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DIABETES AND
OBESITY

respond well to ovulation induction using oral agents (17) such as menopausal type 2 diabetes fail to show a difference when com-
letrozole or clomiphene citrate, with injectable gonadotropins rec- pared to the age at menopause onset for non-diabetic women (20,
ommended as second line ovulation induction agents (18), often in 27). Interestingly, though, women who experience menopause at
combination with IvF (in vitro fertilization) to decrease the risk of an earlier age are more likely to later develop diabetes in the
higher-order multiple gestations. menopause compared with age-matched menopausal controls,
possibly owing to a protective effect of estrogen on glucose me-
Is the reproductive window altered in women tabolism (28).
with diabetes?
Regarding type 1 diabetes, there are some conflicting data over Does improved glycemic control and prevention
whether women may have a shortened reproductive window. While of diabetic complications improve fertility rates?
some studies have detected a significantly earlier average age at While we have all encountered women who seem quite fertile
menopause for women with type 1 diabetes (19), particularly in those despite serious end organ disease associated with uncontrolled or
with a diagnosis of diabetes made at less than age 20 (20), a more re- long-standing diabetes, the pillar of preconception counseling for
cent large cross-sectional study found no association with type 1 di- women with diabetes is that glycemic control and optimization of
abetes and an earlier age for menopause (21) after adjustment for any diabetes-related health conditions is critical for decreasing the
potential confounders. AMH (antimullerian hormone) is now com- maternal and fetal risks associated with pregnancy. Whether
monly used as a marker of ovarian reserve, with lowered levels pos- glycemic control can improve actual fertility is most apparent in
sibly associated with an earlier menopause in reproductive-aged the relationship between hyperglycemia and miscarriage rates (29-
women (22). Two studies have found lowered AMH levels in women 31), with a proportional increase in the risk of first trimester preg-
with type I diabetes compared to age-matched controls (23, 24) which nancy loss noted with increasing glycosylated hemoglobin levels.
may support the risk for an earlier onset of menopause in these Additionally, the risk of congenital malformations is strongly re-
women. Some have suggested that poor glycemic control leading to lated to the degree of hyperglycemia during embryogenesis, and
ovarian vascular compromise may be linked with an earlier thus also pregnancy loss (32). The American diabetes Association
menopause in women with
type 1 diabetes, but studies
examining intensive versus
conventional treatment for
glycemic control fail to show
an association with the age at
menopause (25). The less
frequent diagnosis of prema-
ture ovarian insufficiency in
women under age 40 due to a
possible autoimmune etiol-
ogy may be seen more often
in women with other autoim-
mune disorders such as au-
toimmune thyroid disease
and type 1 diabetes (26).
Studies examining the age
at menopause onset for
women with pre-
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