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Sex is determined by biological characteristics. Gender, however, is a social and cultural construct referring to the role, behaviour, and functions that a society attributes to men and women at a given time and which can be modified.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Disease expression is different according to sex and gender. Most epidemiological studies underestimate gender differences, which makes it difficult to delve deeper into sex differences. In women, the same diseases manifest themselves differently due to genetic, epigenetic, as well as environmental, cultural, psychological, socio-economic and lifestyle factors; so a personalised prevention strategy and treatment is essential to improve therapy adherence, efficacy and morbidity and mortality. The greater vulnerability of women compared to men in some diseases such as diabetes mellitus (DM) and its micro and macrovascular complications is a fact.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Women are underrepresented in clinical trials and the incorporation of variables and categories of analysis related to gender is insufficient, so we do not have enough information to know their diagnostic, clinical and treatment peculiarities. For this reason, a personalized approach to epidemiological analyses and health intervention studies for both sexes is essential.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The latest global estimate published by the International Diabetes Federation indicates that in 2017 the prevalence of DM in the adult population was higher in men, with 9.1%, compared to women, with 8.4%. Data from the study Di@bet.es show that, in Spain, similarly to other countries, 29.8% of women between 61 and 75 years of age suffer from DM, a figure that rises to 41.3% after the age of 75.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Between 90% and 95% of DM in women is type 2 (DM2), a percentage similar to that of men.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Women with DM2 have poorer control of classic or traditional cardiovascular risk factors (CVRF). They are more likely to have an inadequate diet, are less physically active, are more reluctant to identify the disease, seek care at a later stage, receive less treatment, which is also less effective, thus, their DM control is poorer.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In 2015, the American Heart Association published differential aspects regarding traditional CVRFs in women compared to men, among which are the higher prevalence of obesity, arterial hypertension beyond the age of 60, a sedentary lifestyle, a different hormonal profile with a decrease in oestrogen and HDL cholesterol levels from the menopause onwards, a greater deleterious effect of smoking, a greater association between abdominal adiposity with cardiovascular mortality and the poorer control of the cardiovascular risk profile (inflammation, fibrinolysis or coagulation).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In general, women have less visceral fat than men and need to be more overweight for the development of DM2. The consequence is that women are likely to have pre-diabetes for more years. During this stage, women's metabolic profile, blood pressure, lipids, inflammatory markers, and other risk factors continue to deteriorate compared to men, and when DM2 becomes manifest, the vascular damage resulting from subclinical hyperglycaemia has already occurred.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In addition to the traditional ones, there are other emerging CVRFs that are specific to women, which have an impact on the development and control of DM and cardiovascular (CV) health. Thus, during puberty and adolescence, control of type 1 DM (DM1) is more difficult in women due to menstrual fluctuations and a higher incidence of eating disorders. A poor diet and less physical activity in women under 18 years of age favour obesity and the development of DM2 with an increasing frequency and higher frequency than in men.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> During the reproductive years, whether the woman has DM1 or DM2, pregnancy complications increase, so extreme care must be exercised before, during and after pregnancy. Gestational diabetes can occur with pregnancy, especially in women over 35 years of age, obese or with polycystic ovary syndrome and if there is a family history of DM2 and/or gestational diabetes. A history of gestational diabetes conditions the subsequent development of DM2 in up to 19% of cases and doubles the risk of developing cardiovascular disease, both acute myocardial infarction and stroke, ten years after having had it.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> In the same way, hypertensive disorders of pregnancy, especially preeclampsia, carry a CV risk that persists over time.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Later in life, metabolic changes secondary to menopause increase the risk of obesity, which favours the development of DM2.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Likewise, the protective factor of oestrogen disappears, making CV risk equal to that of men in the general population, although the risk is even higher in women with DM. It is at this stage that chronic micro- and macrovascular complications emerge in both newly diagnosed and long-standing DM1 and DM2.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In relation to the macrovascular complications of DM2, cardiovascular disease is the main cause of mortality in women. Women with DM2 have a 25–50% higher relative risk of cardiovascular disease than their male counterparts.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> CVR factors are similar in both sexes, but smoking is an independent factor of poor prognosis in women, leading to 25% more fatal and non-fatal CV events.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> On the other hand, different studies show that women with DM2 have a lower control of HbA1c, arterial hypertension and lipids than men with DM2,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> difference that decreases with aging due to a better adaptation of the specific therapy in the case of women.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In coronary heart disease, women with DM2 experience less arterial obstruction but more diffuse and a predominantly atypical clinical presentation, which delays diagnosis, early revascularisation, and optimal drug therapy, leading to higher mortality and complication rates.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Both DM1 and DM2 are associated with a higher risk of developing heart failure in both sexes, which results in a more severe prognosis and higher mortality than in the non-DM population. The incidence of heart failure increases with age and women's increased longevity works against it.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Among the causes that worsen heart failure in women with DM are again poorer control of CVRFs, atypical symptoms, longer evolution of pre-diabetes, poor glycaemic control, delayed diagnosis and less comprehensive treatment and intensification of treatment.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding stroke, women with DM1 and DM2 have a higher risk of fatal and non-fatal ischemic stroke compared to men, regardless of other CVRFs.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,16</span></a> This may be explained by the delayed diagnosis of DM in women, which leads to an undetected and therefore untreated high chronic cardiovascular risk. This fact underlines the importance of acting earlier on this CV risk and looking into other biological, behavioural, and social factors involved.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Peripheral arterial disease occurs earlier, more extensively and more severely in patients with DM2. Symptomatic disease is more common in women and the risk of intermittent claudication doubles.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The prevalence of vascular necrosis is also higher in men but increases in women with age, up to 40% in those over 85 years of age. The presentation is more atypical in women, which delays diagnosis and impacts on elective revascularisation techniques and increases the rate of complications and mortality.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">With regard to microvascular complications, we observed that in diabetic nephropathy, female sex, which in other forms of chronic kidney disease seems to exert a protective effect, has been identified as an independent risk factor.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Women develop greater glomerular hyperfiltration than men in DM1, which favours the progression of kidney disease.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The onset of kidney failure in DM begins after the menopause due to its relationship with the decrease in oestrogen levels, manifesting itself 10 years later than in men, with a prevalence of non-proteinuric renal disease.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,20</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Diabetic neuropathy is the most common microvascular complication of DM. Diabetic autonomic neuropathy which underlies the failure to recognise the hypoglycaemic state, and which is more common in women, can worsen hypoglycaemia and lead to acute cardiovascular events.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> As for the seldom studied sexual dysfunction in women, it seems to be responsible for vulvodynia.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,18</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">We found no conclusive studies in diabetic retinopathy research that discriminate differential characteristics by sex.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,18</span></a> Its severity has been found to be linked to the male sex, as well as to higher HbA1c, longer duration of DM and higher systolic blood pressure. Only the progression of retinopathy that can occur during pregnancy is linked to the female sex.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,18</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Therefore, it is clear that women have a different profile in the development and complications of DM1 and DM2, and that there are areas for improvement both in research and in the treatment of this disease. Consequently, the gender approach will result in better health, prevention, treatment, and care differentiation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García de Lucas MD, Jiménez Millán AI. Mujer y diabetes mellitus. Med Clin (Barc). 2021;156:606–608.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gender-specific medicine: yesterday’s neglect, tomorrow’s opportunities" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.J. McGregor" 1 => "E. 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Journal Information
Vol. 156. Issue 12.
Pages 606-608 (June 2021)
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Vol. 156. Issue 12.
Pages 606-608 (June 2021)
Editorial article
Woman and diabetes mellitus
Mujer y diabetes mellitus
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