How are menopause and diabetes linked?

If you already have type 2 diabetes (formerly known as adult-onset diabetes), the transition to the menopause can make it worse. If you’re not diabetic, the transition to the menopause can increase your risk of developing type 2 diabetes by worsening any existing underlying prediabetes or insulin resistance.   

Insulin resistance is when your cells don’t respond as well as they should to the hormone insulin. It’s associated with metabolic dysfunction (when your body doesn’t process nutrients as well as it usually does) and abdominal weight gain (gaining weight around your waist) and is also a feature of metabolic syndrome.  

If that sounds complicated and like maybe it doesn’t apply to you — I encourage you to keep reading. Because if you’re over 40, there’s at least a one in two chance you do have insulin resistance, especially if there’s diabetes in your immediate family (e.g., parent or sibling) and/or you had gestational diabetes during pregnancy.  

Insulin resistance can cause weight gain around the middle (your waist and thighs), but more importantly, it can cause high cholesterol and increase your long-term risk of:  

• diabetes 
• heart disease  
• dementia  
• and other diseases 

By taking steps now to identify and reverse insulin resistance, you can dramatically reduce your risk of getting these diseases. The increased risk of insulin resistance with menopause is why a recent Lancet paper identified menopause as an important ‘turning point for women's health.’  

*Note: We have been taking about insulin resistance and type 2 diabetes, which is distinct from type 1 diabetes (formerly known as insulin-dependent or juvenile diabetes), which is an autoimmune disease*

Why menopause worsens diabetes and insulin resistance

During your reproductive years, oestrogen had a beneficial insulin-sensitising effect, which means it improves how well your body responds to insulin. This is why, at that age, you were less likely than men your age to have insulin resistance or diabetes. Lower levels of oestrogen at the menopause removes that ‘oestrogen advantage’ and increases your risk of:  

• insulin resistance 
• abdominal weight gain 
• diabetes
• heart disease 

So, the menopause can cause or worsen insulin resistance and diabetes. At the same time, an underlying problem with insulin resistance or diabetes can result in more hot flushes and generally a more symptomatic menopause transition.   

In fact, the symptom relief from oestrogen therapy may stem, in part, from oestrogen’s ability to improve insulin sensitivity. If you can maintain a healthy metabolism and insulin sensitivity as you approach menopause, you may actually be less likely to require oestrogen therapy.

Diabetes is high blood sugar and is easy to detect with a blood test for blood glucose (sugar) and HbA1c (haemoglobin A1C), which is an estimate of average blood glucose levels over the past three months.  

*Tip: If you’re already diabetic, you’ll want to keep an eye on your HbA1C as you transition into the menopause. And check with your doctor about any necessary changes to your treatment plan.*

Insulin resistance is harder to diagnose than diabetes because blood glucose and HbA1c are typically normal in the early stages of insulin resistance. Instead, you could have metabolic warning signs such as:   

• high blood pressure  
• high cholesterol  
• high triglycerides  
• skin tags 
• high ALT (a liver enzyme)  
• and a high waist-to-hip ratio 

In women, a waist-to-hip ratio of greater than 0.8 suggests insulin resistance. Yet another potential sign of insulin resistance is fatty liver, which is fat accumulation in the liver. If you’ve been told you have non-alcoholic fatty liver disease (NAFLD) — also called metabolic-associated fatty liver disease (MAFLD) — you probably have insulin resistance, even if your doctor did not mentioned it.  

To definitively diagnose insulin resistance, your doctor can test the hormone insulin with one of the following tests: 

1. fasting insulin  
2. HOMA-IR index, which is a ratio of three fasting insulins to glucose, or  
3. a glucose tolerance test with insulin, also called a glucose tolerance insulin response (GTIR).  

A healthy ‘fasting insulin’ should be less than 6.1 mmol/L . Two hours after a glucose tolerance test, a healthy insulin reading should be less than 7.8 mmol/L. High insulin indicates insulin resistance.

Medical treatments for diabetes and insulin resistance

Most people with diabetes will need medication to help keep their blood sugar levels down.

Usually, the first medication that your doctor might offer you is called metformin, which is a drug that helps your body to respond better to insulin.

If metformin on its own is not keeping your blood sugar levels low enough, or if you have other health conditions such as heart disease, you may be offered other medications instead of, or together with, metformin, such as:

• Alogliptin
• Linagliptin
• Pioglitazone
• Gliclazide
• Glimepiride

If these medications don’t work well enough to keep your blood sugar at a healthy level, you will need to start insulin.

Aside from medications, diet and exercise are also important for managing your diabetes, so see Diet and Lifestyle for Diabetes and Insulin Resistance. One reason is because being overweight makes insulin resistance worse. For some people, your doctor may advise:

• Medication to help with weight loss
• Weight loss surgery

It’s important to discuss the pros and cons of these medication with your doctor to find the best options for you. You will also be able to discuss any other medications you may be taking for your menopause symptoms, as they may affect how well your body responds to medication for your diabetes. 

 For example, androgenic or testosterone-like progestins such as levonorgestrel can worsen insulin resistance, so when possible, it’s better to choose oral micronised progesterone (OMP) as the safer ‘progesterone’ part of hormone therapy..  

Diet and lifestyle for diabetes and insulin resistance

We all know that diet and exercise are important parts of a healthy lifestyle, but did you know that healthy eating and physical activity can also reduce your risk for type 2 diabetes, as well as helping to keep your blood sugar levels low if you already have diabetes?

This is because maintaining a healthy weight improves insulin sensitivity. Not only this, but weight loss can also improve HbA1c levels (a blood test that tells you how well your diabetes is being controlled), blood fat levels (total cholesterol, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, triglycerides) and blood pressure. Not surprisingly, as well as improving insulin sensitivity, weight loss may also reduce your risk of cardiovascular disease.

Some studies have shown that the more physical activity you do, the less likely you are to develop diabetes. Although it is difficult to separate the effects of exercise and weight loss, doing 30 mins/day or 150 mins/week of moderate to vigorous activity can really help. All types of moderate to vigorous activity count, including walking, resistance exercise and gardening. 

As well as being mindful of overall calorie intake to stay within a healthy weight range, foods that should be incorporated into a healthy diet, and that might have a protective effect against type 2 diabetes include:

1. Wholegrain products, like wholemeal bread, wholemeal pasta, quinoa and brown rice
2. Fruit, especially blueberries, grapes and apples
3. Vegetables
4. Fermented dairy products, such as yoghurt and cheese (but not too much cheese!)

What about specific diets? There is some evidence that specific diets are more suitable for helping to manage type 2 diabetes than others, such as:

• A Mediterranean diet
• the Dietary Approaches to Stop Hypertension (DASH) diet
• Vegetarian and vegan diets
• the Nordic healthy diet
• a low glycaemic index diet

There is no one diet that is better than the other. The best choice for you depends on different factors like your own personal preferences, potential other health conditions and the nutritional quality, so it’s best to discuss any change in diet with your doctor.