Menstrual cycle differences between women with type 1 diabetes and women without diabetes

Luteinizing hormone supplementation in controlled ovarian stimulation: the Iran Delphi consensus

Introduction

Numerous consensus documents worldwide address luteinizing hormone (LH) supplementation in controlled ovarian stimulation, yet to the best of our knowledge, only one consensus paper has been published in the Arab region. This study presents a Delphi consensus by seven Iranian infertility experts, offering real-world clinical perspectives. The aim was to develop evidence-based opinions on LH's role alongside FSH in various aspects of assisted reproductive technology (ART), including LH levels, monitoring, r-hLH use, and suggested activity.

Methods

Employing the Delphi consensus approach, the Iran consensus unfolded in three steps. In Step 1, eight out of 10 statements gained approval, while two unclear statements were removed. In Step 2, the 20-member extended panel voted on the remaining eight statements.

Results

Only one (statement 3) lacked consensus (55% agreement), prompting a modification. The revised statement (noted as statement 3') obtained an 83% agreement.

Discussion

The clinical perspectives included in this consensus complement clinical guidelines and policies that help further improve treatment outcomes, especially for patients with FSH and LH deficiencies.

Alterations in the Menstrual Cycle as a Peculiar Sign of Type 1 Diabetes Mellitus: A Meta-analytic Approach

BACKGROUND

Menstrual irregularities are present in >30% of women with type 1 diabetes mellitus (T1DM). These abnormalities will likely lead to reduced fertility and earlier menopause. T1DM management has changed over time, with even more emphasis on stringent levels of glycemic management. Thus, we investigated whether therapeutic T1DM changes have an influence on the proportion of menstrual disorders in women with T1DM.

METHODS

A meta-analysis was performed that included clinical trials in which menstrual abnormalities in women with T1DM were studied. The literature was checked for studies in which women with T1DM were compared with healthy, age-matched controls. Case-control, cohort, and cross-sectional studies were included. The primary endpoint was rate of menstrual dysfunction.

RESULTS

Menstrual dysfunction was higher in women with T1DM compared with controls (odds ratio 2.08, 95% confidence interval [CI] 1.43 to 3.03, p<0.001), even when sensitivity analysis was performed, considering only studies published after 2000. The age at menarche was higher for women with T1DM compared with controls (mean difference 0.53, 95% CI 0.32 to 0.74 years, p<0.001). The proportion of menstrual abnormalities in T1DM was inversely related to diabetes duration, but was unrelated to both body mass index and glycated hemoglobin.

CONCLUSIONS

The meta-analytic approach used confirmed the correlation between T1DM and menstrual irregularities. T1DM menstrual dysfunction seemed unrelated to change in therapeutic management across years, as well as to glycemic management and body weight. The underlying pathogenetic mechanisms are not fully understood.

Adverse effects of type 2 diabetes mellitus on ovarian reserve and pregnancy outcomes during the assisted reproductive technology process

Objective

To study the effect of type 2 diabetes mellitus(T2DM)on overall ovarian reserve and pregnancy outcomes during assisted reproductive technology (ART) among childbearing infertile women.

Design

Retrospective cohort study.

Setting

The Reproductive Medicine Special Hospital, The First Hospital of Lanzhou University, between January 2019 and December 2022.

Patients

A total of 265 infertile female patients aged 20-45 years who underwent in vitro fertilization-embryo transfer (IVF-ET), intracytoplasmic sperm injection-embryo transfer (ICSI-ET), or rescue intracytoplasmic sperm injection-embryo transfer (RICSI-ET) in the first fresh cycle.

Interventions

None.

Main Outcome Measures

Serum Anti-Müllerian Hormone (AMH) levels, clinical pregnancy rate (CPR), live birth rate (LBR), and abortion rate (AR) in the T2DM group and non-T2DM group.

Results

Patients with T2DM showed statistically decreased levels of AMH compared to the non-T2DM group. During ovarian stimulation, those with T2DM required significantly higher total and initial doses of gonadotropin (GN), although they had fewer retrieved oocytes and worse pregnancy outcomes than the non-T2DM group. Multivariate logistic regression analysis adjusting for confounding factors showed that T2DM alone was an independent risk factor for CPR and LBR (adjusted odds ratio [a OR], 0.458, adjusted 95% confidence interval [CI], 0.235-0.891, P = 0.022; a OR, 0.227, 95% CI, 0.101-0.513, P<0.001; respectively), and the abortion rate in the T2DM group was 3.316 times higher than the non-T2DM group(a OR, 3.316, 95%CI, 1.248-8.811, P = 0.016).

Conclusion

Infertile patients with T2DM have decreased ovarian reserve, and T2DM has a deleterious impact on clinical pregnancy outcomes during the ART process compared with non-T2DM infertile women.

Capsule

Infertile women with T2DM have decreased ovarian reserve and pregnancy outcomes during the assisted reproductive technology process compared with non-T2DM infertile women.

Variability of Glycemic Outcomes and Insulin Requirements Throughout the Menstrual Cycle: A Qualitative Study on Women With Type 1 Diabetes Using an Open-Source Automated Insulin Delivery System

BACKGROUND

The impact of hormone dynamics throughout the menstrual cycle on insulin sensitivity represents a currently under-researched area. Despite therapeutic and technological advances, self-managing insulin therapy remains challenging for women with type 1 diabetes (T1D).

METHODS

To investigate perceived changes in glycemic levels and insulin requirements throughout the menstrual cycle and different phases of life, we performed semi-structured interviews with 12 women with T1D who are using personalized open-source automated insulin delivery (AID) systems. Transcripts were analyzed using thematic analysis with an inductive, hypothesis-generating approach.

RESULTS

Participants reported significant differences between the follicular phase, ovulation, and luteal phase of the menstrual cycle and also during puberty, pregnancy, and menopause. All participants reported increased comfort and safety since using AID, but were still required to manually adjust their therapy according to their cycle. A lack of information and awareness and limited guidance by health care providers were frequently mentioned. Although individual adjustment strategies exist, achieving optimum outcomes was still perceived as challenging.

CONCLUSIONS

This study highlights that scientific evidence, therapeutic options, and professional guidance on female health-related aspects in T1D are insufficient to date. Further efforts are required to better inform people with T1D, as well as for health care professionals, researchers, medical device manufacturers, and regulatory bodies to better address female health needs in therapeutic advances.

Intrauterine Growth Restriction Due to Gestational Diabetes: From Pathophysiology to Diagnosis and Management

Intrauterine growth restriction (IUGR) represents a condition where the fetal weight is less than the 10th percentile for gestational age, or the estimated fetal weight is lower than expected based on gestational age. IUGR can be caused by various factors such as maternal, placental or fetal factors and can lead to various complications for both the fetus and the mother, including fetal distress, stillbirth, preterm delivery, and maternal hypertension. Women with gestational diabetes are at an increased risk of developing IUGR. This article reviews the different aspects of gestational diabetes in addition to IUGR, the diagnostic methods available for IUGR detection, including ultrasound and Doppler studies, discusses the management strategies for women with IUGR and gestational diabetes and analyzes the importance of early detection and timely intervention to improve pregnancy outcomes.

Type 1 Diabetes and the Menstrual Cycle: Where/How Does Exercise Fit in?

Regular exercise is associated with substantial health benefits for individuals with type 1 diabetes (T1D). However, the fear of hypoglycemia (low blood glucose) due to activity-induced declines in blood glucose levels acts as a major barrier to partaking in exercise in this population. For females with T1D, hormonal fluctuations during the menstrual cycle and their effects on blood glucose levels can act as an additional barrier. The impact that these cyclic changes may have on blood glucose and insulin needs and the consequent risk of hypoglycemia during or after exercise are still unknown in this population. Therefore, in this narrative review, we gathered existing knowledge about the menstrual cycle in T1D and the effects of different cyclic phases on substrate metabolism and glucose response to exercise in females with T1D to increase knowledge and understanding around exercise in this underrepresented population. This increased knowledge in such an understudied area can help to better inform exercise guidelines for females with T1D. It can also play an important role in eliminating a significant barrier to exercise in this population, which has the potential to increase activity, improve mental health and quality of life, and decrease the risk of diabetes-related complications.

