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Menopause and Diabetes
Handling the change of life

Louise is 50 years old and is going through menopause. Although her Type 2 diabetes is under good control, she wonders how this change is going to affect her health. She is also trying to decide whether she should start taking hormones.

Menopause, a natural life process, begins when a woman stops having monthly periods. Four to eight years before the final menstrual period, perimenopause begins. All women experience perimenopause and menopause differently. Changing levels of the hormones estrogen and progesterone may cause symptoms during this process.

The most common menopause symptoms are irregular periods, hot flashes and night sweats. (Night sweats are just hot flashes that happen at night. They can interfere with sleep, leaving a woman tired and irritable.) Symptoms of menopause can be similar to those felt when blood glucose levels are too low (hypoglycemia) or too high (hyperglycemia).

Once a woman has not had a period for one full year, she is considered postmenopausal. By this time, estrogen and progesterone levels in the body have largely dropped. Estrogen and progesterone affect how the body responds to insulin. Estrogen tends to lower the body's resistance to insulin, which in turn helps lower blood glucose. Progesterone can do the opposite. So when hormone levels fall because of menopause, the effect on blood glucose can be hard to predict.

It is very important for a woman with diabetes who is going through menopause to monitor her blood glucose regularly. Adjustments to diabetes medication or insulin can then be made if needed.

On average, women go through menopause at around 51 years of age. A woman can expect to live another third, or more, of her life following menopause. Following good health practices before and after menopause will have a dramatic effect on her postmenopausal years. As she ages, her risk of developing heart disease, osteoporosis and breast cancer increases. Many factors can affect these risks.

Cardiovascular Disease

Cardiovascular disease is disease of the heart and blood vessels. A heart attack is one example of how cardiovascular disease can affect the body. More women die of cardiovascular disease than all the cancers combined.

The bad news is that diabetes is a risk factor for cardiovascular disease. In women who are postmenopausal, those with diabetes are three times more likely to have a heart attack or stroke. Other risk factors for cardiovascular disease include high blood pressure, high blood cholesterol, and having a family history of cardiovascular disease. Smoking, poor nutrition and an inactive lifestyle are also risk factors.

The good news is that there are ways to reduce the risk of cardiovascular disease, even for women with diabetes. Keeping blood glucose within target levels is a great place to start. Glycated hemoglobin (HbA1c) reflects blood glucose control over the past three months. It should be less than seven per cent (<7.0%). Blood pressure and cholesterol should be controlled according to recommended guidelines.

For women with diabetes, blood pressure should be kept below 130/80 mm Hg. LDL (bad) cholesterol should be below 2.5 mmol/L. Many resources are available to help women quit smoking. Eating foods that are heart healthy and getting regular physical activity are also essential to cardiovascular health.

Osteoporosis

Osteoporosis is a condition where the bones become fragile and break more easily. The risk of fracture due to osteoporosis increases with a family history of osteoporosis, low bone density and a previous fracture. A woman’s maximum bone mass is reached during her twenties, then gradually declines. For about ten years following menopause, the lower amount of estrogen available means bone loss occurs at a faster rate.

Prescription medications are available to help stop bone loss or even build bone in women with osteoporosis. These drugs can prevent or treat osteoporosis, and have been proven to reduce the chance of fractures. Although estrogen is one of these medications, it may not be the best choice for a woman with diabetes. The prescription medications Didrocal™ (etidronate), Fosamax™ (alendronate) and Actonel™ (risedronate) are better choices. Another medication used to prevent or treat osteoporosis is Evista™ (raloxifene). However, there is concern that this medication may reduce the body's sensitivity to insulin. Talk to your doctor or pharmacist if you have questions about medications used to treat osteoporosis.

There are ways to reduce your risk of osteoporosis apart from taking drugs. It is very important to get enough calcium and vitamin D. Women under 50 years of age need 1000 milligrams of calcium and 400 IU of vitamin D daily. Women over 50 years of age need 1250-1500 milligrams of calcium and 800 IU of vitamin D daily.

Calcium carbonate is the least expensive form of calcium available. It is absorbed well if taken with meals at doses of no more than 500 or 600 milligrams. Avoid smoking. Too much caffeine and alcohol can affect bone health as well. Regular weight bearing activity and strength training prevent bone loss and can help to prevent falls by promoting balance, strength and flexibility.

Cancer

Having diabetes may slightly increase your risk of breast cancer. The risk increases with age, a family history of breast cancer, being overweight or obese, and drinking alcohol regularly. A woman’s exposure to estrogen over her lifetime also increases her risk. For example, beginning to menstruate at an early age, not having children or having children later in life, and having a late menopause all increase both estrogen exposure and risk. Taking estrogen after menopause puts you at the same risk as having a late menopause.

Once again, regular physical activity is a good way to reduce your risk of breast cancer because it helps maintain a healthy body weight. Avoiding alcohol also reduces your risk.

Regular screening for breast cancer is important. All women should do a monthly breast self-exam, and have a yearly breast exam done by their doctor. The Canadian Cancer Society recommends that women from age 50 to 69 have a mammogram once every two years. The American Cancer Society and the North American Menopause Society recommend yearly mammograms beginning at age 40.

