raised free androgen index (FAI). When the cause of the raised FAI was investigated in both the groups of girls with hirsutism, the raised FAI in the obese girls was due to low serum sex hormone-binding globulin (SHBG) levels. In contrast, the raised FAI of the girls with T1DM and hirsutism was due to hyperandrogenaemia. Menstrual disorders in the T1DM girls were associated also with hyperandrogenaemia unlike obese girls.

CONCLUSIONS

Hirsutism and menstrual disorders are common in obese adolescent girls and adolescent girls with T1DM. Although hyperandrogenaemia is present in both groups of girls, the androgenic profiles of the two groups differ. The hyperandrogenaemia in the obese girls is primarily due to their decreased serum SHBG levels, whereas the hyperandrogenaemia in the girls with T1DM is due to their increased androgen production.

Menarche delay and menstrual irregularities persist in adolescents with type 1 diabetes

BACKGROUND

Menarche delay has been reported in adolescent females with type 1 diabetes (T1DM), perhaps due to poor glycemic control. We sought to compare age at menarche between adolescent females with T1DM and national data, and to identify factors associated with delayed menarche and menstrual irregularity in T1DM.

METHODS

This was a cross-sectional study and females ages 12- 24 years (n = 228) with at least one menstrual period were recruited during their outpatient diabetes clinic appointment. The National Health and Nutrition Examination Survey (NHANES) 2001-2006 data (n = 3690) for females 12-24 years were used as a control group.

RESULTS

Age at menarche was later in adolescent females with T1DM diagnosed prior to menarche (12.81 +/- 0.09 years) (mean+/- SE) (n = 185) than for adolescent females diagnosed after menarche (12.17 0.19 years, p = 0.0015) (n = 43). Average age of menarche in NHANES was 12.27 +/- 0.038 years, which was significantly earlier than adolescent females with T1DM prior to menarche (p < 0.0001) and similar to adolescent females diagnosed after menarche (p = 0.77). Older age at menarche was negatively correlated with BMI z-score (r = -0.23 p = 0.0029) but not hemoglobin A1c (A1c) at menarche (r = 0.01, p = 0.91). Among 181 adolescent females who were at least 2 years post menarche, 63 (35%) reported usually or always irregular cycles.

CONCLUSION

Adolescent females with T1DM had a later onset of menarche than both adolescent females who developed T1DM after menarche and NHANES data. Menarche age was negatively associated with BMI z-score, but not A1c. Despite improved treatment in recent decades, menarche delay and high prevalence of menstrual irregularity is still observed among adolescent females with T1DM.

Bone mass and sex steroids in postmenarcheal adolescents and adult women with Type 1 diabetes mellitus

OBJECTIVE

The aim of this study was to compare the bone mass in young adolescents and adult women with Type 1 diabetes mellitus (T1DM) and determine its relationship with sex steroid and sex hormone-binding globulin (SHBG) levels.

DESIGN

Cross-sectional study.

PATIENTS

We studied a group of adolescents and adult women with T1DM (n=45) and 50 healthy controls (C) matched by gynecological age and body mass index in a case-control study. Girls with menarche within the last 18-40 months (n=17 T1DM and 32 C) and adult women (age=30.4+1.4 years; n=28 T1DM and 18 C) were recruited.

MEASUREMENTS

Bone mass was evaluated with a GE Lunar Prodigy densitometer. Sex steroid levels were measured by radioimmunoassay.

RESULTS

Bone mass was lower in adolescents with T1DM than in control adolescents, but was similar in both groups of postmenarcheal girls after adjusting for age, lean, and fat mass. However, adult T1DM women exhibited lower adjusted and unadjusted (P<.05) Z-femoral neck (-0.2±0.2 vs. 0.4±0.2) and bone mineral content (BMC) (2306±61 vs. 2645±79 g) than adult controls. Adult controls and T1DM adults showed higher whole body BMC than adolescent controls and T1DM adolescents, respectively. Bone mass in T1DM did not correlate with estradiol, free estradiol, testosterone, SHBG, or HbA1c levels.

CONCLUSIONS

The diminished bone mass observed in adult T1DM women does not appear to be related to sex steroid levels. In young adolescents with T1DM, the observed decrease in bone mass appears to be related to differences in body composition and age.

