Can postmenopausal hormone replacement improve plasma lipids in women with diabetes? The Atherosclerosis Risk in Communities Study Investigators

The effect of tibolone treatment on fasting blood sugar, insulin, insulin resistance and endothelial function in postmenopausal women: A meta-analysis of randomized controlled trials

BACKGROUND AND AIM

The menopause is associated in females with the presence of dysglycemia, insulin resistance and with the development of endothelial dysfunction. Tibolone (TIB) is a synthetic steroid compound with selective oestrogenic and, to a lesser extent, progestogenic and androgenic properties prescribed to postmenopausal women to alleviate the symptoms of the climaterium and to prevent the development of osteoporosis. However, the impact of TIB on fasting blood sugar (FBS), insulin, Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) index and flow-mediated dilation (FMD) in women has not been evaluated so far. Thus, to investigate this research question, we conducted the present systematic review and meta-analysis.

METHODS

Two independent reviewers searched the Scopus, Web of Science, PubMed/Medline and Embase databases up to 20 December 2020. The weighted mean differences (WMDs) and the 95% confidence intervals (CI) were calculated using the DerSimonian and Laird random effects models between the TIB and control groups and included in the forest plot.

RESULTS

The overall findings were generated from 12 eligible randomized controlled trials. As compared to controls, TIB administration resulted in a significant reduction of FBS (WMD: -3.06 mg/dL, 95% CI: -5.30 to -0.82, P = 0.007), and of the HOMA-IR index (WMD: -0.61, 95% CI: -1.11 to -0.11, P = 0.01). However, treatment with TIB did not lead to significant changes of the FMD (WMD: 0.78%, 95% CI: -0.20 to 1.77, P = 0.12) or of insulin levels (WMD: -0.10 mIU/L, 95% CI: -2.04 to 1.83, P = 0.91).

CONCLUSION

TIB administration can decrease FBS and the HOMA-IR index in postmenopausal women. However, the use of TIB does not influence insulin levels or FMD.

Hormone replacement therapy for women with type 1 diabetes mellitus

BACKGROUND

There is conflicting information about the impact of the menopause on glycaemic control amongst women with type 1 diabetes. Some menopausal women with type 1 diabetes are treated with hormone replacement therapy (HRT) but the effects of this treatment have, to date, not been established.

OBJECTIVES

To assess the effects of HRT for women with type 1 diabetes mellitus.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL and PsycINFO from their inception to June 2012. The last search was run for all databases on 18 June 2012.

SELECTION CRITERIA

We selected randomised controlled trials or controlled clinical trials that involved peri- or postmenopausal women with type 1 diabetes undergoing HRT as an intervention.

DATA COLLECTION AND ANALYSIS

Two researchers independently applied the inclusion criteria to the identified studies and assessed risk of bias. Disagreements were resolved by discussion or by intervention by a third party. Descriptive analysis was conducted for the review.

MAIN RESULTS

Ninety-two publications were screened. No studies met the inclusion criteria exclusively but one study that included both type 1 and type 2 diabetes participants was considered. This randomised clinical trial (RCT) compared HRT (N = 27) with placebo (N = 29) over 12 months. The outcome measures were cardiovascular risk factors, including lipid profile, glycaemic control, blood pressure and body weight. No significant differences between placebo and HTR were detected. Patient-important outcomes like all-cause mortality, cardiovascular disease, diabetic complications or health-related quality of life were not investigated.

AUTHORS' CONCLUSIONS

There is a lack of evidence around the use of HRT in women with type 1 diabetes. The one study that has been undertaken in this area is underpowered. More RCTs are required in the area to examine the impact of HRT on glycaemic control and cardiovascular outcomes.

Use, intentions, and beliefs about hormone replacement therapy in women with and without diabetes

OBJECTIVES

(1) Describe women's (a) hormone replacement therapy (HRT) use patterns, (b) intentions to use or continue to use HRT among women in the early and late stages of menopause, and (c) beliefs about using HRT and (2) compare these beliefs, patterns, and intentions between women with and without diabetes 10-12 months after news from the women's health initiative was widely publicized.

METHODS

A survey mailed to female enrollees of a not-for-profit managed care organization (MCO) between 46 and 60 years of age and with or without diabetes. Descriptive statistics were calculated. Chi-square analysis was used to determine significant differences between four different HRT use and menopause stage groups, (1) early stage never user, (2) late stage never user, (3) late stage current user, and (4) late stage previous user. Analysis of variance (ANOVA) was used to identify significant belief differences between the four groups. Repeated-measures ANOVA was performed to examine differences between women with and without diabetes.

RESULTS

Most women did not intend to initiate HRT. About 86% of current HRT users intended to continue. Never users with diabetes were significantly more uncertain about HRT intention than non-diabetic women. All beliefs were significantly different (p<0.001) between the four groups, but not between women with and without diabetes.

CONCLUSION

Women in different groups hold different beliefs about HRT use. Uncertainty among women with diabetes is not resolved as quickly as among women without diabetes.

Association of type 2 diabetes mellitus and seroprevalence for cytomegalovirus

BACKGROUND

Infection is known to play a role in type 1 diabetes, but there is a paucity of information on its role in diabetes mellitus type 2. We examined the seroprevalence of selected viruses in a group of predominantly Hispanic patients with type 2 diabetes and control subjects without diabetes.

METHODS

One hundred thirteen patients, 83 with type 2 diabetes and 30 control subjects, all undergoing hemodialysis at the same facility in San Antonio, Texas, were tested for antibodies against coxsackie B viruses, cytomegalovirus (CMV), and parvovirus. Sixty-six of these patients and 25 control subjects were tested bimonthly for 6 months.

RESULTS

We observed a greater seroprevalence of anti-CMV IgG antibodies among patients with diabetes (97.6%), compared with control subjects (86.7%), and the difference was statistically significant [OR = 6.2, 95% CI: 1.1 to 36.0, P < 0.05]. Three draws on a subset of 91 patients produced still greater odds [OR = 12.4, 95% CI: 1.3 to 117, P < 0.05]. There were significantly more (P < or = 0.001) vascular complications among patients with diabetes. There was a colinearity of trends between diabetes, seropositivity to CMV, and age.

CONCLUSIONS

Our findings indicated an up to 12 times greater odds of having type 2 diabetes for persons previously exposed to CMV. Since accelerated atherosclerosis is also associated with diabetes and CMV, past CMV infection may be a common factor that links atherosclerosis and diabetes. No other viruses tested in this study, either coxsackie B viruses or parvovirus, showed a significant association with type 2 diabetes.

