Image from Flickr via (Creative Commons License)
Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change. (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)
This is American Heart Month. Accordingly, this week’s post addresses the concerns of a woman whose complex medial history puts her at risk of heart disease. Dr. Pat has turned for guidance to endocrinologist Andrew Martorella, M.D., an Assistant Attending Physician at New York Presbyterian Hospital who holds an academic teaching position as a Clinical Assistant Professor of Medicine at the Weill Medical College of Cornell University.
Dear Dr. Pat:
I am concerned about my risk for heart disease, since I have a serious family history of diabetes and many of those relatives died from heart failure or heart attacks in their 60s and 70s. I have polycystic ovarian disease, and am told that I have trouble metabolizing my sugar due to an insulin problem. Even though I exercise every day, I am always hungry and have watched in horror as my weight has climbed five pounds a year since menopause at age 48. I am now 55 and weigh 155 at five feet five (BMI doesn’t lie: 26.0, and I know this is in the really overweight group).
I am a health educator in the local high school, so I know about diet and nutrition and exercise, but nothing is working for me. We don’t have any specialists in this town, and traveling to see a diabetes specialist is really a big expense. My hemoglobin A1C is now 5.9 and my fasting blood sugar is around 110. The GP said I wasn’t sick enough yet to start any diabetes medicine and told me, again, to just lose weight.
I have three questions:
- What is the relationship between polycystic ovarian syndrome and diabetes?
- How does diabetes cause heart failure and heart attacks in women?
- Are there any medications I should be taking now to decrease my risk of heart disease and to help with weight loss or managing my sugar problem?
Angie
Dr. Pat Responds:
Dear Angie:
Thanks for writing to us about these complex health matters that have affected you. Many patients have more than one risk factor for heart disease, for example, and it is the difficult job of the health care provider to evaluate each of these risk factors and determine how to decrease their impact on the patient’s overall risk profile.
The type of doctor who will know a great deal about your health problems is an endocrinologist, a physician who has specialized in the study of hormones and how hormones communicate with each other and the various organs in the body that produce and release hormones. This kind of doctor can help you understand what the blood test hemoglobin A1C means in glucose control, and how BMI (body mass index), a measurement of the ratio of height to weight based on national norms and guidelines, can guide risk assessment. For example, BMI under 25 is ideal.
During this February, which is American Heart Month, several physicians on the Medical Advisory Board here at www.womensvoicesforchange.org have agreed to undertake a discussion about how women develop heart disease and what can be done to alter risk factors that cause this number-one killer of women in America. Today, Dr. Andrew Martorella, an endocrinologist in New York City, will discuss your medical questions.
Dr. Pat
Dr. Martorella Responds:
Dear Angie:
The concerns that you express are some of the most common that a medical endocrinologist is confronted with. Your family medical history of heart disease and your personal medical history of polycystic ovarian syndrome (PCOS), along with your recent transition into menopause, present a challenging clinical problem. In my opinion, you have symptoms that suggest early signs of diabetes, often called “pre-diabetes.” You certainly have signs of “insulin resistance,” and this is contributing to your weight gain and fasting blood sugar level. The main purpose of insulin is to activate the muscles so that they absorb and burn off circulating glucose as fuel and energy for the body. Elevated blood sugar levels are known as diabetes, which can lead to heart disease. I’ll include the most recent medical options for these issues; you may want to discuss them with your health care provider.
First of all, there are two types of diabetes: Type 1 and Type 2.
Type 1 diabetes is caused by your own body’s destruction of the insulin-secreting cells (beta cells) in the pancreas. Insulin is what keeps your blood sugar levels in check. The result of the pancreas’s being damaged is that circulating insulin levels are markedly diminished. Type 1 diabetes is commonly referred to as “juvenile diabetes,” since the presentation is often early in life, but it can actually present at any age. The current medical option for patients with Type 1 diabetes is insulin, either in the form of multiple daily injections or the use of an insulin pump. Many clinical trials are ongoing to try to find a cure that restores pancreatic beta cells.
Type 2 diabetes is by far the most common type. It usually occurs later in life; it happens when the muscles become resistant to the effects of insulin. If insulin cannot activate the muscles, then circulating glucose does not get absorbed, and the extra glucose is stored in the body as adipose (fat) tissue. The pancreas senses the muscles’ resistance to insulin and compensates by producing even more insulin. Surprisingly, the lab work of a typical patient with early type 2 diabetes contains high insulin levels. The excess insulin in the system can cause direct harm to the rest of the endocrine system and other body systems, increasing a patient’s risk for PCOS and heart disease.
PCOS (Polycystic Ovarian Syndrome) is a common medical condition that often shows up early in life, during the teenage years, with symptoms of infrequent menstrual periods, acne, and too much hair growth on the face and body, as well as infertility. Patients with PCOS have a higher incidence of diseases like heart disease later in life. The classical presentation of PCOS is the triad of cystic ovaries on ultrasound, irregular menstrual cycles, and high levels of androgens (male hormones) in the bloodstream, usually in the form of testosterone.
While the actual cause is still not clear, female patients with high insulin levels and other signs of pre-diabetes often struggle with PCOS to a greater degree. Recent evidence indicates that high insulin levels may actually stimulate the ovaries to produce testosterone and other male hormones. As the level of testosterone increases, the effects of “insulin resistance” become more pronounced. Then the pancreas responds with even greater insulin production, producing a vicious cycle. Once the level of insulin reaches a certain point, the ability of the muscles to metabolize glucose becomes compromised. Then the blood sugar starts to increase, as reflected in your elevated fasting glucose and hemoglobin A1C test (a measure of your average blood sugar over a three-month period). The only dietary options are to minimize carbohydrates and simple sugars, along with portion control, so that the muscles do not have to work as hard to metabolize glucose. Weight loss—as little as 5 percent or a few pounds—can result in the return of insulin levels to a more normal range; this will diminish the ovarian production of androgens and restore menstrual cycles. (Endocrine Rev. 1997 Dec; 18(6): 774-800)