Development of a nutrition screening tool to identify need for dietetic intervention in female infertility

BACKGROUND

One in seven couples are impacted by infertility in the UK, and female infertility is often associated with several health conditions impacted by nutrition. Despite many studies aimed at identifying the critical role of nutrition in infertility, there is currently no screening tool that identifies nutritional risk factors for infertility.

AIM

To propose a self-administered screening tool to identify women who would benefit from nutritional intervention to promote fertility.

METHODS

A narrative review was carried out to identify and summarise modifiable nutritional risk factors that can influence female fertility, including comorbidities that can influence nutrition intake, absorption, and metabolism.

KEY FINDINGS

A nutrition screening tool outlining modifiable nutrition risk factors potentially improving female fertility has been proposed, comprising of BMI, medical history and quality of diet and lifestyle which would aid in designing evidence based dietetic services for female infertility.

Altered sperm fate in the reproductive tract milieu due to oxidative stress leads to sub-fertility in type 1 diabetes females: A Drosophila-based study

AIMS

Female sub-fertility, a prominent complication due to Type 1 diabetes (T1D), is generally attributed to disturbances in menstrual cycles and/or ovarian defects/disorders. T1D women, however, are high in oxidative stress, although the impact of the same on their reproduction and associated events remains unknown. Therefore, we assessed the repercussions of elevated oxidative stress on the sperm fate (storage/utilization) in the reproductive tract milieu of T1D females and their fertility using the Drosophila T1D model (Df[dilp1-5]), which lacks insulin-like peptides and displays reduced female fertility.

MAIN METHODS

We mated Df[dilp1-5] females to normal males and thereafter examined sperm storage and/or utilization in conjunction with oxidative stress parameters in mated Df[dilp1-5] females at different time points. Also, the impact of antioxidant (Amla or Vitamin C) supplementation on the above oxidative stress parameters in Df[dilp1-5] females and the consequences on their sperm and fertility levels were examined.

KEY FINDINGS

Df[dilp1-5] females showed elevated oxidative stress parameters and a few of their reproductive tract proteins are oxidatively modified. Also, these females stored significantly fewer sperm and also did not utilize sperm as efficiently as their controls. Surprisingly, amelioration of the oxidative stress in Df[dilp1-5] females' milieu through antioxidant (Amla or vitamin C) supplementation enhanced sperm storage and improved fertility.

SIGNIFICANCE

Hyperglycemia coupled with elevated oxidative stress within the female reproductive tract environment affects the sperm fate, thereby reducing female fertility in T1D. In addition, these findings suggest that antioxidant supplementation may substantially aid in the mitigation of sub-fertility in T1D females.

Factors influencing health-related quality of life in adolescent girls: a path analysis using a multi-mediation model

BACKGROUND

Recent studies have reported gender differences in adolescents' health-related quality of life (HRQOL), with females scoring significantly lower than males. Researchers have identified the female puberty process as one of the causes of the differences in HRQOL between male and female adolescents. This study examines mechanisms of how social support, dietary habits, sleep quality, and depression contribute to predicting HRQOL in relation to menstrual health among adolescent girls.

METHODS

A cross-sectional study was conducted with 295 students recruited from middle and high schools in Korea using a self-report questionnaire. A multi-mediation model was constructed based on previous literature and tested using path analysis with AMOS, version 21.0.

RESULTS

The study results showed that menstrual health, social support, sleep quality, dietary habits, and depression had significant effects on HRQOL. Both sleep quality and depression had significant direct effects on menstrual health. Dietary habits, social support, sleep quality, and depression had significant indirect effects on HRQOL, mediated through menstrual health. According to serial mediation analysis, the path from social support to HRQOL via dietary habits → sleep quality → depression → menstrual health → HRQOL was significant. However, mediation models including the path of dietary habits → depression were not supported. The study variables explained 57% of the total variance for HRQOL.

CONCLUSIONS

The findings suggest menstrual health is an important factor that mediates the effects of eating, sleeping, psychological health, and social support on HRQOL. Early complaints about sleep disorders and depressive symptoms with poor dietary habits could be an ominous sign for adolescent girls at high risk of menstrual problems and lower HRQOL. Empirical evidence from this study suggests the need to develop and test interventions addressing multiple modifiable behavioral and psychosocial factors to improve HRQOL in adolescent girls. Interventions or supportive systems that aim to improve eating habits and sleep quality thereby achieving a healthier lifestyle need to be developed and incorporated into school health services.

Prevalence of Hysterectomy by Self-Reported Disability Among Canadian Women: Findings from a National Cross-Sectional Survey

Introduction: Our objective was to investigate differences in prevalence of hysterectomy by self-reported disability status among Canadian women.

Materials and Methods: We analyzed cross-sectional data from the Canadian Community Health Survey 2012 on 30,170 women aged ≥20 years. Disability was defined as reports of sometimes or often (vs. never) experiencing functional limitations or reduction in daily activities at home, school, or work. Frequency of these limitations was used as a proxy for disability severity. The outcome was self-reported hysterectomy status. Modified Poisson regression was used to quantify the prevalence ratio (PR) and 95% confidence interval (CI) for hysterectomy according to any, functional, or activity-limiting disability, after adjustment for household income, employment, education, ethnicity, and marital status. Results were stratified by age at time of data collection, categorized as childbearing (20–44 years), perimenopausal (45–59 years), and postmenopausal (60 years and older).

Results: Disability was significantly and consistently associated with higher prevalence of hysterectomy in women. The strength of association was inversely related to age category, and PRs for a given age category were similar across disability types and severity levels. PRs for the association between any disability and hysterectomy were 2.18 (95% CI 1.36–3.50) for childbearing-aged women, 1.48 (95% CI 1.21–1.80) for perimenopausal women, and 1.12 (95% CI 1.02–1.24) for postmenopausal women.

Conclusions: Prevalence of hysterectomy is disproportionately higher among women with self-reported disabilities compared with women without disabilities, with these differences most pronounced in women of childbearing age.

mTOR inhibitors and risk of ovarian cysts: a systematic review and meta-analysis

OBJECTIVE

To summarise the available evidence on frequency of ovarian cyst development during mammalian target of rapamycin inhibitors (mTORi) treatment.

METHODS

PubMed/Medline and EMBASE databases were searched, from 1990 up to March 2020, using the following keywords: 'tacrolimus', 'sirolimus', 'temsirolimus', 'everolimus', 'deforolimus', 'mTOR' and 'ovarian cysts' (Limit: Human, English, full article). Studies were selected for the review if they met the following criteria: clinical studies, studies reporting original data, studies reporting the number of patients using mTORi, studies reporting the number of patients with ovarian cysts.We selected 7 of 20 retrieved studies. Study design, population, sample size, criteria for diagnosis of ovarian cysts, drug doses and follow-up length were extracted. Pooled estimate of incidence was calculated for ovarian cysts as a percentage, with 95% CI.

RESULTS

Four hundred-six women were included in the selected studies. The pooled incidence was 37.0% (95% CI 16.0% to 58.1%) for all ovarian cysts, and 17.3% (95% CI 5.6% to 29.1%) for clinically significant ovarian cysts. Based on two articles, comparing mTORi and non-mTORi for immunosuppression, pooled OR for ovarian cyst incidence was 4.62 (95% CI 2.58 to 8.28).

CONCLUSION

Ovarian cyst development is a common adverse event during immunosuppression treatment with mTORi. These cysts are benign conditions, but they require pelvic ultrasound follow-up and in some cases hospital admission and surgery.

Can Resistance Exercise Be a Tool for Healthy Aging in Post-Menopausal Women with Type 1 Diabetes?