Terapêutica com tibolona em mulheres diabéticas na pós-menopausa: parâmetros clínicos e laboratoriais de segurança

OBJETIVO: determinar o perfil de segurança clínico-laboratorial da terapia com tibolona em mulheres portadoras de diabetes mellitus não-insulinodependente (DMNID). MÉTODO: estudo prospectivo, longitudinal, aberto e controlado envolvendo 24 mulheres na pós-menopausa portadoras de DMNID, tratadas seqüencialmente com placebo (6 meses) e tibolona 2,5mg/dia (6 meses). Parâmetros clínicos, antropométricos, bioquímicos, hormonais e ultra-sonográficos foram avaliados no período basal, após 6 (tempo 1) e 12 meses de acompanhamento (tempo 2). Análise estatística foi realizada utilizando-se ANOVA para medidas repetidas, com nível de significância 5%. RESULTADOS: efeitos colaterais surgiram apenas durante uso da tibolona (cefaléia e mastalgia em 8,3% e sangramento genital em 16,6%). Houve diminuição significativa dos sintomas climatéricos avaliados através do índice de Blatt-Kuperman [22,2 ± 7,1 (basal) vs. 13,6 ± 6,7 (tempo 1) vs. 3,1 ± 3,3 (tempo 2); p< 0,0001]. Após uso da tibolona, evidenciamos reduções significativas no percentual de gordura corporal, pressão arterial diastólica, níveis de transaminases, triglicerídeos e HDL-colesterol. Não houve variações significativas na pressão arterial sistólica, freqüência cardíaca, índice de massa corporal, relação cintura/quadril, glicemia de jejum, hemoglobina glicosilada, uréia, colesterol total e LDL-colesterol. A avaliação ultra-sonográfica não revelou variações significativas do volume uterino e espessura endometrial. CONCLUSÃO: o tratamento com tibolona em curto prazo mostrou bom perfil de segurança clínico-laboratorial em pacientes na pós-menopausa portadoras de DMNID.

Associations of Postmenopausal Hormone Therapy with Markers of Hemostasis and Inflammation and Lipid Profiles in Diabetic and Nondiabetic American Indian Women: The Strong Heart Study

OBJECTIVES

To examine the associations of postmenopausal hormone therapy (PHT) with indicators of hemostasis and inflammation and with lipid profiles in American Indian women and to determine if diabetes modifies these associations.

METHODS

This report is a cross-sectional analysis of data from 1446 postmenopausal women who were free from cardiovascular disease (CVD) at the second Strong Heart Study examination (1993-1995). Diabetes was diagnosed by WHO criteria. Postmenopausal hormone use was ascertained by review of the medications brought to the examination or by medical record review. Lipoproteins, plasminogen activator inhibitor type 1 (PAI-1), fibrinogen, and C-reactive protein (CRP) were measured in fasting plasma samples.

RESULTS

Among nondiabetic women, current PHT users had lower mean fibrinogen, PAI1, and low-density lipoprotein cholesterol (LDLC) levels than those in never users (38.4 mg/dl, 8.68 ng/ml, and 14.16 mg/dl lower, respectively) but higher CRP and triglyceride levels (1.53 mg/l and 31.43 mg/dl higher, respectively). Multivariate adjustment did not alter any of these associations. In diabetic women, current PHT use was associated only with lower PAI-1 (5.48 ng/ml lower) and higher high-density lipoprotein cholesterol (HDLC) levels (3.33 mg/dl higher) compared with never users.

CONCLUSIONS

In American Indian women without diabetes, PHT was associated with lower levels of hemostatic markers but higher levels of an inflammatory marker. Associations were less marked in women with diabetes. The relation of PHT with lipid profiles also differed in nondiabetic and diabetic women. These data provide an additional rationale for considering diabetes status when deciding whether or not to use PHT.

Effect of hormone replacement therapy on cardiovascular risk factors in postmenopausal women with diabetes

BACKGROUND

Hormone replacement therapy (HRT) in postmenopausal women improves menopausal symptoms, decreases the incidence of osteoporotic fracture, but the effects on cardiovascular risk factors remain controversial.

AIM

To test the hypothesis that HRT may have beneficial effects on the cardiovascular risk profile in postmenopausal women with diabetes.

METHODS

One hundred and fifty postmenopausal patients with type 1 (T1DM) and type 2 diabetes (T2DM) were randomized to receive HRT (Kliofem) or placebo for 12 months. We monitored the effects on cardiovascular risk factors, including lipid profile, glycaemic control, blood pressure and body weight.

RESULTS

Mean low-density lipoprotein (LDL) cholesterol was associated with a nonsignificant decrease [-0.14 mmol/l (CI=-0.44, 0.17) (p=0.37)] in the Kliofem-treated group. Total cholesterol fell by 0.42 mmol/l (CI=-0.78, -0.05) (p=0.027). High-density lipoprotein (HDL) cholesterol was reduced by a mean of 0.07 mmol/l compared to a mean rise of 0.12 mmol/l on placebo. There were apparent differences in the treatment effects between T1DM and T2DM. There was no change in triglycerides or apoprotein B and no effect on glycaemic control, blood pressure or menopausal symptom scores. In the Kliofem group, BMI fell by 0.66 kg/m2 compared to an increase of 0.14 kg/m2 for placebo patients (p=0.046).

CONCLUSIONS

Although the long-term effects of HRT in women with or without diabetes appear to suggest that some types of HRT either confer no cardiovascular protection or may increase risk, the impact of Kliofem diabetic women on cardiovascular risk factors is probably neutral.

The neointimal response to endovascular injury is increased in obese Zucker rats

BACKGROUND

Restenosis after revascularization procedures is accelerated in persons with type 2 diabetes.

AIM

The current study tested the hypothesis that the neointimal response to endovascular injury is enhanced in female obese Zucker (OZ) rats, a model of type 2 diabetes.

METHODS

Animals were randomized to receive either a standard diet (SD) or a diabetogenic diet (DD) for 6 weeks. Four weeks later, balloon injury of the right common carotid artery was induced. All rats were euthanized 2 weeks after injury. Lean Zucker (LZ) rats served as controls.

