Patient with diabetes in an outpatient gynecology clinic: most frequent clinical problems

Diabetes is one of lifestyle diseases as 6.4% of people are affected (aged 20-79), and in 95% of cases this is type 2 diabetes. In Poland there are 1.5 million patients with this type of diabetes, of which 60% are women. Type 2 diabetes lasts long with no symptoms, remaining undiagnosed and untreated, leading to irreversible changes in internal organs. Often a tendency towards occurrence of purulent skin infection or mycosis is the first symptom. According to PTG expert group data, superficial mycoses are among most frequent infections in women. Drugs of the azole group and polyene antibiotics are used in vulvovaginal candidiasis (VVC). In acute VVC and in prevention of recurring infections, triazole derivatives (fluconazole, itraconazole) are recommended. Latest trials indicate that extended fluconazole therapy is more effective in recurrent candidal vulvitis and vaginitis than, as yet used, “short” therapy treatments.

One of more frequent reasons for gynecological appointments for diabetic women is selection of the contraception method. It is particularly important for diabetic women given a higher pregnancy risk for the woman and the child, when unplanned. Lesser effects on lipid and carbohydrate metabolism and on the coagulation system should be sought when selecting the method. Progestins potentially compromise lipid and carbohydrate metabolism. It seems that progestin mini-pill with the 3rd generation progestin is safe in diabetic women. Hormonal contraception should not be recommended to patients with labile blood sugar, de novo diagnosed diabetes, patients with diabetic complications (retinopathy, nephropathy, coronary disease or lower limb atherosclerosis), high cholesterol or TG level with hypertension. IUDs with copper (no progestins) might be an alternative for diabetic patients. Intense climacteric symptoms may also be another reason for a gynecological appointment. Menopausal Hormonal Therapy (MHT) reduces climacteric symptoms but diabetic patients are often afraid that diabetes management can worsen. A combination of transdermal estradiol and norethisterone acetate seems to be the best MHT choice in diabetes, considering no important influence on carbohydrate metabolism and its TG reducing effect. Transdermal application causes no rise in TG and blood pressure levels, which is particularly important in type 2 diabetes patients with frequently concomitant dyslipidemia and high BP levels, as in metabolic syndrome. It is estimated that the so-called vaginal symptoms, resulting from atrophic vaginitis, occur in almost every third woman in the perimenopausal period and in almost every second woman in the postmenopausal period. Diabetes results in a 2.5-fold increase in the risk of incontinence but this mechanism is still a mystery. More and more data indicate that type 2 diabetes is a risk factor for cancer and cancer induced deaths. Meta-analysis of type 2 diabetes and cancer concomitance pointed to a relative risk factor for endometrial cancer of RR 1.2, breast cancer of 1.20 and colorectal cancer of 1.30.