Age at menarche and menstrual irregularities of adolescents with type 1 diabetes

STUDY OBJECTIVE

The aim of the study was to investigate the age at menarche and menstrual irregularities in adolescents with type 1 diabetes.

DESIGN

This was an aged-matched, controlled study.

SETTING

The study was done in the diabetes center of a children's hospital in Athens and in high schools in major regions of central Greece.

PARTICIPANTS

The study involved two groups: a group of 100 female adolescents, 12 to 18 years of age, with type 1 diabetes; and a control group of 225 healthy adolescents, matched for age.

MAIN OUTCOME MEASURES

The relationship between age at menarche and menstrual irregularities was studied.

RESULTS

The mean age at menarche differed significantly in the two groups (P=0.000). In particular, the mean age at menarche in the study group was 12.2 years (+/- 1.4) and in the control group it was 11.7 years old (+/- 1.2). The mean age of menarche was older in the subgroup of adolescents who had received a diagnosis of diabetes before the age of 10 than it was in those diagnosed after the age of 10.

CONCLUSIONS

Menarche was observed to be delayed in adolescents with type 1 diabetes who had been diagnosed before the age of 10 in comparison with those diagnosed after the age of 10. Menstrual irregularities were found to be more common in adolescents with type 1 diabetes than in healthy ones.

Environmental influences on human growth and development: historical review and case study of contemporary influences

Over the past 100 years, the study of environmental influences on human physical growth and development has focused on the influences of social and economic factors; family and household characteristics; urbanization/modernization; nutrition; and features of the physical environment such as altitude, temperature and climate. Continuing in this tradition are current investigations into the roles of pollutants and other aspects of the human-made environment in affecting patterns of human growth and development, specifically the timing of sexual maturation and the development of obesity. Some of the methodological problems in conducting such studies are presented, as are results from an ongoing investigation among one Native American community that show relationships of pollutants to sexual maturation, overweight/obesity and thyroid system function which can impact growth and maturation.

Persistent organic pollutants and anti-thyroid peroxidase levels in Akwesasne Mohawk young adults

Persistent organic pollutants, such as polychlorinated biphenyls (PCBs), hexachlorobenzene (HCB), and p,p'-dichlorophenyldichloroethylene (DDE), have been found to elicit a broad spectrum of biologic, metabolic, and immunologic responses. The potential of these pollutants to impair immune responses and trigger autoimmune disease is of growing concern, given their structural similarity to thyroid hormones and their potential to modulate the mechanisms and interfere with the binding of these hormones. We examine the relationship of different groupings of PCBs, according to chlorination and structure, and of p,p'-DDE and HCB to anti-thyroid peroxidase antibody, a useful tool in the evaluation of thyroid dysfunction, among 115 young adults of the Akwesasne Mohawk Nation. Overall, 18 participants (15.4%) had anti-thyroid peroxidase antibodies (TPOAb) levels above the normal laboratory reference range (23% of females, 9% of males). Among participants who were breast fed (n=47), those with an elevated TPOAb level had significantly higher levels of all PCB groupings, with the exception of levels of non-persistent PCBs which did not differ significantly. Levels of p,p'-DDE were also significantly elevated, while HCB and mirex were not higher among those with elevated TPOAb. Also, after stratifying by breast-feeding status, participants who were breast fed showed significant, positive relationships between TPOAb levels and all PCB groupings, except groups comprised of non-persistent PCBs, and with p,p'-DDE, HCB, and mirex. No effects were evident among non-breast-fed young adults. Further studies are necessary to elucidate the site and mechanism of action of these persistent organic pollutants (POPs) and to establish thresholds for these effects, especially among populations with background levels of toxicant exposure.

The development of microalbuminuria is associated with raised longitudinal adiponectin levels in female but not male adolescent patients with type 1 diabetes

AIMS/HYPOTHESIS

We determined the longitudinal relationship between adiponectin levels and the development of microalbuminuria in an inception cohort of children with type 1 diabetes.

METHODS

Blood samples collected annually over a median of 9.0 (range 1.3-14.9) years were assayed for adiponectin and HbA(1c) in 55 children (36 girls) with type 1 diabetes and microalbuminuria whose age of onset of diabetes was 9.4 years (range 2.2-15.4). Samples were also assayed from normoalbuminuric children (controls) matched for age, sex and duration of diabetes.

