Carol J. Homko, RN, PhD, CDE1
1Homko is an associate research professor in the Department of Medicine, Temple University School of Medicine, Philadelphia, PA.
Diabetes is a serious chronic illness that affects ~29 million people in the U.S. Although men and women are equally affected by type 1 diabetes (T1D), the prevalence of type 2 diabetes (T2D) is higher in women than in men. More women die each year from diabetes and its complications than from breast cancer, making diabetes a significant “women’s health issue.”1 Women with diabetes face special health challenges throughout their lives. This chapter examines the available data concerning the impact of diabetes on women, beginning with the implications for childbearing and ending with its effects in later life on the risks of cardiovascular disease (CVD) and osteoporosis.
PREGNANCY IN DIABETES
The American Diabetes Association 2017 Standards of Medicare Care states that for women with preexisting type 1 or type 2 diabetes, starting at puberty, preconception counseling should be incorporated into routine diabetes care for all girls of childbearing potential.2 In 2014, the Centers for Disease Control and Prevention (CDC) reported that up to 9.2% of pregnancies are complicated by gestational diabetes.3 Moreover, recent evidence suggests that the prevalence of both gestational diabetes (GDM) and preexisting diabetes is increasing.4,5 In fact, the rate of preexisting diabetes complicating pregnancy more than doubled from 1999 to 2005 with most of the increase representing women with T2D. White’s classification remains the most commonly accepted system for categorizing diabetes during pregnancy (see Table 27.1).6,7 This system relates the onset of disease, disease duration, and presence of vascular complications to pregnancy outcome. Women in the highest categories and their offspring are at the greatest risk of diabetes-related adverse pregnancy outcomes—that is, a class A pregnancy is at least risk, whereas a class T pregnancy is at highest risk (see Table 27.2).6,7
Table 27.1—White’s Classification of Diabetes in Pregnancy
Class A GDM
Class B Onset at 20 years of age and <10 years’ duration
Class C Onset between 10 and 19 years of age or 10–19 years’ duration
Class D Onset <10 years of age or >20 years’ duration
Class F Diabetic nephropathy
Class R Proliferative retinopathy
Class FR Nephropathy and proliferative retinopathy
Class H Coronary artery disease
Class T Renal transplantation
Table 27.2—Pregnancy Complications
Fetal or neonatal
Altered fetal growth
Worsening of diabetic retinopathy, nephropathy
Respiratory distress syndrome
Pregnancy is recognized as having a profound effect on maternal carbohydrate metabolism. These pregnancy-related alterations are necessary to meet the demands of the developing fetus. Early pregnancy is characterized by greater-than-normal insulin sensitivity, which produces a milieu that favors maternal fat accumulation in preparation for the increasing energy requirements of late gestation and lactation. Late pregnancy is characterized by accelerated growth of the feto-placental unit, increasing plasma concentrations of several diabetogenic hormones, including human placental lactogen and estrogens, and increasing insulin resistance. Studies have demonstrated that insulin sensitivity is reduced by 33–50% by the third trimester of pregnancy.8,9 The cause or causes of this decline in insulin sensitivity are not entirely clear. The parallel development of insulin resistance and increases in blood levels of human placental lactogen and other diabetogenic hormones, including cortisol, progesterone, and estrogens, suggest that these hormones are responsible for much of the observed insulin resistance. In healthy pregnant women, insulin secretion must be increased by 200–300% in late gestation to overcome insulin resistance and to maintain euglycemia. Women who are unable to increase their insulin secretion to compensate for the physiological changes of advancing gestation go on to develop impaired glucose tolerance (IGT) and GDM.
