For many women menopause can herald a rather turbulent time. For women living with diabetes, the turbulence can be tumultuous. In other words, managing menopause and blood glucose presents significant challenges but is possible.
Let’s first make sense of all the terms that get used during this period.
Menopause is officially the time when the ovaries have stopped working and reproductive life is at an end. A woman is said to be in menopause when she has not had a period for a year. The average age range of menopause is 45 – 55 years.
Peri-menopause is the time before menopause when oestrogen levels start to decline and some symptoms of this may occur, for example: sleep disturbances, night sweats, hot flashes and mood changes. This can start eight to 10 years before menopause.
Post-menopause is the time after menopause and is life-long.
Early menopause is when menopause occurs before age 45 years and often there is no other cause.
Premature menopause occurs before age 40 years. It can be due to surgical removal of or damage to the ovaries from radiation or infection. In many instances this is genetic or autoimmune.
Natural menopause occurs due to aging of the ovaries and a decrease in the production of oestrogen. Surgical menopause occurs if both ovaries are removed.
Menopausal symptoms are traditionally divided into:
Vasomotor – This includes hot flashes (sudden sensation of heat in body) and night sweats (these can be in the day as well).
Mood changes – New onset or worsening anxiety and depression; insomnia.
However, there is a long list of other symptoms which women may experience, such as local vaginal dryness and urinary problems; headaches; decreased libido; decreased concentration; hair thinning or falling out, and the one concern almost all women have, weight gain.
Changes in a women’s body at menopause
Oestrogen decreases during peri-menopause and will eventually be undetectable in the female body. Studies have shown that this hormonal change was the reason for decreased energy expenditure. If there is no simultaneous decrease in energy intake, that is daily calories remain the same, then weight gain begins. This weight being gained is all fat. In fact, menopause itself is associated with muscle loss, a condition called sarcopenia. This affects the distribution of weight and hence, the despised middle-aged spread. This increase in fat around the middle of the body as well as the reduction in lean muscle mass is what can cause insulin resistance.
At this time of a woman’s life, she is often less physically active, and the cycles of work stress, family responsibilities and having to deal with unpleasant menopausal symptoms often triggers unhealthy eating. This worsens weight gain and insulin resistance, and of course diabetes control.
Is diabetes more common after menopause?
There is a definite relationship between oestrogen levels and blood glucose levels. The European Prospective Investigation into Cancer Study showed that women with premature menopause had a 32% higher risk for developing Type 2 Diabetes. This data has been replicated in several studies. If a woman has other risks, such as a family history of diabetes or increased body weight, it’s a good idea to be screened for diabetes. Interestingly, women who experience hot flashes and other vasomotor symptoms have an increased risk of developing Type 2 diabetes.
Is diabetes harder to control after menopause?
As mentioned, insulin resistance is a feature of menopause, so this will make diabetes management more challenging. It is possible that there will be a deterioration in HbA1c, requiring an increase in medication, particularly insulin doses. However, key to improving glucose levels is a healthy lifestyle and maintaining a normal body weight.
For many years menopausal women with Type 2 diabetes were not offered menopausal hormone therapy (MHT) due to the concern that this would increase the risk of cardiovascular disease. In fact, research has shown benefit rather than risk. MHT can reduce insulin resistance, abdominal fat and improve glucose metabolism, as well as other cardiovascular risk factors, such as blood pressure and cholesterol levels. This is largely due to MHT acting directly on the liver and pancreas.
MHT comes in various combinations:
Oestrogen only – Oestrogen is the hormone that gives most relief to symptoms and overall benefit. Only women who have had their womb removed can use this.
Oestrogen plus progesterone – Women who still have their womb have to take progesterone to stop unopposed oestrogen effect on the lining of the womb which could cause cancer.
MHT can be given either as a pill or patch. Oestrogen alone is also available as a gel. The advantage of giving MHT through the skin (transdermally) is that it does not get metabolised through the liver and this reduces its overall side effect profile.
For women concerned only about vaginal dryness, oestrogen is available as vaginal creams or pessaries. As this is only absorbed locally, side effects are much lower.
Overall side effects of MHT are low, especially if used at the time of menopause, the lowest effective dose, shortest time necessary and transdermally. There is always concern about the risk of:
Breast cancer – Risk is seen with more than five years of continuous use of combination MHT and increases in the over 60 years age group. In most instances, women who have had breast cancer or have a first-degree relative (mother or sister) with breast cancer are not given MHT.
Blood clots – All MHT can increase the risk of deep vein thrombosis and lung embolism but this is rare in the 50 – 59-year age group. If a woman has had a blood clot or has a strong family history of blood clots, then she should not use MHT.
Most effective therapy
MHT is the most effective therapy for controlling the symptoms of menopause. Additionally, it prevents osteoporosis and given at the time of menopause provides cardiovascular protection. These latter two are significant advantages in the women with Type 2 diabetes.
Each woman should discuss these pros and cons with her doctor. MHT should improve overall glucose control, but again there can be a variable response. Home glucose testing is important during this time.
Many women will navigate menopause without any treatment or choose herbal or natural remedies. Women with diabetes need to be aware of the risk of deteriorating glucose control. As always, the most effective protection and management of this is a healthy lifestyle which aims to maintain a normal (or as close to as possible) body weight.
MEET THE EXPERT
Dr Angela Murphy qualified as a specialist physician in 2000 and joined the Department of Endocrinology and Metabolism at Charlotte Maxeke Johannesburg Academic Hospital. Currently she sees patients at Sunward Park Medical Centre and retains a special interest in endocrinology and a large part of her practice is diabetes and obesity.
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