RESULTS

Overall, adiponectin levels were higher in girls than in boys, but only after 11 years of age (median [range]: 15.3 [5.8-124.4] vs 11.6 [4.1-26.5] mg/l, p < 0.001). Furthermore, adiponectin levels were higher in girls with microalbuminuria than in control girls, but this was only apparent after the onset of microalbuminuria (p = 0.001, adjusted for BMI, daily insulin dose, HbA(1c) and age). In boys, adiponectin levels did not differ between those with microalbuminuria and controls. Further sex-related discordant associations with adiponectin levels were observed; in girls, adiponectin levels were positively related to HbA(1c) levels (r = 0.2, p = 0.05) and urine albumin excretion (r = 0.3, p < 0.05) and inversely related to BMI (r = -0.2, p < 0.05). These associations were absent in boys.

CONCLUSIONS/INTERPRETATION

In adolescent girls with type 1 diabetes but not in boys, adiponectin levels increase with increasing urine albumin excretion and onset of microalbuminuria. Although causal links cannot be inferred, this sexual dimorphism may reflect interactive effects of hyperglycaemia and sex steroids on risk of complications and adiponectin production.

Reproductive history and hormonal birth control use are associated with coronary calcium progression in women with type 1 diabetes mellitus

CONTEXT

Coronary artery disease is increased in women with type 1 diabetes (T1D), compared with nondiabetic (Non-DM) women. Women with T1D have more menstrual dysfunction and are less likely to use hormonal birth control (BC) than Non-DM women.

OBJECTIVE

The purpose of this study was to determine whether coronary artery calcium (CAC) is associated with menstrual dysfunction and BC use in women with T1D.

MATERIALS AND METHODS

This was a prospective cohort study, and participants were followed up for an average of 2.4 yr.

PATIENTS

Patients included 612 women (293 T1D, 319 Non-DM) between the ages of 19 and 55 yr who had CAC measured twice by electron beam tomography.

RESULTS

Irregular menses and amenorrhea were more common in T1D than Non-DM women (22.1 vs. 14.9%, P < 0.05 and 16.6 vs. 7.0%, P < 0.001). T1D women reported less BC use than Non-DM women (79.8 vs. 89.9%, P < 0.001) and reached menarche at an older age (13.1 +/- 1.8 vs. 12.8 +/- 1.5 yr, P < 0.05). Use of BC was associated with less CAC progression in all women, but this association was stronger in T1D women (P value for interaction = 0.02). Irregular menses were associated with greater CAC progression only among T1D women.

CONCLUSIONS

A prior history of BC use is associated with reduced CAC progression among all women, with a stronger association in T1D than in Non-DM women. Women with T1D who report irregular menses have increased CAC progression, compared with those with regular menses.

In vitro evidence of glucose-induced toxicity in GnRH secreting neurons: high glucose concentrations influence GnRH secretion, impair cell viability, and induce apoptosis in the GT1-1 neuronal cell line

OBJECTIVE

To evaluate for direct toxic effects of high glucose concentrations on cellular physiology in GnRH secreting immortalized GT1-1 neurons.

DESIGN

Prospective experimental design.

SETTING

In vitro experimental model using a cell culture system.

INTERVENTION(S)

GT1-1 cells were cultured in replicates in media with two different glucose concentrations (450 mg/dL and 100 mg/dL, respectively) for varying time intervals (24, 48, and 72 hours).

MAIN OUTCOME MEASURE(S)

Effects of glucose concentrations on GnRH secretion by the GT1-1 neurons were evaluated using a static culture model. Cell viability, cellular apoptosis, and cell cycle events in GT1-1 neurons maintained in two different glucose concentrations were assessed by flow cytometry (fluorescence-activated cell sorter) using Annexin V-PI staining.

RESULT(S)

Adverse influences of high glucose concentrations on GnRH secretion and cell viability were noted in cultures maintained in high glucose concentration (450 mg/dL) culture medium for varying time intervals. A significantly higher percentage of cells maintained in high glucose concentration medium demonstrated evidence of apoptosis by a fluorescence-activated cell sorter.

CONCLUSION(S)

We provide in vitro evidence of glucose-induced cellular toxicity in GnRH secreting GT1-1 neurons. Significant alterations in GnRH secretion, reduced cell viability, and a higher percentage of apoptotic cells were observed in GT1-1 cells maintained in high (450 mg/dL) compared with low (100 mg/dL) glucose concentration culture medium.

