Navigating diabetes through the menopause transition

If you would like to learn more about the impact of your symptom(s) complete our free online menopause questionnaire here.

According to Diabetes UK, around 4.5 million people in the UK are estimated to have diabetes – around one in 15 of the population, while 1.2 million people could be living with type 2 diabetes who are yet to be diagnosed.  For women with diabetes, both type 1 and type 2, navigating the hormonal changes of menopause can make managing blood sugar levels and overall health more challenging.

Managing diabetes is essential for your future health as it can help reduce the risk of serious complications, including heart and kidney disease, plus problems with your feet and eyes.

Type 1 diabetes is a lifelong condition that occurs when the body’s immune system attacks the cells in the pancreas that produce insulin. It affects around 8% of those with diabetes.

Type 2 diabetes, the most common kind of diabetes, is a chronic metabolic disease that occurs when the body is unable to use insulin properly, resulting in high blood sugar levels. This usually occurs in mid-life, or later in life. Around 90% of people with diabetes have type 2 diabetes. Rarer forms of diabetes make up the other 2%.

For women with diabetes, both type 1 and type 2, navigating the hormonal changes of the menopause transition can make managing blood sugar levels and overall health more challenging. This is because the fluctuating levels of the hormones oestrogen and progesterone can impact your body’s response to insulin. Symptoms of the menopause can be affected by fluctuating blood sugars and the long-term health consequences of the menopause can add to the longer-term health risks of diabetes.

This is why it’s important to appreciate the impact of diabetes on the menopause, and of the menopause on diabetes.

Does menopause cause diabetes?

The drop of oestrogen during the menopause transition can result in insulin resistance. This is where the body is less sensitive to insulin released when we eat carbohydrates. Insulin resistance is a factor contributing to the redistribution of fat to round the middle – and this is a risk factor for type 2 diabetes. So, while the menopause does not cause diabetes, it may increase your risk of developing type 2 diabetes.

Other risk factors for type 2 diabetes include high blood pressure, high cholesterol, family history, increasing age, lack of physical activity, ethnicity (people of South Asian, Chinese, African-Caribbean, or Black African descent have an increased risk), having had gestational diabetes, having a history of polycystic ovarian syndrome (PCOS), having pre-diabetes and a history of pancreatic damage – for example chronic pancreatitis.

How menopause influences blood sugar and insulin sensitivity

Menopause brings a natural decline in oestrogen and progesterone, two hormones that play essential roles in blood sugar regulation and insulin sensitivity. Here’s what this means during each stage of the menopause transition:

Perimenopause

This transition phase leading up to menopause can last several years and features fluctuating hormone levels. These changes may cause a range of symptoms, for example, irregular periods, hot flushes and night sweats, mood swings, brain fog and many more (you can read more about the symptoms of menopause here). For women with diabetes, this period can be challenging as hormone swings may lead to unpredictable blood sugar levels. A drop in your level of oestrogen may make your body more resistant to insulin, and changes in progesterone can also impact blood sugar control. Erratic and fluctuating hormone levels mean that you may need to review and alter your diabetes medication under the guidance of your diabetic team^[1].

Postmenopause

After a full year without a period, you’ve entered the postmenopause. At this stage, oestrogen levels stabilise at a much lower level than before. Lower oestrogen can increase insulin resistance, which means your body may need more insulin to maintain stable blood glucose levels. This heightened resistance can lead to higher blood sugar levels and increase the risk of complications unless your diabetes is actively managed.

Symptoms of the menopause and their impact on diabetes

The symptoms of perimenopause and postmenopause can make diabetes management more challenging, particularly when it comes to keeping blood sugar levels stable:

• Hot flushes and night sweats: These classic menopause symptoms can disrupt sleep, leading to fatigue and increased insulin resistance. Sleep loss is also known to affect blood sugar control, which is why it’s important to find ways to manage hot flushes and improve sleep quality
• Mood swings and anxiety: Shifts in hormones can lead to mood changes and anxiety. Stress and emotional changes can elevate cortisol, a stress hormone, which can in turn raise blood glucose levels. Managing stress through activities like exercise, meditation, or talking to a counsellor can be particularly helpful for women with diabetes experiencing menopause-related mood swings.
• Weight gain: Many women experience weight gain during menopause, particularly around the abdomen, due to hormonal shifts and a naturally slowing metabolism. This added weight can increase insulin resistance, making blood glucose harder to control.

If you are tired as a direct effect of changing hormones, or as an indirect effect of poor sleep due to menopause symptoms, you may be less likely to exercise or make healthier dietary choices. Regular physical activity and a balanced diet are key to managing weight gain and supporting blood sugar control during menopause. This can be challenging, and you may need more support from those around you to make healthier choices for you.

Other impacts of diabetes on menopause symptoms

• Fluctuating blood sugars can add to menopause symptoms: Fluctuating blood sugars can cause hot flushes and night sweats, and high blood sugars can add to fatigue and lethargy as well as impacting on mood. Crashing low sugars can add to feelings of anxiety.

• Vaginal symptoms and infection: Vaginal symptoms such as irritation, pain, burning sensations and pain and discomfort during sex are common symptoms of the menopause. Complications of high blood sugar and diabetes can increase the risks of thrush. High blood sugars over long periods can add to vaginal dryness and loss of sensation – including orgasm.
• Bladder symptoms and infections: The risks of bladder infections plus other bladder symptoms increase in the menopause – such as bladder irritability, urgency and frequency of needing to pass urine. With diabetes, and higher blood sugar levels, bladder symptoms and infection can also increase.

