Treatments including Hormone Therapy and Alternatives for Women with Diabetes

Hormone Therapy (HT) is a treatment used to relieve symptoms caused by hormonal imbalances or deficiencies, often related to aging, menopause, or specific medical conditions. It involves supplementing the body with hormones, typically estrogen and progesterone, to protect the endometrial lining and restore balance and alleviate symptoms. In previous articles, we have discussed the role of estrogen and progesterone in overall perimenopausal and postmenopausal wellness. We have seen the effects that a deficiency can have. Now, we will take a look at how to replenish these hormones. Here’s an overview:
1. Types of HT
- Estrogen-only HT: Often prescribed for women who have had a hysterectomy (removal of the uterus). It replaces the estrogen the body no longer produces after menopause.
- Combined HT (Estrogen and Progesterone/Progestin): Used for women who still have a uterus, combining estrogen with progesterone to reduce the risk of endometrial cancer (cancer of the uterus) that estrogen-alone therapy may cause.
2. Common Uses of HT
- Menopause: HT is often relevant for the average woman to manage symptoms of menopause, such as hot flashes, night sweats, mood swings, vaginal dryness, and sleep problems.
3. Benefits
- Symptom Relief: HT can greatly improve the quality of life by alleviating uncomfortable symptoms associated with hormonal changes, like hot flashes, mood swings, or loss of sexual drive.
- Bone Health: Estrogen in HT can help prevent osteoporosis by maintaining bone density.
- Cardiovascular Health: Some evidence suggests HT, started at the onset of menopause, may have heart health benefits, though this is still debated.
4. Risks and Side Effects
- Blood Clots: Some forms of HT, especially oral estrogen, may increase the risk of blood clots and stroke. This risk is quite small but still present.
- Breast Cancer: Combined estrogen-progesterone HT has been associated with a small increased risk of breast cancer if used long-term.
- Heart Disease: HT can potentially raise the risk of heart disease in older women, particularly if started many years after menopause.
- Other Side Effects: These can include headaches, nausea, bloating, breast tenderness, and mood changes.
5. Forms of HT
- Oral Pills: One of the most common forms, though they may carry a higher risk of blood clots.
- Patches: These are applied to the skin and can release hormones into the bloodstream more consistently.
- Gels, Creams, and Sprays: Applied to the skin, offering a more localized option.
- Implants: Tiny pellets placed under the skin that release hormones over time. This form of HT is not FDA-approved and may deliver an unreliable dose of hormone.
- Vaginal Rings, Creams, or Tablets: Local or systemic treatments for vaginal and urinary symptoms, such as dryness or irritation.
6. Individualized Approach
- HT is not a one-size-fits-all treatment. It should be tailored to an individual’s symptoms, age, medical history, and personal preferences. A healthcare provider will evaluate the benefits versus the risks for each patient, considering factors like age, the onset of menopause, and other health conditions.
7. Alternatives to HT
For those who cannot or choose not to take HT, alternatives include (but are not limited to):
- Non-hormonal Medications: Certain antidepressants or one anti-seizure medication that can help manage symptoms like hot flashes. Antidepressants decrease menopausal symptoms, specifically hot flashes, by working on serotonin. Serotonin is a neurotransmitter that plays a key role in regulating mood and body temperature. Antidepressants that increase serotonin levels in the brain can help stabilize the body’s temperature regulation, reducing the frequency and severity of hot flashes.
A classification of medication called Neurokinin 3 Receptor (NK3R) Antagonists offers promising treatment to women suffering from moderate to severe hot flashes and night sweats. This drug class acts in the area of the hypothalamus that regulates body temperature. Specifically, it blocks a chemical binding to a brain receptor, which triggers hot flashes and night sweats.
Lastly, the anti-seizure medication gabapentin, in low doses, has effects on the hypothalamus (the brain’s temperature control center). Gabapentin can also reduce the severity and frequency of hot flashes by preventing the abnormal surges in temperature that lead to hot flashes.
- Lifestyle Changes: Regular exercise, a balanced eating plan, stress management, and reduced caffeine, sugar, and alcohol, in addition to quitting smoking, can help alleviate some symptoms.
- Herbal Remedies and Supplements: Some people turn to natural options like black cohosh or phytoestrogens, though these are not rigorously tested or FDA-regulated like prescription treatments.
8. Monitoring and Duration
HT is often prescribed for the shortest duration necessary to relieve symptoms, and regular monitoring is essential. The decision to continue or stop HT depends on symptom relief, side effects, and individual risks and benefits.
HT can be an effective treatment for managing hormone-related symptoms, but it requires careful consideration of its benefits and risks under the guidance of a healthcare professional.
