Author: Diabetes Focus eMag

metal fillings

Metal fillings’ place in modern-day dentistry

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Metal fillings (amalgam) has had its place in dentistry for decades. Dr Marc Sher educates us on the facts and the myths.

Patients frequently ask what should they do with their metal (amalgam) fillings. Mostly, it’s because they’ve read an article that says metal fillings are poisonous and can cause cancer, dementia, Alzheimer’s, and a host of other deadly diseases.

There are also patients, whom have visited a ‘holistic’ health practitioner, and have been advised to remove all their metal fillings. Then, there are patients that simply don’t like the dark shadow they see when they smile or open their mouth.

Whatever the reason, amalgam has had its place in dentistry for decades. It’s important to separate the facts from the myths, and for you to understand the facts to be able to choose the best course of treatment.

What you need to know about metal fillings

Amalgam, a metal alloy, made up of mainly mercury, silver, zinc and copper was the filling of choice for many dentists across the globe for decades. It’s been clinically proven to withstand all the complexities that the oral environment can deliver as well as been shown to last for many years, without wearing down, breaking, or changing its shape.

Amalgam is not moister sensitive (a big issue in the mouth) and it’s condensed into a cavity using the tooth undercuts for mechanical retention. It has a low-cost output for the dentist and a short working time. Which means many dentists have chosen this as a filling of choice to increase production and turnover. There is no wonder that many government dental clinics only offer amalgam as the filling of choice.

Patients more aesthetically demanding

In my 10 years in the dental industry, my personal journey with amalgam has been short. We were taught, and instructed, to place a certain number of amalgam fillings in dental school and had to be fully competent in its application.

We were also taught about resin (white) fillings, but to a much lesser extent. When I left dental school, and entered private practice, naturally I did what I was taught in the beginning. So yes, I was placing amalgam fillings.

As I grew in my role as a private practitioner, I developed a passion for aesthetic dentistry, leading me into the world of tooth-coloured/white fillings. I’ve done research, tried different resin, ceramic and glass ionomer filling materials, and attended courses and workshops learning about their application and function.

As my patients became more aesthetically demanding, I had to make a choice on filling material, and what it basically boiled down to was a simple question, “Why place a metal filling in a white tooth?” The last time I recall placing an amalgam filling was in 2010.

Advances in filling material

As technology and innovation drives the growth and changes in every industry, dentistry has seen a paradigm shift in filling materials. The dental material companies, manufacturing tooth-coloured fillings, have pushed each other to create filling materials that can truly withstand all that the mouth can throw at them.

It’s been a long road, but the science has shown that composite resin, glass ionomers, ceramics and other tooth-coloured materials are a superior choice. There is no reason, other than increased productivity and low-costs, that dentists should turn to an amalgam filling in this day and age.

Technique sensitive

Placing a tooth-coloured filling is extremely technique sensitive; all the steps need to be followed to ensure the correct bonding of the filling to the tooth. There will still be instances where these tooth-coloured fillings will fail, but this is mostly due to poor technique or incorrect material selection. Every other aspect of the tooth-coloured materials we are using nowadays is superior to amalgam.

The difference between amalgam and tooth-coloured fillings

The fundamental difference between amalgam and tooth-coloured fillings is that tooth-coloured materials are ‘bonded’ onto the tooth surface, and metal is not. Metal is held in place mechanically.

What now?

Do you rush to your dentist and have he/she replace all your amalgam fillings? My advice, definitely not! If you have sound, functional metal fillings that do not give you a moments trouble then let sleeping dogs lie.

Unless your dentist has pointed out that there is a health issue (secondary decay), functional issue (broken or chipped), or an aesthetic issue with your amalgam filling, I do not recommend removing them.

Is there scientific proof that metal fillings are poisoning the body?

The short answer is no. Nothing has been clinically proven, and the literature on the topic states that they cannot conclusively prove that amalgams are the cause of said illness. What is known, is that the ‘feel-good factor’ and ‘placebo effect’ have been shown to reign true when it comes to removing metal fillings.

Another important fact is when a dentist picks up his/her drill to remove the amalgam filling, that process completely vaporises the filling into millions of tiny particles. At which time, the patient is at the greatest risk of swallowing and inhaling the harmful metal alloys that the filling contains. Basically, it’s safer in then out.

Removing metal fillings

If you need to have an amalgam filling removed, please request that the dentist places a rubber dam (isolation device) and uses a high-powered suction. This will greatly limit your exposure to debris caused when having an amalgam filling removed.

