Understanding women's sex hormone physiology—A priority in diabetes care

IF 3.4 3区 医学 Q2 ENDOCRINOLOGY & METABOLISM
Céline Isabelle Laesser, Bettina Weber, David Studer, Reem Jalal Alshareef, Lia Bally
{"title":"Understanding women's sex hormone physiology—A priority in diabetes care","authors":"Céline Isabelle Laesser,&nbsp;Bettina Weber,&nbsp;David Studer,&nbsp;Reem Jalal Alshareef,&nbsp;Lia Bally","doi":"10.1111/dme.70109","DOIUrl":null,"url":null,"abstract":"<p>Women experience profound, dynamic changes in sex hormone exposure throughout their lifespan that directly influence diabetes pathophysiology and management. In the pre-pubertal period, sex hormone levels remain consistently low, but with the onset of puberty, women begin experiencing the remarkable fluctuations characteristic of reproductive biology. The menstrual cycle alone produces 5- to 50-fold variations in oestradiol and progesterone,<span><sup>1</sup></span> while hormonal contraceptives, except for local intrauterine devices, alter these patterns. Pregnancy elevates oestradiol 100- to 200-fold and progesterone 15-fold,<span><sup>2</sup></span> with assisted reproduction achieving even higher levels. The menopausal transition then precipitates a sharp decline in oestradiol exposure to levels that actually fall below those of age-matched men. While menopausal hormone therapy can restore sex hormone concentrations approximating premenopausal follicular phase levels, the achieved exposure shows substantial variability depending on formulation specifics, dosage and administration route.<span><sup>3</sup></span> Additionally, body weight changes represent another important modifier of oestrogen exposure, with weight loss consistently associated with decreased oestrogen levels.<span><sup>4</sup></span></p><p>Beyond their reproduction functions, female sex hormones, particularly oestradiol, interact extensively with glucose and energy metabolism pathways.<span><sup>5, 6</sup></span> Oestradiol enhances insulin sensitivity, increases insulin secretion, improves β-cell viability, delays gastric emptying and promotes favourable adipose tissue distribution—all collectively promoting glucose homeostasis. These metabolic advantages are further amplified by oestradiol's critical role in modulating energy expenditure and promoting satiety.<span><sup>5</sup></span> While many mechanistic insights originate from preclinical models, human evidence from studies of the impact of menopause and anti-oestrogenic cancer therapies on diabetes incidence, and investigations on the glycaemic effect of oestradiol replacement (including menopausal hormone therapy) generally corroborate the glycaemic benefits of oestradiol.<span><sup>7</sup></span> In contrast to oestradiol's beneficial effects, progesterone demonstrates a less well-characterized and predominantly unfavourable metabolic profile, with its characteristic mid-luteal phase surge consistently linked to decreased insulin sensitivity.<span><sup>8</sup></span> Similarly, both androgenic progestins (frequently utilized in hormonal contraceptives) and states of hyperandrogenism, as clinically seen in polycystic ovary syndrome (PCOS), have been associated with impaired insulin sensitivity.<span><sup>9</sup></span></p><p>While sex hormones demonstrably influence diabetes risk and manifestations, this relationship is fundamentally bidirectional, as impaired glucose homeostasis substantially affects the hypothalamic–pituitary–gonadal axis. This is clinically evidenced by the higher prevalence of delayed menarche, menstrual cycle abnormalities, ovulatory dysfunction, subfertility and premature menopause in women with diabetes compared to those without.<span><sup>10</sup></span> A landmark prospective study of menstrual cycles in adolescents demonstrated that those with type 1 diabetes had a sixfold greater risk of menstrual irregularities compared to their non-diabetic peers, with the risk escalating proportionally with increasing HbA1c levels.<span><sup>11</sup></span> The authors further quantified this relationship, showing menstrual cycle length increased by 5 days for each 1% (11 mmol/mol) rise in HbA1c, powerfully illustrating the intimate connection between metabolic control and reproductive function in type 1 diabetes. While PCOS and type 2 diabetes frequently coexist, clinicians must remain alert to the growing recognition of PCOS in women with type 1 diabetes.</p><p>These findings underscore the complex, still incompletely understood interactions between glucose metabolism, insulin signalling and ovarian function involving multiple levels of the reproductive endocrine system. Ovarian insulin receptors, when exposed to supraphysiological insulin exposure, may mediate gonadotropin-like effects, increasing androgen production.<span><sup>12</sup></span> Hyperglycaemia itself promotes abnormal ovarian folliculogenesis and accelerates follicular apoptosis, likely contributing to the observed cycle abnormalities and earlier menopause in diabetes populations. Glucose and insulin influence reproductive function not only peripherally at the ovarian level but also centrally through hypothalamic–pituitary regulation. Insulin serves as a critical modulator of the hypothalamic–pituitary–gonadal axis, with insulin deficiency known to suppress kisspeptin expression—a key upstream regulator of GnRH secretion.<span><sup>13</sup></span> While less thoroughly investigated, chronic hyperglycaemia may additionally exert direct inhibitory effects on hypothalamic GnRH release. Together, these central and peripheral disruptions likely predispose women with diabetes to the well-documented spectrum of reproductive abnormalities including hypogonadism, delayed puberty and menstrual cycle disturbances. Clinical epidemiology further reveals the impact of diabetes on fertility potential, with cohort studies demonstrating 24% and 36% reductions in fecundity rates among women with type 1 and type 2 diabetes, respectively, compared to their non-diabetic counterparts.<span><sup>14</sup></span> Although the increased PCOS prevalence among women with diabetes may contribute to their reproductive challenges, other factors are likely to play a role, underscoring significant knowledge gaps in this area. These clinical uncertainties are further compounded by insufficient research examining the impact of glucose-insulin homeostasis on assisted reproductive technology outcomes, and reciprocally, the effects of ovarian stimulation protocols on glycaemic control and metabolic parameters in women with diabetes.</p><p>In conclusion, women experience remarkable physiological variations in sex hormone exposure throughout their lifespan that exert profound, clinically significant effects on glucose regulation and metabolic homeostasis. The bidirectional relationship between reproductive endocrinology and glucose metabolism creates complex pathophysiological interactions, where dysfunction in either system propagates through both central neural circuits and peripheral target tissues. Despite these fundamental connections, current research paradigms remain disproportionately focused on pregnancy-related physiology, while other critical hormonal states—including pubertal transitions, menstrual cycle dynamics, contraceptive use, assisted reproduction, menopausal changes and endocrine cancer therapies—have been systematically understudied. Given the substantial clinical consequences of these interactions, advancing our understanding of women's sex hormone physiology across all these contexts must become an urgent priority.</p><p>CIL has received a YTCR grant from both the Bangerter-Rhyner Foundation and the Swiss Academy of Medical Sciences, as well as support from the Siegenthaler Foundation. LB received a grant from the Swiss National Science Foundation (SNSF-Grant 10000574). None of the authors reports conflicts of interest related to this work.</p>","PeriodicalId":11251,"journal":{"name":"Diabetic Medicine","volume":"42 10","pages":""},"PeriodicalIF":3.4000,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/dme.70109","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Diabetic Medicine","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1111/dme.70109","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"ENDOCRINOLOGY & METABOLISM","Score":null,"Total":0}
引用次数: 0