Clinical review: Hyperandrogenism and polycystic ovary syndrome in women with type 1 diabetes mellitus

CONTEXT

At present, women with type 1 diabetes (DM1) are being treated with supraphysiological doses of exogenous insulin with the aim of providing a strict metabolic control, thereby avoiding the long-term complications of this disease. We hypothesized that PCOS would be especially prevalent in DM1, as might happen in any condition in which the ovary and the adrenals are exposed to excessive insulin concentrations. As will be seen in the present review, androgen excess and PCOS are very frequent complaints in women with DM1, yet nowadays hyperandrogenism is seldom diagnosed in these patients.

EVIDENCE ACQUISITION

We conducted a systematic review of all the published studies addressing hyperandrogenic symptoms in women with DM1, identified through the Entrez-PubMed search engine, followed by a comprehensive review of the pathophysiology and clinical and laboratory features of PCOS in women with DM1.

EVIDENCE SYNTHESIS

The prevalence of PCOS in adult women with DM1 is 12-18, 40, and 31% using National Institute for Child Health and Human Development, Rotterdam, and Androgen Excess Society criteria, respectively. Mild hirsutism and biochemical hyperandrogenism are present in 30 and 20% of the patients, respectively. In addition, menstrual abnormalities are observed in 20% of adult women with DM1, and a prevalence of 50% of polycystic ovarian morphology is reported.

CONCLUSIONS

Physicians treating women with DM1 should be aware of the risk of hyperandrogenism in them and should include evaluation of hirsutism, menstrual abnormalities, and biochemical hyperandrogenism in their routine examinations. Future studies are needed to determine the best preventive and therapeutic options for the hyperandrogenism of these patients.

The hypothalamus–pituitary–ovary axis and type 1 diabetes mellitus: a mini review

A high prevalence of menstrual cycle and fertility disturbances has long been associated with diabetes mellitus. However, rationalization of the intrinsic mechanisms of these alterations is controversial and even contradictory. This review considers (i) the relationship between diabetes mellitus, especially type 1 diabetes mellitus (T1DM), and the hypothalamus-pituitary-ovary (HPO) axis, (ii) the state of our knowledge concerning neuroendocrine control and its relationship with dopaminergic and opioid tonus, and (iii) the influence of the hypothalamus-pituitary-adrenal axis on ovarian function. Functional disturbances that occur as a consequence of diabetes are also discussed, but some T1DM-related diseases of autoimmune origin, such as oophoritis, are not further analysed. Although there are clear indications of a relationship between menstrual and fertility alterations and glycaemic control, in many instances the improvement of the latter is not sufficient to reverse such alterations. It appears that the oligoamenorrhoea and amenorrhoea associated with T1DM is mainly of hypothalamic origin (i.e. failure of the GnRH pulse generator) and may be reversible. The importance of the evaluation of the HPO axis in T1DM women with menstrual irregularities, even in the presence of adequate metabolic control, is emphasized.

Increasing urine albumin excretion is associated with growth hormone hypersecretion and reduced clearance of insulin in adolescents and young adults with type 1 diabetes: the Oxford Regional Prospective Study

HYPOTHESIS

We previously described lower insulin-like growth factor I (IGF-I) levels in association with increased microalbuminuria (MA) risk in type 1 diabetic subjects followed from diabetes diagnosis through puberty into adulthood. By inference lower IGF-I levels may be associated with higher GH levels and changes in insulin sensitivity.

METHODS

To test this hypothesis, microalbuminuric subjects (MA+, n = 14) from the same cohort had overnight GH levels measured during euglycaemia (5 mmol/l, 01:00-07:30 h) maintained by a variable rate insulin infusion followed by a 2-step hyperinsulinaemic, euglycaemic clamp study using [6.6 2H2] glucose, and were compared to MA- controls (MA-, n = 14), matched for age (median 19.3 years, range 15.8-30.5), sex, duration of diabetes (11.1 years, range 5.1-16.4).