It is also expected that a tooth will experience some post-operative sensitivity after amalgam has been removed. Most often, the sensitivity is short-lasting and will settle. However, there are exceptions, and removal can lead to further treatment needed on the tooth, such as root canal and a ceramic crown or overlay.

MEET OUR EXPERT - Dr Marc Sher

Dr Marc Sher (B.Ch.D) practices at The Dental Practice in Sea Point, Cape Town, and can be reached via email: marc@drmarcsher.co.za
Quinoa Loaf

Quinoa Loaf

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Suganon is a range of great tasting sugar alternatives to help you maintain a healthier lifestyle.

Range endorsed by:
‱ Diabetes SA
‱ GI Foundation   

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Ingredients

  • 300g whole uncooked quinoa (soaked in plenty of cold water overnight in the fridge)
  • 60g chia seeds (soaked in Âœ cup water until gel-like overnight, stirring a few times in the beginning)
  • Âœ cup water
  • 60ml olive oil
  • Âœ t bicarbonate of soda
  • Âœ t Himalayan rock salt
  • Âœ T Suganon Xylitol
  • Juice from Âœ lemon

Method

  1. Preheat oven to 160° Celsius.
  2. Drain quinoa and rinse thoroughly.
  3. Place the quinoa into a food processor followed by chia gel, water, olive oil, bicarb soda, salt, Suganon Xylitol and lemon juice. Mix for 3 minutes.
  4. The batter should be fairly thick with some whole quinoa still left in the mix.
  5. Spoon mixture into a loaf tin lined with baking paper.
  6. Bake for 1 œ hours or until bread is firm to touch and bounces back when pressed with your fingers.
  7. Remove from the oven and cool for 30 minutes in the tin, then remove it and cool completely before eating.

Popular sugar substitute in cooking and baking

Click here to read more about Suganon.

Suganon is a product of: Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021, South Africa. Tel. +27 11 635 0000

caramel popcorn

Caramel popcorn

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Ingredients

  •  1/2 cup brown sugar substitute blend* equivalent to 1/2 cup brown sugar
  • 3 tablespoons lower-fat, soft tub-like margarine
  • 1/2 teaspoon salt
  • 1 teaspoon vanilla essence
  • 12 cups air-popped popcorn

Preparation

  1. Preheat oven to 180 degrees C.
  2. Combine brown sugar, margarine, and 1/4 teaspoon of the salt in a small saucepan. Stir over medium heat, just until boiling and when the sugar is dissolved. Stir in vanilla essence.
  3. Place air-popped popcorn in a shallow roasting pan. Drizzle the brown sugar mixture over popcorn and toss to coat. Bake, uncovered, for 20 minutes in the pre-heated oven, tossing once. Sprinkle with the remaining 1/4 teaspoon of salt.
  4. Transfer to a large piece of foil; allow to cool for 1 hour.
  5. Place in small bags for trick-or-treating or an airtight container (2 days).
halloween

Don’t let glucose levels scare you this Halloween

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If your family is planning to go trick-or-treating, Donna van Zyl shares ways to enjoy Halloween without fussing over glucose levels.

Halloween need not only be about the trick-or-treating. Encourage your child to partake in non-food activities, such as carving a pumpkin; make decorations; having fun with friends and family whilst watching a scary movie; dressing up or visiting a ‘haunted’ house. It is, however, important to know what your child is looking forward to on this day, so that you can help meet their diabetes management in the middle.

Plan ahead

Sit down with your family and make Halloween plans in advance so your child knows what to expect. Create boundaries and general rules with your family. Your child will be more likely to be on board with a plan they helped create.

The rules of the plan may include:

  • Make sure your child does not go alone.
  • Ensure your child eats well and smart throughout the day, prior to the trick-or-treating so he/she can start off the evening with normal blood sugar level.
  • Then, make a deal with your child to avoid snacking until you’re both home from trick-or-treating.
  • Your child should take his/her own water or non-sugary drinks along, as they may get thirsty.
  • Your child should keep track of his/her sugar levels throughout the evening. Trick-or-treating may include a lot of excitement, running around or even having a treat out of the extraordinary.
  • Be prepared – test and ensure your child has something appropriate to treat a hypo. It is likely that he/she will have something in their bag to treat a hypo, however, the chocolate containing sweets do not necessarily act rapidly. Ideally, they should choose the sugary option and may need a follow-on snack, like a half of a peanut butter sandwich.
  • Friends and family can be very supportive and have healthy snacks waiting for your child. These options may include nuts, dark chocolate and fruit (strawberries dipped into dark chocolate). If they do have chocolate, encourage them to make sure they’re the snack-size versions.