Abstract

Women experience profound, dynamic changes in sex hormone exposure throughout their lifespan that directly influence diabetes pathophysiology and management. In the pre-pubertal period, sex hormone levels remain consistently low, but with the onset of puberty, women begin experiencing the remarkable fluctuations characteristic of reproductive biology. The menstrual cycle alone produces 5- to 50-fold variations in oestradiol and progesterone,1 while hormonal contraceptives, except for local intrauterine devices, alter these patterns. Pregnancy elevates oestradiol 100- to 200-fold and progesterone 15-fold,2 with assisted reproduction achieving even higher levels. The menopausal transition then precipitates a sharp decline in oestradiol exposure to levels that actually fall below those of age-matched men. While menopausal hormone therapy can restore sex hormone concentrations approximating premenopausal follicular phase levels, the achieved exposure shows substantial variability depending on formulation specifics, dosage and administration route.3 Additionally, body weight changes represent another important modifier of oestrogen exposure, with weight loss consistently associated with decreased oestrogen levels.4

Beyond their reproduction functions, female sex hormones, particularly oestradiol, interact extensively with glucose and energy metabolism pathways.5, 6 Oestradiol enhances insulin sensitivity, increases insulin secretion, improves β-cell viability, delays gastric emptying and promotes favourable adipose tissue distribution—all collectively promoting glucose homeostasis. These metabolic advantages are further amplified by oestradiol's critical role in modulating energy expenditure and promoting satiety.5 While many mechanistic insights originate from preclinical models, human evidence from studies of the impact of menopause and anti-oestrogenic cancer therapies on diabetes incidence, and investigations on the glycaemic effect of oestradiol replacement (including menopausal hormone therapy) generally corroborate the glycaemic benefits of oestradiol.7 In contrast to oestradiol's beneficial effects, progesterone demonstrates a less well-characterized and predominantly unfavourable metabolic profile, with its characteristic mid-luteal phase surge consistently linked to decreased insulin sensitivity.8 Similarly, both androgenic progestins (frequently utilized in hormonal contraceptives) and states of hyperandrogenism, as clinically seen in polycystic ovary syndrome (PCOS), have been associated with impaired insulin sensitivity.9