Due to improvements in diabetes care, people with type 1 diabetes (T1D) are living longer. Studies show that post-menopausal T1D women have a substantially elevated cardiovascular risk compared to those without T1D. As T1D may also accelerate age-related bone and muscle loss, the risk of frailty may be considerable for T1D women. Exercise and physical activity may be optimal preventative therapies to maintain health and prevent complications in this population: They are associated with improvements in, or maintenance of, cardiovascular health, bone mineral density, and muscle mass in older adults. Resistance exercise, in particular, may provide important protection against age-related frailty, due to its specific effects on bone and muscle. Fear of hypoglycemia can be a barrier to exercise in those with T1D, and resistance exercise may cause less hypoglycemia than aerobic exercise. There are currently no exercise studies involving older, post-menopausal women with T1D. As such, it is unknown whether current guidelines for insulin adjustment/carbohydrate intake for activity are appropriate for this population. This review focuses on existing knowledge about exercise in older adults and considers potential future directions around resistance exercise as a therapeutic intervention for post-menopausal T1D women.

Reduced FSH and LH action: implications for medically assisted reproduction

Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) play complementary roles in follicle development and ovulation via a complex interaction in the hypothalamus, anterior pituitary gland, reproductive organs, and oocytes. Impairment of the production or action of gonadotropins causes relative or absolute LH and FSH deficiency that compromises gametogenesis and gonadal steroid production, thereby reducing fertility. In women, LH and FSH deficiency is a spectrum of conditions with different functional or organic causes that are characterized by low or normal gonadotropin levels and low oestradiol levels. While the causes and effects of reduced LH and FSH production are very well known, the notion of reduced action has received less attention by researchers. Recent evidence shows that molecular characteristics, signalling as well as ageing, and some polymorphisms negatively affect gonadotropin action. These findings have important clinical implications, in particular for medically assisted reproduction in which diminished action determined by the afore-mentioned factors, combined with reduced endogenous gonadotropin production caused by GnRH analogue protocols, may lead to resistance to gonadotropins and, thus, to an unexpected hypo-response to ovarian stimulation. Indeed, the importance of LH and FSH action has been highlighted by the International Committee for Monitoring Assisted Reproduction Technologies (ICMART) in their definition of hypogonadotropic hypogonadism as gonadal failure associated with reduced gametogenesis and gonadal steroid production due to reduced gonadotropin production or action. The aim of this review is to provide an overview of determinants of reduced FSH and LH action that are associated with a reduced response to ovarian stimulation.

Prevalence of urinary system, pelvic organ, and genital tract disorders among women with type 1 diabetes in Germany

AIM

Type 1 diabetes can lead to various long-term complications including macro- and microvascular disorders and osteoporosis. However, published data on the association between type 1 diabetes (T1D) and urinary system and genital tract disorders is limited. The aim of this work was to estimate the prevalence and incidence of urinary system- and genital tract disorders among women with T1D treated in gynecological practices in Germany.

METHODS

This retrospective cohort study included women aged 16 years or older with T1D diagnosis between January 2015 and December 2018 from 268 gynecological practices in Germany (IMS Disease Analyzer database). T1D patients were matched 1:5 by age and physician with non-diabetic patients. The main outcome of the study was the prevalence of different urinary system, pelvic organ and genital tract disorders documented between the first documentation of T1D diagnosis and the last outpatient visit. All study disorders were included as dependent variables in multivariate logistic regression models, while T1D was applied as an impact variable. In each model, the effect of T1D on the defined disorder was adjusted for all other study disorders.

RESULTS

The present study included 1357 women with and 6785 women without T1D (mean age 45.6 years). T1D was significantly associated with acute vulvitis (OR: 2.12 (95% CI: 1.56-2.90), other specified urinary incontinence (OR: 1.64 (95% CI: 1.19-2.26), acute cystitis (OR: 1.46 (95% CI: 1.10-1.95), and absent, scanty and rare menstruation (OR: 1.37 (95% CI: 1.13-1.67).

CONCLUSION

These findings may have implications for the future care of women with T1D. Firstly, the focus should not be on diabetes management alone, but also on identifying and handling additional associated comorbidities including urinary system and genital tract disorders. Secondly, the data suggest that patients with T1D should be asked specifically about symptoms they may be experiencing that are related to the associated disorders identified.

Women with Type 1 diabetes (T1D) experience a shorter reproductive period compared with nondiabetic women: the Pittsburgh Epidemiology of Diabetes Complications (EDC) study and the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

Evidence suggests that insulin deficiency and hyperglycemia may disrupt the female reproductive system's normal function, leading to delayed menarche and premature ovarian aging. We thus compared the length of the reproductive period of women with type 1 diabetes (T1D) to women without diabetes.

METHODS

Women with childhood-onset T1D (diagnosed in 1950-80) from the prospective Epidemiology of Diabetes Complications (EDC) study and nondiabetic women from the Pittsburgh site of the Study of Women's Health Across the Nation (SWAN) were studied. Exclusion criteria comprised not having reached natural menopause, hysterectomy/oophorectomy before menopause, and sex hormone therapy during the menopausal transition. Reproductive history was self-reported. The historical and Women's Ischemia Syndrome Evaluation hormonal algorithms were also used to assess menopause status.

RESULTS

Women in the T1D cohort (n = 105) were younger, more likely to be White, never smokers, with lower BMI and higher high-density lipoprotein cholesterol levels (all P values < 0.05) compared with women without diabetes (n = 178). After covariate adjustment, T1D women were also older at menarche (0.5-y delay, P = 0.002) but younger at natural menopause (-2.0 y, P < 0.0001). Women with T1D thus experienced 2.5 fewer reproductive years compared to those without diabetes (P < 0.0001). These findings were restricted to the subgroup of women who were diagnosed with T1D before reaching menarche (n = 80).

CONCLUSION

Women with T1D onset before menarche have a shorter reproductive period compared with nondiabetic women, exhibiting delayed menarche and earlier natural menopause. Factors that may be related to a shorter reproductive period in T1D should be investigated.

Obesity, menstrual irregularity and polycystic ovary syndrome in young women with type 1 diabetes: A population-based study

BACKGROUND

Type 1 diabetes (T1D) is associated with reproductive dysfunction, particularly in the setting of poor metabolic control. Improvements in contemporary management ameliorate these problems, albeit at the cost of increased exogenous insulin and rising obesity, with emerging reproductive implications.

OBJECTIVE

To evaluate changes in body mass index (BMI) and the relationship between obesity, menstrual irregularity and polycystic ovary syndrome (PCOS) in young women with T1D, compared with controls.

METHODS

Longitudinal observational study using data from the Australian Longitudinal Study in Women's Health of the cohort born in 1989-95, from 2013 to 2015. Three questionnaires administered at baseline and yearly intervals were used to evaluate self-reported menstrual irregularity, PCOS and BMI.

RESULTS

Overall, 15 926 women were included at baseline (T1D, n = 115; controls, n = 15 811). 61 women with T1D and 8332 controls remained at Year 2. Median BMI was higher in women with type 1 diabetes (25.5 vs 22.9 kg/m² , P < .001), where over half were overweight or obese (54.4% vs 32.9%, P < .001). Median BMI increased by 1.11 and 0.45 kg/m² , in the T1D and control groups, respectively. T1D was independently associated with an increased risk of menstrual irregularity (RR 1.22, 95% CI 1.02-1.46) and PCOS (RR 2.41, 95% CI 1.70-3.42). Obesity conferred a 4-fold increased risk of PCOS, compared to those with normal BMI (RR 3.93, 95% CI 3.51-4.42).

CONCLUSIONS

Obesity is prevalent amongst women with T1D and may be a key contributor to the higher risk of menstrual irregularity and PCOS in this cohort, representing an important opportunity for prevention and intervention.

The Menstrual Disturbances in Endocrine Disorders: A Narrative Review

CONTEXT

Menstrual cycle is considered the fifth vital sign among women. This study aimed to summarize the menstrual disturbances in different endocrine disorders.