RESULTS

In MA+ cases GH levels, measured by the Pulsar programme, were higher (baseline; 1.8 +/- 1.4 vs. 0.7 +/- 0.5 ng/ml, P = 0.02, mean; 3.8 +/- 1.3 vs. 2.6 +/- 1.6 ng/ml, P = 0.03, maximum; 16.7 +/- 7.0 vs. 12.3 +/- 5.4, P = 0.02), despite similar HbA1(c) levels (9.8%vs. 9.6%, P = 0.6) and body or truncal fat mass. Fourier transform revealed increased GH pulse amplitude at all periodicities and overnight insulin clearance was reduced (11.7 +/- 6.9 vs. 20.1 +/- 6.5 ml/kg/min, P < 0.02). In multiple regression analysis, urine albumin excretion was associated with higher GH levels and reduced insulin clearance, independent of HbA1(c) and body composition. In female cases (n = 9), dextrose requirements were reduced during the first step of the euglycaemic clamp (1.7 +/- 0.8 vs. 2.7 +/- 1.4, P < 0.05) but no such differences existed in males or in the rate of glucose production or disposal.

CONCLUSION

The development of MA during puberty and young adulthood is associated with higher GH levels and abnormalities in insulin metabolism, particularly in females. These data extend support for our previous findings indicating a role for the GH/IGF-I axis in the pathogenesis of MA.

Cyclic changes in glycemia assessed by continuous glucose monitoring system during multiple complete menstrual cycles in women with type 1 diabetes

Many women with diabetes notice changes in glucose control perimenstrually. To describe the pattern of changes in glucose control throughout the complete menstrual cycle, and the reproducibility of these changes, we performed a pilot study evaluating glycemic profiles continuously for three cycles in four women with type 1 diabetes. All participants had hemoglobin A1c <7.5% and regular menstrual periods off oral contraceptives. They used Medtronic MiniMed (Northridge, CA) Continuous Glucose Monitoring System (CGMS) devices continuously for three complete menstrual cycles, checked capillary glucose measurements six times daily, changed their own sensors every 3 days, and were seen seven times per menstrual cycle to download data and draw blood. Prolonged monitoring was safely carried out over three consecutive menstrual cycles. We observed two different patterns of glycemic control in relation to the menstrual cycle in these women. The first pattern, seen in two women, was characterized by increased frequency of hyperglycemia in the luteal phase. One of these women also had a hyperglycemic peak in the follicular phase. In the other two women, no characteristic cycle-related pattern was noted. The glucose profiles appeared reproducible between cycles in all women, but varied between women. Thus the menstrual cycle has a reproducible effect on glucose control in a subset of women with type 1 diabetes. Prolonged use of continuous glucose monitoring was safe in the subjects studied, and is the first method clinically available to monitor glucose control over prolonged periods in individuals with diabetes.

Body composition in adolescent girls with type 1 diabetes

AIMS

To compare body composition in adolescent girls with Type 1 diabetes with healthy controls.

RESEARCH DESIGN AND METHODS

In this population-based study, body composition was examined, using dual-energy X-ray absorptiometry (DXA) and skinfold measurements, in 18 adolescent post-menarcheal females, 16-19 years of age, with Type 1 diabetes since childhood in comparison to age-matched healthy control subjects.

RESULTS

Body mass index was 2.7 kg/m2 higher in diabetic patients (26.3 +/- 2.6 vs. 23.6 +/- 3.8; P < 0.05). The overweight consisted almost entirely of increased fat mass, as evaluated by both skinfold measurements and DXA. Bone mineral density did not differ between the two groups. In diabetic females, the distribution of the fat mass was increased in the upper part of the body. The fat distribution, expressed as the abdominal-to-leg ratio, was significantly correlated to glycated haemoglobin (HbA1c) (r = 0.69; P < 0.005), daily dosage of insulin expressed per kilogram body weight (r = 0.78; P < 0.0005) and total cholesterol (r = 0.60; P < 0.001).

CONCLUSIONS

The observed overweight in adolescent females with Type 1 diabetes is explained by an increased fat mass. Abdominal fat accumulation was associated with poor glycaemic control, increased need for insulin and elevated blood lipids.

Low IGF-I and elevated testosterone during puberty in subjects with type 1 diabetes developing microalbuminuria in comparison to normoalbuminuric control subjects: the Oxford Regional Prospective Study

OBJECTIVE

To describe longitudinal variations in pubertal hormonal variables in subjects with and without microalbuminuria (MA).