Diabetes-Related Congenital Malformations
Congenital malformations continue to complicate between 6% and 10% of all diabetic pregnancies and account for ~40% of the perinatal mortality among these infants.10 The malformations associated with diabetes can involve multiple organ systems, but the cardiovascular and nervous systems most frequently are involved. The defects most often associated with diabetes occur before the seventh week of gestation. Both animal and human studies have demonstrated that diabetes-associated malformations are related to hyperglycemia during the period of organogenesis.10–13 In addition, numerous clinical trials in humans have demonstrated that strict glycemic control before and during early pregnancy can, in most cases, reduce the rate of structural defects to the background level.14,15 Despite this evidence, ~60% of women with diabetes still seek medical care only after they learn that they are pregnant.16
Care of women with T1D or T2D ideally begins 3–6 months before conception to allow for sufficient time to evaluate the mother’s health status and to maximize glycemic control. The prepregnancy assessment includes a careful history and thorough physical examination to assess the patient’s vascular status. Baseline creatinine clearance and protein excretion levels are evaluated, and an electrocardiogram is performed. Ideally, these women are referred for an ophthalmologic consultation. Care should include counseling about the risks associated with hyperglycemia. Achieving low-risk glycemia requires a plan for reaching glycated hemoglobin A1c (A1C) levels <6.5% to reduce the risk of congenital abnormalities.2 This level of blood glucose control needs to be achieved before the woman is advised to become pregnant, and women need to receive appropriate contraceptive therapy while they are preparing for pregnancy. For patients who have not met treatment goals, an extensive period of education and the initiation of self–blood glucose monitoring are also necessary.17 Women with T2D controlled with oral antihyperglycemic agents that are classified as teratogenic need to begin insulin therapy.
• Maximize glucose control
• History and physical examination for vascular status
• Baseline creatinine clearance
• Baseline urine total protein
• Fundoscopic examination (ideally before pregnancy or in the first trimester)
GDM is a common problem. It complicates ~7–14% of all pregnancies in the U.S.,4 and data demonstrate that the prevalence is increasing.4,18 The likelihood of developing GDM is increased significantly among certain subgroups, including individuals with a family history of T2D, advancing maternal age, obesity, and nonwhite ethnicity. Excess risks for both GDM and IGT have been demonstrated in African American, Hispanic, and Native American women as well as in women from the Indian subcontinent and the Middle East.19
Glucose testing is recommended for women in all high-risk groups and should be done at the first prenatal visit to evaluate for and diagnose overt diabetes. The diagnostic criteria for GDM differ around the world and are currently a topic of much debate. GDM screening can be accomplished using either the traditional two-step approach that utilizes a 3-h oral glucose tolerance test (OGTT) for women who screen positive on the glucose challenge test or using the one-step approach that utilizes a 2-h 75 g OGTT.20 Diagnostic criteria differ between these two approaches. The one-step approach is based on the findings of the Hyperglycemia and Adverse Pregnancy Outcome study,21 and originally was championed by the International Association of Diabetes and Pregnancy Study Groups (IADPSG).22 Screening should be performed between the 24th and 28th week of gestation for those of average risk and in women at high risk whose initial screening did not lead to diagnosis of GDM or overt diabetes (see Chapter 1, Nurse’s Roles Evolve in Diabetes Care and Education).
The presence of fasting hyperglycemia (>105 mg/dL [>5.8 mmol/L]) may be associated with an increase in the risk of intrauterine fetal death during the last 4–8 weeks of gestation. GDM also is associated with an increased incidence of maternal hypertensive disorders.23
Management of Pregnancy Complicated by Diabetes
The main goal of management for pregnancies complicated by diabetes is to achieve or maintain euglycemia throughout gestation. The treatment approach requires a combination of medical nutrition therapy, exercise, insulin therapy, and daily multiple blood glucose determinations. The goals of nutrition therapy are to provide adequate maternal and fetal nutrition, to achieve appropriate gestational weight gain, and to minimize glucose excursions. For both women with preexisting diabetes and those with GDM, guidelines suggest that the composition of the meal plan should be based on an individualized nutritional assessment. In GDM, it is generally accepted that the amount and type of carbohydrate can be adjusted to achieve postprandial glucose targets.24
Evidence regarding the risk and benefits of either periodic or regular exercise in pregnant women with preexisting diabetes is limited. Mild exercise in the form of walking, however, is possible for most women and has been reported to improve lipid profiles and blood glucose control.25 In GDM, exercise has been recommended as an adjunct to nutritional therapy. Regular aerobic exercise has been shown to lower fasting and postprandial glucose concentrations. Several randomized controlled trials have demonstrated that upper-extremity exercise for 20 min three times a week can significantly lower blood glucose levels in women with GDM.26,27 In addition, these trials found no significant increase in either maternal or neonatal complications.
