Menopause is really a single point in time, and it refers to the very last menstrual period that a woman has about the age of 50. But the problem is we really can’t know that for certain until it’s been a full year, a full 12 months without a menstrual cycle.

So one of the questions is what’s going on from a physiological standpoint at mid-life in women. And in order for us to understand that, we really lean on the data that has been generated from the Study of Women’s Health Across the Nation, or the SWAN study.

It was found that women developed lipid problems, an elevation in LDL cholesterol, an elevation of triglycerides, a lowering of HDL cholesterol before they even reached menopause. And we think that this can be a very important factor in women’s future health related to onset of diabetes and related to cardiovascular health.

One of the questions that people ponder is whether or not natural menopause is in and of itself enough to increase the risk of diabetes.

One of the important things that we have to try to factor in while we try to figure this out is what’s related to menopause or the reduction of estrogen in our bodies and other factors, and what’s just simply due to aging, because we know that a lot of things like blood pressure, blood glucose, insulin really were related more to chronologic age per se, than necessarily menopause.

A number of prospective longitudinal studies that have been carried out for a number of years, some for a number of decades now, have been quite reassuring that menopause in and of itself does not necessarily contribute to the risk of type 2 diabetes.

So having said that though, I think it’s important to talk about the difference between natural menopause and menopause that might occur earlier as possible links to the risk of diabetes. Women that have an early menopause, meaning usually less than age 45, or a premature menopause, that can mean less than age 40, are going to be more likely to have a higher risk of type 2 diabetes.

I’m happy to say that when we consider how best to counsel women who are approaching this juncture there are some very good randomized controlled trial data, one of which is the Diabetes Prevention Program. And we know that with diet, just to try to lose between 5% and 7% of weight and exercise to the tune of about 30 minutes a day was effective in the Diabetes Prevention Program of reducing the risk of new diabetes by 58%. This almost 60% reduction is remarkable.

What happens to a woman who already has diabetes when she’s approaching or experiencing menopause?

So when we’re working with our patient who is living with diabetes, it’s important to step back and take a really broad look at some of the health issues that we want to address: managing her blood glucose and eye care and the renal function and nerve function. From a cardiovascular standpoint, somehow women are still missing this message that we are at risk for heart disease, and so we know that women with diabetes are amongst the highest risk. So in addition to managing their diabetes, we need to be certain that we are treating their blood pressure and then to be aggressive with lipid therapy or the use of statins.

The second arena is thinking about her bone health. We know that women with type 1 diabetes have a very high risk of fracture, and we know that women with type 2 diabetes, their bone density when we measure it, is often quite robust, but they still have an issue with bone quality and can have an increased risk of fractures on that basis.

A final area of, again, women’s kind of global health that I think is important is talking with patients about cancer prevention or early detection. Following things like breast cancer evaluation, we know that women with diabetes are at increased risk. Women with diabetes can have an increased risk of cancer in the lining of the uterus, and things like following screening for colon cancer, for example, so just making sure that we’re maintaining our health in the best way possible across the board.

So some of the other issues that come up are related to common menopausal symptoms in the way of mood shifts, particularly depressive symptoms, sleep disruptions, but one issue that’s not necessarily talked about as much are some of the vaginal changes. And these can be very awkward and difficult for women to bring up. We know that some women with particularly long-standing type 2 diabetes on the basis of vascular changes and neuropathy changes might already have some vaginal dryness and difficulty with sex. So just being aware that some of these issues can come up, but there are also very effective measures to improve them.

Menopausal hormone therapy is always the big question. The primary indication for the use of hormone therapy is treatment of symptoms of menopause. During that treatment of hot flashes or vaginal symptoms, women might find that their blood sugar control can be improved a little bit. Careful evaluation of the individual, sticking with women in their 50s who don’t have evidence of cardiovascular disease or things like breast cancer, and using lower doses and probably a transdermal preparation, enable us to give a chance for women to not only have their symptoms relieved, but also maybe help keep their diabetes in check a little bit while doing so.

What more can we do? What more can we learn and how can we do that? We really need more studies looking at women during the menopause transition.

Diabetes is complicated, and menopause is complicated. Sometimes we feel like we’re in a situation where the more we learn, the more complicated it gets, but I feel very confident that moving forward that a lot of professional women in the realm of endocrinology, menopause physiology, cardiovascular health are really helping to move this field forward.