EVIDENCE ACQUISITION

In this narrative review, relevant studies (up to December 2019) were searched based on the MeSH keywords diabetes, polycystic ovary syndrome, Cushing's syndrome, thyroid dysfunction, hyperprolactinemia, menstrual cycle, uterine bleeding, and menstruation. Databases used for searching articles included Google Scholar, Scopus, PubMed, and Web of science for observational, experimental, and review studies.

RESULTS

Endocrine disorders trigger the onset of menstrual disturbance across the reproductive lifespan of women. Endocrine glands (pituitary, thyroid, pancreas, adrenal, and ovaries) have a functional role in endocrine regulation of the menstrual cycle. According to available evidence, oligomenorrhea (cycles longer than 35 days) is the most common menstrual disturbance among endocrine disorders (thyrotoxicosis, hypothyroidism, polycystic ovary syndrome, Cushing's syndrome, and diabetes). Complex endocrine pathways play an essential role in a women's menstrual calendar.

CONCLUSIONS

The menstrual cycle length and amount of bleeding can be indicative of endocrine disorders. Further studies are needed to identify the unknowns about the association between endocrine disorders and the menstrual cycle.

Live-born children after assisted reproduction in women with type 1 diabetes and type 2 diabetes: a nationwide cohort study

AIMS/HYPOTHESIS

Type 1 and type 2 diabetes are among the most prevalent chronic diseases in women in the fertile years and women with diabetes may experience several reproductive issues. We aimed to examine the chance of biochemical pregnancy, clinical pregnancy and live birth after assisted reproductive technology (ART) treatment in women with type 1 and type 2 diabetes and whether obesity per se influenced the results.

METHODS

This nationwide register-based cohort study is based on the Danish ART Registry comprising 594 women with either type 1 diabetes or type 2 diabetes from 2006 to 2017.

RESULTS

Relative to women without diabetes, the adjusted OR (95% CI) of a live birth per embryo transfer was 0.50 (0.36, 0.71) in women with type 2 diabetes and 1.10 (0.86, 1.41) in women with type 1 diabetes.

CONCLUSIONS/INTERPRETATION

Our data on the efficacy of ART treatment in women with type 1 and type 2 diabetes is the first in this field. When compared with women without diabetes, women with type 1 diabetes had an equivalent chance of a live birth per embryo transfer whereas women with type 2 diabetes had a reduced chance. The findings in women with type 2 diabetes did not seem to be driven by obesity per se as the same pattern was seen in both normal-weight and obese women. Graphical abstract.

Diabetes: a metabolic and reproductive disorder in women

Reproductive dysfunction is a common but little studied complication of diabetes. The spectrum of reproductive health problems in diabetes is broad, and encompasses delayed puberty and menarche, menstrual cycle abnormalities, subfertility, adverse pregnancy outcomes, and potentially early menopause. Depending on the age at diagnosis of diabetes, reproductive problems can manifest early on in puberty, emerge later when fertility is desired, or occur during the climacteric period. Historically, women with type 1 diabetes have frequently had amenorrhoea and infertility, due to central hypogonadism. With the intensification of insulin therapy and improved metabolic control, these problems have declined, but do persist. Additional reproductive implications of contemporary diabetes management are now emerging, including polycystic ovary syndrome and hyperandrogenism, which are underpinned by insulin action on the ovary. The sharp rise in type 2 diabetes incidence in youth suggests that more women of reproductive age will encounter diabetes-related reproductive problems in their lifetimes. With an ever increasing number of young women living with diabetes, clinicians need to be aware of and equipped for the challenges of navigating reproductive health concerns across the lifespan.

Effect of age at menarche on microvascular complications among women with Type 1 diabetes

AIM

To test the hypothesis that delayed menarche is associated with an increased microvascular complication risk among women with Type 1 diabetes.

METHODS

We studied the female participants of an ongoing prospective study of childhood-onset Type 1 diabetes diagnosed during the period 1950-1980. Of 325 women, we included data from 315 who had reached menarche by the study baseline (1986-1988) and who self-reported their age at menarche. Both cross-sectional and prospective analyses over the 25-year follow-up were used to assess the relationship of age at menarche with the prevalence, incidence and cumulative incidence of microvascular complications, comprising overt nephropathy, proliferative retinopathy and confirmed distal symmetric polyneuropathy.

RESULTS

In cross-sectional analyses at baseline, the odds of overt nephropathy increased 1.24 times (P=0.02) with each annual increase in age at menarche, and 3.2 times (P=0.009) in those with delayed menarche compared with women with normal menarche onset, after adjustment. Similarly, the cumulative incidence of overt nephropathy increased 1.16 times (P=0.01) with each older year of menarche and women with delayed menarche were at twofold increased risk of overt nephropathy (hazard ratio 2.30, P=0.001) compared with women with normal menarche onset. However, age at menarche was not significantly associated with either proliferative retinopathy or confirmed distal symmetric polyneuropathy after adjusting for covariates.

CONCLUSIONS

Age at menarche was significantly associated with the prevalence and cumulative incidence of overt nephropathy, but not with proliferative retinopathy or confirmed distal symmetric polyneuropathy in Type 1 diabetes. Women with delayed menarche may therefore be targeted for early screening and timely interventions to prevent the development of nephropathy.

Does Chronic Hyperglycemia Affect Female Rat Sexual Behavior? Differences in Paced and Non-Paced Mating

INTRODUCTION

Diabetes mellitus has been associated with sexual dysfunction; however, in women this relationship is controversial. A study using a model of type 2 diabetes mellitus (DM2) failed to find a reduced receptivity in the non-paced mating (NPM), but the appetitive aspects of female sexual behavior have not been evaluated, for example, in the paced mating (PM) paradigm.

AIM

To evaluate all components of female sexual behavior (in NPM and PM) in a model of DM2 using ovariectomized (OVX) (treated with steroids) or intact female rats (non-OVX) in natural proestrus.

METHODS

Neonatal females (3-4 days) were administered streptozotocin (STZ, 70 mg/kg, intraperitoneally) or citrate buffer. At week 8, a glucose tolerance test was performed. At week 10, half of the females were OVX, and in the other half (non-OVX) the estrous cycle was monitored. At the twelfth week, the sexual behavior tests were conducted; OVX females were treated with estradiol benzoate (10 μg, -24 hours) and progesterone (3 mg, -4 hours), whereas the non-OVX were evaluated on vaginal proestrus.

MAIN OUTCOME MEASURES

We registered in NPM and PM receptivity (lordosis quotient and intensity), as well as the number of proceptive and aggressive behaviors. Additionally, in PM we calculated the percentage of exits and the return latencies after receiving stimulation and the time the female remained in the male's compartment.

RESULTS

The STZ-treated females presented glucose intolerance and were hyperglycemic. Neonatal STZ treatment provoked changes in the females' sexual behavior depending on the paradigm and the hormonal condition. In the NPM, STZ-OVX females had decreased lordosis quotient and intensity and increased aggression, whereas, in the STZ-non-OVX females, there was a decrease in proceptivity; such changes were not observed in PM. Regardless of whether the STZ-treated females were OVX, they failed to perform the pacing behavior.

CLINICAL IMPLICATION

These data support the idea that chronic mild hyperglycemia, like that observed in DM2 (which represents 90% of the clinical cases), provokes marginal changes in most aspects of female sexual behavior.

STRENGTHS & LIMITATIONS

The main strength of this work is the evaluation of consummatory and motivational aspects of female sexual behavior in a model of DM2. The main limitation is the duration of the experimental design that does not resemble the course of the disease in humans. No histologic or biochemical analyses were performed.

CONCLUSION

These results suggest that chronic hyperglycemia produces decreases in sexual behavior. Hernández-Munive AK, Rebolledo-Solleiro D, Fernández-Guasti A. Does Chronic Hyperglycemia Affect Female Rat Sexual Behavior? Differences in Paced and Non-Paced Mating. J Sex Med 2019;16:1130-1142.

Menstrual Cycle Changes as Women Approach the Final Menses: What Matters?