In the U.S., insulin is the only therapy approved for the treatment of diabetes during pregnancy. Evidence has supported the use of glyburide and metformin as useful and clinically effective alternatives to insulin for women with GDM,28,29 but both cross the placenta to the fetus, with metformin likely crossing to a greater extent than glyburide. All oral agents lack long-term safety data. Therefore, current the American Diabetes Association’s 2017 Clinical Practice Guidelines2 recommend insulin as the first-line agent for treatment of gestational diabetes., because insulin does not cross the placenta to a measurable extent. Sulfonylureas had been suggested as a safe alternative, but several recent meta-analyses and large observational studies have suggested that in comparison with metformin and insulin, there was an increased risk for neonatal hypoglycemia and macrosomia.2 The goal of pharmacotherapy is to achieve blood glucose levels that are nearly identical to those observed in healthy pregnant women.
Several approaches to insulin administration can be used during pregnancy, and the superiority of one regimen over another has never been fully demonstrated. None of the currently available insulin preparations have been demonstrated to cross the placenta. The rapid-acting insulin analogs with peak hypoglycemic action 1–2 h after injection offer the potential for improved postprandial glucose control. Studies support their safety during pregnancy and their ability to improve glycemic control.30,31 Continuous subcutaneous insulin infusion pumps are another treatment option that has been used successfully during pregnancy.32
Diabetes control is monitored through blood glucose levels, ketone measurements, and A1C concentrations. It is widely accepted that the level of metabolic control achieved in the pregnancy complicated by diabetes significantly affects perinatal outcome. Emerging evidence suggests that a continuum of risk exists between carbohydrate intolerance and both perinatal and neonatal morbidity. The A1C is lower in normal pregnancy than in normal nonpregnant women due to the increase in red blood cell turnover. The A1C target in pregnancy is 6–6.5%, although <6% may be optimal if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% if necessary to prevent hypoglycemia.2 The logical approach is to achieve as near-normal glucose levels as possible without undue severe hypoglycemia. The most recent recommended plasma blood glucose goals in pregnancy are ≤95 mg/dL fasting; ≤140 mg/dL 1-h postprandial; and ≤120 mg/d 2-h postprandial.2 It may be difficult for women with T1D to meet these goals without significant hypoglycemia. Less stringent targets may be appropriate for some women.2
Antepartum and Intrapartum Management
Guidelines for the antepartum management of pregnant women with diabetes can be found in Table 27.3. Early enrollment in prenatal care is encouraged for all women with preexisting diabetes. The frequency of prenatal visits will depend on the level of glycemic control. Maternal blood pressure should be evaluated at each visit, and all pregnancies complicated by diabetes require additional fetal evaluation and assessment. Fetal ultrasonography in the first trimester or early in the second trimester allows confirmation of gestational age and helps to verify the absence of any malformations. A fetal echocardiogram in midpregnancy is used to screen for congenital heart defects. Serial ultrasounds thereafter are used to assess fetal growth, measure amniotic fluid volume, and evaluate the placenta.33
Table 27.3—Monitoring a Pregnancy Complicated by Diabetes
• Daily self-monitoring of blood glucose (fasting and 1–2 h after meals)
• Serial ultrasound examinations in third trimester
• Nonstress test at 34–36 weeks, then weekly
• A1C every 4–6 weeks
• No 24-h urine, ophthalmologic evaluation, or fetal electrocardiogram necessary
Classes B and C
• Daily self-monitoring of blood glucose (5–7 times/day)
• Level II ultrasound and fetal electrocardiogram at ~20 weeks, then follow-up every 4–6 weeks
• A1C every 4–6 weeks
• Nonstress test at 32 weeks, then weekly
• Ophthalmologic evaluation, follow-up according to findings
• 24-h urine, initially and in each trimester
• Daily fetal movement counts (beginning at 28 weeks’ gestation)
Classes D to FR
• Above, plus electrocardiogram initially
• Uric acid, liver function test, fibrinogen, fibrin split products (may repeat in each trimester)
During labor and delivery, optimal blood glucose control should be maintained to prevent neonatal hypoglycemia. Maternal blood glucose levels should be maintained at a level <100 mg/dL by using an insulin and/or glucose infusion. After delivery, maternal insulin requirements tend to dramatically fall as a result of the significant decrease in the level of placental hormones.
