Menopause and diabetes: Keeping women’s health and well-being on track

With the conference season is drawing to a close, there is a great deal to reflect on. From new evidence on the efficacy of the GLP-1 RA medication class and the disappointing shortages in their availability, to life-changing developments in diabetes technology and who will be eligible for hybrid closed-loop systems once imminent guidelines are published.

We have a report from the 59^th European Association for the Study of Diabetes (EASD) Annual Conference within the current issue of the journal, so please do have a look for a quick guide to the most interesting sessions.

On the theme of conferences – a tenuous link, I admit – I wish to draw attention to World Menopause Day. This is held each year on 18 October to raise awareness of menopause, address the stigma around it, and highlight the support available for improving health and well-being for those experiencing it. 

It was very apt, therefore, that completely coincidently, on the 18 October this year, a session on diabetes and the menopause was delivered at the 23^rd Abracadabra Diabetes Nursing Conference. The factors affecting diabetes from menopause are far reaching. Owing to fluctuating hormonal levels, insulin sensitivity is directly impacted, leading to phases of glycaemic instability. Coupled with this, the wide and varied menopausal symptoms can easily be misinterpreted as hypoglycaemic symptoms, and vice versa. Symptoms from the menopause can exacerbate challenges with diabetes control and, conversely, sub-optimal diabetes control can exacerbate menopausal symptoms. As such, this is an area we all need to increase our awareness of, in order to offer support and advice to women at this crucial time in their lives.

In addition, it is alarming to consider that diabetes itself, particularly type 1 diabetes, may be a causal factor for early menopause. This area has been debated for many years, with some experts stating that type 1 diabetes is linked to early menopause, with others maintaining that there is no causal link at all. This is not helpful to us when trying to discuss the issue of family planning with our type 1 population. However, at the 2022 North American Menopausal Society Meeting it was reported that, compared to the background population, diabetes does increase the risk of early menopause. In fact, not only type 1 diabetes diagnosed before the age of 30 years, but also type 2 diabetes diagnosed between the ages of 30 and 39 years, can, according to the report, lead to earlier menopause. 

There may be something about diabetes that affects the body and reproductive system, and how the ovaries function and age. The study authors called for increased research in this important area to find a causal relationship.

We spend many years advising women regarding pregnancy planning and supporting them to achieve optimal control prior to conception, which may include delaying starting to conceive until their glycaemic control has been optimised. In addition, we are also seeing a generation of women delaying starting a family for a whole host of reasons, with the average age at first pregnancy now rising to 30.9 years, compared to 28.8 years two decades ago (Figure 1).

With recent advances in the use of technology in pregnancy, namely the increased use of continuous glucose monitoring and pump therapy, we have seen steady improvements in pregnancy outcomes in our type 1 population. However, type 2 diabetes now accounts for 56% of all pre-existing diabetes in pregnancy, and the outcomes for this cohort are less than ideal (Figure 2).

There is clearly so much more we have to do for all women with pre-existing diabetes, not only in pregnancy, but right across their reproductive lifetime. There must be more focus on pre-pregnancy preparation, especially in our early onset type 2 population, but, equally, we all need to increase our awareness and open discussions with women around the time of menopause. These women may experience debilitating symptoms of menopause heightened by their pre-existing diabetes. It is incumbent upon us all to provide greater recognition and support for these women, if we are to improve the outcomes and experiences for all.