Increased variability in menstrual cycle length marks the onset of the menopausal transition, with the likelihood of long cycles increasing as women approach menopause. This article describes the STRAW+10 bleeding criteria for recognizing onset of the early and late menopausal transition, as well as the specific bleeding changes a woman may experience during this life stage, including how women's bleeding experiences differ. The high probability of episodes of excessive and prolonged bleeding as women approach their final menstrual period is documented, as is the continuing probability of ovulation as women reach their final menstrual period.

Long-term apoptosis-related protein expression in the diabetic mouse ovary

Emerging evidence has shown that oocytes from diabetic ovaries exhibit delayed maturation, mitochondrial dysfunction and meiotic defects, which are related increased apoptosis. The main objective of the present study was to analyze the apoptosis pathways activated during follicular loss at multiple time points in a diabetic mouse model. Twenty BALB/c mice were used in this study, and diabetes mellitus was induced by streptozotocin injection. Three diabetic and two control animals were sacrificed on days 15, 20, 70 and 80 posttreatment. The ovaries were then removed; one was used for follicular counting, TUNEL, immunohistochemistry and immunofluorescence, while the other was used for Western blot analysis. The proteins studied were BAX, BCL2, t-BID, FAS, FASL, active caspase 8, active caspase 9 and active caspase 3. Follicular apoptosis decreased over time, with the highest values observed at 15 days posttreatment. Granulosa cells were positive for active caspase 3, which showed constant expression levels at all time points. FAS, FASL, t-BID and active caspase 8 showed strong cytoplasmic immunostaining in the oocytes and granulosa cells of the diabetic mice, with significant increases observed at 15, 20 and 70 days posttreatment. BAX expression was slightly higher in the diabetic mouse ovaries than in the control ovaries at 15, 20 and 70 days posttreatment, whereas the highest active caspase 9 expression was at observed 20 days posttreatment. Low BCL2 protein levels were detected in the diabetic mouse ovaries at all time points. This study describes for the first time the behavior of apoptosis-related proteins in the diabetic mouse ovary and shows not only that the FAS/FASL pathway contributes to follicular loss but also that antral follicles are the most affected.

High Prevalence of Polycystic Ovary Syndrome in Type 1 Diabetes Mellitus Adolescents: Is There a Difference Depending on the NIH and Rotterdam Criteria?

BACKGROUND

Polycystic ovary syndrome (PCOS) is more frequently observed in type 1 diabetes mellitus (T1DM) adult women than in nondiabetic women. No such prevalence has yet been studied in adolescent girls with T1DM.

AIM

The aim of this study was to evaluate the prevalence of PCOS in adolescent girls with T1DM and to determine the clinical and hormonal features associated with the disorder.

METHODS

A cross-sectional study of 53 adolescent girls (gynecological age >2 years) referred for routine evaluation for T1DM was conducted. We diagnosed PCOS using the National Institutes of Health (NIH) and Rotterdam criteria.

RESULTS

26.4 and 47.9% of adolescents had PCOS according to NIH (NIH-PCOS) and Rotterdam (Rotterdam-PCOS) criteria. 66.7% of NIH-PCOS adolescents had a complete phenotype associated with hyperandrogenism, oligomenorrhea, and polycystic ovarian morphology, unlike only 33.3% of the Rotterdam-PCOS adolescents. A family history of type 2 diabetes mellitus (T2DM) was more frequent in PCOS than in non-PCOS girls, whichever criteria were used. Late pubertal development and a T1DM diagnosis close to puberty were factors associated with NIH-PCOS.

CONCLUSION

Adolescents with T1DM had a high prevalence of PCOS. More differences between PCOS and non-PCOS patients were found using the NIH criteria, suggesting that clinical characteristics might be more accurate for diagnosing PCOS in girls with T1DM. A family history of T2DM is associated with a high risk of PCOS.

Ovarian markers and irregular menses among women with type 1 diabetes in the Epidemiology of Diabetes Interventions and Complications study

OBJECTIVE

Women with type 1 diabetes have increased risk of infertility compared to women without diabetes even after adjustment for irregular menses, but aetiologies are incompletely understood. Our aim was to examine the prevalence of abnormalities in ovarian markers consistent with polycystic ovary syndrome in women with type 1 diabetes and associations with irregular menses and diabetes-specific variables.

DESIGN, PATIENTS AND MEASUREMENTS

We conducted a secondary analysis of women in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study (DCCT/EDIC), a randomized trial and observational follow-up of intensive insulin therapy for type 1 diabetes. We included women with anti-Müllerian hormone (AMH) measurements among women not using oral contraceptives (n = 187). Initial AMH and testosterone measures were performed between EDIC years 1 and 4. History of irregular menses was assessed annually.

RESULTS

The median age of women was 35 (interquartile ratio 29, 40) years; 133 (35%) had elevated AMH and 62 (17%) reported irregular menses. Twelve per cent of women had relative elevations in total testosterone. In multivariable models, lower insulin dosages were associated with higher AMH concentrations (P = .0027), but not diabetes duration, glycemic control, body mass index or irregular menses. Neither irregular menses nor diabetes-specific variables were associated with testosterone concentrations.

CONCLUSIONS

Among women with type 1 diabetes in their thirties, abnormalities in ovarian markers are common and not associated with irregular menses and thus may partially account for decreased fecundity in women with type 1 diabetes.

Development and psychometric validation of the Menstrual Health Instrument (MHI) for adolescents in Korea

The aims of the researchers were to develop and test initial psychometric properties of the Menstrual Health Instrument, a measure of menstrual health in adolescents that comprehensively evaluates menstrual health. Data were collected with a convenience sample of 230 Korean adolescent girls. As a result of exploratory factor analysis with the 29-item instrument, five factors were extracted: affective symptoms, somatic symptoms and school life, daily habits for menstrual health, menstrual cycle characteristics, and attitudes and perceptions on menstruation. The reliability and validity estimates indicate the Menstrual Health Instrument could be used for screening in school or community settings.

Anti-Müllerian hormone and its relationships with subclinical cardiovascular disease and renal disease in a longitudinal cohort study of women with type 1 diabetes

Background

Reproductive age may be a risk factor for vascular disease. Anti-Müllerian hormone (AMH) is produced by viable ovarian follicles and reflects reproductive age. We examined whether AMH concentrations were associated with markers of subclinical cardiovascular disease (CVD) and kidney disease among women with type 1 diabetes.

Methods

We performed a cross-sectional analysis of the Epidemiology of Diabetes Interventions and Complications Study. Participants included women with type 1 diabetes and ≥1 AMH measurement (n = 390). In multivariable regression models which adjusted for repeated measures, we examined the associations between AMH with CVD risk factors, estimated glomerular filtration rate, and albumin excretion ratio. We also examined whether initial AMH concentrations were associated with the presence of any coronary artery calcification (CAC) or carotid intima media thickness (cIMT).

Results

After adjustment for age, AMH was not associated with waist circumference, blood pressure, lipid profiles, or renal function. Higher initial AMH concentrations had borderline but non-significant associations with the presence of CAC after adjustment for age (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.00, 1.16) which were minimally altered by addition of other CVD risk factors, although women in the 3rd quartile of AMH had lower odds of CAC than women in the lowest quartile (OR 0.40, 95% CI 0.17, 0.94). After adjustment for age, higher AMH was associated with statistically significant but only slightly higher cIMT (0.005 mm, p = 0.0087) which was minimally altered by addition of other CVD risk factors.

Conclusions

Among midlife women with type 1 diabetes, AMH has slight but significant associations with subclinical measures of atherosclerosis. Future studies should examine whether these associations are clinically significant.

Trial registration

NCT00360815 and NCT00360893 Study Start Date April 1994.

Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline

COSPONSORING ASSOCIATIONS

The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society.

OBJECTIVE

To formulate clinical practice guidelines for the diagnosis and treatment of functional hypothalamic amenorrhea (FHA).

PARTICIPANTS

The participants include an Endocrine Society-appointed task force of eight experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and cosponsoring organizations reviewed and commented on preliminary drafts of this guideline.