Returning home

Once both of you have returned home, allow your child to choose his/ her favourite treat and administer an insulin dose accordingly.

The non-chocolate treats could be sorted into 15g carb packets and kept to treat a hypo. Those chocolate coated treats can be exchanged for a desired gift i.e. a toy, TV game, movie ticket, or a trip to the zoo etc. The exchange of sweets for a desired toy or game could apply to all the children of the house. The exchanged treats can also be donated to the less fortunate community groups as a treat they often do not receive.

Diabetic-friendly Halloween recipes

You can also make great Halloween diabetic-friendly recipes that will allow your children with diabetes to enjoy the day, without missing out treats.

Suitable Halloween treats:

MEET OUR EXPERT - Donna Van Zyl

Donna van Zyl is a private practicing dietitian for Nutritional Solutions, Bloemfontein. She is growing in the field of paediatrics and plays a key role in individualising nutritional therapy for Type 1 diabetics. She has a special interest in optimising health, managing chronic lifestyle related diseases, and sports nutrition. She lectures part-time at the University of the Free State, which she enjoys thoroughly.
irritable bowel syndrome

Irritable bowel syndrome – do you have it?

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It seems every second person you talk to nowadays has irritable bowel syndrome (IBS), but what exactly is it? Dr Trevlyn Burger sheds insight.

Irritable bowel syndrome is synonymous with ‘leaky gut’ or ‘spastic colon’. It is a condition that affects the function and behaviour of the intestine. It is the most commonly diagnosed gastrointestinal condition and thus has a large impact on healthcare costs. An estimated 10 to 20% of the general population experience symptoms of IBS. Many people experience only mild symptoms, but for some, symptoms can be severe and impact on quality of life and work productivity.

Symptoms
The primary symptoms are abdominal cramping and bloating, a feeling of incomplete evacuation, and altered bowel movements. Some people have frequent, watery bowel movements while others are constipated, and some switch back and forth between diarrhoea and constipation.

Causes
Despite intensive research, the cause of irritable bowel syndrome remains incompletely understood. IBS is a heterogeneous disorder and no single abnormality accounts for IBS symptoms in all patients. Postulated causes include:

  • Post infectious – Some people develop IBS after a severe gastrointestinal infection (e.g. salmonella or campylobacter jejuni). It is not, however, clear how infections trigger IBS.
  • Food intolerances – This raises the possibility that it is caused by food sensitivity or allergy. The best way to detect an association between symptoms and food sensitivity is to eliminate certain food groups systematically (an elimination diet). Note: eliminating foods without assistance from a nutritionist can lead to omission of important sources of nutrition. Several foods known to cause symptoms include gluten, dairy, legumes, and cruciferous vegetables amongst others.
  • Heightened sensitivity of the intestines to normal sensations (visceral hyperalgesia) – The theory proposes that nerves in the bowels are overactive in people with IBS, thus normal amounts of gas or movement are perceived as excessive and painful.
  • Anxiety and stress – These are known to affect the intestine. A strong association exists in patients who have experienced significant early-life emotional trauma.
  • Abnormal contractions of the intestines – There may be an intense prolonged, spastic contraction due to an abnormal electrical system. When two parts of the colon contract simultaneously, the colon between stretches like a balloon resulting in bloating and distension.
  • Alteration in faecal microflora – Emerging data suggests that the faecal microbiota (normal bacterial load in the intestine) in individuals with IBS differs from that of healthy controls.
  • Genetics – Studies suggest a genetic susceptibility in some patients with IBS.
  • Bile acid malabsorption – In some patients, excess bile in the colon may result in diarrhoea-predominant IBS.

Diagnostic approach

Many disorders present with symptoms similar to irritable bowel syndrome, thus it is important to exclude other causes. ‘Alarm’ or atypical symptoms that are not compatible with IBS include:

  • Rectal bleeding.
  • Nocturnal waking with pain and bowel movements.
  • Weight loss.
  • Laboratory abnormalities, such as anaemia, elevated inflammatory markers or electrolyte disturbances.
  • Family history of colorectal cancer, inflammatory bowel disease or celiac disease.

The diagnostic evaluation depends on whether the predominant symptoms are diarrhoea or constipation. The most common conditions that need to be excluded are inflammatory bowel syndrome, hormonal disturbances, infections, diverticular disease and colorectal cancer.