RESULTS

At the time of death, plasma glucose was elevated in OZ rats fed a SD (208 +/- 13 mg/dl) and a DD (288 +/- 21 mg/dl) compared to corresponding LZ rats (SD: 153 +/- 8; DD: 132 +/- 7 mg/dl). The ratio of high-density lipoprotein cholesterol (HDLc) to total cholesterol (Totc), an index of atherogenicity, was reduced in OZ rats on both diets (SD: 0.77 +/- 0.06; DD: 0.80 +/- 0.09) compared to LZ controls (SD: 1.11 +/- 0.02; DD: 1.20 +/- 0.05). Histomorphometric analysis of injured arteries showed that the intima to media (I : M) ratio was significantly increased in OZ (1.37 +/- 0.07) compared to LZ (0.79 +/- 0.08) rats. Elevations in plasma glucose and triglycerides (Tg) correlated positively and decreases in HDLc negatively with an increased I : M ratio. Administration of the DD did not further enhance the I : M ratio in LZ (0.87 +/- 0.06) or OZ (1.29 +/- 0.09) rats.

CONCLUSIONS

These results suggest that neointima formation following endoluminal injury of the carotid artery is enhanced at an early stage in the development of diabetes mellitus.

Gender, hyperlipidemia, and coronary artery disease

The importance of statins for the prevention and treatment of coronary artery disease (CAD), the recent paradoxical effects of hormone replacement therapy on prevention of CAD, and the role of nontraditional risk factors in CAD in women are examined.

The effects of transdermal estradiol alone or with cyclical dydrogesterone on markers of cardiovascular disease risk in postmenopausal women with type 2 diabetes: a pilot study

The objective of this open, longitudinal, controlled study was to assess the effect of transdermal estradiol alone or combined with cyclical dydrogesterone on the markers of cardiovascular disease (CVD) risk in postmenopausal women with type 2 diabetes. The control group consisted of postmenopausal diabetic women who declined menopausal hormone replacement therapy (HRT). Twenty-eight postmenopausal women (19 on HRT and 9 controls) with type 2 diabetes were followed up for 12 months. From the active treatment group 14 women with a uterus in situ had 80 microg/24 hr transdermal estradiol (Fematrix 80; Solvay Healthcare Ltd, Southampton, UK) and oral dydrogesterone 10 mg daily for the first 12 days of the calendar month, whereas 5 women with previous hysterectomy had 80 microg/24 hr transdermal estradiol (Fematrix 80) alone. CVD risk markers were measured before and at regular intervals after starting HRT. The main outcome measures were weight, systolic and diastolic blood pressure, fasting plasma glucose, glycated hemoglobin (HbA1c), glucose/insulin ratio, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, lipoprotein (a), high-sensitivity C-reactive protein (hs-CRP), fibrinogen, and endothelin-1. Transdermal estradiol with or without dydrogesterone in women with type 2 diabetes did not adversely affect any of the measured markers of cardiovascular risk. There was a significant decrease in HbA1c, total cholesterol, and LDL cholesterol at 6 months in women receiving HRT. Some of the cardiovascular disease risk markers may improve in postmenopausal women with type 2 diabetes with transdermal estradiol. This effect may have important clinical implications and it deserves further investigation in appropriately designed trials.

An observational study of severe hypertriglyceridemia, hypertriglyceridemic acute pancreatitis, and failure of triglyceride-lowering therapy when estrogens are given to women with and without familial hypertriglyceridemia

BACKGROUND

We assessed severe hypertriglyceridemia, hypertriglyceridemic acute pancreatitis, and failure of triglyceride-lowering therapy when estrogens were given to 56 women with and without familial hypertriglyceridemia. The 56 women had been consecutively referred to our center over a 3-year period because of triglycerides >400 mg/dl despite diet-drug treatment and/or a history of hypertriglyceridemic acute pancreatitis (AP). Of the 56 women, 17 had received estrogen replacement therapy (ERT), hormone replacement (HRT, n=6), or selective estrogen receptor modulators (SERM, n=1).

METHODS

After study at entry, in 56 women (median age, 52 years), 36 with familial hypertriglyceridemia, to lower triglycerides, estrogens and SERMs (hormone treatment, HT) were stopped; a very low fat diet (<15% of calories), gemfibrozil (1.2-1.5 mg/day), and omega-3-fatty acid (4-12 g/day) were started, with restudy 2-4 weeks later.

RESULTS

Of the 56 women, 24 (43%) were taking HT at entry, with median fasting triglycerides 1270 mg/dl in the HT group and 1087 mg/dl in the no-HT group. Seventeen women (30%) had a history of AP, nine of whom (53%) were/had been on HT at the development of AP. Significant positive correlates of triglycerides at entry in a stepwise regression model were hemoglobin A(1C) (partial r(2)=10.7%, p<0.05) and an interaction between estrogen use and familial hypertriglyceridemia (partial r(2)=15%, p=0.017). After 2-4 weeks on therapy, median triglycerides in the previous-HT group fell from 1270 to 284 mg/dl (p<0.0001) and in the no-HT group from 1087 to 326 mg/dl (p<0.0001).

CONCLUSIONS

Before starting HT, to avoid HT induced hypertriglyceridemic AP and exacerbation of overt or covert familial hypertriglyceridemia, triglycerides must be measured. HT is contraindicated in women with preexisting hypertriglyceridemia (triglycerides> or =500 mg/dl). Triglyceride-lowering diets and drugs often fail in the presence of HT and/or poorly controlled diabetes mellitus, but commonly succeed when HT is stopped and diabetes mellitus is tightly controlled.

Post hoc analysis of data from the Multiple Outcomes of Raloxifene Evaluation (MORE) trial on the effects of three years of raloxifene treatment on glycemic control and cardiovascular disease risk factors in women with and without type 2 diabetes

BACKGROUND

The long-term effects of the selective estrogen-receptor modulator raloxifene hydrochloride on glycemic control and markers of cardiovascular disease risk in postmenopausal women with type 2 diabetes mellitus are unknown.

OBJECTIVE

The aim of this analysis was to compare the effects of 3-year treatment with raloxifene 60 mg/d versus placebo on glycemic control and markers of cardiovascular disease risk in osteoporotic postmenopausal women with and without type 2 diabetes.

METHODS

In this analysis, we included women from the Multiple Outcomes of Raloxifene Evaluation trial (a multicenter, double-masked trial) who were randomized to receive raloxifene 60 mg/d (n = 2557) or placebo (n = 2576). Baseline and 36-month fasting plasma glucose (FPG) and total cholesterol (TC) were measured for all participants. Glycated hemoglobin (HbA1c), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGs), apolipoprotein (apo) A-I, apo B, and fibrinogen were assessed in approximately 1800 participants from selected larger sites.