Diabetes does increase the risk of cancer of the uterus, also called endometrial cancer. (The uterus is where a baby develops before birth.) Vaginal bleeding that occurs at unexpected times is the most common symptom of endometrial cancer. Discuss any unusual bleeding like this with your doctor.

Hormone Replacement Therapy – Good or Bad?

Ten years ago, doctors routinely offered all menopausal patients estrogen and progesterone (hormone replacement therapy or HRT). These hormones were thought to prevent heart disease and other health problems due to aging. The results of a few large studies have recently proved this theory wrong.

We now know that long-term HRT does not prevent heart disease. It may even increase the risk of heart disease and breast cancer in some women. On the positive side, HRT can protect against fractures due to osteoporosis and colon cancer. Since HRT holds different risks and benefits for each woman, it is best to discuss your specific situation with your doctor.

Cooling Hot Flashes

Using hormones for a short time (three to five years) may still be a good way to treat severe symptoms of menopause in some women. This includes women with diabetes. Sometimes hot flashes and night sweats can be so bad that a woman feels very miserable. She may find it difficult to function on a daily basis. When quality of life is affected in a negative way, estrogen may be the best choice.

For women with diabetes, some forms of estrogen may be better than others. Estrogen should be taken at the lowest effective dose for the shortest period of time. Estrogen in tablet form can change the lipid (cholesterol or triglyceride) levels in the body. It helps by lowering LDL (bad) cholesterol and increases HDL (good) cholesterol. However, it also increases triglycerides. High triglycerides are already common in people with diabetes, so adding estrogen in tablet form may make matters worse.

Estrogen patches placed on the skin have a lesser effect on triglyceride levels. A woman with diabetes who also has high triglycerides may find estrogen patches a better choice. Natural progesterone (Prometrium™) is thought to be better than synthetic progesterone (Provera™ or medroxyprogesterone acetate) because of better effects on lipids.

Prescription Medications

A few prescription medications work in treating hot flashes. Most of these medications were taken by women for other problems, and were discovered by chance to also reduce hot flashes.

Dixarit™ (clonidine) helps hot flashes by making blood vessels stable. It can cause drowsiness or dizziness, and may also lower blood pressure in some women. The antidepressants Effexor™ (venlafaxine), Prozac™ (fluoxetine), Paxil™ (paroxetine) and Zoloft™ (sertraline) can reduce the number and severity of hot flashes. These drugs can cause a variety of side effects, so it may take a little trial and error to find the best one. Neurontin™ (gabapentin) was first used to treat seizure disorders, but has since been used for many purposes. It works for hot flashes and usually causes few side effects.

‘Natural’ Health Products

Many women try natural health products for menopause symptoms because they are easy to obtain and are thought to be safer than prescription medications. Remember these products contain biologically active substances that can cause side effects and may act poorly with prescription medications. Talk to your pharmacist or doctor if you have questions about natural health products.

Soy food contains phytoestrogens or plant estrogens called isoflavones. Isoflavones act like weak estrogen in the body. Studies about the benefits of isoflavones are ongoing and it is thought that eating a diet high in soy foods such as soybeans, soy milk and tofu (or supplements) may help to relieve mild hot flashes, provide benefits for bone health and lower the risk of cardiovascular disease by improving cholesterol levels and blood glucose control.

Black cohosh is an herb that affects the body in a way similar to estrogen. It may improve mild hot flashes within about four weeks. Dong quai, chastetree berry, evening primrose oil and vitamin E have not been found very effective for menopause symptoms. Vitamin E can also reduce the effectiveness of cholesterol-lowering medications.

Wild yam is used in the manufacturing of hormones. It does not work for menopause symptoms since it does not actually contain hormones that can be used by the body.

Though progesterone cream may be effective for mild hot flashes, its safety for women with diabetes is unknown. It may have negative effects on lipid levels.

Lifestyle Changes

Small lifestyle changes can have a huge impact on health after menopause. They may be all that is needed to relieve bothersome symptoms.

Avoiding certain hot flash triggers can prevent hot flashes. Hot foods and drinks, spicy foods, caffeine and alcohol are known triggers. Stress can also bring on hot flashes. Take time to relax every day with strategies to relieve stress, perhaps including exercise, yoga, tai chi, massage or meditation. Dressing in layers may help as clothing can be removed when a hot flash starts. Room temperatures should be kept cool, especially at night.

For a woman with diabetes, the primary goal is to maintain the best possible blood glucose control and reduce the risk of cardiovascular disease. Good health habits are essential. Enjoy heart healthy nutrition that is low in saturated fats and cholesterol and high in fiber. Ideal body weight should be achieved and maintained through nutrition and physical activity.

Regular physical activity is the single most effective way to maintain good health. It will help with blood glucose, cholesterol and blood pressure control, promote bone health and even reduce hot flashes. Smoking and alcohol should be avoided.

After learning more about menopause and diabetes, Louise decides that hormones are not the right option for her. Instead, she focuses on good nutrition and starts doing more physical activity. If her symptoms become severe she will discuss the risks and benefits of different treatment options with her pharmacist and doctor. Louise has discovered that menopause is a great time to make positive changes which will affect her health for the rest of her life.