RESEARCH DESIGN AND METHODS

Blood samples collected annually from subjects recruited at diagnosis of type 1 diabetes and followed prospectively through puberty (median follow-up 9.3 years, range 4.7-12.8) were analyzed for total and free IGF-I, IGF binding protein-1, testosterone, sex hormone-binding globulin, and HbA(1c). A total of 55 subjects who developed MA (MA(+) group) were compared with 55 age-, sex-, and duration-matched control subjects who did not develop MA (MA(-) group).

RESULTS

For female subjects, total IGF-I (MA(+) 1.2 mU/l vs. MA(-) 1.4 mU/l, P = 0.03) and free IGF-I levels (MA(+) 1,767 ng/l vs. MA(-) 2010 ng/l, P = 0.002) were lower, whereas the free androgen index (MA(+) 2.4 vs. MA(-) 2.0, P = 0.03) was higher in those with MA. These changes were less pronounced in male subjects. For both sexes, in a Cox model after adjusting for puberty, the presence of MA was associated with lower free IGF-I levels, higher testosterone standard deviation score (SDS), and poor glycemic control. We found that 22 of 55 case subjects (40%) developed persistent MA, whereas 33 (60%) had transient MA. In the persistent MA group compared with the transient and control groups, total IGF-I levels were lower (1.1 vs. 1.3 vs. 1.4 mU/l, P = 0.002) as were free IGF-I levels (1,370.9 vs. 1,907.3 vs. 1,886.7 ng/l, P < 0.001), whereas HbA(1c) levels were higher (11.8 vs. 10.3 vs. 9.9%, P < 0.001).

CONCLUSIONS

Poor glycemic control and differences in IGF-I levels and androgens, particularly in female subjects, accompany development of MA at puberty. These differences may in part account for the sexual dimorphism in MA risk during puberty and could relate to disease progression.

Menstrual cycle differences between women with type 1 diabetes and women without diabetes

OBJECTIVE

To evaluate menstrual cycle histories among women with type 1 diabetes, their sisters, and unrelated control subjects without diabetes across all reproductive ages.

RESEARCH DESIGN AND METHODS

Menstrual and reproductive histories were obtained by questionnaire from 143 women with type 1 diabetes, 186 sisters without diabetes, and 158 unrelated control subjects without diabetes participating in the Familial Autoimmune and Diabetes study.

RESULTS

Women with type 1 diabetes had more menstrual problems (long cycles, long menstruation, and heavy menstruation) before age 30 years than sisters and control subjects. These differences were all statistically significant, except for heavy menstruation at age <20 years. No differences were observed after age 30 years. Women with type 1 diabetes experienced later menarche, earlier natural menopause, fewer pregnancies, and more stillbirths than women without diabetes. Multiple regression analyses revealed that type 1 diabetes caused an approximate twofold increased risk of any menstrual problem before age 30 years. These were primarily related to long cycles and long menstruation in women aged <20 and 20-29 years, as well as with heavy menstruation from 20 to 29 years. Oral contraceptives were protective for any menstrual problem and heavy menstruation from 30 to 39 years of age. With history of pregnancy from 20 to 40 years of age, any menstrual problem and long menstruation were more likely.

CONCLUSIONS

The results suggest that type 1 diabetes is an independent risk factor for menstrual disturbances in young adults. Future studies may determine whether addressing menstrual disturbances improves quality of life and health for these women.

Polycystic ovary syndrome in adolescence and early adulthood

Polycystic ovaries and the associated syndrome are recognized as the most common cause of endocrine disturbances in adult women, but much less research has been performed to examine how polycystic ovary syndrome (PCOS) presents in girls and young women. Polycystic ovaries have been demonstrated in childhood, and there is evidence to show that even very young women may show symptoms and signs of the associated syndrome. Closer examination of younger populations (less-than-or-eq, slant 25 years of age), and in particular, studies of girls during the transition from puberty into early adulthood (adolescence), may provide new insights into the pathogenesis and natural history of polycystic ovaries and PCOS, and may indicate whether polycystic ovaries could potentially be considered as a marker for health screening. Consideration should be given to the management of girls and young women with polycystic ovaries and PCOS as this group may have different needs and health risks compared with older women.

Clinical features in women with polycystic ovaries: relationships to insulin sensitivity, insulin gene VNTR and birth weight

OBJECTIVE

Polycystic ovaries are a common ultrasound finding, yet few of these women have many clinical features of polycystic ovary syndrome. Clinical presentation may relate to degree of insulin resistance, common polymorphism at the insulin gene VNTR, and birth weight. We therefore examined the relationship between insulin sensitivity, insulin gene VNTR genotype, birth weight and presence of polycystic ovaries/features of polycystic ovary syndrome in a normal population study.