RESULTS

At baseline, 202 of all 5133 women (3.9%) had type 2 diabetes. Of the approximately 1800 women who were assessed for HbA1c, LDL-C, TGs, apo A-I, apo B, and fibrinogen, 70 (3.9%) had type 2 diabetes at baseline. Compared with placebo, raloxifene did not significantly affect HbA1c, FPG, HDL-C, or TGs in women with or without diabetes. Raloxifene produced statistically significant reductions in TC, LDL-C, and fibrinogen both in women with diabetes (all P < or = 0.004) and without diabetes (all P < 0.001). Raloxifene significantly increased apo A-I (P < 0.001) and reduced apo B (P < 0.001) in women without diabetes. In the raloxifene-treated group, body weight increased by a mean 0.31 kg (P < 0.001) in women without diabetes.

CONCLUSIONS

In osteoporotic postmenopausal women with or without type 2 diabetes, raloxifene 60 mg/d did not affect glycemic control and had favorable effects on TC, LDL-C, and fibrinogen levels.

Molecular mechanisms of diabetic cardiovascular disease

Cardiovascular disease is a major cause of morbidity and mortality in persons with diabetes mellitus. This population represents an important target for preventive therapies aimed at reducing atherosclerosis. Recent molecular research has uncovered many of the cellular mechanisms that lead to atherosclerosis in the diabetic patient. This review, part 1 of a 2-part series, is geared toward clinicians and discusses these mechanisms as they pertain to prevention of cardiovascular disease in patients with diabetes.

Lipids and diabetes mellitus: a review of therapeutic options

Diabetes mellitus ia very common disease with a high cardiovascular morbidity and mortality. This articles reviews the types of lipid disorders that can accompany diabetes mellitus and the evidence that treatment of dyslipidaemia improves primary and secondary endpoints, i.e. lipid levels, cardiovascular events, and mortality. Specific lipid-lowering strategies are discussed, including diet and exercise, treatment of hyperglycaemia, and the use of lipid-lowering therapy such as statins, fibric acid derivatives, bile acid sequestrants, nicotinic acid and its derivatives, fish oil and hormone replacement therapy. An approach to the patient with diabetes mellitus and dyslipidaemia is provided.

HRT in women with diabetes--review of the effects on glucose and lipid metabolism

Hormone replacement therapy (HRT) is prescribed less frequently to women with diabetes. In this article, we review the effects of HRT on glucose metabolism and plasma lipids in women with type 2 diabetes. Current evidence is reassuring about the effects of HRT in women with diabetes, although as in all women, HRT should be prescribed on an individual basis with appropriate consideration given to advantages and disadvantages of therapy.

Vascular effects of estrogen in type II diabetic postmenopausal women

OBJECTIVES

We assessed the effects of estrogen on vascular dilatory and other homeostatic functions potentially affected by nitric oxide (NO)-potentiating properties in type II diabetic postmenopausal women.

BACKGROUND

There is a higher cardiovascular risk in diabetic women than in nondiabetic women. This would suggest that women with diabetes do not have the cardioprotection associated with estrogen.

METHODS

We administered placebo or conjugated equine estrogen, 0.625 mg/day for 8 weeks, to 20 type II diabetic postmenopausal women in a randomized, double-blinded, placebo-controlled, cross-over design.

RESULTS

Compared with placebo, estrogen tended to lower low-density lipoprotein (LDL) cholesterol levels by 15 +/- 23% (p = 0.007) and increase high-density lipoprotein (HDL) cholesterol levels by 8 +/- 16% (p = 0.034). Thus, the ratio of LDL to HDL cholesterol levels significantly decreased with estrogen, by 20 +/- 24%, as compared with placebo (p = 0.001). Compared with placebo, estrogen tended to increase triglyceride levels by 16 +/- 48% and lower glycosylated hemoglobin levels by 3 +/- 13% (p = 0.295 and p = 0.199, respectively). However, estrogen did not significantly improve the percent flow-mediated dilatory response to hyperemia (17 +/- 75% vs. placebo; p = 0.501). The statistical power to accept our observation was 81.5%. Compared with placebo, estrogen did not significantly change E-selectin, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, monocyte chemoattractant protein-1 or matrix metalloproteinase-9 levels. Compared with placebo, estrogen tended to decrease tissue factor antigen and increase tissue factor activity levels by 7 +/- 46% and 5 +/- 34%, respectively (p = 0.321 and p = 0.117, respectively) and lower plasminogen activator inhibitor-1 levels by 16 +/- 31% (p = 0.043).

CONCLUSIONS

The effects of estrogen on endothelial, vascular dilatory and other homeostatic functions were less apparent in type II diabetic postmenopausal women, despite the beneficial effects of estrogen on lipoprotein levels.

The use of hormone replacement therapy in postmenopausal women with type 2 diabetes

In healthy postmenopausal women, estrogen or hormone replacement therapy (ERT or HRT) can alleviate menopausal symptoms and prevent osteoporosis and may also protect against cardiovascular disease (CVD). In addition to improving lipid metabolism, there are reports that estrogen also improves parameters regulating carbohydrate metabolism, including insulin resistance, in healthy women. Therefore, it is likely that ERT or HRT would also benefit women with type 2 diabetes, not only in relieving menopausal symptoms but also in improving the metabolic abnormalities associated with diabetes and in preventing cardiovascular disease.

Physician gender and hormone replacement therapy discussion

Hormone replacement therapy (HRT) is a major issue confronting millions of women today, and general internal medicine and family practice physicians are an important source of information and counseling on this issue. Previous studies have suggested that HRT discussion and prescribing are more frequent with female than with male physicians, but others have suggested age and practice setting may be the reason for observed differences. We attempted to determine if physician gender influenced HRT discussion frequency between physicians and their patients using cross-sectional, secondary analysis of data collected at general internal medicine and family practice clinics at the University of New Mexico Health Sciences Center. Twenty-seven family practice and internal medicine resident physicians (15 female, 12 male) participated. There were 127 female patients age 45 and older. Audio-taped observations of patient-physician visits collected during 1995 for a study on patient-physician communication and patient satisfaction were used. There was less frequent discussion with female than male physicians (OR = 0.42, p = 0.0014). HRT was discussed during 51 visits. Patients initiated HRT discussion in 39.2% of visits in which it was discussed. Patients with diabetes were less likely to discuss HRT (OR = 0.25, p = 0.0122). Increasing year of physician residency was associated with decreased discussion of HRT (OR = 0.51, p < 0.0001). In this health sciences center, with physicians similar in age and training, male physicians discussed HRT significantly more often than did female physicians.