In diarrhoea-predominant, a stool sample is sent for testing and celiac disease needs to be excluded. In constipation-predominant, other causes of constipation, e.g. an underactive thyroid or high calcium need to be excluded.

All persons over the age of 50 years should have a colonoscopy at least once a year.

Treatment

  • Education and reassurance – It is important to establish a therapeutic clinician-patient relationship to validate the patient’s symptoms, and to understand that IBS does not increase the risk of cancer, but that it is a chronic (long-standing) disease. In patients with mild and intermittent symptoms that do not impair quality of life, we initially recommend lifestyle and dietary modification alone. In those with more significant symptoms, we suggest adjunctive pharmacological therapy.
  • Dietary modification – A careful dietary history may reveal patterns of symptoms related to specific foods. More than half of patients’ symptoms are improved by eating smaller meals, avoiding milk products, avoiding fatty foods and gluten.

Patients with IBS may benefit from exclusion of gas-producing foods; a diet low in fermentable oligo-, di- and monosaccharide’s and polyols (FODMAPS), as it is thought that there are bacteria in the colon that ‘feed off’ these foods changing bowel function and behaviour.

There is insufficient evidence to support routine food allergy testing in patients with IBS. The role of fibre is controversial, but given the absence of serious side effects and potential benefits, psyllium and ispagulla should be considered in those constipated.

  • Psychological intervention – Cognitive behavioural therapy may be of benefit.
  • Physical activity – This is advised to be of benefit.
  • Pharmacological therapy
    • Constipation-predominant:
      Loperamide (Imodium) is usually the first line of treatment. Lubiprostone (Amitiza) and linaclotide as second line (not freely available in South Africa).
    • Diarrhoea-predominant:
      Antidiarrheal agents, such as loperamide, as first line treatment. Bile acid sequestrants, such as cholestyramine (Questran and Questran Lite), are used as second line treatment.
    • Abdominal pain and bloating:
      • Antispasmodics as needed.
      • Iberogast
      • Colpermin
      • Simethicone
    • Antidepressants – Tricyclic antidepressants (TCAs) are considered in patients in whom laxatives, loperamide or antispasmodics have not helped. Selective serotonin reuptake inhibitors can also be considered.
    • Antibiotics – Not routinely recommended. A two-week trial of rifaximin may give long-lasting symptom relief, emphasising the role of the gut bacteria. (Microbiome)
    • Probiotics – Not routinely recommended. Although, they have been associated with an improvement in symptoms. The magnitude of benefit and the most effective species and strain are uncertain. Faecal microbiota transplants (stool transplants) are being evaluated in clinical trial.
    • Other therapies – Herbs, acupuncture, enzyme supplements and mast cell stabilisers have been evaluated, but their role in irritable bowel syndrome remains uncertain.

Patients with refractory symptoms should be carefully reassessed, paying specific attention to the type of ongoing symptoms, the degree to which symptoms have changed, compliance with medications, and the presence of any alarm symptoms.

Reassurance that there is no sinister underlying illness is of great importance with these patients as their pain and bowel habits are often abnormal and real, and this can cause anxiety.

MEET OUR EXPERT - Dr Trevlyn Burger

Dr Trevlyn Burger is a consultant gastroenterologist at Morningside Mediclinic, with an interest in inflammatory bowel disease, functional disease and liver pathology.
heart awareness month

Power up for Heart Awareness Month

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The Heart and Stroke Foundation South Africa (HSFSA) is powering up this September for Heart Awareness Month (HAM). They aim to reach the global goal of reducing premature deaths from cardiovascular disease (CVD) by 25% by the year 2025.

Why a whole month for Heart Awareness Month?

Heart disease is the world’s number one killer, claiming nearly 17 million lives every year. Although the incidence of heart disease has steadily declined in high-income countries, the burden on middle and low-income countries has never been greater.

In South Africa, the burden of heart disease and stroke follows HIV and AIDS; 1 in every 5 deaths are caused by heart diseases and strokes, totalling nearly 82 000 lives lost annually.

Contributing factors

Despite advances in medical care, contributing factors, such as high blood pressure (hypertension), obesity, a poor diet, lack of exercise and pollution, are all on the rise. Tobacco use has decreased, but 37% of men and 7% of women in SA are still regular smokers, tripling their risk of heart disease.

Heart disease in SA is further exacerbated by inequality. While high blood pressure is common across socio-economic groups, awareness and appropriate treatment is much lower among people living in poverty. Making healthier choices to eat better, stop smoking or to get active are far less achievable for South Africans trapped in poverty.

