Key points
- HRT use in women with diabetes may worsen hypertriglyceridemia.
- The American Diabetes Association (ADA) recommends 81 to 325 mg of aspirin a day for the prevention of adverse cardiovascular events associated with diabetes.
- A menopausal woman with diabetes has a 75% chance of death from cardiovascular disease, whereas a menopausal woman without diabetes has a 45% risk.
Females in the menopause are more vulnerable to developing diabetes, as it is well known that the incidence of the disease increases with age. Nowadays, diabetes is nearing epidemic proportions, due to an increased number of older Americans, and a greater prevalence of obesity and sedentary lifestyles. In fact, the number of women over the age of 45 with diabetes has increased 10-fold in the past century.1,2,3 As a result, more and more menopausal women with diabetes are presenting to their Ob/Gyn to help them manage this potentially dangerous duo.
The risk for CVD is increased 2- to 4-fold in menopausal women with diabetes.
It is difficult enough for a woman to weather the symptoms associated with menopause. Add diabetes to the list and she faces other, more pressing problems. While diabetic management and glycemic swings add to the difficulties of living with—and beyond—the menopause, the combination presents a more important concern: cardiovascular disease (CVD). Lower levels of estrogen during and after menopause are thought to increase a woman’s risk for CVD. This risk is increased 2-to 4-fold in women with diabetes. In fact, studies have shown that a menopausal woman with diabetes has a 75% chance of death from CVD, whereas a menopausal woman without diabetes has a 45% risk. In addition, patients with diabetes also may have other complications, including dyslipidemia, hypertension, and atherothrombotic changes, that can exacerbate coronary health risks.3
The good news is that there are preventive measures. Here, I will focus on 4 medical interventions that the Ob/Gyn can employ to lessen the chance of myocardial events in the menopausal woman with diabetes.
Determining risk factors
A menopausal woman with diabetes should be screened twice a year to assess her risk for cardiovascular disease (fixed and modifiable factors). Fixed risk factors include family history, age, and race. Evidence suggests that diabetes is more common in African-Americans, Latinos, Native Americans, Asian-Americans, and Pacific-Islanders, as well as the aged population. In addition, a woman’s chance of a coronary event is more than doubled from age 40 to 50.4
The presence of fixed risk factors should alert physicians to check for modifiable risk factors such as high cholesterol, high blood pressure, smoking, and obesity (Table 1). In doing so, the clinician can then determine effective management strategies and/or proper chemoprophylaxis interventions.
It is clear that lifestyle changes offer considerable benefits to reducing the risk of CVD. Therefore, it is vital that the patient be counseled to quit smoking, incorporate a nutritious, low-fat diet into her daily routine and exercise for at least 30 minutes on most days. Unfortunately, complying with these directives can be difficult. Some women fear that if they quit smoking, they will gain weight. However, the benefits of not smoking are much greater than the risks associated with the expected weight gain.5 In fact, smoking cessation accounts for a 50% decrease in coronary heart disease-related events.
To increase compliance, it is important for Ob/Gyns to set goals with their patients, i.e., stop smoking within 3 months and exercise twice a week and build up to 4 days per week. These simple measures will go a long way toward minimizing the incidence of CVD.
TABLE 1
Prevalence of cardiovascular risk factors: women older than 40 with and without diabetes
| PERCENT | DIABETES | NO DIABETES | ||
|---|---|---|---|---|
| REPORTING | 40-59 | ≥60 | 40-59 | ≥60 |
| High blood pressure | 14.1 | 6.2 | 6.4 | 7.8 |
| High cholesterol | 16.1 | 14.2 | 9.8 | 9.9 |
| Smoking | 22.2 | 9.2 | 21.4 | 10.7 |
Prophylaxis intervention
Hormone fluctuations during menopause may significantly alter blood glucose levels. With less progesterone, a woman with diabetes may have greater insulin sensitivity, but with less estrogen, there is the chance of increased insulin resistance. Either way, this hormonal imbalance can lead to serious cardiovascular events.
Most prospective randomized controlled trials have studied the effects cardiovascular intervention has on men. However, some research confirming its benefits on women exists.6 In trials studying women, researchers noted the positive effects hormone replacement therapy (HRT), low-dose aspirin, angiotensin converting enzyme (ACE) inhibitors, and thiazolidinediones (TZDs) have in preventing CVD. The following is an assessment of the risks and benefits of each: HRT. Typically, menopausal women without diabetes take HRT for the treatment of vasomotor symptoms, urogenital maintenance, and the prevention of osteoporosis. For some women, HRT also may offer some cardiac protection and may help in the prevention of Alzheimer’s disease. HRT confers a similar or greater benefit to menopausal women with diabetes (Table 2).7,8,9 Why? Research indicates that HRT has a direct action on the vascular wall and improves lipid profiles, thereby maximizing cardiovascular protection in the menopausal patient with diabetes. Two caveats: Studies have shown that HRT use in women with diabetes may worsen hypertriglyceridemia, and women who have had a prior cardiac event are at a higher risk of a second after starting HRT.10 Also, women in general may have a greater chance of breast cancer when taking HRT.