The big M – menopause

Dr Louise Johnson helps us understand how the big M (menopause) may affect the management of diabetes.

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Menopause is a normal condition involving the permanent end of the menstrual cycles due to the cessation of the production hormones from the ovaries for at least 12 consecutive months.

The name menopause comes from the Greek word pausis which means pause, and men which means month. Menopause occurs in all menstruating females due to oestrogen deficiency, usually between the ages of 45 and 56 in most women. The median age of natural menopause is 51 years.

As women live longer, they spend roughly 40% of their lives in the post-menopausal years which equates to more than 30 years for most women.¹

About 5% of women experience early natural menopause, occurring between the ages of 40 and 45 years.

Symptoms related to oestrogen deficiency

1. Vasomotor symptoms

These are the most common symptoms during menopause. Up to 80% of women experience vasomotor symptoms consisting of night sweat, palpitations, migraine, and hot flushes.

Hot flushes occur day and night at unpredictable intervals, often lasting approximately three to four minutes each. A hot flash starts with a sensation of flushing that spreads to the upper body due to the central nervous system changes specific to thermoregulation.

The vasomotor symptoms last on average one to six years but can last 15 years in 10 to 15% of post-menopausal women. They may be worsened by smoking, alcohol, obesity, physical inactivity, and emotional stress. If untreated, vasomotor symptoms will eventually dissipate after approximately 7.4 years.

2. Genitourinary symptoms

Approximately 50 – 75% of women experience genitourinary syndrome. The vagina lining thins and there is reduced elasticity. It causes vagina dryness, burning, pruritus (itchiness,) and irritation.

Urinary symptoms of frequently passing urine and the urge to go immediately occurs as well as burning urination. The low oestrogen levels in the bladder also cause frequent urinary tract infection.

Urinary incontinence is not related to menopause. The causes are overweight, diabetes, and increasing age. A decline in sexual function and libido is also part of the syndrome.³

3. Psychogenic symptoms

Up to 70% of women experience psychogenic symptoms associated with peri-menopause and menopause. These symptoms include anger, irritability, anxiety, tension, depression, loss of concentration, and loss of self-esteem and confidence.

Sleep apnoea, insomnia, and restless leg syndrome may cause further sleep disturbance that aren’t explained by night sweats. The risk of depressive symptoms and a higher level of depression severity are noted in the peri-menopausal women compared to pre-menopausal women.

Making a diagnosis

Physical examination

The following abnormalities are observed:

• Blood pressure is elevated.
• Weight gain is noted and an additional decrease in height associated with osteoporosis.
• Breasts have an increase in fatty deposition.
• Vagina has increase dryness and atrophy (wasting) of urethra (bladder pipe opening).
• Arthralgias (joint pains) and sarcopenia (loss of muscle mass, function and strength).

Lab tests

Tests are typically not needed to diagnose menopause. Under certain circumstances the following tests can be done:

• Follicle-stimulating hormone (FSH) will be increased. An elevated serum FSH greater than 30mIU/ml is an objective indicator of menopause.
• Oestrogen will be decreased. An oestrogen value less than 20pg/ml is suggestive of menopause.
• Thyroid stimulating hormone (TSH) to rule out an underactive thyroid since it can cause similar symptoms to those of menopause.

Staging

In 2011, The Stage of Reproductive Aging Workshop (STRAW) divided the female reproductive cycle into three categories:

1. Reproductive stage

This start with the beginning of menstruation. During these years the menstrual cycle is regular.

2. Menopausal transition stage

This is when peri-menopause occurs. During this stage, the menstrual cycle undergoes variability in duration of menstruation. As this stage progresses, women can experience no menstruation (amenorrhea) for a time of up to 60 days.

3. Post-menopausal stage

This stage begins when menstruation has ceased for up to one year.

Menopause and Type 2 diabetes

These are both conditions that often occur in midlife. Menopause causes a sharp drop in oestrogen levels, leading to various changes that can affect body weight, fat distribution, and insulin sensitivity. These changes can raise the risk for Type 2 diabetes or make managing your diabetes more challenging.

Menopause may increase the risk of developing Type 2 diabetes due to:

• Hormonal changes – Oestrogen and progesterone affect how cells respond to the hormone insulin. When oestrogen and progesterone levels drop, cells may not be as sensitive to insulin. This can lead to high glucose levels.
• Blood glucose fluctuations – Hormonal changes can cause blood glucose to fluctuate throughout the day. This can make managing diabetes a challenge.
• Weight gain – Menopause is commonly associated with weight gain, up to 7.5 kg. Excess weight is a known risk factor for Type 2 diabetes.
• Disturbed sleep – Menopause can lead to restless sleep due to night sweats and palpitations. A lack of sleep has been linked with a higher risk of Type 2 diabetes.
• Depression – Depression is more common in menopause than before it. People who are depressed may have an increased risk of diabetes due to increase eating and less exercise.²

Treatment

Menopause requires no medical treatment. Instead, treatment focus on relieving signs and symptoms and managing chronic conditions that may occur with aging. Treatments may include:

• Hormone therapy

Oestrogen therapy is the most effective therapy for relieving menopausal hot flashes. Your doctor may recommend the lowest dose for the shortest time frame to provide symptomatic relief. If you still have a uterus, you will require progesterone as well to prevent endometrium increase. Oestrogen helps bone loss, but the long-term use should be carefully considered due to the risk of breast cancer and blood clotting, such as deep venous thrombosis and pulmonary emboli (blood clot to the lung).

• Vaginal oestrogen

Oestrogen can be delivered directly to the vagina to prevent dryness, discomfort with intercourse, and some urinary symptoms. This modality is a lot safer than oral oestrogen and has a lot less complications.

• Low-dose antidepressant

Certain antidepressants related to the class SSRI, such as paroxetine, escitalopram or venlafaxine, may decrease hot flashes and help with depression and mood stabilising.

• Gabapentin

This drug is approved for seizures but has shown to reduce hot flashes.

• Clonidine

This tablet is typically used in high blood pressure but has shown to relieve hot flushes.

Lifestyle remedies

1. Drink enough cold water and dress in layers. Try to pinpoint your trigger that may include alcohol, caffeine, stress, and spicy food.
2. Decrease vaginal discomfort with a vaginal lubricant.
3. Get enough sleep by avoiding caffeine and too much alcohol.
4. Strengthen your pelvic floor by doing Kegel exercises.
5. Adopt a balanced diet.
6. Don’t smoke.
7. Exercise regularly. Do aerobic exercises, such as walking 30 minutes per day five days a week and weight-bearing exercises twice a week.

Remember that hormonal therapy comes with risks such as stroke, heart attacks, blood clots, and breast- and uterus cancer. Discuss with your healthcare provider and choose the correct treatment specific for you. Menopause is a condition that can be effectively managed by your health team.

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References

1. Mangiome CM, Barry MJ et. al. “Hormone therapy for the primary prevention of chronic conditions in postmenopausal persons” JAMA 2022;328 (17):1740-46
2. Slopien R, Wender-Ozegowska E et. al. “Menopause and diabetes” Maturitas, 2018;117:6-10
3. Talauliker V.”Menopause transition:Physiology and symptoms” Best Praxct Res Clin Obstet Gynaecol. 2022,81:3-7

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