CONCLUSIONS

FHA is a form of chronic anovulation, not due to identifiable organic causes, but often associated with stress, weight loss, excessive exercise, or a combination thereof. Investigations should include assessment of systemic and endocrinologic etiologies, as FHA is a diagnosis of exclusion. A multidisciplinary treatment approach is necessary, including medical, dietary, and mental health support. Medical complications include, among others, bone loss and infertility, and appropriate therapies are under debate and investigation.

Menopause, hormone therapy and diabetes

Over the past three decades, the prevalence of diabetes has increased four-fold. Coupled with the global obesity epidemic and aging of the world's population, a perfect metabolic storm is brewing. The influence of menopause and exogenous estrogen and progestogens must be included in this equation. In this review, criteria for diagnosing diabetes and recommendations for screening are described. The reported effects of menopause on diabetes risk in healthy women are reviewed as well as the relationship between established diabetes and the timing of menopause. The effects of menopausal hormone therapies (MHT) on glucose control in women with diabetes and the effect of MHT on diabetes risk in menopausal women without diabetes are described. Evidence-based strategies to prevent diabetes in midlife women are highlighted. The augmenting effect of diabetes on chronic health concerns of aging women, such as cardiovascular disease, osteoporosis, and cancer, along with current recommendations for screening and prevention are presented. Given the current demographics of today's world, the content of this review may apply to as many as one-third of the average practitioner's postmenopausal patient population.

Antimüllerian hormone among women with and without type 1 diabetes: the Epidemiology of Diabetes Interventions and Complications Study and the Michigan Bone Health and Metabolism Study

OBJECTIVE

To compare concentrations of antimüllerian hormone (AMH) in women with and without type 1 diabetes.

DESIGN

Cross-sectional analysis of longitudinal studies, adjusting for repeated measures.

SETTING

Not applicable.

PATIENT(S)

Women aged 30-45 years who had not undergone oophorectomy, hysterectomy, or natural menopause at the time of AMH measurement were included (n = 376 in the Michigan Bone Health and Metabolism Study and n = 321 in the Epidemiology of Interventions and Complications Study). Linear mixed regression was used to evaluate whether AMH concentrations differed by diabetes status, adjusting for repeated measurements of AMH within individual women, body mass index, smoking status, and oral contraceptive use.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Concentrations of AMH.

RESULT(S)

In unadjusted comparisons, women with and without diabetes had similar median AMH values before 35 years of age, although women with type 1 diabetes had a lower proportion of women with elevated AMH concentrations (≥5.0 ng/dL). After adjustment for covariates and multiple observations per woman, log AMH concentrations were significantly lower among women with type 1 diabetes compared with women without diabetes (β-coefficient -1.27, 95% confidence interval [-2.18, -0.36] in fully adjusted models) before 35 years of age.

CONCLUSION(S)

Before 35 years of age, women with type 1 diabetes have lower AMH levels than women without diabetes. Further investigation is needed to determine the etiologies of this difference and how it may contribute to reproductive disorders among women with type 1 diabetes.

Early Vascular Damage in Young Women with DM-1 and Its Relation to Anti-Müllerian Hormone: A Cross-Sectional Study

Vascular function is suggested to be associated with ovarian reserve, but the relationship with microvascular function has never been studied. In this cross-sectional pilot study, the relationship of microvascular damage markers with AMH was studied in premenopausal women. Twenty-two regularly cycling women with type 1 diabetes (DM-1) and a reference group of 20 healthy regularly cycling women were included, from whom blood was drawn in the early follicular phase of the menstrual cycle. The main outcome was the correlation between circulating progenitor cells (CPCs), markers for early vascular damage, and AMH, a marker for ovarian reserve. Secondary endpoints for early vascular impairment were circulating angiogenic cells and additional biomarkers. Median AMH levels were 2.2 µg/L [1.2-3.5] in the DM-1 group and 2.1 µg/L [0.85-3.8] in the reference group. CPCs were significantly decreased in women with DM-1; 1204 ± 537 CD34+/CD45dim cells were counted in the DM-1 group, compared to 2264 ± 1124 in the reference group. CPCs and other markers of early vascular damage were not correlated with AMH levels in a multivariable analysis. These results underscore previous findings of early vascular damage in DM-1 and suggest that there may not be a relationship between vascular function and ovarian reserve. Trial Registration. This trial is registered with Clinicaltrials.gov NCT01665716.

Diagnosis and Management of IUGR in Pregnancy Complicated by Type 1 Diabetes Mellitus

This review discusses available literature on the diagnosis and management of intrauterine growth restriction (IUGR) in women with type 1 diabetes. IUGR is diagnosed when ultrasound-estimated fetal weight is below the 10th percentile for gestational age. IUGR diagnosis implies a pathologic process behind low fetal weight. IUGR in pregnancy complicated by type 1 diabetes is usually caused by placental dysfunction related to maternal vasculopathy. Prevention of IUGR should ideally start before pregnancy. Strict glycemic control and intensive treatment of nephropathy and hypertension are essential. Low-dose aspirin initiated before 16 gestational weeks can also reduce IUGR risk in women with vasculopathy. Umbilical and uterine artery Doppler studies can guide diagnosis and surveillance of fetuses with IUGR. Decisions regarding the timing of delivery should be based on assessment of umbilical artery Doppler. The risk of prematurity and impaired fetal lung maturation should always be considered, especially in fetuses younger than 32 weeks.

Influences of gender on cardiovascular disease risk factors in adolescents with and without type 1 diabetes

Background

Women with type 1 diabetes (T1D) have a four-fold increased risk for cardiovascular disease (CVD) compared to non-diabetic (non-DM) women, as opposed to double the risk in T1D men compared to non-DM men. It is unclear how early in life CVD risk differences begin in T1D females. Therefore, our objective was to compare CVD risk factors in adolescents with and without T1D to determine the effects of gender on CVD risk factors.

Methods

The study included 300 subjects with T1D (age 15.4±2.1 years, 50 % male, 80 % non-Hispanic White (NHW), glycated hemoglobin (A1c) 8.9±1.6 %, diabetes duration 8.8±3.0 years, BMI Z-score 0.62±0.77) and 100non-DM controls (age 15.4±2.1 years, 47 % male, 69 % NHW, BMI Z-score 0.29±1.04). CVD risk factors were compared by diabetes status and gender. Multivariate linear regression analyses were used to determine if relationships between diabetes status and CVD risk factors differed by gender independent of differences in A1c and BMI.

Results

Differences in CVD risk factors between T1D subjects and non-DM controls were more pronounced in girls. Compared to boys with T1D and non-DM girls, T1D girls had higher A1c (9.0 % vs. 8.6 % and 5.1 %, respectively), BMI Z-score (0.70 vs. 0.47 and 0.27), LDL-c (95 vs. 82 and 81 mg/dL), total cholesterol (171 vs. 153 and 150 mg/dL), DBP (68 vs. 67 and 63 mmHg), and hs-CRP (1.15 vs. 0.57 and 0.54 mg/dL) after adjusting for Tanner stage, smoking status, and race/ethnicity (p <0.05 for all). In T1D girls, differences in lipids, DBP, and hs-CRP persisted even after adjusting for centered A1c and BMI Z-score.

Testing interactions between gender and T1D with CVD risk factors indicated that differences were greater between girls with T1D and non-DM compared to differences between boys with T1D and non-DM. Overall, observed increases in CVD risk factors in T1D girls remained after further adjustment for centered A1c or BMI Z-score.

Conclusions

Interventions targeting CVD risk factors in addition to lowering HbA1c and maintaining healthy BMI are needed for youth with T1D. The increased CVD risk factors seen in adolescent girls with T1D in particular argues for earlier intervention to prevent later increased risk of CVD in women with T1D.