While sex hormones demonstrably influence diabetes risk and manifestations, this relationship is fundamentally bidirectional, as impaired glucose homeostasis substantially affects the hypothalamic–pituitary–gonadal axis. This is clinically evidenced by the higher prevalence of delayed menarche, menstrual cycle abnormalities, ovulatory dysfunction, subfertility and premature menopause in women with diabetes compared to those without.10 A landmark prospective study of menstrual cycles in adolescents demonstrated that those with type 1 diabetes had a sixfold greater risk of menstrual irregularities compared to their non-diabetic peers, with the risk escalating proportionally with increasing HbA1c levels.11 The authors further quantified this relationship, showing menstrual cycle length increased by 5 days for each 1% (11 mmol/mol) rise in HbA1c, powerfully illustrating the intimate connection between metabolic control and reproductive function in type 1 diabetes. While PCOS and type 2 diabetes frequently coexist, clinicians must remain alert to the growing recognition of PCOS in women with type 1 diabetes.

These findings underscore the complex, still incompletely understood interactions between glucose metabolism, insulin signalling and ovarian function involving multiple levels of the reproductive endocrine system. Ovarian insulin receptors, when exposed to supraphysiological insulin exposure, may mediate gonadotropin-like effects, increasing androgen production.12 Hyperglycaemia itself promotes abnormal ovarian folliculogenesis and accelerates follicular apoptosis, likely contributing to the observed cycle abnormalities and earlier menopause in diabetes populations. Glucose and insulin influence reproductive function not only peripherally at the ovarian level but also centrally through hypothalamic–pituitary regulation. Insulin serves as a critical modulator of the hypothalamic–pituitary–gonadal axis, with insulin deficiency known to suppress kisspeptin expression—a key upstream regulator of GnRH secretion.13 While less thoroughly investigated, chronic hyperglycaemia may additionally exert direct inhibitory effects on hypothalamic GnRH release. Together, these central and peripheral disruptions likely predispose women with diabetes to the well-documented spectrum of reproductive abnormalities including hypogonadism, delayed puberty and menstrual cycle disturbances. Clinical epidemiology further reveals the impact of diabetes on fertility potential, with cohort studies demonstrating 24% and 36% reductions in fecundity rates among women with type 1 and type 2 diabetes, respectively, compared to their non-diabetic counterparts.14 Although the increased PCOS prevalence among women with diabetes may contribute to their reproductive challenges, other factors are likely to play a role, underscoring significant knowledge gaps in this area. These clinical uncertainties are further compounded by insufficient research examining the impact of glucose-insulin homeostasis on assisted reproductive technology outcomes, and reciprocally, the effects of ovarian stimulation protocols on glycaemic control and metabolic parameters in women with diabetes.

In conclusion, women experience remarkable physiological variations in sex hormone exposure throughout their lifespan that exert profound, clinically significant effects on glucose regulation and metabolic homeostasis. The bidirectional relationship between reproductive endocrinology and glucose metabolism creates complex pathophysiological interactions, where dysfunction in either system propagates through both central neural circuits and peripheral target tissues. Despite these fundamental connections, current research paradigms remain disproportionately focused on pregnancy-related physiology, while other critical hormonal states—including pubertal transitions, menstrual cycle dynamics, contraceptive use, assisted reproduction, menopausal changes and endocrine cancer therapies—have been systematically understudied. Given the substantial clinical consequences of these interactions, advancing our understanding of women's sex hormone physiology across all these contexts must become an urgent priority.

CIL has received a YTCR grant from both the Bangerter-Rhyner Foundation and the Swiss Academy of Medical Sciences, as well as support from the Siegenthaler Foundation. LB received a grant from the Swiss National Science Foundation (SNSF-Grant 10000574). None of the authors reports conflicts of interest related to this work.

