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How Is Diabetes Different in Women?

Rose Salata, MD; Mary Korytkowski, MD

ObGyns should be aware of the gender-specific effects of diabetes on their patients, including concerns of body image, menstrual variability in glycemic control, pregnancy, menopausal symptoms, sexual dysfunction, and depression.

The prevalence of type 1 and 2 diabetes is evenly distributed between women and men, with type 2 diabetes accounting for approximately 90% of all cases. There are approximately 11.5 million women older than 20 who have diabetes.1 A diagnosis of diabetes presents issues specific to women at each life stage that can interfere with the ability to achieve and maintain metabolic treatment goals as recommended by the American Diabetes Association.2 Factors such as menstrual unpredictability in glycemic control, pregnancy, and a greater prevalence of eating and mood disorders can be associated with glycemic variability that adversely affects risk for end-organ complications as well as health-related quality of life (HRQL).

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Adolescence

The majority of adolescent girls with diabetes have type 1; however, there is also a growing prevalence of type 2 diabetes in this population.1 Both types of diabetes may heighten body awareness, with the need to coordinate food intake with blood glucose measurements and medications, including insulin.

Eating Disorders

One potential outcome of this heightened attention to food and body image is the development of eating disorders such as bulimia and anorexia, which are twice as common in adolescent and young adult women with type 1 diabetes as compared to peers without diabetes.3 Some women report omitting or reducing usual insulin doses to avoid weight gain. In adolescents with type 2 diabetes, eating disorders are often characterized by caloric intakes in excess of energy requirements, increasing the risk for both obesity and diabetes-related complications early in life.4 Eating disorders in young women with type 1 diabetes are associated with an increase in frequency of hospitalizations for severe hypoglycemia or hyperglycemia, which over time creates a greater risk for diabetes-related complications.5 In one study, the risk of retinopathy was 3-fold higher in women with diabetes and a coexistent eating disorder.

The index of suspicion for disturbed eating behavior or an eating disorder should be high in adolescents and young women with persistently poor diabetic control. In a recent longitudinal study, factors predictive for development of disturbed eating behavior in girls with type 1 diabetes included higher body mass index, greater concerns about weight and body shape, lower self-esteem, and other depressive symptoms.3 In adolescent girls with type 2 diabetes, lifestyle interventions to promote weight loss with diet and exercise for the entire family are optimally recommended as a way of promoting success.4 Early screening and psychological intervention may reduce abnormal eating behaviors, as well as their unintended consequences, in women with either type 1 or 2 diabetes.

Menstrual Fluctuations

Both types of diabetes have a negative effect on mood in girls, most likely due to the cyclic hormonal fluctuations that occur with the onset of puberty.6 Menarche presents additional challenges to maintaining desired levels of glycemic control. Some girls experience more frequent hypoglycemic episodes, while others describe more hyperglycemia for several days to weeks preceding each menstrual cycle.7 These cyclic fluctuations in glycemic management can extend into adulthood; however, many women eventually learn how to cope by adjusting their caloric intake or insulin doses.

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Young Adulthood

A woman with diabetes must consider not only how a pregnancy might affect her own health but also the health of her offspring. Prepregnancy counseling that includes discussions of available contraceptive choices is imperative. Women with preexisting diabetes who are considering pregnancy require careful planning with attention to achieving tight glycemic control as a way of reducing risk for fetal malformations.8

Contraception

Hormonal contraception remains the most effective contraceptive method.9 However, some health care professionals and women with diabetes hold the misconception that hormonal contraception is dangerous and therefore contraindicated. Concerns related to hormonal contraception include deteriorations in glycemic control, blood pressure, and lipids or an acceleration of vascular disease in women already at high risk for these events.10 The majority of studies that have investigated the use of combination oral contraceptives in women with type 1 diabetes have demonstrated no differences in glycemic control or accelerated vascular complications when compared with nonusers.9,11 There are few studies of hormonal contraceptive use in women with type 2 diabetes; however, these women have the same requirement for family planning as those with type 1 diabetes.12 This has led to the recommendation that nonsmoking otherwise healthy women with diabetes younger than 35 who are free of advanced end-organ complications be considered candidates for hormonal contraception.9 If hormonal contraception is prescribed, agents with estrogen doses less than 35 µg per day and low androgenic progestins are preferred. Close monitoring of blood glucose, blood pressure, and lipids allows for early determination of any adverse effects. For women who choose to avoid oral contraceptives, alternative methods of family planning such as IUDs or barrier methods may be discussed and used as indicated.9

