Hormone replacement therapy,cardiovascular risk factors and diabetes

Abstract

The woman with type 2 diabetes mellitus is at increased risk of developing coronary heart disease at all ages compared to the nondiabetic woman, due not only to the presence of the diabetic state but also to the increased prevalence of multiple cardiovascular risk factors. This coronary risk increases further following natural or surgical menopause. Through an improvement in some of the modifiable risk factors with oestrogen replacement, this absolute risk may be reduced. There is emerging evidence in diabetic groups that oral oestrogen improves insulin sensitivity, dyslipidaemia, fibrinolysis and may improve endothelial dysfunction, with no apparent adverse effect on blood pressure, body weight or anthropometry. The use of 17_β-oestradiol appears advantageous over conjugated equine oestrogen especially with regard to improvement in dyslipidaemia and the threat of oestrogen induced hypertriglyceridaemia. The choice of progestagen is less clear, but micronised progesterone or dydrogesterone would seem to have the least adverse effect on insulin sensitivity and HDL cholesterol concentrations. Long term studies are clearly required to identify whether this improvement in cardiovascular risk profile reduces coronary heart disease events for those women with type 1 or type 2 diabetes. Hormone replacement therapy is indicated for use in women with diabetes who require relief of symptoms of oestrogen deficiency or preservation of bone mineral density. It may be considered for improvement of cardiovascular risk, even though data on end-points specific for women with diabetes are still awaited.