了解女性性激素生理-糖尿病护理的重点。
女性一生中性激素暴露经历了深刻的动态变化,直接影响糖尿病的病理生理和管理。在青春期前,性激素水平一直很低,但随着青春期的开始,妇女开始经历生殖生物学特征的显著波动。月经周期本身就会产生5到50倍的雌二醇和黄体酮变化,而激素避孕药,除了局部宫内节育器,会改变这些模式。怀孕使雌二醇升高100到200倍,孕酮升高15倍,辅助生殖甚至达到更高的水平。绝经期的过渡导致雌二醇暴露水平急剧下降,实际上低于同龄男性的水平。虽然绝经期激素治疗可以使性激素浓度恢复到接近绝经前卵泡期水平,但所达到的暴露量根据配方的具体情况、剂量和给药途径而有很大的差异此外,体重变化是雌激素暴露的另一个重要调节因素,体重减轻一直与雌激素水平下降有关。除了生殖功能外,女性性激素,尤其是雌二醇,还与葡萄糖和能量代谢途径广泛相互作用。5,6雌二醇增强胰岛素敏感性,增加胰岛素分泌,提高β细胞活力,延缓胃排空,促进有利的脂肪组织分布——所有这些共同促进葡萄糖稳态。这些代谢优势被雌二醇在调节能量消耗和促进饱腹感方面的关键作用进一步放大虽然许多机制见解来自临床前模型,但更年期和抗雌激素癌症治疗对糖尿病发病率的影响研究以及对雌二醇替代(包括绝经期激素治疗)的降糖作用的研究的人类证据通常证实了雌二醇的降糖益处与雌二醇的有益作用相反,黄体酮表现出较少的特征和主要不利的代谢特征,其典型的黄体中期激增始终与胰岛素敏感性降低有关同样,雄激素孕激素(常用于激素避孕药)和高雄激素血症,如临床上多囊卵巢综合征(PCOS),都与胰岛素敏感性受损有关。虽然性激素明显影响糖尿病的风险和表现,但这种关系基本上是双向的,因为葡萄糖稳态受损会严重影响下丘脑-垂体-性腺轴。临床证明,与没有糖尿病的女性相比,糖尿病女性月经初潮推迟、月经周期异常、排卵功能障碍、生育能力低下和过早绝经的发生率更高一项具有里程碑意义的青少年月经周期前瞻性研究表明,与非糖尿病同龄人相比,1型糖尿病患者月经不规律的风险高6倍,并且随着HbA1c水平的升高,风险成比例地升高作者进一步量化了这种关系,显示HbA1c每升高1% (11 mmol/mol),月经周期长度增加5天,有力地说明了1型糖尿病代谢控制与生殖功能之间的密切联系。虽然多囊卵巢综合征和2型糖尿病经常共存,但临床医生必须对1型糖尿病女性多囊卵巢综合征的日益认识保持警惕。这些发现强调了葡萄糖代谢、胰岛素信号和卵巢功能之间复杂的、尚未完全理解的相互作用,涉及生殖内分泌系统的多个层面。卵巢胰岛素受体,当暴露于生理上的胰岛素暴露时,可能介导促性腺激素样作用,增加雄激素的产生高血糖本身会促进卵巢卵泡的异常生成,加速卵泡的凋亡,可能导致糖尿病患者的周期异常和更年期提前。葡萄糖和胰岛素不仅在卵巢水平外周影响生殖功能,而且还通过下丘脑-垂体调节中枢影响生殖功能。胰岛素是下丘脑-垂体-性腺轴的关键调节剂,已知胰岛素缺乏会抑制kisspeptin的表达,而kisspeptin是GnRH分泌的关键上游调节剂慢性高血糖可能对下丘脑GnRH释放有直接抑制作用,但研究较少。综上所述,这些中枢和外周紊乱可能使女性糖尿病患者易患各种生殖异常,包括性腺功能减退、青春期延迟和月经周期紊乱。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
求助全文
约1分钟内获得全文 求助全文
来源期刊
Diabetic Medicine
Diabetic Medicine 医学-内分泌学与代谢
CiteScore
7.20
自引率
5.70%
发文量
229
审稿时长
3-6 weeks
期刊介绍: Diabetic Medicine, the official journal of Diabetes UK, is published monthly simultaneously, in print and online editions. The journal publishes a range of key information on all clinical aspects of diabetes mellitus, ranging from human genetic studies through clinical physiology and trials to diabetes epidemiology. We do not publish original animal or cell culture studies unless they are part of a study of clinical diabetes involving humans. Categories of publication include research articles, reviews, editorials, commentaries, and correspondence. All material is peer-reviewed. We aim to disseminate knowledge about diabetes research with the goal of improving the management of people with diabetes. The journal therefore seeks to provide a forum for the exchange of ideas between clinicians and researchers worldwide. Topics covered are of importance to all healthcare professionals working with people with diabetes, whether in primary care or specialist services. Surplus generated from the sale of Diabetic Medicine is used by Diabetes UK to know diabetes better and fight diabetes more effectively on behalf of all people affected by and at risk of diabetes as well as their families and carers.”
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:604180095
Book学术官方微信