Diabetes and Menopause

During menopause, women's body composition, sex hormone profile, and metabolic profile may change dramatically. In this review, we summarize studies examining whether the menopausal transition and physiologic factors characterizing the transition are associated with increased risk of diabetes. We review the evidence for estrogen therapy and diabetes risk and studies examining the relationship between diabetes and menarche, which represents an extension of the reproductive life span at the opposite end of the age spectrum. Although studied less extensively, the presence of type 1 or type 2 diabetes may increase the risk of ovarian failure, and we review this literature. In conclusion, we note that the evidence linking menopausal sex hormone changes with increased diabetes risk is weak, although rapid changes as observed with oophorectomy may increase risk. Further studies should investigate the contradictory effects of estrogen therapy upon hepatic and glucose metabolism in mid-life women.

Pregnancy and primary biliary cirrhosis: a case-control study

A very critical feature in women's health is the identification of risk factors for pregnancy and adverse fetal outcome. Primary biliary cirrhosis is an autoimmune disease of the liver that predominantly affects older women. However, the serologic onset of this disease appears to precede clinical manifestations by many years. The goal of this case controlled study was to analyze fertility in primary biliary cirrhosis (PBC) and investigate the outcome of pregnancy, and the influence of pregnancy on the course of the disease. The study included 233 consecutive female patients with PBC seen between 1987 and 2012. Among them, 186 had at least one conception and were matched for age with a 1:2 group of controls (367 healthy women with at least one conception in their life). PBC patients experienced 507 pregnancies as opposed to 700 pregnancies among controls (mean 1.91 vs 2.73, p < 0.05). The two groups' life history was similar in terms of miscarriages, voluntary interruptions of pregnancy, and term and preterm deliveries. The rates for one or more cesarean deliveries were lower for PBC patients (5.7 vs 11.7 %, p < 0.05). Pruritus during pregnancy was recorded in 15 pregnancies involving 13 PBC patients (3.0 %) and none of the controls. Perinatal and postnatal deaths and complications at childbirth were only recorded in the PBC patients, involving a total of 11 babies (2.7 %, p < 0.05). Eight pregnancies occurred after PBC was diagnosed in six patients, all of which had a favorable course at term, with no complications at childbirth. Ursodeoxycholic acid was continued during pregnancy and no exacerbation of the disease was observed. In conclusion, successful completion of pregnancy is a realistic expectation for PBC patients, though pregnancy and delivery must be monitored for the potentially higher than normal risk of childbirth complications.

MENSTRUAL AND REPRODUCTIVE FUNCTION IN WOMEN WITH TYPE 1 DIABETES

OBJECTIVE

Menstrual irregularities, reproductive abnormalities, and androgen excess are reported to be more prevalent in women with type 1 diabetes (T1D). The objective of this study was to investigate the prevalence of menstrual irregularities, reproductive abnormalities, and androgen excess among women with T1D and their age-matched controls.

METHODS

A survey requesting information regarding menstrual and reproductive histories was administered to all participants. Results were stratified according to age (18 to 40, 40 to 50, and >50 years).

RESULTS

There were no significant differences between women with and without diabetes in age at menarche, cycle length, or androgen excess in any group. Women who self-reported difficulty with glycemic control were more likely to report irregular menses than controls (P = .04). Among women who reported ever being pregnant, there were fewer pregnancies (P = .02) and live births (P = .002) in women with T1D. Women with T1D reported a lower frequency of oral contraceptive use (P = .003), despite being less likely to smoke (P = .016).

CONCLUSION

Menstrual and reproductive abnormalities were not observed more frequently in women with T1D in this study. Subtle but measurable differences in menstrual and reproductive function were confined to the subgroup of women who perceived poor control of their diabetes. Additional prospective studies of T1D and menstrual and reproductive function would be useful.

Early age at menarche: a risk factor for overweight or obesity in patients with type 1 diabetes living in urban areas?

AIMS

Determine the relationship between age at menarche, glycemic control and cardiovascular risk factors in patients with type 1 diabetes living in urban areas.

METHODS

This was a multicenter cross-sectional study conducted in 20 cities in four Brazilian geographic regions. Data were obtained from 1527 female patients, 59.3% Caucasians, aged 25.1 ± 10.6 years. Diabetes duration was 11.4 ± 8.1 years. Age at menarche was stratified in four groups: 8-11 (group 1, early menarche), 12 (group 2), 13 (group 3) and 14-18 years (group 4, late menarche).

RESULTS

The mean age at menarche was 12.7 ± 1.7 years without difference among geographical regions, economic status, level of care and ethnicity. BMI had an inverse correlation with age at menarche (r=-0.14, p<0.001). No significant difference was observed among the four groups for blood pressure, lipid profile and diabetes-related chronic complications. Logistic regression analysis showed that early age at menarche, 8-11 years (odds ratio (ORs) 1.77 [1.30-2.41], p<0.001) and duration of diabetes [ORs 1.01 (1.00-1.03), p=0.02], were related to greater risk of patients' overweight or obesity; adherence to diet [ORs 0.78 (0.60-0.93), p=0.01], physical activity [ORs 0.75 (0.94-0.94), p=0.01], and lower insulin dose (U/kg) [ORs 0.54 (0.59-0.90), p=0.001] were related to lower risk for overweight or obesity.

CONCLUSIONS

Early menarche occurred in 23.4% of women with type 1 diabetes living in Brazilian urban areas and was strongly associated with overweight/obesity in pubertal/adult life. Further studies are warranted to establish the relationship between early menarche, glycemic control and cardiovascular risk factors.

Systematic review and meta-analysis of age at menarche and risk of type 2 diabetes

The relation of early menarche with type 2 diabetes mellitus (T2DM) remains inconsistent across studies. The objective of this systematic review and meta-analysis of published population-based observational studies was to assess the association between age at menarche and T2DM risk. We searched online data bases through December 2013 and examined the reference lists of pertinent articles. Summary relative risks (RRs) with 95 % confidence intervals (CIs) were calculated with a random-effects model. A total of 14 effect estimates from 10 eligible studies (three cross-sectional and seven cohort studies) included 315,428 participants and 22,085 cases of T2DM. Compared with the highest or middle category, women in the lowest category of age at menarche had higher risk of T2DM [summary RR (95 % CI) 1.22 (1.17, 1.28)]. These results were consistent between studies that conducted in the United States and in Europe. The association between age at menarche and T2DM was slightly stronger for cohort than for cross-sectional studies. These findings strongly support an association between younger age at menarche and increased risk of T2DM. Age at menarche may help identify women with increased risk of developing T2DM.

Evidence that insulin signalling in gonadotrophin-releasing hormone and kisspeptin neurones does not play an essential role in metabolic regulation of fertility in mice

Insulin in the brain plays an important role in regulating reproductive function, as demonstrated via conditional brain-specific insulin receptor (Insr) deletion (knockout). However, the specific neuronal target cells mediating the central effects of insulin on the reproductive axis remain unidentified. We first investigated whether insulin can act via direct effects on gonadotrophin-releasing hormone (GnRH) neurones. After clearly detecting Insr mRNA in an immunopurified GnRH cell fraction, we confirmed the presence of insulin receptor protein (InsR) in approximately 82% of GnRH neurones using dual-label immunohistochemistry. However, we did not observe any insulin-induced phospho-Akt (pAkt) or phospho-extracellular-signal-regulated kinase 1/2 in GnRH neurones, and therefore we investigated whether insulin signals via kisspeptin neurones to modulate GnRH release. Using dual-label immunohistochemistry, InsRs were detected only in approximately 5% of kisspeptin-immunoreactive cells. Insulin-induced pAkt was not observed in any kisspeptin-immunoreactive cells in either the rostral periventricular region of the third ventricle or arcuate nucleus in response to 200 mU of insulin treatment, although a more pharmacological dose (10 U) induced pronounced (> 20%) pAkt-kisspeptin coexpression in both regions. To confirm that insulin signalling via kisspeptin neurones does not critically modulate reproductive function, we generated kisspeptin-specific InsR knockout (KIRKO) mice and assessed multiple reproductive and metabolic parameters. No significant differences in puberty onset, oestrous cyclicity or reproductive competency were observed in the female or male KIRKO mice compared to their control littermates. However, significantly decreased fasting insulin (P < 0.05) and a nonsignificant trend towards reduced body weight were observed in male KIRKO mice. Thus, InsR signalling in kisspeptin cells is not critical for puberty onset or reproductive competency, although it may have a small metabolic effect in males.