Postmenopause hormone treatment in women with NIDDM or impaired glucose tolerance: the MEDIA randomized clinical trial

OBJECTIVE

To assess the biological safety of four hormone replacement treatment (HRT) combinations in women with non insulin dependent diabetes mellitus (NIDDM) or impaired glucose tolerance (IGT).

SUBJECTS AND METHODS

Randomized, double-blind, placebo-controlled trial to analyze the variation of fibrinogen, factor VII, PAI1, and TG blood levels in women (n=99), with NIDDM or IGT, receiving a 3-month course of either oral oestradiol (1 or 2 mg) combined with Chlormadinone Acetate 5 mg, or transdermal oestradiol 50 microg/24 h in association with Norethisterone Acetate (11.2 or 22.4 mg), or placebo. Follow-up lasted 3 months.

RESULTS

Ninety nine patients, mean age 56 years (SD 5), mean diabetes duration 7 years (S.D. 7), mean glycated hemoglobin (7.3%) were enrolled. There was no significant difference between the groups for any of the primary hemostasis criteria (n=77). Triglycerides (TG) variation significantly differed between groups, P=0.01, from -21% in the large patch group, to +22% in the placebo group (n=82). Treatment administration routes did not significantly differ for any of the criteria. There was a significant difference in the total cholesterol variation between groups, from +8.7% in the placebo group to -10.8% in the oral 1 mg group (P=0.001).

CONCLUSION

The treatments had no highly deleterious effect in these patients with NIDDM or with IGT. Long-term trials can be performed with such patients, and an hormone treatment can be prescribed to relieve symptoms. Since these patients had a well-controlled NIDDM, results might be different in less well-controlled diabetes. The data do not support the hypothesis of an impaired oestrogen effect in patients with NIDDM.

Hormone replacement therapy in postmenopausal women with diabetes mellitus: a risk-benefit assessment

Hormone replacement therapy (HRT) has been shown to be beneficial in reducing osteoporosis and alleviating climacteric symptoms. HRT has been suggested to reduce the risk for coronary heart disease (CHD), but data are controversial. Unopposed estradiol therapy seems to have a favourable effect on lipid profile and glucose tolerance whereas addition of a progestogen may attenuate these favourable metabolic changes. Data on HRT in women with diabetes mellitus are scarce but of potential interest since these women are often characterised by hyperandrogenicity, insulin resistance and dyslipidaemia and are at a high risk for developing CHD. Present evidence suggests that short term unopposed oral estradiol therapy has a beneficial effect on glucose homeostasis, lipid profile and fibrinolytic activity, which may be compatible with a reduced risk for CHD. Accordingly, it may be hypothesised that HRT in women with diabetes mellitus may be at least as beneficial as in women without diabetes mellitus. However, women with diabetes mellitus are at increased underlying risk for venous thromboembolism and endometrial cancer. Whether HRT further increases this risk is not yet clear, but this possibility must be considered. It is, however, likely that the benefits with HRT in postmenopausal women with diabetes mellitus outweigh the risks, but randomised studies are required before any more definite risk-benefit assessment can be made long term.

Effects of hormonal replacement therapy on lipid and haemostatic factors in post-menopausal ESRD patients

BACKGROUND

Hormone replacement therapy (HRT) has been known to have beneficial effects on various atherosclerotic parameters in the general population of post-menopausal women. To evaluate the effects of HRT on those factors in end-stage renal disease (ESRD) patients, we evaluated the changes of lipid profile, coagulation and fibrinolysis markers, and plasma homocysteine levels after treatment.

METHODS

Sixty-five post-menopausal women on maintenance haemodialysis were randomly assigned to either an HRT group (n=33) or a control group (n=32). Median age (range) and duration of haemodialysis (range) were 57 years (40-73) and 42 months (6-150) in the HRT group and 61 years (44-78) and 54 months (8-174) in the control group respectively. Oral conjugated oestrogen (0.625 mg) combined with medroxyprogesterone acetate (2.5 mg) was given daily for 12 weeks to the HRT group. Total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), lipoprotein (a) (Lp(a)), fibrinogen, plasminogen activator type 1 antigen (PAI-1), tissue plasminogen antigen (t-PA), von Willebrand factor (vWF), and plasma total homocysteine (tHcy) were measured before and 12 weeks after the start of the study in both groups.

RESULTS

There was no difference in baseline values between the control and HRT groups. At 12 weeks, HRT increased HDL-C by 12% (P:<0.01) and TG by 20% (P:<0. 01). HRT decreased LDL-C by 9% (P:<0.01), and Lp(a) by 36% (P:<0.01). PAI-1 and t-PA concentrations were also reduced by 21% (P:<0.01) and 9% (P:<0.05) respectively. The mean values of TC, fibrinogen, vWF, and tHcy levels did not change significantly after HRT.

CONCLUSIONS

The above results suggest that HRT has favourable effects on atherosclerosis risk parameters in post-menopausal women with ESRD as in the general population of post-menopausal women.

Diabetic dyslipidaemia: current treatment recommendations

Insulin deficiency and hyperglycaemia in type 1 (insulin-dependent) diabetes mellitus produce lipid abnormalities, which can be corrected by appropriate insulin therapy. Diabetic nephropathy, which is the main risk factor for coronary heart disease (CHD) in type 1 diabetes, causes pro-atherosclerotic changes in lipid metabolism. Detection and treatment of elevated cholesterol levels is likely to be of benefit in these patients. Type 2 (noninsulin-dependent) diabetes mellitus is associated with abnormal lipid metabolism, even when glycaemic control is good and nephropathy absent. Elevated triglyceride levels, reduced high density lipoprotein (HDL) cholesterol and a preponderance of small, dense low density lipoprotein (LDL) particles are the key abnormalities that constitute diabetic dyslipidaemia. The prevalence of hypercholesterolaemia is the same as for the nondiabetic population, but the relative risk of CHD is greatly increased at every level of cholesterol. Based on effectiveness, tolerability and clinical trial results, treatment with HMG-CoA reductase inhibitors to lower LDL cholesterol is recommended as primary therapy. These agents are also moderately effective at reducing triglyceride and increasing HDL cholesterol levels. If hypertriglyceridaemia predominates, treatment with fibric acid derivatives is appropriate, although there is currently only limited clinical trial evidence that the risk of CHD will be reduced. In type 1 diabetes, but particularly in type 2 diabetes, lipid disorders are likely to contribute significantly to the increased risk of macrovascular complications. especially CHD. Management of the disordered lipid metabolism should be given a high priority in the clinical care of all patients with diabetes.