DESIGN AND PATIENTS

In 224 young women recruited as normal volunteers, ovarian morphology was determined by transabdominal ultrasound and features of polycystic ovary syndrome were identified on clinical and biochemical examination. Insulin sensitivity was estimated from fasting glucose and insulin levels using the homeostasis model. Insulin gene VNTR genotypes were determined in women and their parents.

MEASUREMENTS AND RESULTS

Thirty-three per cent (74/224) had polycystic ovaries on ultrasound. These women had higher birth weights (P = 0.004), higher insulin sensitivity (P = 0.02) and higher leptin levels for body mass index (P = 0.04) than women with normal ovaries. However among women with polycystic ovaries, increasing severity of clinical phenotype (based on number of features of: menstrual irregularity, acne, hirsutism, serum testosterone > 3 mmol/l and LH > 10 IU/l) was associated with decreasing insulin sensitivity (P < 0.0001) and related to paternally transmitted insulin gene VNTR class III alleles (P = 0.03).

CONCLUSION

Women with polycystic ovaries on ultrasound have increased insulin sensitivity and possible leptin resistance, which could predispose to future weight gain. However, in these women the appearance of clinical features of polycystic ovary syndrome is related to insulin resistance and insulin gene VNTR class III alleles.

Diabetes control deteriorates in girls at cessation of growth: relationship with body mass index

AIM

Diabetic patients, particularly girls, often experience poor metabolic control during puberty and adolescence. The aim of this study was to investigate metabolic control during adolescence, especially in relation to pubertal stages, growth, insulin treatment and body mass index (BMI).

METHODS

We studied the records of 38 (consecutive) girls with prepubertal onset of Type 1 diabetes mellitus. Data from the age of 10 to 18-20 years were obtained with regard to glycaemic control, growth, age at menarche, final height and BMI, and analysed in relation to both chronological age and age at menarche.

RESULTS

HbA1c was lowest 3 years before menarche; mean (+/- sd) 7.6 (+/- 1.2). After the pubertal growth spurt, there was a marked impairment of metabolic control, the highest level of HbA1c occurring 3 years after menarche. Mean age at menarche was 13.3 (+/- 1.1) years and mean linear growth after menarche only 4.7 cm, giving a final height of 164.9 (+/- 5.3) cm which is 2.7 cm below the Swedish mean. During adolescence the degree of correlation between BMI and HbA1c continuously increased, pointing out the effect of body fat on metabolic control in this age group. The level of HbA1c at 10 years of age could not predict the metabolic control after cessation of puberty, but prepubertal BMI appears to be a risk factor for both obesity and poor glycaemic control in late adolescence.

CONCLUSIONS

The highest HbA1c was found after cessation of growth. Prepubertal BMI is a possible predictor of metabolic control in adolescent diabetic girls.

Complications of pediatric and adolescent type 1 diabetes mellitus

Type 1 diabetes mellitus is potentially associated with serious microvascular and macrovascular complications, although these are usually subclinical during the pediatric and adolescent years. There is no "grace" period for the beginnings of such complications. Duration of diabetes, glycemic control, age, and pubertal stage are critical factors contributing toward development of such problems. Other risk factors include family history (genetic predisposition), hyperlipidemia, hypertension, and smoking. The Diabetes Control and Complications Trial (DCCT) proved the importance of glycemic control and emphasized the ability of improved glucose control to prevent or decrease retinopathy, nephropathy, and neuropathy using a multidisciplinary same-philosophy-of-care approach plus targeted glucose and hemoglobin A(1c) values. Other natural history and intervention studies support the findings of the DCCT. Although our current tools are not perfect, they allow us to decrease microangiopathic complications very significantly if we educate our patients and their family members. Metabolic control counts.

Premenarchal and postmenarchal girls with insulin-dependent diabetes mellitus: ovarian and other organ-specific autoantibodies, menstrual cycle

STUDY OBJECTIVE

To estimate various organ-specific autoantibodies and detect other endocrine autoimmune disorders and menstrual cycle characteristics in girls with Type 1 insulin dependent diabetes mellitus (IDDM).

DESIGN

Prospective cohort study from 1993 to 1998, duration 4.5 years.