Is South Africa ready for 25 by 25?

The World Health Organisation has set nine global targets to address lifestyle-related diseases. One of these goals is a 25% reduction in premature heart disease and a 25% reduction in blood pressure by 2025. Can this be achieved within the South African context?

Over the last 25 years, neither heart disease nor blood pressure levels have improved in SA. In fact, given that more people are overweight and have high blood pressure now than ever before, SA may even see an increase in heart disease as obesity and hypertension are known contributors to cardiovascular (CVD) disease.

How to reduce the burden of heart disease

To reduce the burden of heart disease, we need to encourage lifestyle changes in SA. This starts with encouraging South Africans to eat nutritious food, drink less alcohol, exercise more, manage day-to-day stress and give up tobacco smoking.

Early detection and diagnosis of CVD, treatment of hypertension, raised cholesterol (especially bad cholesterol-LDL), and managing diabetes can further help to prevent the onset of heart disease. Together, these factors can prevent up to 80% of all heart diseases, before the age of 70 years, if the individuals affected adopt healthy behaviours.

Heart Awareness Month is earmarked by the HSFSA every year to encourage South Africans to re-evaluate their heart health and to start adopting healthy behaviours to take back control and Power Their Lives.

Getting to the hearts of young people in SA

The damage inside blood vessels that leads to most heart disease already starts in childhood. Healthy lifestyles in childhood therefore has a direct positive effect on heart health, but even more importantly, it often creates a blueprint for lifestyle choices made in adulthood.

Ten percent of boys and 22% of girls, between the ages of 10 and 14 years, are overweight. One South African study found girls who were obese between the ages of 4 and 8, were 40 times more likely to be obese when they finished high school. Numerous primary school children eat unhealthy foods on a daily basis, and don’t participate in enough physical activity.

Skip Smart for your Heart Schools Programme

To start Heart Awareness Month, the HSFSA is raising awareness among young South Africans of the importance of keeping their hearts healthy. The HSFSA selected 13 schools, nationally, to participate in the Skip Smart for your Heart Schools Programme between August and September 2017.

The Skip Smart for your Heart Schools Programme aims to inform primary school children about the importance of their heart and brain health and what they can do to take care of these vital organs by eating smart, breathing fresh air, avoiding tobacco smoke and being physically active.

Exercise with Hearty

Children will be further encouraged by Hearty to exercise. The HSFSA mascot will visit the schools, and the children will be given a free skipping rope. His presentation teaches five simple exercise moves that we can all use daily.

Finally, the HSFSA will showcase a performance from a professional skipper to captivate the learners with extraordinary tricks and skills, using a mere skipping rope, thus making moving more a cool and aspirational thing to do.

Moreover, the staff at the 13 selected schools will have a Health Risk Assessment conducted by health promotions officers and nurse practitioners.

Caring for adult hearts – get tested for free

Less than 50% of South African adults living with high blood pressure are unaware of their condition. The prevalence of hypertension is said to be around 45% among adults.

Similarly, many people who are pre-diabetic and have raised cholesterol are unaware, and as a result do not improve their lifestyles nor gain access to medication.

Blood pressure should be checked at least annually for all adults, and blood glucose annually when overweight. Many people unaware of the dangers of hypertension prefer to postpone a medical check or, simply, cannot afford to get tested.

Professor Pamela Naidoo, CEO of the HSFSA, urges all South Africans to have a Health Risk Assessment (which includes checking their blood pressure, blood glucose, cholesterol levels and weight) done free during Heart Awareness Month at all Dischem Pharmacies. Prof Naidoo expresses her gratitude to Dischem Pharmacies for partnering with the HSFSA to raise awareness of CVD and to mobilise communities to know their diagnosis and get treatment when necessary.

Build-up to World Heart Day (WHD)

The HSFSA’s build-up to WHD (29 September), during Heart Awareness Month, will focus on lifestyle factors which have a major impact on one’s risk for developing heart disease. Each week there will be a focus on important risk factors. These focus areas are detailed below:

  1. Your body does not want the extra salt: To encourage the reduction of extra salt for your heart health, a Salt Reduction Campaign will run from 1 – 8 September, funded by the National Lotteries Fund (NLC) and supported by the Department of Health (DOH).
  2. Keep it light: bring obesity down: Emphasising how physical activity and healthy eating go hand in hand, we need to evaluate what we eat and portion control. Healthy eating should not be a ‘diet’ but rather a lifestyle. The importance of physical activity in conjunction with eating well, how much exercise is enough, and simple ways to incorporate this into everyday life are imperative.
  3. You can do it: This unappealing habit (smoking) can be conquered, HSFSA can help with smoking cessation and dispel any myths and misconceptions associated with tobacco smoking. Tobacco smoking is one of the biggest drivers of CVD.
  4. Power up on WHD – The HSFSA, together with key staff at UCT’s Faculty of Medicine and Health Sciences, will be involved in activities aligned with the World Heart Federation’s mission and vision to bring to South Africa’s attention that we can work together to reduce the burden of heart disease.

