Menopause in Women With Diabetes: Hormonal-Glycemic Storm

I was walking out of the 600-bed academic teaching hospital in which I work as an in-patient certified diabetes educator today, when Susan, a nurse I have known for some time, stopped me and said “Isn’t menopause a bitch?” While it was not my intention to curse in my first blog for EndocrinologyNetwork, this is what she asked. She complained that the 3:00 am wake-up calls of menopause were making it tough for her to get through her long day as an operating room nurse. “I have no energy” and “I'm sweaty all the time,” and “I really don't want to take HRT but I honestly feel like I'm being tortured.”

Fluctuating hormone levels, which women experience monthly, can contribute to fluctuating blood glucose levels. We know that the rise and fall of estrogen and progesterone can increase glucose levels in premenstrual women. The woman with diabetes, whose insulin rose in response to these glucose changes, could develop hypoglycemia when the rapid drop in these hormone levels occurs with the start of menstrual bleeding. Now, imagine the increased challenge of the hormonal rises and falls of menopause coupled with never knowing when, or if, that period will appear. For some women, this fluctuation is more drastic than others, resulting in severe symptoms. 

The glycemic challenges for women with previously diagnosed type 1 or type 2 diabetes become even greater than the challenges posed by menopause for women without diabetes. The oscillating hormones (mainly progesterone and estrogen) cause serotonin levels to fluctuate as well. This fluctuation results in appetite changes (carbohydrate cravings) and may cause depression and weight gain, both of which contribute to worsening control of diabetes. While much is written on the increased risk for development of type 2 diabetes for post menopausal women, very little is written on how to handle these dynamic challenges for women with already existing type 1 or 2 diabetes.  

Research has shown that the insulin resistance of type 2 diabetes contributes to an increased risk of heart disease. The current thinking is that this same cause and effect may be at work for those with type 1 diabetes as well.  And people with diabetes experience nearly triple the rate of heart disease and stroke of those without diabetes. Mid-life women with diabetes have roughly the same risk of death from heart disease, as do men without diabetes.  And most of us with diabetes will ultimately die from heart disease.

So, does the need to stabilize glucose control outweigh the increased potential risks of hormone replacement therapy (HRT) for women with type 1 or type 2 diabetes that predates menopause?  Are there drugs other than HRT that might be helpful in the stabilization of glycemic control?  Is the woman with diet- or oral-agent controlled type 2 diabetes now more likely to require insulin to manage her diabetes?  What are the effects of GLP-1 inhibitors in women in this age group?

Please leave comments below to share your thoughts, clinical cases, antidotes, and evidence. I'd love to hear your contributions to this discussion on menopause and diabetes. We need to have a better understanding about methods and strategies to help our female patients get safely and comfortably through a life stage that can last a decade or more.