Because of the high risk of developing T2D after GDM, women should have their glycemic status retested 4–12 weeks after delivery according to standard (nonpregnant) diagnostic criteria and at least every 3 years thereafter.18 Only 34% to 73% of women with GDM complete the recommended postpartum glucose screening. A recent review of the literature indicated that the most common barriers to postpartum screening included clinician perception that screening guidelines are inconsistent, patient cost and inconvenience, lack of documentation of a history of GDM on patient problem lists, and poor communication between obstetricians and primary care providers.34 Opportunities for the earlier diagnosis of diabetes and prediabetes clearly are being missed and therefore greater emphasis needs to be placed on the retesting as part of postpartum patient education.
The primary goal of the postpartum period for women with preexisting diabetes is continued maintenance of euglycemia. An immediate decrease in insulin requirements will be noted in women with T1D, T2D, and GDM. Typically, women with GDM who required insulin during pregnancy will no longer need insulin after delivery. Women with T1D may need very little insulin for up to 48 h after delivery. Lack of a reduction in insulin requirement may signal an underlying infection.
In light of the immediate nutritional and immunological benefits of breast-feeding for the baby, all women including those with diabetes should be supported in attempts to breast-feed. Women who breast-feed are more likely to need less insulin than mothers who do not breast-feed. Mothers should be encouraged to monitor blood glucose regularly. Breast-feeding mothers expend more energy and require more calories than non–breast-feeding mothers. Education on the prevention of hypoglycemia should be provided. Additional blood glucose testing and snacks may be required before, during, or after breast-feeding.35
For women with GDM, the goal is to prevent subsequent diabetes. An individualized reproductive health plan will need to be developed that addresses contraception, importance of planning future pregnancies, and lifestyle changes aimed at preventing diabetes or its long-term complications. Both metformin and intensive lifestyle intervention prevent or delay progression to diabetes in women with prediabetes and a history of GDM. The risk of GDM occurring in subsequent pregnancies has been reported to be 60–90%, depending on the woman’s weight in the first trimester.36 If GDM occurred in the first pregnancy, woman have a 13.2-fold increased risk of developing gestational diabetes in a second pregnancy.37
The use of contraception in all women with diabetes or a prior history of GDM not wishing to become pregnant cannot be emphasized strongly enough. Contraception is the only way to ensure that preconception care can be provided. A variety of family planning methods are currently available. Natural family planning is a contraceptive method that requires that women abstain from intercourse during the fertile phase of the menstrual cycle. Barrier methods of contraception create mechanical or chemical barriers to fertilization and include diaphragms, male and female condoms, spermicidal foam, jelly or foam, and cervical caps. Although these methods do not pose health risks to women with diabetes, they are user dependent and therefore have a high failure rate, particularly in the first year after delivery.
Oral contraceptives remain the most popular form of birth control despite controversy over potential side effects. The main reasons for their popularity include their low failure rate (generally <1%) and ease of use. Low-dose formulations are preferred and are recommended only for patients without vascular complications or additional risk factors, such as smoking or a strong family history of myocardial disease. Their effects on carbohydrate and lipid metabolism are minimal. Progestin only (“minipill”) oral contraceptives are an option for women with contraindications to the estrogen component, such as hypertension or thrombosis.38
An intrauterine device (IUD) is the most effective nonhormonal contraceptive device. It should be offered only to women with diabetes who have a low risk of sexually transmitted diseases because any infection might place the patient with diabetes at risk for sepsis and ketoacidosis. Patient education should include the early signs of sexually transmitted diseases, such as increased and abnormal vaginal discharge; dyspareunia; heavy, painful menses; lower abdominal pain; and fever.38,39
Longer-acting progestin-only contraceptives also are available and include an injectable form (Depo-Provera) administered every 3 months and a subcutaneous implant (Implanon) that is replaced every 3 years. Their high efficiency and long period of action make them an attractive option for women with a history of poor medication compliance.38,39 Unfortunately, this long-acting progestin has not been well studied in women with diabetes.
Permanent sterilization, including tubal ligation or vasectomy, may be considered by the patient or her partner when they desire no more children.