SETTING

Diabetes & Endocrine Clinic of the University Hospital, Motol, Prague.

PATIENTS

53 IDDM girls (group A--43 postmenarchal, group B--10 premenarchal), 15.5 +/- 2.5 (8-19) years old, 6.2 +/- 4.3 years after IDDM onset.

MAIN OUTCOME MEASURES

Ovarian autoantibodies directed to ooplasm, zona pellucida, membrana granulosa, theca folliculi interna, and lutein cells, insulin autoantibodies, thyroid peroxidase and thyroglobulin autoantibodies. Menstrual cycle character, endocrine glands disturbance. Diabetes control, body mass index, duration of IDDM.

RESULTS

Ovarian autoantibodies in at least one of the followed structures were found in 67.9% of the IDDM girls. In the control group of 21 healthy girls of corresponding age, the positive findings in lutein cells were found in only 4.8% of the girls (P < 0.01 versus IDDM girls). The lutein cells commonly associated with theca folliculi interna cells were the most frequent immunopositive structures in diabetic girls (P < 0.05 versus another positive ovarian autoimmune structure). Autoantibodies directed to ovarian steroid producing cells were frequent in IDDM patients with both irregular and normal menstrual cycles. Irregular menstrual cycles were diagnosed in 27.9% of IDDM girls, polymenorrhea in half of them, and oligomenorrhea in the remainder. Diabetes control in our patients (glycosylated hemoglobin HbA1c in postmenarchal girls 10.1 +/- 2.0%) did not differ between those with regular and those with irregular menstrual cycles. Over a follow-up period one-third of the girls with oligomenorrhea and a long-term noncompliance (HbA1c 13.5%) developed secondary amenorrhea. Insulin autoantibodies were found in 67.8%, thyroid peroxidase autoantibodies in 12.5%, and thyroglobulin autoantibodies in 10.4% of the IDDM girls. Autoimmune thyroiditis was diagnosed in 5 IDDM patients (9.4%); hypothyroidism developed in 3 of them. Menstrual cycle was irregular in 4 of the 5 girls with autoimmune thyroiditis (polymenorrhea in 1, oligomenorrhea in another 3 girls).

CONCLUSIONS

An increased incidence of various circulating autoantibodies may be markedly demonstrated in IDDM girls. Their reproductive function might have an important relationship to an evidence of ovarian autoantibodies. Menstrual cycle disturbances could be linked to the poor diabetes control, to the presence of ovarian and other autoantibodies, and also to other autoimmune disease.

Gynecologic care of medically complicated adolescents

Gynecologic care of adolescents presents a challenge under the best of circumstances, but when the patient has significant medical processes that interact with the process of puberty, the care of these patients may become extremely difficult. A review of the more common medical illnesses of adolescents and the interaction on the events of puberty and normal menstrual function is presented with emphasis on contraception and future fertility. Although many of the contraceptive options present a possible increased risk to these patients, it must be kept in mind that these adolescent patients will develop emotionally and become sexually active at some point in their lives, and the potential risk of the resultant pregnancy must be weighed carefully. The various options of management for gynecologic problems are discussed.

Does early growth delay occur in diabetic pregnancy?

OBJECTIVE

To identify the date of ovulation in pregnant women with Type 1 diabetes in order to assess the validity of the concept of early growth delay.

DESIGN

Identification of ovulation by measurement of urinary luteinising hormone and assessment of fetal growth using ultrasound scan.

SETTING

Diabetic pre-pregnancy and antenatal clinic in a teaching hospital.

SUBJECTS

Twenty women with Type 1 diabetes who had attended a pre-pregnancy clinic.

MEASURES

Urinary LH, by laboratory and kit methods, during conception cycles. Human chorionic gonadotrophin measured in early pregnancy. Early ultrasound scans by a single observer blind to menstrual and ovulation dates.

OUTCOME

Gestation calculated from ovulation date and gestation estimated from menstrual dates, compared with gestation at age indicated by early ultrasound scan.

RESULTS

When the date of ovulation was identified in 20 women with Type 1 diabetes there was no evidence of growth delay in any pregnancy. When gestation was estimated from menstrual dates there was apparent early growth delay in six pregnancies.

CONCLUSION

This study, together with others discussed, indicates that early growth delay is probably an artefact of incorrectly estimated ovulation date.