Discrepancy in term calculation from second trimester ultrasound scan versus last menstrual period in women with type 1 diabetes

OBJECTIVE

To study differences in ultrasound-based compared to menstrual-based term estimation in women with type 1 diabetes.

DESIGN

Nationwide register study.

SETTING

Norway.

POPULATION

Deliveries in Norway 1999-2004 by women registered in the Norwegian Childhood Diabetes Registry (n = 342) and the background population (n = 307 248), with data on both ultrasound-based and menstrual-based gestational age notified in the Birth Registry of Norway. Births with major malformations were excluded.

METHODS

Linkage of two nationwide registries, the Medical Birth Registry of Norway and the Norwegian Childhood Diabetes Registry.

MAIN OUTCOME MEASURES

Estimated gestational age at delivery based on routine second trimester ultrasound measurements and last menstrual period.

RESULTS

In women with type 1 diabetes, the distribution of gestational age at delivery was shifted considerably towards a lower gestational age when using second trimester ultrasound data for estimation, compared with last menstrual period data. The difference between the two estimation methods was larger among women with type 1 diabetes, although also evident in the general population. One in four women with diabetes and a certain last menstrual period date had their ultrasound-calculated term postponed 1 week or more, while one in 10 had it postponed 2 weeks or more. Corresponding numbers in the background population were one in five and one in 20.

CONCLUSIONS

We found a systematic postponement of ultrasound-based compared with menstrual-based term estimation in women with type 1 diabetes. Relying solely on routine ultrasound-based term calculation for delivery decision may imply a risk of going beyond an optimal pregnancy length.

Estrogen restores brain insulin sensitivity in ovariectomized non-obese rats, but not in ovariectomized obese rats

OBJECTIVE

We previously demonstrated that obesity caused the reduction of peripheral and brain insulin sensitivity and that estrogen therapy improved these defects. However, the beneficial effect of estrogen on brain insulin sensitivity and oxidative stress in either ovariectomy alone or ovariectomy with obesity models has not been determined. We hypothesized that ovariectomy alone or ovariectomy with obesity reduces brain insulin sensitivity and increases brain oxidative stress, which are reversed by estrogen treatment.

MATERIALS/METHODS

Thirty female rats were assigned as either sham-operated or ovariectomized. After the surgery, each group was fed either a normal diet or high-fat diet for 12 weeks. At week 13, rats in each group received either the vehicle or estradiol for 30 days. At week 16, blood and brain were collected for determining the peripheral and brain insulin sensitivity as well as brain oxidative stress.

RESULTS

We found that ovariectomized rats and high-fat diet fed rats incurred obesity, reduced peripheral and brain insulin sensitivity, and increased brain oxidative stress. Estrogen ameliorated peripheral insulin sensitivity in these rats. However, the beneficial effect of estrogen on brain insulin sensitivity and brain oxidative stress was observed only in ovariectomized normal diet-fed rats, but not in ovariectomized high fat diet-fed rats.

CONCLUSIONS

Our results suggested that reduced brain insulin sensitivity and increased brain oxidative stress occurred after either ovariectomy or obesity. However, the reduced brain insulin sensitivity and the increased brain oxidative stress in ovariectomy with obesity could not be ameliorated by estrogen treatment.

Menarcheal age of type 1 diabetic Bengali Indian females

BACKGROUND

It has been observed that menstrual characteristics are generally influenced by lifestyle, socio-cultural and biological factors.

AIM

The present study examines: (a) variation in menstrual characteristics between Type1 Diabetic females of rural and urban adolescents, i.e. the resident status; and (b) whether these characteristics can be predicted from various socio-economic, stress variables related to place of residence.

SUBJECTS AND METHODS

The sample of the present study constituted 103T1DM females from West Bengal, a State of India. These girls belong to a Bengali-speaking ethnic group. Data on socio-economic variables and menstrual characteristics were collected using pretested questionnaires.

RESULTS

Menstrual irregularity was common in our study participants, with age of menarche, but was not associated with current BMI, physical activity or insulin dose.

CONCLUSIONS

Our study displays that age at menarche is delayed in young women with T1DM compared to the concurrent overall mean age at menarche in the West Bengal population.

Quantifying the impact of gestational diabetes mellitus, maternal weight and race on birthweight via quantile regression

BACKGROUND

Quantile regression, a robust semi-parametric approach, was used to examine the impact of gestational diabetes mellitus (GDM) across birthweight quantiles with a focus on maternal prepregnancy body mass index (BMI) and gestational weight gain (GWG).

METHODS

Using linked birth certificate, inpatient hospital and prenatal claims data we examined live singleton births to non-Hispanic white (NHW, 135,119) and non-Hispanic black (NHB, 76,675) women in South Carolina who delivered 28-44 weeks gestation in 2004-2008.

RESULTS

At a maternal BMI of 30 kg/m² at the 90(th) quantile of birthweight, exposure to GDM was associated with birthweights 84 grams (95% CI 57, 112) higher in NHW and 132 grams (95% CI: 104, 161) higher in NHB. Results at the 50(th) quantile were 34 grams (95% CI: 17, 51) and 78 grams (95% CI: 56, 100), respectively. At a maternal GWG of 13.5 kg at the 90(th) quantile of birthweight, exposure to GDM was associated with birthweights 83 grams (95% CI: 57, 109) higher in NHW and 135 grams (95% CI: 103, 167) higher in NHB. Results at the 50(th) quantile were 55 grams (95% CI: 40, 71) and 69 grams (95% CI: 46, 92), respectively.

SUMMARY

Our findings indicate that GDM, maternal prepregnancy BMI and GWG increase birthweight more in NHW and NHB infants who are already at the greatest risk of macrosomia or being large for gestational age (LGA), that is those at the 90(th) rather than the median of the birthweight distribution.

Is the risk and nature of CVD the same in type 1 and type 2 diabetes?

The incidence of both type 1 and type 2 diabetes is increasing globally, most likely explained by environmental changes, such as changing exposures to foods, viruses, and toxins, and by increasing obesity. While cardiovascular disease (CVD) mortality has been declining recently, this global epidemic of diabetes threatens to stall this trend. CVD is the leading cause of death in both type 1 and type 2 diabetes, with at least a two- to fourfold increased risk in patients with diabetes. In this review, the risk factors for CVD are discussed in the context of type 1 and type 2 diabetes. While traditional risk factors such as dyslipidemia, hypertension, and obesity are greater in type 2 patients than in type 1 diabetes, they explain only about half of the increased CVD risk. The role for diabetes-specific risk factors, including hyperglycemia and kidney complications, is discussed in the context of new study findings.

Fertility in people with childhood-onset type 1 diabetes

AIMS/HYPOTHESIS

To assess the number of live births in a population-based, retrospective cohort of women and men with childhood-onset type 1 diabetes, and matched controls.

METHODS

The reproductive histories of people in a Finnish cohort of 2,307 women and 2,819 men with type 1 diabetes and two matched controls (for each case) were obtained from National Population Register data. All persons with diabetes were diagnosed with the disease in 1965-1979 at the age of 17 or under. A proportional hazards model was used to model the association between the rate of live births as a function of the age of an individual and the observed covariates (sex and age at onset of diabetes).

RESULTS

Both women and men with diabetes had a smaller number of live births than the controls; the HR of having a first child for diabetic women compared with controls was 0.66 (95% CI 0.62, 0.71) and for men was 0.77 (95% CI 0.72, 0.83). In women, a birth cohort effect was detected; in more recent birth cohorts, the difference between diabetic women and controls as regards having children was significantly smaller than in earlier cohorts. Later age at onset of diabetes was associated with a higher rate of having a first child among men (p = 0.04) and having a second live birth among women (p = 0.002).

CONCLUSIONS/INTERPRETATION

Type 1 diabetes affects the number of live births in both women and men. The age at onset of diabetes is associated with the pattern of reproduction in both diabetic women and men.