Pharmacodynamics of oestrogens and progestogens

The ovaries cyclically secrete estradiol and progesterone. Cyclic ovarian estradiol secretion is associated with a bone-saving and vascular protection effect. Endogenous progesterone does not modify the vasodilator effect of oestrogens. At physiological concentrations, the natural sex steroids have low antigonadotropic effects. More potent synthetic derivatives with more antigonadotropic effects were synthesized in the 1950s. After the menopause, there is no longer any need to use hormonal steroids as antigonadotropics. In addition, vascular contraindications are more common in an older population. Contraceptive steroids (particularly ethinyl estradiol) are therefore rarely used. The oestrogen that is most widely prescribed for post-menopausal replacement is a complex formulation of conjugated oestrogens of equine origin that is administered orally in a single daily dose. Improvements in hormone replacement therapy may result from the use of parenteral estradiol (providing sufficient doses are reached) and of a progestogen chemically more similar to progesterone.

Lipoproteins and low-dose estradiol replacement therapy in post-menopausal Type 2 diabetic patients: the effect of addition of norethisterone acetate

AIMS

Low-dose continuous oestrogen/progestogen may increase patient compliance long-term but the cardioprotective effects in diabetes are unknown. The aim of this study was to compare the effect of low-dose oral oestrogen (1 mg, 17-beta-estradiol) treatment with oestrogen (1 mg 17-beta-estradiol) in combination with low-dose (0.5 mg) continuous norethisterone acetate (NETA) on lipoproteins in Type 2 diabetic patients.

METHODS

Thirty-four post-menopausal Type 2 diabetic patients in moderate control (mean haemoglobin A1c 7.7%) who had a serum oestradiol level of < 50 pg/ml were examined over a 6-month period. Serum lipids, and lipoprotein composition of very low density lipoprotein (VLDL), low density lipoprotein (LDL) and high density lipoprotein (HDL) were measured. Serum lipoprotein(a) was determined by an ELISA method, LDL fatty acids by gas-liquid chromatography and LDL oxidizability by thiobarbituric acid reactive substances (TBARS assay). Cholesteryl ester transfer protein (CETP), and cell cholesterol were measured.

RESULTS

There was a reduction in serum cholesterol on both treatments but no significant difference between treatment groups. LDL cholesterol decreased by 17% in each group. There was a no significant difference between the groups in serum VLDL or HDL cholesterol or serum triglycerides during the study. The change in lipoprotein(a) during the study was not significantly different between the groups. There was no significant difference in 4 h LDL oxidizability between groups. Although CETP increased with time in both groups there was no significant difference in the change between the groups.

CONCLUSION

In this small study, the addition of continuous low-dose NETA did not reduce the potentially beneficial effects of low-dose 17-beta-estradiol on the progression of atherosclerosis in diabetes.

The effects of hormone replacement therapy on plasma lipids in type II diabetes

OBJECTIVES

The effects of hormone replacement therapy on cardiovascular risk factors in postmenopausal women with non-insulin dependent diabetes mellitus (type II diabetes) is uncertain.

METHODS

The effects of estrogen replacement therapy (ERT, conjugated equine estrogen0.625mg orally daily), combined estrogen and continuous progestogen therapy (HRT, 0.625 mg of conjugated equine estrogens plus medroxyprogesterone acetate 5 mg daily) or placebo was compared in 20 postmenopausal type II diabetic women and 20 normal postmenopausal women in a double blind, randomised, crossover study. Patients receiving insulin were excluded from the study and all lipid modifying drugs were ceased at least 4 weeks prior to randomisation. Other medication including oral hypoglycaemics was kept constant for the duration of the study.

RESULTS

Women with type II diabetes were a similar age (58.7+/-1.3 years) to the non-diabetic women (59.6+/-1.6 years) but they had a significantly greater body mass index, a higher incidence of treated hypertension, higher fasting plasma glucose levels, higher triglycerides and lower HDL cholesterol levels than non-diabetic women. ERT reduced total cholesterol and LDL cholesterol by a similar extent (8.9-12.3%) in normal and type II diabetic women and increased HDL cholesterol to a similar extent in both groups (11.0 and 8.9% respectively). ERT did not significantly alter fasting triglyceride levels in either group. The addition of medroxyprogesterone acetate 5 mg daily abolished the increase in HDL cholesterol associated with ERT in both groups but did not significantly affect any of the other lipid measurements. ERT and HRT did not significantly alter fasting insulin levels nor alter fasting glucose levels in either non-diabetic women or women with type II diabetes.

CONCLUSIONS

ERT and HRT have similar effects on lipids in women with type II diabetes and non-diabetic women after 1 month of therapy.

Screening for cardiovascular disease. Concepts, conflicts, and consensus

CVD in the United States is prevalent, costly, and disabling. Wherever in the arterial tree atherosclerosis occurs, the process appears to begin in youth, to develop under the influence of the same risk factors, and to be amenable to the same interventions. The relationship between CVD and its associated risk factors is continuous, is graded, and extends below thresholds previously defined as normal. This observation, in turn, is based on an appreciation that in our society, the gap between normal and optimal can be considerable. CVD is a multifactorial process, often related to modifiable lifestyle choices; we focus on any single risk factor to the exclusion of others puts patients in danger. Because risk factors rarely occur in isolation, risk assessment must be as multifactorial as the underlying disease process. By understanding differences between risk factors in terms of the impact of their modification on the underlying disease, targeted interventions become possible that are tailored to the likelihood of an individual patient acquiring CVD. To change the overall prevalence of an epidemic disease such as CVD, however, such a high-risk approach must be applied in concert with a population strategy that seeks to effect smaller degrees of change in the large segment of society that may be at only moderate risk but--because of their great numbers--bears most of the morbidity and mortality of CVD. Finally, despite the remarkable progress that has been made in our understanding of the pathophysiology of CVD and the effectiveness of risk factor modification, significant gaps remain between knowledge and behavior. Fewer than 50% of diabetics are even aware that they have the disease. Only a third of those whose lipid levels qualify them for treatment receive intervention of any kind, including dietary advice. Only 27% of hypertensives have their blood pressure adequately controlled. The potential impact of more vigorous screening practices in the primary care setting on the health of individuals and communities cannot be overstated.

