Menopausal treatment in women with diabetes and hypertension

Abstract

Menopausal transition is associated with increased risk of hypertension and metabolic changes predisposing for type 2 diabetes. Moreover, hypertension and type 2 diabetes are independent risk factors for cardiovascular disease, which is the leading cause of morbidity and mortality in women. It is well-known that endogenous estrogen protects against cardiovascular disease by vasodilatation through mechanisms including increased nitric oxid synthesis and reduced angiotensin receptor activity leading to reduced blood pressure. What about menopausal hormone treatment (MHT), could MHT be beneficial and prevent from development of diabetes and cardiovascular disease? Furthermore, is MHT safe in women with pre-existing diabetes and hypertension? Well-controlled diabetes and/or hypertension are not contraindications for MHT. Vasomotor symptoms should be indication for treatment also in these women with special consideration of cardiovascular risk. In fact, MHT can improve diabetic control. However, there is no clear evidence to support that MHT can prevent from developing diabetes. The oral route of MHT can affect blood pressure by liver induction of plasma proteins, which may increase blood pressure and aggravate hypertension. Furthermore, oral estrogen increaes coagulation factors and therby increases the risk of thrombosis. In women with hypertension, transdermal estrogen might be the most appropriate MHT. Transdermal estrogen does not increase blood pressure and is preferable for women with moderate risk for cardiovascular disease. Progestogens with neutral effect on metabolic parameters could also be recommended. The risk benefit balance of using MHT for healthy women is favorable if introduced early in relation to menopause, but the timing hypothesis for primary prevention of cardiovascular disease is still under debate. These questions and the management of menopausal symptoms in women with diabetes and hypertension will be illustrated by a patient case.