Infants of Women with Diabetes
The offspring of women with diabetes have an increased risk for perinatal mortality and morbidity. The two major causes of perinatal mortality are unexplained fetal death and congenital malformations.40 The causes of unexpected death are not well understood. In animal models, sustained hyperglycemia has been associated with increased insulin secretion, elevated fetal oxygen consumption, acidosis, and death. It has been postulated that fetal polycythemia and increased platelet aggregation could explain the increased incidence of intravascular thrombosis in infants of diabetic mothers and that thrombotic episodes could be the underlying cause of late unexplained intrauterine deaths.40–43
Macrosomia is a hallmark of the pregnancy complicated by diabetes and is reported to occur in 20–25% of pregnancies complicated by diabetes. Macrosomia is defined as excessive birth weight (>90%) for gestational age or birth weight >4,000 g. Increased adiposity is the primary cause of the increased birth weight seen in offspring of women with diabetes. Numerous studies have established a relationship between macrosomia and the level of maternal glucose control achieved during pregnancy. Other factors associated with an increased risk for fetal macrosomia include increased maternal weight, increased parity, previous delivery of a macrosomic infant, and insulin requirements >80 units/day.39,40 Perinatal mortality is associated with macrosomia. These infants also have an increased demand for oxygen, and asphyxia can occur, which may account for the increased death rate for macrosomic infants.
Hypoglycemia occurs in infants when plasma glucose levels fall <40–45 mg/dL.42
Infants of mothers with diabetes can develop hypoglycemia during the first few hours of life, particularly in cases of poor glycemic control. Macrosomic infants and infants with elevated cord-blood C-peptide or immunoreactive insulin levels are also at increased risk. The incidence of hypoglycemia is reported to range from 25% to 40% in infants of mothers with diabetes. Both poor glycemic control during pregnancy and elevated maternal plasma glucose levels at the time of delivery increase the risk of its occurrence.
The incidence of hypocalcemia also is significantly increased in infants of women with diabetes. Hypocalcemia generally occurs in association with hyperphosphatemia and occasionally with hypomagnesemia. Neonatal hypocalcemia is defined as a calcium level <7 mg/dL. Serum calcium levels are usually lowest on the second or third day of life.
Polycythemia is defined as a venous hematocrit >65% and is reported to occur in one-third of neonates born to women with diabetes. Polycythemia is believed to occur as a result of chronic intrauterine hypoxia, which leads to an increase in erythropoietin and consequently results in an increase in red blood cell production. Neonates born to women with diabetes also have a higher incidence of hyperbilirubinemia compared with nondiabetic control subjects.40,43
Women who are anovulatory may ovulate when metformin and glitazone are prescribed. Premenopausal women without appropriate contraception may be at risk for pregnancy. All premenopausal women should be counseled regarding the risk for pregnancy and provided guidance regarding appropriate contraception.
Offspring born to women with diabetes are at increased risk of developing various hypertrophic types of cardiomyopathies and congestive heart failure. The exact incidence is not known, but one study reported that 10% of infants born to women with diabetes might have evidence of myocardial and septal hypertrophy. Thickening of the interventricular septum as well as the left or right ventricular wall can occur and is thought to be a result of the fetal hyperinsulinemic state. In most cases, these infants are asymptomatic and the myocardial abnormalities regress by 6 months of age.
Respiratory distress syndrome (RDS) is another common complication associated with diabetes. In the past, offspring born to women with diabetes had a four- to sixfold greater incidence of RDS, but this incidence has decreased dramatically with the initiation of strict metabolic control. More recent studies, in fact, seem to indicate that stringent metabolic control may reduce the incidence of RDS in neonates of women with diabetes to near the background level in the population.40-43 Diabetic pregnancies may pose long-term consequences, including childhood obesity, neuropsychological deficits, and increased tendency to develop overt diabetes.
OTHER WOMEN’S HEALTH ISSUES
Effects of the Menstrual Cycle on Glucose Control
Menstrual cycle–related alterations in blood glucose control have been reported in some women with T1D. Most of these women describe deterioration in glycemic control around the time of menstruation, although some women have reported improvements.44 As a result, both diabetic ketoacidosis and mild and severe hypoglycemia have been noted to occur more frequently during menstruation. The exact mechanism of these changes in glucose homeostasis in women with diabetes is unknown, but it is presumed to be related to changes in levels of estrogen, progesterone, and other reproductive hormones.