Evaluating the pros and cons of HT for women with diabetes
Hormone Therapy (HT) for women with diabetes has both potential benefits and risks. Since diabetes affects how the body regulates glucose, and hormones like estrogen and progesterone can impact insulin sensitivity, it’s important to carefully weigh the pros and cons of HT in this context. Here’s an overview and a review of what we have discussed in prior articles.
Potential Benefits of HT for Women with Diabetes
- Relief from Menopausal Symptoms:
- HT can effectively reduce common menopausal symptoms such as hot flashes, night sweats, mood swings, and vaginal dryness. These improvements can enhance the overall quality of life for women with diabetes, who may already be dealing with the complexities of managing their condition.
- Improved Insulin Sensitivity:
- Estrogen in HT has been shown to improve insulin sensitivity in some women. This can lead to improved blood glucose management, especially in postmenopausal women, where a drop in estrogen levels may increase insulin resistance.
- Some studies suggest that women who begin HT soon after menopause may have improved blood glucose management, although this effect is not seen with every woman with diabetes.
- Cardiovascular Health:
- Postmenopausal women with diabetes are at higher risk of cardiovascular disease. Some research indicates that estrogen therapy may help improve cholesterol levels, reduce arterial stiffness, and provide some cardiovascular benefits in women with diabetes, particularly if HT is initiated early in menopause.
- By improving lipid profiles (raising HDL, lowering LDL), HT may help protect against heart disease, which is a major concern for women with diabetes.
- Bone Health:
- Women with diabetes are at a higher risk of osteoporosis and fractures, and HT can help maintain bone density and reduce the risk of osteoporosis-related fractures by replenishing estrogen.
Potential Risks of HT for Women with Diabetes
- Increased Risk of Blood Clots:
- HT, particularly oral forms, increases the risk of blood clots, which can lead to deep vein thrombosis (DVT) or pulmonary embolism. Women with diabetes, especially those who are overweight, have high blood pressure, or smoke, may already be at a higher risk of clotting, which can be made worse by HT.
- Impact on Glucose Management:
- While estrogen can improve insulin sensitivity, progesterone can have the opposite effect, potentially increasing insulin resistance and making blood glucose management more challenging. However, many women on estrogen or estrogen-progesterone therapy had improved glycemic management than those not on hormone therapy. Remember, if a postmenopausal woman has a uterus, she will need estrogen and progesterone if she desires hormonal supplementation.
- Some women on HT may experience fluctuations in blood glucose levels, requiring adjustments in diabetes medications.
- Cardiovascular Risks:
- Although early initiation of HT may offer heart health benefits, starting HT later in life (more than 10 years after menopause) or after the age of 60 can increase the risk of heart disease and stroke, particularly in women with diabetes, who are already at increased cardiovascular risk. This requires an in-depth discussion with your healthcare provider about the risks and benefits of starting this therapy.
- Breast Cancer Risk:
- Combined estrogen-progesterone HT slightly increases the risk of breast cancer with long-term use. Since diabetes itself has been associated with an increased risk of certain cancers, adding HT may heighten this risk further, especially with prolonged use.
- Weight Gain:
- Some women experience weight gain due to fluid retention and bloating while on HT, which can complicate diabetes management. Maintaining a healthy weight is crucial for blood glucose management, and weight gain could increase insulin resistance.
- Monitoring and Adjustments:
- Women with diabetes using HT may require more frequent monitoring of their blood glucose levels and possible adjustments to their diabetes medication regimen. The interaction between hormones and insulin regulation can make diabetes management more complex.
Special Considerations
- HT Type and Route: Transdermal (skin patch) forms of HT may have fewer metabolic side effects, as they bypass the liver, where oral estrogen can increase clotting risk and adversely affect lipid metabolism. This route may be preferred for women with diabetes.
- Timing: Starting HT at the onset of menopause may offer more benefits (such as improved insulin sensitivity and cardiovascular protection) compared to starting it later in life.
- Lifestyle: Women with diabetes on HT should maintain a healthy lifestyle, including regular exercise, a balanced eating plan, and weight management, to reduce risks associated with both HT and diabetes.
Alternatives to HT: natural supplements that can alleviate menopause symptoms and aid in diabetes management
For women seeking natural alternatives to Hormone Therapy (HT), several supplements and herbal remedies may help manage menopausal symptoms like hot flashes, night sweats, mood swings, and vaginal dryness. The side effects and effectiveness of these alternatives vary from person to person, however the scientific evidence supporting their benefits is limited. Always consult with a healthcare provider before starting any new supplement, especially if you have underlying health conditions or take other medications. A few will be listed with details, and others just listed.
Phytoestrogens (Plant-Based Estrogens): Phytoestrogens are naturally occurring compounds in plants that can mimic the effects of estrogen in the body, though they are much weaker than human estrogen. There is limited evidence in scientific studies that support the pros and cons of their usage in menopause.