The HSFSA will light up iconic landmarks on WHD as they drive the global goal of reducing premature deaths from CVD by 25% by the year 2025. They will explore risk factor reduction and influencing the behavioural and uptake of health risk assessments.

heart awareness month

#CheckyourPower 

This year, HSFSA have once again partnered with Dischem Pharmacies who will make available free testing in their stores across South Africa – please call 08601 (HEART) 43278 for more information. Free health risk assessments offered at Dischem, during September and October, will include blood pressure, blood glucose and cholesterol levels, and body mass index. 

diabetes sex hormones

Sex hormones and diabetes

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People living with diabetes should consider the use of either female or male hormones during their lifetime to improve quality of life, however, many factors need to be considered. Dr Louise Johnson walks us through these factors, explaining diabetes and sex hormones.

Women and sex hormones

In the reproductive years, a female should consider contraception methods (sex hormones) to prevent unplanned pregnancies. The risk of unplanned pregnancies has a possibility of miscarriage and foetal abnormalities if the HbA1c (average 3-month glucose value) is not at a normal or near normal value. The HbA1c should be 6 to 6,5% to promote developing a healthy baby.

The menstrual cycle

During a 28-day cycle, there are two different hormones, oestrogen and progestogen, at play that prepare the ovaries to produce an egg, which can then be fertilised should it encounter sperm.

The cycle starts off with the follicle of the ovary secreting oestrogen so that the endometrium (inside of the uterus lining) increases rapidly in thickness, from the 5th to the 14th day of the menstrual cycle. This is where blood vessels grow in preparation of a possible egg cell. This is called the proliferative phase.

On day 14, ovulation occurs and the egg cell is secreted from the ovaries. The blood vessels are then on its thickest, under the influence of oestrogen. Should there be no implantation of a fertilised egg cell and sperm, the hormonal support begins to be withdrawn. This causes the inner layer of the uterus to be necrotic, and then bleeding of the inner wall occurs, known as menstruation.

After the bleeding, the endometrium becomes ready again for the proliferative phase, which is the preparation of the lining for possible implantation, which will occur after day 14 in the secretory phase. The secretory phase is constant at 14 days. The variation in the menstrual days is due to the thickness of the layer that formed in the proliferative phase3.

diabetes sex hormonesOral contraceptives

There are two types of contraceptives – local and systemic contraceptives.

Local contraceptive

  • An intrauterine device (IUD) is placed inside the womb and can prevent pregnancies. This is a Copper T and does not release sex hormones.
  • The intrauterine system (IUS) is placed inside the womb and secretes low-doses of levonorgesterol hormone to prevent pregnancy.
  • Implantable contraceptive in arm. It releases a steady dose of progestogen to prevent pregnancy.

Systemic contraceptives

  • Progestogen-only tablets or depot injection every eight to 12 weeks. This is usually the safest systemic combination for women: living with diabetes, who smoke, suffer with migraines, are overweight, or have other medical conditions.
  • Combination therapy of oestrogen and progestogen.

Choosing the correct method

In deciding which would be the correct method for you, your doctor should take into consideration that it should not interfere with your carbohydrate metabolism or with your lipid profile. The method should not increase long-term microvascular and macrovascular complications.

In a review of literature, it was found that there is currently no one method that is superior to another. The methods should be discussed with the female diabetic patient, where all the pros and cons of each method are understood7.

It’s important to remember that only condoms can protect against STDs. Other methods can protect against pregnancy only.

Contraceptives that are more than 99% effective, if used correctly:

  • Contraceptive implant – lasts up to three years.
  • IUS system – lasts up to five years.
  • IUD – lasts up to five to 10 years.
  • Female sterilisation – permanent.
  • Male sterilisation or vasectomy – permanent.

Contraceptives that are more than 99% effective, if always used correctly but generally less than 95% effective with typical use:

  • Contraceptive injection – important to renew strictly every eight to 12 weeks, depending on the type.
  • Combination pill – take every day for three weeks out of four weeks. Can skip the red or placebo tablets, if menstruation is wanted to be avoided.
  • Progesterone-only pill – take every day.
  • Contraceptive patch – renewed each week for three weeks in every month.
  • Vaginal ring – renewed once a month.