Studies examining this phenomenon have yielded controversial results. Some studies have demonstrated decreased insulin sensitivity during the luteal phase compared with the follicular phase, but other studies have not found these differences.44–48 Data from Widom, Diamond, and Simonson49 suggest that a subgroup of women with T1D exhibit worsening premenstrual (luteal phase) hyperglycemia and a decline in insulin sensitivity. In these studies, this deterioration in glucose utilization was associated with greater increments in estradiol levels from the follicular to the luteal phase. From a clinical perspective, women with diabetes need to be counseled regarding the possibility of altered glucose control at various points in the menstrual cycle. They will need to monitor blood glucose levels more frequently and adjust insulin dosages accordingly. In some women, increases in cravings for high-carbohydrate food during the premenstrual phase may further accentuate the loss of glucose control; therefore, attention to meal planning and dietary changes is also important.
Polycystic Ovary Syndrome
Polycystic ovary syndrome (PCOS) is an endocrine disorder that affects 4–6% of all women and is the leading cause of infertility in the U.S. There is no firm consensus as to the definition of PCOS. The diagnosis, however, is based on findings of hyperandrogenism and ovulatory dysfunction after all other known causes of androgen excess or ovulatory dysfunction are excluded. The presence of polycystic ovaries on sonography is suggestive of PCOS but not diagnostic because these can be present in women without PCOS. The vast majority of women with PCOS will demonstrate frank elevations in circulating androgens, particularly free testosterone, and ~60% of these women are obese.49 Although not part of the diagnostic criteria, many women with PCOS are also insulin resistant and exhibit secondary hyperinsulinemia.
PCOS should be suspected in women who present with infertility, amenorrhea or irregular menses, hirsutism, acne, and obesity. Acanthosis nigricans may be present, as well as dyslipidemia.50 PCOS tends to develop shortly after menarche and persists throughout most of the woman’s reproductive life. The menstrual irregularities and hyperandrogenism appear to normalize as women approach perimenopause. The associated metabolic abnormalities, especially glucose intolerance, actually worsen with age. The inherent insulin resistance present in PCOS that is aggravated by the high prevalence of obesity places these women at increased risk of IGT. Approximately 40% of individuals with PCOS develop either T2D or IGT.51,52
The most common reason that women with PCOS present to the gynecologist is infertility, secondary to chronic anovulation. Treatment with metformin in combination with clomiphene has been shown to be effective in restoring ovulation. Weight reduction also helps to improve insulin sensitivity and restore ovulation. Women with PCOS are at increased risk for spontaneous abortions as well as the development of GDM during pregnancy. Treatment of PCOS with metformin during pregnancy has been associated with reductions in both spontaneous abortion rates and the development of GDM. Despite favorable outcomes and an absence of serious side effects, currently no guidelines are available regarding its use in gestation.53 Counseling for women with PCOS should emphasize the importance of lifestyle interventions to prevent diabetes. Metformin, when used to treat PCOS and induce ovulation, need not be continued once pregnancy has been confirmed.
DIABETES IN OLDER WOMEN
CVD is the leading cause of death in women with diabetes, surpassing both breast and ovarian cancers.1 Women without diabetes generally are protected from heart disease before menopause. For women with diabetes, however, this protective effect is absent. Studies have found that individuals with diabetes are at greater risk for CVD than individuals without diabetes and that the risk for women with diabetes actually exceeds that of men with diabetes. In a population-based study of ~2,500 men and women, Lundberg et al.54 found that the relative risk for CVD was 2.9 in men with diabetes but 5.0 in women with diabetes. In addition, the mortality rate from myocardial infarction was four times higher in men with diabetes and seven times higher in women with diabetes compared with healthy individuals. Both the Strong Heart Study55 and the Rancho Bernardo Study56 reported similar increases in mortality.
Not only are women with diabetes at increased risk for CVD compared with their nondiabetic female counterparts, but they also appear to fare worse in terms of morbidity and mortality compared with men with diabetes.57–59 Other sex-based differences have been found in the management of modifiable CVD risk factors60 and in the presentation and treatment of coronary heart disease in women. Studies have found that women are more likely to have their initial manifestation as angina pectoris, are more likely to be referred for diagnostic tests at a more advanced stage of disease, and are less likely than men to have corrective invasive procedures.60Early and ongoing assessment of cardiovascular risk factors coupled with intense intervention and education is needed for all women with diabetes.