Prenatal Planning

Women with diabetes must consider their current medications, levels of glycemic control, and presence of existing and potential complications before pursuing pregnancy.8,13 In women with suboptimal glycemic control before and during pregnancy, there is a greater risk for both maternal and fetal complications. When the decision is made to become pregnant, insulin therapy should be intensified according to results of more frequent blood glucose measures to ensure a favorable outcome.8

Gestational Diabetes

Many women with type 2 diabetes are first diagnosed during a pregnancy complicated by gestational diabetes (GDM). These women require similar levels of glycemic control to those with type 1 diabetes, with special attention to preventing excessive weight gain as a way of minimizing the risk for complications at delivery and beyond. Women with GDM are at high risk for type 2 diabetes in the future, particularly if they are obese. Again, lifestyle interventions with strategies for weight reduction and increased physical activity can benefit the woman as well as her offspring, who are also at higher risk for obesity and type 2 diabetes.12,13

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Older adulthood

The prevalence of type 2 diabetes and its associated complications increases with age.1 While some complications such as cardiovascular disease, macular degeneration, or sexual dysfunction occur in an aging population in the absence of hyperglycemia, diabetes greatly exaggerates the frequency and severity of these disorders. The risk is further amplified if glycemic control is inadequate.

Cardiovascular Disease

Coronary heart disease (CHD) is the number 1 cause of death for anyone with diabetes.14 While microvascular and macrovascular complications occur with a similar frequency in women and men with diabetes, the presence of diabetes erases any protective female advantage for CHD.14,15 Women with diabetes also experience more disability and higher mortality following vascular events.14 The reasons underlying this acceleration in risk for vascular disease are likely multifactorial, which emphasizes the need for aggressive management of cardiovascular risk factors such as hypertension and dyslipidemia.

Menopause

Women with diabetes experience physiologic and metabolic changes similar to those of women without diabetes during transition from the perimenopausal to the menopausal state, with similar indications and contraindications to use of postmenopausal hormone therapy (HT).15 Currently, there is no evidence to suggest that postmenopausal women with diabetes should be denied short-term use of HT for symptomatic treatment of hot flashes or vaginal dryness.15 The decision to use these regimens is highly individualized and requires careful consideration of the potential benefits and risks.

Sexual Function

While sexual dysfunction is a well-recognized complication in men with diabetes, it is underrecognized in women. Diabetes can adversely affect all areas of postmenopausal female sexuality, including desire, arousal, lubrication, orgasm, satisfaction, and comfort during intercourse.16 Postmenopausal women with diabetes report a lower frequency of sexual intercourse per month than do nondiabetic women. Factors associated with sexual dysfunction in women with diabetes include autonomic neuropathy of the genitourinary tract with decreased vaginal lubrication and also depression.17,18 Whether sexual dysfunction causes depression or depression leads to sexual dysfunction and a lower overall quality of the marital relationship is not clear.

Specific therapy for sexual dysfunction in women with diabetes has not been studied. Treatment involves a symptomatic approach including use of vaginal lubricants, estrogen creams, and antidepressant medications when indicated. It is important to note that several classes of antidepressant medications, particularly serotonin reuptake inhibitors, commonly have sexual dysfunction as a side effect. Because sexual problems are prevalent in women with diabetes and negatively impact HRQL, this complication deserves more study and clinical awareness.

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Depression

Depression can occur at any life stage. Children with diabetes have a 2-fold greater prevalence and adolescents a 3-fold greater prevalence of depression when compared to those without diabetes.19 Women with either type 1 or 2 diabetes report more depression and score lower on HRQL measures than women without diabetes or men with diabetes.20 This is significant, as depression is identified as an independent risk factor for diabetes-related complications.18

Careful questioning of patients who may have underlying depression serves as an important point for intervention. Antidepressant medications may elevate a patient’s mood to levels that allow for more active participation in diabetes management and, at the same time, may enable the patient to explore underlying problems contributing to the mood disorder.

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Summary

Diabetes is a common disorder, affecting 8% of the population in the United States, with the potential to disrupt the lives of women at each life stage. It is likely that health care professionals across a wide range of disciplines will be involved in the care of women with diabetes. An awareness of the gender-specific concerns related to body image, menstrual variability in glycemic control, pregnancy, menopausal symptoms, sexual dysfunction, and depression allows for early diagnosis and intervention with the potential to favorably affect long-term outcomes.

The authors report no actual or potential conflicts of interest in relation to this article.

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Rose Salata, MD, is an Associate Professor of Medicine; Mary Korytkowski, MD, is a Professor of Medicine. Both are members of the Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, PA.

References

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