Contraceptives that are 92 to 96% effective, if used correctly:

  • Female condom (every time you have sex).
  • Diaphragm with spermicide (every time you have sex).
  • Cap with spermicide (every time you have sex).

Factors to consider

  • How soon do you want to fall pregnant and is your HbA1c level at target?
  • How conscientious are you in taking medication or applications regularly? Do you remember to take tablets on a daily basis? This is vital with the contraceptive pill, since it is not effective if not taken regularly.
  • Do you want to menstruate every month or would you prefer a method that takes that away, or alter it causing lighter or sometimes heavier bleeding?
  • Do you smoke? Diabetic patients should not be smoking due to the increased vascular risk of atherosclerosis (calcification of blood vessels) of small and large vessels disease, such as eye-, feet-, kidney-, brain- and heart blood vessel damage.
  • If you are currently smoking and are over 35 years of age, the combination pill will not be suitable to use due to the possible increase in vascular disease. If you prefer a pill, the progestogen-only pill would be an option, or the IUD, IUS, or contraceptive injection.
  • Are you overweight? The contraceptive method that can cause a slight increase in weight is the contraceptive injection, if used for more than two years.
  • Do you have additional medical conditions, such as breast cancer? If yes, you are not suitable to use combination hormonal therapy. Other methods, such as IUD, are suitable.
  • Do you suffer from migraines? If so, you should be careful when using contraceptives, since it can aggravate this condition. You should use the IUD, IUS, progestogen-only pill, contraceptive injection or implantation. Stay clear from oestrogen preparations.

diabetes sex hormonesHormonal replacement therapy (HRT) in menopause

Usually around 50 years of age, women reach menopause when their ovaries stop producing sex hormones. The symptoms of menopause may differ between women. Some have profuse sweating, palpitations, moodiness, tiredness and insomnia, while others have very little symptoms.

The natural menopause can be divided into three stages:

  • Perimenopause – this is the time between the start of the symptoms and up to one year after the final menstruation.
  • Menopause is confirmed 12 months after the last menstrual cycle.
  • Post-menopause is the years after the menopause.

The replacement of female sex hormones should be carefully evaluated in each person since there are risks associated with this. There are two types of HRT:

  • Oestrogen-only therapy (ET): oestrogen is the hormone that provides the most menopausal symptom relief. ET is prescribed for women without a uterus (womb) due to a hysterectomy.
  • Oestrogen plus progestogen therapy (EPT): the progestogen is added to the oestrogen therapy to protect the uterus against endometrial cancer (womb cancer) from oestrogen alone.

Diabetic women and HRT

The diabetic women with symptoms severe enough to require systematic hormones should be started on the lowest effective dose for the shortest amount of time.

The benefit-risk ratio is favourable for women who initiate HRT close to menopause (ages 50-59 years) but the benefits becomes riskier with time from menopause and advancing age.

Women with early menopause (before 40 years of age) without a family history of breast cancer can take HRT until the typical age of menopause at 51.

Your doctor will evaluate your risks and possible benefits since there is no ‘one size fits all’ therapy.

Benefits of HRT

Improvement of symptoms of hot flashes, vaginal dryness, night sweats, and bone loss which can lead to osteoporosis. These benefits can lead to improved sleep, sexual relations and quality of life.

Risks of HRT

The importance of low-hormonal dosage for a short period of time cannot be reiterated enough. In the Women’s Health Initiative (WHI), done in 2002, an evaluation was done on the side effects of HRT. It was shown that there was an increased risk of breast cancer. Also, an increased risk of blood clots in the veins were shown, known as deep venous thrombosis (DVT) and pulmonary embolism (PE). The risks were higher in women older than 60 years of age.

Women who still have their uterus, should be prescribed a combination of oestrogen and progestogen to protect against uterine cancer.

Remember, there are other options available to help with hot flashes and moodiness other than sex hormones. Certain antidepressants, such as Venlafaxine and Clonidine, can help with vascular symptoms of hot flashes.

Men and sex hormones

diabetes sex hormones

Sexual dysfunction in Type 2 diabetes

The most common presentation of Type 2 diabetes with sexual dysfunction is erectile dysfunction (ED), also called impotence.

ED is defined as the inability to sustain adequate penile erection for satisfactory sexual activity. It is common in adult men with Type 2 diabetes (50-75%). This has a negative impact on quality of life. ED has been described in up to a third of newly diagnosed men with diabetes1.

