Women and Diabetes- The Primary Care Perspective. Sara G. Tariq, M.D., F.A.C.P. Associate Prof, Internal Medicine

Transcription

1 Women and Diabetes- The Primary Care Perspective Sara G. Tariq, M.D., F.A.C.P. Associate Prof, Internal Medicine

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4 Goals/Objectives Highlight issues in Diabetes risk factors/ management specific to women PCOS Candidal Infections Sexual Dysfunction Pregnancy

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6 We know how big DM is! Estimated 7% of US population is diabetic Twice that many have pre-diabetes 21% of those over 60 have diabetes 45% of new diagnoses are being made in children and adolescents

7 Ms. C 35-year-old woman who presents to your clinic to establish care. She has recently been diagnosed with DM after being seen in the ED two weeks ago with blurry vision, deemed secondary to hyperglycemia. They started her on Metformin and told her to follow up with her PCP. Labs from the ED show BS in 350 range, HbAIC 12%, BMP normal, CBC normal. UA is negative

8 Ms. C PMHx- PCOS PSHx- C-section X 2 Fam Hx- Mother had breast cancer, father had DM Meds- Metformin 500 mg daily All- NKDA Soc Hx- Her mother lives with her, currently divorced. Works in IT, more than 50 hours/week. Supports both kids on her own. No T/E/D. Has little knowledge about DM, less time to manage it. Currently sort of dating a gentleman- sexually active, using appropriate contraception, no h/o STIs

9 Ms. C Ob/Gyn- G2P2, had gestational DM with second child. ROS + blurry vision + fatigue +polydipsia, polyuria + sexual dysfunction + Recurrent yeast infections

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11 Larger Issues to Consider With chronic illness comes unique challenges Patient engagement through partnership Self-management through education Empowerment through both

12 Larger Issues to Consider With chronic illness comes unique challenges Patient engagement through partnership Self-management through education Empowerment through both

13 HCWs have the easier job- we give info Patients have to understand, process, and implement at home

14 Issues to consider for Ms. C What overall approach should one take in managing patients with DM? How strong is the PCOS-Diabetes connection? What is the role of DM with sexual dysfunction? What if she wants to get pregnant?

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17 How to introduce lifestyle changes Have all the patient information Advise in small amounts (2-5 things) Get the patient s view on your recommendation

18 How to introduce lifestyle changes? You must have all the info Take a detailed diet history What does their day look like? Discuss 2 concepts (no more than 5) It is going to be really important for you to cut down on the amount of fast food you eat. Starting exercise will lower your blood sugar naturally- kind of like an insulin shot

19 Motivational Interviewing How confident (on 1-10 scale) are you that you can: Start exercising for 30 minutes- 3 times per week? Prepare your lunches 4 days/week? What would help you be more confident? Miller, W.R. and Rollnick, S. Motivational Interviewing: Preparing People to Change, 2nd ed. NY: Guilford Press, 2002.

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21 Role of Polycystic Ovarian PCOS Syndrome Cause of both menstrual irregularity and androgen excess Frequently associated with obesity Most common cause of infertility One of the most common endocrinopathies in women of reproductive age

22 PCOS and DM Connection The risk of type 2 diabetes is increased in PCOS In a study of 122 obese women with PCOS, 45 percent had either impaired glucose tolerance (35 percent) or type 2 diabetes mellitus (10 percent) by age 40 Diabetes Care. 1999;22(1):141.

23 PCOS and DM connection Up to 85% of women with PCOS are overweight or obese compared with agematched controls Insulin resistance is present in both lean and obese women with PCOS (30 and 70 percent, respectively)

24 How should we screen for DM in pts with PCOS? A two-hour oral glucose tolerance test (OGTT; with measurement of fasting and two-hour glucose) in all women with PCOS at initial diagnosis. If this is not feasible, a fasting glucose should be obtained together with a measurement of the hemoglobin A1C Patients with impaired glucose tolerance should be screened annually for development of type 2 diabetes. American Association of Clinical Endocrinologists Position Statement on Metabolic and Cardiovascular Consequences of PCOS

25 Why am I obsessing over this?

26 The bottom line Undiagnosed diabetes can cause progressive microvascular damage. At the time of diagnosis, approximately 20 percent of newly diagnosed patients with Type 2 diabetes have diabetic retinopathy and 10 percent have nephropathy Arch Intern Med. 1988;148(1):181.