Effect of 17-beta estradiol on pre-existing atherosclerotic lesions: role of the endothelium

The atheroprotective effects of estrogen during the process of atherogenesis is well documented, whereas limited information is available about the effect of estrogen on pre-existing atherosclerotic lesions. After bilateral ovariectomy, 24 New Zealand White rabbits were randomized into three groups of eight animals each and subsequently fed a 0.5% cholesterol diet. In group I, the vessels were excised at day 84, whereas in group II, the cholesterol diet was continued for a total of 168 days. In group III, the animals were first fed with a cholesterol diet for 84 days; in the second phase of the experiment, the cholesterol diet was continued for a further 84 days with a combined estrogen treatment (1 mg estradiol valerate per kg body weight per week intramuscularly). At the end of the experiment, the proximal aortic arch, right carotid artery, thoracical aorta and abdominal aorta of each animal were excised and prepared for histological and immunohistological examination. By day 168, morphometrical analysis displayed a significantly lower plaque development under estrogen therapy in the carotid artery (0.08+/-0.18 mm(2) vs. 0.60+/-0.39 mm(2)), the thoracic aorta (0.56+/-0.94 mm(2) vs. 3.63+/-2.06 mm(2)), and in the abdominal aorta (0.55+/-0.70 mm(2) vs. 1.71+/-1.05 mm(2)) in comparison with the corresponding 168 day control group. However, estrogen treatment has failed to reduce further atherosclerotic plaque development in the aortic arch (9.42+/-1.79 mm(2) vs. 11. 64+/-3.29 mm(2)). Immunohistological detection of the 'anti-human factor VIII related antigen', i.e. the 'von Willebrand factor' (vWF), showed a significantly lower number of luminal cells positive for vWF in the aortic arch in the 84-day cholesterol group, compared with the corresponding controls of normocholesterolemic rabbits (65. 9+/-12.4% vs. 83.1+/-6.2%; P<0.05). Estradiol was able to inhibit the further progression of atherosclerosis when moderate vessel wall alterations were present, whereas pre-existing severe atherosclerosis was associated with a failure of the anti-atherosclerotic estrogen action. As suggested by the in situ detection of vWF as a morphological marker for endothelial cells, an intact endothelial layer might play an important role in mediating the beneficial effect of estrogen in the process of atherosclerosis.

Improving the adverse cardiovascular prognosis of type 2 diabetes

Approximately 80% of all patients with diabetes die of cardiovascular disease. The traditional management of type 2 diabetes has been ineffective in altering this dismal prognosis. Insulin resistance is the fundamental defect of type 2 diabetes. Insulin resistance often leads to hyperinsulinemia, which is associated with hypertension, atherogenic dyslipidemia, left ventricular hypertrophy, impaired fibrinolysis, visceral obesity, and sedentary lifestyle. Although all these conditions are associated with atherosclerosis and adverse cardiovascular events, the therapeutic efforts in patients with diabetes have focused predominantly on normalizing glucose levels. Improved insulin sensitivity through lifestyle modifications or pharmacologic therapy (troglitazone and metformin) will lower both insulin and glucose levels as well as diminish dyslipidemia and hypertension. In contrast, sulfonylurea agents lower glucose by increasing insulin levels and may increase the risk of cardiovascular events. Therapy including aspirin, lipid agents (for example, statins), angiotensin-converting enzyme inhibitors, beta-adrenergic blockers, postmenopausal estrogen replacement, and vitamin E should be considered for patients with type 2 diabetes. In most patients with diabetes who have multivessel coronary artery disease, coronary artery bypass grafting is superior to coronary angioplasty for improving long-term cardiovascular prognosis. This superiority is mediated in part by the use of a left internal mammary graft to the left anterior descending coronary artery. Urgent coronary angioplasty or thrombolytic therapy should be considered for all patients with diabetes who have acute myocardial infarction.

Estrogen induces glomerulosclerosis in analbuminemic rats

Progression of chronic renal disease is usually more rapid in males, both in humans and in experimental animals. Estrogen-replacement studies indicate that this may be related to the beneficial effects of estrogen on the lipoprotein profile. However, in hyperlipidemic analbuminemic rats (NAR), females are more prone to develop renal injury than males, and ovariectomy tends to decrease triglyceride levels and prevent renal disease. Therefore, we studied the effects of estrogen administration on lipoproteins, and the induction of renal injury in uninephrectomized female and male NAR. Ovariectomized and orchidectomized uninephrectomized NAR were treated with estradiol implants for 24 weeks. In an additional group of ovariectomized rats, the implant was removed after 12 weeks. Both in ovariectomized and orchidectomized NAR, estradiol caused severe hypercholesterolemia (9 to 12 mmol/liter) and hypertriglyceridemia (6 to 8 mmol/liter) after six weeks. Subsequently, these rats developed severe proteinuria, reaching 209 +/- 25 and 95 +/- 43 mg/day, respectively, after 24 weeks. At this point there was severe glomerular sclerosis, with a respective score of 107 +/- 21 and 61 +/- 33. In terminal blood samples the most pronounced increase in lipid levels were observed in very low density lipoproteins (VLDL), intermediate density lipoproteins (IDL) and low density lipoproteins (LDL). In contrast, ovariectomized NAR and orchidectomized NAR without exogenous estrogen had much lower lipid levels (cholesterol 5 to 7 mmol/liter and triglycerides 1 to 2 mmol/liter) after six weeks. These rats, or ovariectomized NAR where the estrogen treatment had been withdrawn, had practically no proteinuria (4 +/- 1, 19 +/- 11, and 13 +/- 4 mg/day, respectively) or renal damage (glomerulosclerosis score 1 +/- 0.4, 5 +/- 3 and 3 +/- 1, respectively) after 24 weeks. Thus, in hypertriglyceridemic analbuminemic rats, estrogen-treatment causes further increases in both triglycerides and cholesterol. Most probably these changes contribute to the development of renal injury by estrogen in this model. This effect of estrogen, which has also been observed in the Zucker rat, is unique for the hypertriglyceridemic state and deserves further study.

