Thinking about Menopause?

Then you should also be thinking about diabetes

If you are reading this, there is a good chance you are thinking about menopause. Either because you are in menopause yourself or sauntering up to, or you are being proactive because one day you will go through menopause, or maybe you are a health care professional who provides care to people who will experience menopause (a.k.a. half the population).

And while hot flashes, brain fog, vaginal dryness, and hormone therapy are all very important, they tend to dominate the conversation and drown out other important topics, so today, I want to focus on metabolic health, specifically screening for diabetes. Because if you are thinking about menopause, you should also be thinking about being screened for diabetes.

The diabetes we are talking about in the menopause transition and beyond is type 2 diabetes, which is related to insulin resistance. Insulin helps our body use sugar, but with insulin resistance, cells stop responding to insulin. To compensate, the pancreas makes more insulin, and rising insulin levels and other factors, such as inflammation, result in a cascade of events that lead to what is known as glucose intolerance (or impaired glucose tolerance) and then eventually diabetes.

Why Should We Care?

Diabetes is associated with an increased risk of heart disease, kidney disease, endometrial cancer, and nonalcoholic fatty liver disease (NAFLD; read more about that here), to name a few significant complications. When we know someone has diabetes, there is treatment to reduce these complications.

Sometimes, people have glucose intolerance and not diabetes, and often this is called prediabetes. Glucose intolerance doesn’t mean someone will absolutely develop diabetes. Still, their risk is much higher, and knowing that you have glucose intolerance might trigger some people to take action to reduce their risk of diabetes.

Glucose intolerance is also significant health-wise, independent of the diabetes risk. For example, it’s associated with an increased risk of cardiovascular disease and NAFLD. It’s also one of the components of metabolic syndrome. In this condition, someone has three of the following: high blood pressure, high blood sugar, excess body fat around the waist, elevated LDL, and low HDL (LDL and HDL are lipids). Metabolic syndrome is associated with an increased risk of heart disease, diabetes, and NAFLD.

Menopause Poses Unique Risks

During the menopause transition, the risk for metabolic syndrome starts to rise. There are likely several reasons, including an increase in visceral fat (metabolically active fat around organs, meaning you can’t see it), changes in lipids, and a decrease in muscle mass. The reasons women gain visceral fat during the menopause transition aren’t fully understood (and I’ve written more about that here), but what’s important to know is the menopause transition is a time when metabolic risks start to rise, so it’s a good time to think about screening for glucose intolerance and diabetes.

How to Screen for Diabetes

There are three tests to screen for diabetes, and they all have advantages and disadvantages.

Fasting glucose (sugar) level is the cheapest test. However, it’s not always convenient to come in fasting. It also doesn’t pick up everyone with glucose intolerance/diabetes because the first signs are usually how your body handles a glucose load, not what your body is like before it gets a load of glucose. A result of 100-125 mg/dl (or 5.6-6.9 mmol/L) is glucose intolerance, and ≥ 126 mg/dl (≥ 7.0 mmol/L) is diabetes. An elevated fasting glucose level is part of the criteria for metabolic syndrome.

A hemoglobin A1C measures the average glucose level over the past two to three months. The advantage is you don’t have to be fasting, the disadvantage is that, similar to fasting glucose, it can miss some folks with glucose intolerance and diabetes. It is not an accurate test for people with hemoglobinopathies. The hemoglobin A1C result is a percentage; 5.7-6.4% is impaired glucose tolerance, and ≥6.5% is diabetes.

A 2-hour glucose tolerance test. This test involves more effort, but it tells you more about how you use glucose. You come in fasting and drink a solution with 75 g of glucose, and 2 hours later, your blood glucose level is tested. This is the most expensive test. It’s also the gold standard and will identify more people. A result of 140-199 mg/dl (7.8 mmol/L-11.0 mmol/L) is impaired glucose tolerance, and ≥ 200 (11.1 mmol/L) mg/dl is diabetes. Impaired glucose tolerance on this test is part of the criteria for metabolic syndrome.

While the choice of test often comes down to cost, convenience, and desire to not sit around for 2 hours waiting to have a blood test, the 2-hour glucose tolerance test is the best test for those who have been diagnosed with polycystic ovarian syndrome and/or anyone who previously had gestational diabetes as they are more likely to have their glucose intolerance missed with a fasting glucose or a hemoglobin A1C.

When Should I Be Screened?

Screening for diabetes should start at age 45. If you have other risk factors, such as PCOS, high blood pressure, abnormal lipids, an increased waist circumference (> 88 cm or > 35 inches), or a parent or sibling with type 2 diabetes, screening should start earlier. It’s important to talk with your own provider who knows your history best because there may be other reasons to screen earlier. For example, I test people who develop significant yeast infections on their vulva (not a typical vaginal yeast infection, which is redness, swelling, and itching that extends onto the vulva).

If the test is negative, screening every three years is generally recommended, but you may need to be screened more often based on your risk factors.

Putting it All Together

Diabetes is commonly underdiagnosed. In fact, almost one-third of people in the United States who have diabetes don’t know they are affected. This means they are missing out on the opportunity to treat their diabetes and prevent complications. They may also not be getting the screening they need for health conditions associated with diabetes, for example, nonalcoholic fatty liver disease (NAFLD). And there can be other implications of not knowing. For example, metabolic syndrome and diabetes are risk factors for endometrial cancer, so knowing if someone has one of these conditions might affect the evaluation of abnormal bleeding.

The risk of glucose intolerance, metabolic syndrome, and diabetes starts to rise around the time of the menopause transition, so being informed and being proactive is an important part of menopause care.

Remember, there is a lot of menopause care that has nothing to do with hormone therapy!

And

I’m at the Menopause Society annual meeting all week, so I’m going to mix it up here with some short daily posts with updates.

References

ACOG Guidelines for Women’s Health Care. Fourth Edition.

DeFronzo, R., Ferrannini, E., Groop, L. et al. Type 2 diabetes mellitus. Nat Rev Dis Primers 1, 15019 (2015). https://doi.org/10.1038/nrdp.2015.19

Vijan S. In the clinic. Type 2 diabetes. Ann Intern Med. 2015 Mar 3;162(5):ITC1-16. doi: 10.7326/AITC201503030. PMID: 25732301.