Long-term health consequences of the menopause and diabetes

• Heart disease: Both menopause and diabetes independently raise the risk of cardiovascular disease, and the combination can compound these effects. It’s important for postmenopausal women with diabetes to prioritise their heart health by monitoring blood pressure and cholesterol levels, staying active and managing their diet.
• Osteoporosis: The menopause increases the risk of osteoporosis (thinning of the bones) and related fractures. Women with type 1 diabetes are also at increased risk of osteoporosis. The relationship is not as clear for women with type 2 diabetes. It is important that all women take vitamin D, particularly in the winter months, and ensure sufficient calcium in their diet. Weight-bearing exercise and maintaining muscle mass by exercising using weights are other ways of helping maintain bone density.

Practical tips for managing diabetes through the menopause transition

Here are some practical ways to help maintain steady blood sugar levels and manage menopause symptoms effectively:

• Regular blood sugar monitoring: Menopause-related hormonal changes can make blood sugar levels more unpredictable. Depending on your level of diabetic control, you may be advised to do more regular monitoring of blood sugar levels to help you catch and manage fluctuations. It’s important to go to your regular review appointments to review control and adjust medication as needed.
• Stay active: Physical activity can help counteract weight gain, improve mood, and enhance insulin sensitivity. The NHS recommends at least 150 minutes of moderate exercise per week. Try activities like walking, swimming, or strength training to maintain muscle mass and support blood glucose control.
• Heart-healthy diet: Eating a balanced, heart-healthy diet is essential during and after menopause. Focus on whole foods, lean proteins, fibre, and low-glycaemic carbohydrates to keep blood sugar stable and support cardiovascular health. Minimise alcohol which increases the risk of heart disease.
• Stop smoking, seek out support if needed: Smoking increases the risk of heart disease and osteoporosis.
• Prioritise sleep: Good sleep is vital for maintaining blood sugar stability, but menopause symptoms can make it hard to get restful sleep. Speak with your healthcare provider if night sweats or insomnia are interfering with sleep, as they may have recommendations to help.
• Manage stress and emotional health: Mood swings and stress are common during menopause and can impact blood glucose control. Activities like meditation, deep breathing exercises, or connecting with friends can help manage stress levels and support your mental health.

Hormone replacement therapy (HRT) and diabetes

Hormone replacement therapy (HRT) is a treatment option that many women use to manage menopause symptoms – from hot flushes and night sweats to psychological symptoms such as changes in mood, anxiety, cognition and physical symptoms such as aches and pains, heavy periods, headaches and many more (see here for more information on menopause symptoms).

For most women, HRT is the most effective way of managing most symptoms of the menopause and the benefits outweigh the small risks. Just because you have diabetes doesn’t mean you can’t take HRT. You should discuss the most appropriate type of HRT for you with your GP or a menopause specialist who can help you assess the benefits and the risks.

HRT can also help reduce the risk of cardiovascular disease in a number of ways. More research is needed to look into how effective HRT is in reducing the risk of heart disease for diabetic women. HRT can help manage symptoms of the menopause that may prevent you from taking regular exercise – so it may have an indirectly positive effect on risks in helping you manage healthy lifestyle choices.

HRT also helps reduce the risk of osteoporosis and related fractures.

Women who have type 2 diabetes are at additional risk of cancer of the womb lining and this can be linked also with a body mass index that falls into the obese range or above. This makes it important that you take a sufficient progestogen dose for your dose of oestrogen. This should be something that your menopause doctor talks about with you. It is worth considering a Mirena coil as the progestogen arm of your HRT as this is an effective way of keeping the womb lining thin for up to 5 years.

There are potential benefits of HRT for insulin sensitivity. Studies have indicated that taking HRT may improve fasting glucose and insulin resistance in women with type 2 diabetes. Oestrogen may also help reduce the abdominal fat linked to insulin resistance, which can also be beneficial for diabetes management.

Vaginal oestrogens

Vaginal oestrogens can help manage vaginal irritation, soreness and pain as well as painful sex. Vaginal oestrogens can also help urinary frequency and reduce the risk of urinary tract infections.

Risks and Considerations

While for most women HRT offers many benefits, there are some small risks, and these can depend on the type of HRT you take. These include a risk of breast cancer diagnosis, related to how long you take HRT for. Obesity also increases the risk of breast cancer and can have a more significant impact on risk of breast cancer than HRT.

If you have and are considering HRT, you should have a detailed discussion with your GP about the most appropriate type and dose of HRT for you.

Oral oestrogens increase the risk of blood clots on legs and lungs and stroke. If your body mass index is around 30 or more, your baseline risk also increases. Transdermal (through the skin) oestrogens such as patches, sprays or gels do not increase your baseline risk of blood clots and so are a safer option.

HRT is not thought to increase the risk of heart disease overall, but some types of progestogen can negatively impact lipids (like cholesterol). If you have risk factors for heart disease and stroke, it is important to discuss the safest option for you.

Alternatives to HRT

If HRT isn’t an option for you, there are non-hormonal treatments available, including:

• certain antidepressants that can help manage hot flushes and mood changes
• clonidine, which is a blood pressure tablet which is also licensed to treat hot flushes and night sweats
• Veoza (fezolinetant) which has been shown to be effective in reducing moderate to severe hotflushes and sweats. Veoza is only available privately at present – for more information see here.

Herbal supplements and lifestyle modifications, such as dietary adjustments, can also provide relief. However, it’s important to consult with a healthcare provider before starting any new treatments to ensure there is no impact on diabetic management.