Osteoporosis is the most prevalent metabolic bone disease in the U.S. Although more common in white women, it does affect both sexes and all ethnic groups. Whether risk of osteoporosis is increased in individuals with T1D or T2D remains controversial. Increasing evidence does suggest, however, that individuals with both T1D and T2D are at increased risk for osteoporotic fractures.60 Most studies in women with T1D have reported lower bone mineral density (BMD) levels than in either nondiabetic control subjects or women with T2D.61 Why these differences occur is not well understood. All women with diabetes should be evaluated for the risk of osteoporosis and related fractures. Consensus is lacking on when to begin BMD testing, but screening is recommended for all postmenopausal women >65 years of age or those who are considered at high risk.62 In addition, they should be counseled regarding appropriate preventive measures, which include adequate dietary calcium and vitamin D intake, regular exercise, and avoidance of smoking and other potential risk factors Educational information is available at https://www.nof.org/preventing-fractures/general-facts/bone-basics/are-you-at-risk/. As with the other complications, women with diabetes should be counseled to optimize glucose control as most studies have found a positive effect of glycemic control on bone status.63,64
Hormone Replacement Therapy
Conventional wisdom based on cross-sectional data is to prescribe hormone replacement therapy (HRT) for postmenopausal women with the goal of reducing CVD, preventing osteoporosis, preserving memory, promoting sexual well-being, and maintaining overall health and vitality. Data specific to HRT in women with diabetes are scarce but of potential interest because these women are at high risk of developing CVD. The Third National Health and Nutrition Examination Survey65 found that postmenopausal women with diabetes had increased dyslipidemia compared with nondiabetic counterparts. Among women with diabetes in that trial, individuals using HRT had significantly better lipoprotein profiles and glycemic control than women with diabetes who never had used or previously had used HRT. The Heart and Estrogen/Progestin Replacement Study (HERS),66 however, demonstrated that HRT had an early adverse effect in women with preexisting coronary disease. Furthermore, the Woman’s Health Initiative,66,67 which investigated the health risks and benefits of combined estrogen and progestin replacement therapy in healthy postmenopausal women, was concluded early because increased risk of breast cancer as well as increased risk of coronary heart disease, stroke, and pulmonary embolism outweighed the evidence for benefits in the rates of fracture and possibly colon cancer. Estrogen replacement alone has not been associated with an increased risk of breast cancer and has demonstrated benefits associated with coronary heart disease.68 HRT may be appropriate for short-term therapy for menopausal symptoms, including vasomotor instability with hot flushes, sleep disturbance, night sweats, and mood lability. Current recommendations include individualization based on current benefit-risk considerations in the decision to use HRT. Furthermore, use of combination therapy (estrogen and progesterone) should not exceed 3–5 years, whereas estrogen-only therapy, because of its more favorable profile, can be utilized for symptom management for longer durations of treatment.68
Nursing plays a key role in the education and care of women throughout the life cycle. In women with diabetes, health concerns begin at puberty and continue through preconception and pregnancy, culminating in menopause-related issues. Anticipatory guidance and education in each phase of development can help avoid health-care problems and achieve desired outcomes.
• Diabetes is a significant health problem that affects women throughout their life cycles.
• Strict blood glucose control before conception and throughout gestation can reduce or eliminate the excess risk for both mother and baby.
• All women with diabetes of childbearing potential should be counseled regarding the importance of preconception glycemic control and of planning their pregnancies.
• All pregnant women should be screened for GDM between 24 and 28 weeks’ gestation. Women deemed to be a high risk should be tested for preexisting diabetes at the first prenatal visit.
• Women with PCOS are at increased risk for developing prediabetes and T2D.
• Women with diabetes not only are at increased risk for CVD compared with their female counterparts who do not have diabetes, but also appear to fare worse in terms of morbidity and mortality compared with men with diabetes.
Frequently, women who see specialists for health-care management do not have primary care providers. As a consequence, they may not receive routine screenings, such as Pap smears and mammograms. As practitioners of preventive care, nurses need to remind women of the need for these screening tests.
Future nursing research is needed in the treatment of women with diabetes:
• Identification of the modifiable barriers to preconception care and strategies to increase the proportion of women with diabetes who plan their pregnancies is needed.
• The development and testing of innovative programs and strategies to prevent CVD and reduce excessive risk for poor outcomes among women with diabetes should be explored.
• The effects of various treatment modalities on the psychosocial impact of high-risk pregnancy require investigation.
• The impact of the patient–provider relationship on compliance and self-care behaviors in women with diabetes is important to determine the success of any treatment regimen.
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