27 Are Diabetic women at increased risk of candidal vaginal infections?

28 Pathophysiology- Candida Increased glucose levels in genital tissues enhance yeast adhesion and growth. Vaginal epithelial cells bind to Candida albicans with greater propensity in diabetic patients than in nondiabetic patients

29 Candida risk factors.. Candida infection associated with Older age Type 1 diabetes (3x more likely than DMII) Abnormal HbA1c level Recent antibiotic use within two weeks BMC Infectious Diseases 2002

30 Treatment In RCTs, oral and topical meds achieved comparable clinical cure rates (>90%) Patients consistently reported a preference for the convenience of oral treatment, even though oral meds take 1-2 days longer to relieve symptoms Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database Syst Rev

31 Should recurrent yeast infections = screening for DM? No current guidelines to screen patients with recurrent vulvovaginal candiasis (more than 4 per year) for Diabetes May raise red flag to screen for DM in woman who has recurrent yeast infections New England Journal of Medicine 1997, 337:1896

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33 Sexual dysfunction Lack of sexual desire Impaired arousal Anorgasmia Pain with sexual activity or a combination of these issues.

34 What is the role of DM in sexual dysfunction? Women rarely bring up their sexual problems Sexual health reflects overall health and QOL How many doctors ask about sexual health as part of history or ROS? Only 35 percent of primary care physicians report that they often or always take a sexual history Do you have any concerns about your sex life or sexual health? Am J Prev Med. 1991;7:141 5.

35 Significantly more women with diabetes (27%) than women in the control group (15%) reported sexual dysfunction DIABETES CARE, VOLUME 25, NUMBER 4, APRIL 2002

36 What is the role of DM in sexual dysfunction? Autonomic neuropathy anorgasmia, difficulty with arousal Decreased vaginal lubrication, resulting in vaginal dryness Decreased or no desire for sexual activityfatigue of DM is a significant factor

37 Is there anything we can treat? Prevent progression of hyperglycemia Get HbAIC to goal Prevent neuropathy

38 What is the PCP s role in managing pregnant patients? Prenatal Pregnancy Post-partum

39 Prenatal Issues in Diabetics Women who are in poor glycemic control during the period of fetal organogenesis, which is nearly complete by seven weeks post-conception: High incidence of spontaneous abortion Fetuses with congenital anomalies Get HbAIC to goal BEFORE attempting to get pregnant Preconception AIC goal : < 6% Diabetes Care. 2013;36 Suppl 1:S11.

40 Gestational Diabetes Hyperglycemia with onset or first recognition during Pregnancy Characterized by accelerated growth of the fetus A rise in blood levels of several diabetogenic hormones that induce insulin resistance Food ingestion results in higher and more prolonged plasma glucose concentration

41 Fetal Risks Macrosomia - shoulder dystocia and related complications LGA children or those born to obese mother have a 7% risk of developing IGT at 7-11 yrs age There is increasing evidence that infants exposed to diabetes in utero have an increased incidence of childhood obesity and diabetes CDA CPG 2008

42 Maternal Risks Increased risk of C-section Pre-eclampsia- partly due to insulin resistance Recurrence risk of GDM is 30-50% 30-60% lifetime risk in developing IFG, IGT or type 2 diabetes Am J Obstet Gynecol. 2010;202(3):255.e1. CDA CPG 2008

43 Management of Gestational Diabetes Strive to achieve glycemic targets Receive nutrition counseling from an Registered Dietitian Encourage physical activity If BG targets are not reached within 2 weeks of diet then insulin therapy should be started Diabetes Care October 2011vol. 34 no

44 Metformin story Metformin is known to cross the placenta American Diabetes Association (ADA) consensus statement advises against oral medications for GDM because of the unknown effects of Metformin to fetus

45 The Metformin Story: MiG Trial 751 women were randomized to receive either metformin or insulin There was no significant difference in the composite fetal outcome between the two groups although preterm birth was found to be increased in the metformin group. Women in the metformin group had less weight gain compared with women in the insulin group ACOG has endorsed the use of oral anti-hyperglycemic agents during pregnancy in the United States Rowan et al. Moore MP; N Engl J Med 2008;358: Obstet Gynecol. 2013;122:406.

46 Post-partum risk Most women with GDM are normoglycemic after delivery. They are at high risk for recurrent GDM, impaired glucose tolerance and overt diabetes over five years Responsibility of the MD to check screen for DM yearly

47 5% take home What overall approach should one take in managing patients with DM? Long-term relationship Patient s daily life How strong is the PCOS-Diabetes connection? Strong enough that PCOS patients need yearly screening for DM What is the role of DM with sexual dysfunction? Multifactorial- getting AIC to goal is central to improving this Pregnancy issues You must get her AIC to less than 6% for optimal pregnancy outcomes GDM Oral meds remain somewhat contraversial Postpartum- yearly screening with fasting glucose or HbAIC

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