- Soy Isoflavones: Found in soybeans, soy milk, tofu, and other soy products, soy isoflavones are one of the most well-researched natural alternatives to HT.
- Red Clover: Another rich source of isoflavones, red clover is often used in supplements to reduce hot flashes and night sweats.
- Black Cohosh: One of the most popular herbal supplements for menopause symptoms, especially hot flashes and mood disturbances.
- Dong Quai: Often called “female ginseng,” dong quai is a traditional Chinese herb used to treat gynecological conditions, including menopause.
- Evening Primrose Oil: A natural oil rich in gamma-linolenic acid (GLA), a type of omega-6 fatty acid, evening primrose oil is often used for menopausal symptoms.
- Maca Root: A Peruvian plant root used for centuries to boost energy, stamina, and libido.
- St. John’s Wort: An herb traditionally used to treat depression and mood disorders.
- Ashwagandha: An herb used in Ayurvedic medicine, ashwagandha helps the body manage stress and balance hormones.
- Vitamin D and Calcium: Essential nutrients that support bone health, which can decline after menopause.
- Omega-3 Fatty Acids: Found in fish oil and flaxseeds, omega-3s have anti-inflammatory properties and support heart and brain health.
In addition to these options, the 2023 recommendations from The Menopause Society (TMS) for non-hormonal therapies focus on evidence-based options to manage menopause symptoms, particularly vasomotor symptoms like hot flashes and night sweats, for women who cannot or prefer not to use hormone therapy. Some key recommendations include:
- Cognitive Behavioral Therapy (CBT) and Clinical Hypnosis: These have been shown to be effective for managing hot flashes and improving overall quality of life.
- Prescription Medications:
- Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) have demonstrated effectiveness in reducing hot flash frequency. These medications are also used as antidepressants.
- Gabapentin and Oxybutynin are also recommended for reducing hot flashes, though gabapentin may cause side effects like drowsiness, dizziness, and issues with balance. Oxybutynin has potential cognitive risks with long-term use.
- NK3 Receptor Antagonists offer promising treatment to women suffering from moderate to severe hot flashes and night sweats. This drug class acts in the area of the hypothalamus that regulates body temperature. Specifically, it blocks a chemical binding to a brain receptor, which triggers hot flashes and night sweats.
- Lifestyle and Behavioral Interventions: Weight loss is also recommended, while other approaches like exercise, paced respiration, and mindfulness are not supported by sufficient evidence.
Notably, TMS does not recommend many commonly used alternatives such as herbal supplements, soy products, acupuncture, yoga, or cannabinoids for vasomotor symptoms due to a lack of proven efficacy. They also do not recommend “pellet therapy” as it is not FDA-approved or regulated.
These guidelines provide clarity for healthcare providers to recommend non-hormonal therapies that are backed by scientific evidence, helping women avoid ineffective treatments.
Key questions to ask during consultations
Due to the challenges that some providers may have with their training and experience prescribing HT, patients need to ensure their provider has enough comfort and experience to safely prescribe HT. Some providers are very conservative with prescribing, and for this reason, may be hesitant to offer HT at all! Some may not be familiar with the nuances of prescribing, such as when to start or stop HT. There are also some providers who use long-acting reversible contraceptives, including the progesterone-secreting IUD, to provide the progesterone component of hormone therapy. The estrogen component of the HT can then be prescribed with a patch.
For women with diabetes, HT can offer relief from menopausal symptoms and potentially improve insulin sensitivity and bone health. However, it also comes with increased risks of blood clots, cardiovascular events, and possibly negatively impact glucose management. The decision to use HT should be made on an individual basis in consultation with a healthcare provider, who will weigh the potential benefits against the risks and consider factors such as age, type of diabetes, cardiovascular health, and personal preferences. Using a personalized approach, some women with diabetes may benefit from HT, especially with careful monitoring and lifestyle management. They should ensure that their provider is comfortable with prescribing and managing HT, and this should involve a discussion regarding the risks and benefits of HT.
About the Author
Dr. Mala Freeman-Kwaku, lead physician at Arboretum Gynecology, has over 22 years of experience specializing in gynecologic care, including treating uterine fibroids, heavy menstrual bleeding, and menopausal symptoms. A graduate of the University of Virginia and Georgetown University Medical Center, she transitioned from a group practice to create a more intimate healthcare environment, successfully rebranding her practice while maintaining patient loyalty. Skilled in hysteroscopy and advanced procedures like the Sonata fibroid ablation, she shares her expertise as a speaker for Gynesonics and through her private consulting firm, MFK Advising Group, LLC. Dr. Freeman-Kwaku is married with four children, enjoys traveling, and remains active in her church and community.
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