[Age related decrease of high density lipoproteins (HDL) in women after menopause. Quantification of HDL with genetically determined HDL arylesterase in women with healthy coronary vessels and in women with angiographically verified coronary heart disease]

BACKGROUND

The decline in the concentration of high density lipoproteins (HDL) observed in postmenopausal women is thought to contribute to the increasing incidence of coronary artery disease (CAD) after menopause. Human serum arylesterase (EC 3.1.1.2) is exclusively associated with HDL. We therefore investigated possible differences in the decline of HDL-levels and of HDL-subfractions HDL2 and HDL3 between postmenopausal women without and with angiographically documented CAD.

PATIENTS AND METHODS

HDL-, HDL2-and-HDL3- concentrations were studied in postmenopausal women with angiographically documented CAD (n = 24; 51 to 72 years mean: 62 years) and compared to HDL-parameters of women without CAD (n = 22; 51 to 81 years, mean: 58 years). Arylesterase activities of HDL2-and HDL3-subfractions and HDL2-cholesterol concentrations were determined after differential precipitation with polyethylene glycol (4.7 mM PEG). Phenotyping of HDL-arylesterase was achieved in CAD patients and in women without CAD after determining hydrolysis of arylesterase substrates paraoxon (PO) and phenylacetate (PA) by calculating paraoxonase/arylesterase activity ratios R (R = [PO]/[PA] x 1000): phenotype A (n = 26) with R < 2.5, phenotype AB (n = 16) with 5.0 < R < 10.7, and phenotype B (n = 4) with R > 13.5.

RESULTS

In postmenopausal women with documented CAD, as compared to women without CAD, HDL-cholesterol (55 +/- 3 mg/dl vs. 69 +/- 3 mg/dl HDL2-arylesterase (25 +/- 1 kU/l vs. 33 +/- 2 kU/l), and HDL3-arylesterase (89 +/- 4 kU/l vs. 106 +/- 5 kU/I) were found to be significantly reduced. Analysis of the correlation of lipid parameters and age revealed in CAD patients, but not in postmenopausal women without CAD, a significant increase of total cholesterol (r = 0.42), and significant reductions of both HDL2-arylesterase (r = -0.47) and HDL3-arylesterase (r = 0.74) with increasing age. In contrast, HDL-cholesterol (r = -0.14) and HDL2-cholesterol (r = -0.06) of CAD patients showed only slight and non-significant reductions with age. Since HDL3-arylesterase was found to be age-dependently reduced in women without CAD (r = 0.17), HDL2-arylesterase of postmenopausal women, among all lipid parameters showed the most pronounced differences between women without CAD and CAD patients. The age-dependent decrease of HDL2-arylesterase in postmenopausal women with CAD does not result from an increased frequency of B-allele carriers in the subgroup of CAD patients with an age above the median (64 years).

CONCLUSION

Genetically determined serum HDL-arylesterase is well suited to quantify HDL in postmenopausal women without and with CAD. HDL2-arylesterase of postmenopausal women should be evaluated as a screening parameter for both primary and secondary CAD prevention.

Metabolic effects of tibolone in postmenopausal women with non-insulin dependent diabetes mellitus

OBJECTIVE

Postmenopausal women with non-insulin dependent diabetes (NIDDM) are frequently obese, hypertensive and hyperlipidaemic and hence at particular risk of coronary heart disease (CHD). They might therefore benefit from menopausal therapy. In view of the improvement in insulin sensitivity and the reduction in triglyceride levels induced by tibolone in healthy postmenopausal women we evaluated the effects of 12 months of tibolone on glycaemic control, serum insulin and lipid levels in postmenopausal women with NIDDM.

DESIGN

A prospective 12 months before/after intervention study.

PATIENTS

Fourteen postmenopausal women (mean age 58.14 +/- 1.25 years; mean duration of menopause 121.21 +/- 13.42 months; mean BMI: 26.55 +/- 0.97) with NIDDM (mean duration of diabetes 113.79 +/- 13.89 months).

MEASUREMENTS

Fasting and postprandial blood glucose levels were assessed monthly, serum fructosamine, fasting and postprandial insulin every 3 months and serum lipids (total cholesterol, triglyceride, HDL-cholesterol and LDL-cholesterol) every 6 months.

RESULTS

Changes in blood glucose, both fasting and postprandial, were not statistically significant during the treatment period. Serum fructosamine concentration increased significantly after 9 months. A significant decrease in fasting and postprandial insulin concentrations was observed after 9 months. A non-significant decrease was observed in total cholesterol, LDL cholesterol and triglyceride but no change in HDL cholesterol. Body weight did not change during the period of observation.

CONCLUSION

A slight deterioration in glycaemic control, a fall in insulin concentration and no change in serum lipids were observed in women with NIDDM during 12 months treatment with tibolone.

Menopause in normal and uncomplicated NIDDM women: physical and emotional symptoms and hormone profile

OBJECTIVE

To compare the physical characteristics, emotional symptoms and metabolic conditions of menopausal women with and without non insulin dependent diabetes mellitus (NIDDM).

METHODS

We studied 100 menopausal women 45-72 years of age, 51 with and 49 without NIDDM, in a cross-sectional design. Biological characteristics were collected and emotional symptoms were assessed with a modified Hamilton and Bech-Rafaelsen scale, scoring depression, anxiety, non specific symptoms of depression (NSSD) and the empty nest syndrome (ENS). Weight, body mass index (BMI), waist/hip and abdomen/hip ratios and percent of body fat were registered. The sulfoconjugated form of the dehydroepiandrosterone (DHEAS), follicle stimulating hormone (FSH), cortisol and fasting, as well as postprandial insulin/glucose ratios, were measured in blood.

RESULTS

Women with NIDDM had earlier mean age for menopause, more central obesity and less peripheral fat; they had also more prevalent emotional symptoms than non diabetic menopausal women. In women with NIDDM, symptoms were associated with years since diagnosis and with BMI. In non diabetic menopausal women schooling and attitudes to sexuality were associated with symptoms. FSH was inversely associated with BMI in both diabetic and non diabetic women; postprandial insulin/glucose ratio was correlated with central obesity in the group without NIDDM and cortisol with sitting systolic blood pressure (SBP) in the group with NIDDM.

CONCLUSION

The diagnosis of NIDDM and its metabolic conditions were associated with an increased frequency of some symptoms in menopausal women.

The clinical decision regarding hormone replacement therapy

The complexity of the decision to recommend hormone replacement therapy (HRT) for the postmenopausal woman depends on the medical status of the patient, her concerns and goals, and the indications being considered. This article suggests a practical approach that leads to informed, collaborative decision making between the health care professional and patient.