Low testosterone levels in men have been shown to predict insulin resistance and the future development of Type 2 diabetes5. In studies, it was found that hypogonadism (diminished functional activity of testes) in Type 2 diabetic men may be as high as 33%2.

Additional risk factors for ED include:

  • Duration of diabetes
  • Increasing age
  • Poor glycaemic control
  • Cigarette smoking
  • Hypertension
  • High cholesterol
  • Cardiovascular disease

ED in diabetic men

ED occurs 10-15 years earlier in men with diabetes. It is more severe and less responsive to oral drugs than in non-diabetic subjects.

It is important to tell your doctor if you suffer from ED since it is associated with an earlier risk for cardiovascular disease. The risk for cardiovascular disease, such as heart attacks, is 20% higher in low-testosterone groups.

In the Copenhagen City Heart Study, it was shown that a low testosterone level could increase the risk of stroke with 34%, compared with normal testosterone individuals6.

Screening with an effort ECG will help to identify the high-risk individual. The first line of treatment for ED is addressing the risk factors effectively. The first therapeutic option would be to start with a PDE5 inhibitor (Viagra, Cialis, Levitra). A specialist should be consulted for second line therapy, should the patient not respond to these tablets.

Testosterone replacement

It is important to measure testosterone in all adult Type 2 diabetic men since up to 40% will have low levels4. It is also important to measure these levels in all patients presenting with ED.

A change in hormonal state is not unique to women. In men, it is called andropause; men will suffer with irritation, aggression, depression, hair loss and, sometimes even, loss in muscle mass.

Hypogonadism or andropause is present when there are symptoms, such as impaired cognitive and sexual functioning, associated depression and low testosterone levels. It is of importance to remember that the testosterone levels should be tested between 7am and 11am, after an overnight fast.

Testosterone therapy is approved for treatment if these factors are present. A trial therapy of three to 12 months is of importance to fully access response.

Types of testosterone replacement

  • Tablets (testosterone undecanoate) three to four capsules daily.
  • Intramuscular injection every six to 10 weeks. The interval will depend on the response to medication and testosterone levels.

Monitoring of testosterone treatment

It is important to monitor a few parameters after three, six and 12 months of starting therapy. These parameters are:

  • Serum testosterone level towards the end of the testosterone interval.
  • PSA (prostate specific antigen).
  • Haematocrit (red blood cell count).
  • Regular examination of the prostate.

The evaluation of the prostate, before and during treatment, is important because of concerns that exist between prostate cancer and testosterone therapy.

The importance of measuring the haematocrit is that testosterone can increase the haematocrit in some individuals and they then have an increase risk in cardiovascular events. The haematocrit should stay below 54%. If treatment is needed and this value continues to be above 54% then the person should have regularly phlebotomies (donating of blood for medical purposes).

References:

  1. Al-Hunayan A, Al-Mutar M, Kehinde EO et. al. (2007) ‘ The prevalence and predictors of erectile dysfunction in men with newly diagnosed type 2 diabetes mellitus.’ BJU Int ,99 p130-3
  2. Dhindsa S, Prabhakar S, Sethi M et. al. (2004) ‘ Frequent occurrence of hypogonatrophic hypogonadism in type 2 diabetes.’ J of Clin Endocrinol Metab, 89 p5462-5468
  3. Ganong WF (1993) ‘ Review of medical physiology’ 16th edition, a Lange medical book, San Francisco
  4. Hackett G (2015) ‘Should PDE5Is be prescribed routinely for all men with newly diagnosed type 2 diabetes?’ Br J Diabetes Vasc Dis, 15 (4) p184-186
  5. Haffner SM, Shaten J, Stern MP (1996) ‘ Low levels of sex hormone binding globulin and testosterone predict the development of non-insulin dependent diabetes mellitus in men.’ Am J of Epidemiology, 143 p889-897
  6. Holmboe SA, Jensen TK, Linneberg A et. al. (2016) ‘ Low testosterone: a risk marker rather than a risk factor Type 2 diabetes.’ JCEM , 101 p69-78
  7. Visser J, Snel M, Van Vlier HAAM. Hormonal versus non-hormonal contraceptives in women with diabetes mellitus type 1 and 2. Cochrane Database Syst Rev. 2013;3:CD003990. doi: 10.1002/14651858.CD003990.pub4.

MEET OUR EXPERT - Dr Louise Johnson

Dr Louise Johnson
Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.