Menopause is a significant transition in a woman’s life, marking the end of the reproductive years. For women with type 1 diabetes, this phase presents a unique set of challenges that impact their health and wellbeing. Exploring the link between menopause and type 1 diabetes is vital for effective management and maintaining quality of life, with women spending more than one-third of their lives in a post-menopausal state.¹

Diabetes affects approximately 10% of adult females worldwide,² and we frequently encounter menopausal women in our daily practice. In women with diabetes, blood glucose regulation can change during and after menopause. It is clinically recognised that these changes often result in more hyperglycaemic episodes and higher glucose variability, which lead to an increased risk of diabetes-related complications.³

It is crucial to emphasise the importance of optimising blood glucose control during menopause to our female patients. With the drop in oestrogen levels during menopause, the body can become more resistant to insulin, while a decrease in progesterone levels can improve insulin sensitivity. Therefore, it is essential to closely monitor and adjust diabetes medication during menopause to optimise blood glucose control effectively. Symptoms of menopause include:¹

• Hot flushes
• Night sweats (occur in 80% of women)
• Sleep disruption
• Vaginal dryness, irritation
• Weight gain
• Joint pain
• Genitourinary symptoms
• Mood changes.

Hot flushes and hypoglycaemia

Menopause can introduce a range of new challenges for women with type 1 diabetes, particularly concerning blood glucose management. Among these challenges, the interplay between menopausal hot flushes and hypoglycaemia is significant and warrants careful attention. 

Hot flushes, one of the most common symptoms of menopause, can complicate blood glucose management. These sudden episodes of intense heat, sweating, and flushing can mimic the symptoms of hypoglycaemia, such as sweating, palpitations, and a feeling of anxiety. This similarity can make it challenging for women with type 1 diabetes to distinguish between a hot flush and an actual hypoglycaemic episode, potentially delaying necessary treatment.

Risks of cardiovascular complications

Both menopause and type 1 diabetes are linked to a higher risk of cardiovascular complications. When a woman reaches menopause, the cardioprotective effects of oestrogen diminish.² This reduction in oestrogen levels can cause changes in lipid profiles, such as increased LDL cholesterol and decreased HDL cholesterol levels, which can further raise the risk of cardiovascular disease in women with type 1 diabetes. Therefore, managing blood pressure, blood glucose levels and cholesterol levels, along with maintaining a healthy lifestyle, becomes crucial during this stage.²

Bone health and osteoporosis

A woman’s bone density begins to decrease when oestrogen levels drop around the time of menopause, which increases the risk of osteoporosis. The decrease in oestrogen levels during menopause can cause changes in bone density and structure, potentially raising the risk of osteoporosis and bone fractures. Oestrogen plays a crucial role in maintaining bone density by regulating the activity of osteoblasts (cells that build bone) and osteoclasts (cells that break down bone).⁴

As oestrogen levels decrease during menopause, bone reabsorption may exceed bone formation, resulting in a loss of bone mass. This raises the likelihood of fractures, particularly in weight-bearing bones such as the hips, spine and wrists. 

For women with type 1 diabetes, who may already face an elevated risk of bone fractures due to factors like peripheral neuropathy, this is an additional concern.⁴ Ensuring adequate calcium and vitamin D intake and engaging in weight-bearing exercises are crucial for preserving bone health during menopause.  Maintaining bone health during menopause requires a comprehensive approach that includes proper nutrition, regular exercise, lifestyle modifications, and, in some cases, medical intervention.⁵

Nerve damage

Nerve damage, or diabetic neuropathy, is a common complication of type 1 diabetes. This condition occurs due to prolonged high blood glucose levels, which can damage the nerves throughout the body. Diabetic neuropathy can manifest in several forms, each affecting different parts of the nervous system. 

Diabetic neuropathy, in women with type 1 diabetes can present unique challenges. Some symptoms of autonomic neuropathy in women with type 1 diabetes resemble those of menopause, which can complicate diagnosis and management, for example through genitourinary symptoms such as: ²

• Loss of sensation: Nerve damage can reduce sensation in the genital area, affecting sexual function and pleasure
• Vaginal dryness: Reduced blood flow due to nerve and blood vessel damage can lead to vaginal dryness, making intercourse uncomfortable or painful
• Bladder issues: Autonomic neuropathy can lead to bladder dysfunction, causing symptoms like frequent urination, urgency or incontinence.

Menopause treatments and blood glucose levels¹

Menopause treatments can have varying effects on blood glucose levels, depending on the type of treatment used:

• Hormone replacement therapy (HRT)
• Non-hormonal treatments
• Alternative and complementary therapies
• Lifestyle modifications.

For women with type 1 diabetes going through menopause, it is crucial to closely monitor blood glucose levels and work with the diabetes team to adjust treatment plans as needed, especially if commenced on treatment for menopause. 

Based on the International Diabetes Federation Atlas 2021, Ireland holds the 7th position globally when it comes to diabetes-related healthcare expenses per capita.⁶ Hospitalisations of people with diabetes put an extra burden on healthcare resources, highlighting the fact that diabetes-related complications not only pose a considerable burden on patients and the healthcare system but can also have a significant impact on society due to loss of productivity, such as days off work due to illness. 

The Health Service Executive (HSE) estimates that diabetes management consumes about 12-14% of the annual health budget, equating to approximately €2 billion. A substantial portion of this expenditure, around 65%, is dedicated to treating complications such as cardiovascular issues, stroke, renal problems, eye conditions and foot complications.⁷

As menopause can significantly impact blood glucose levels, as healthcare professionals, it is crucial to emphasise to our menopausal patients the importance of maintaining good blood glucose control during this period and assist them in doing so to prevent long-term complications.

The role of technology 

  Given society’s increasing dependence on technology, its role in managing diabetes has become more significant than ever. Technological advancements play a crucial role in helping diabetes patients navigate their health journeys with greater ease. Introducing the hybrid closed-loop insulin pump into diabetes management during menopause provides substantial improvements in blood glucose control compared to multiple daily insulin injections.³

What is a hybrid closed-loop insulin pump?

Hybrid closed-loop (HCL) insulin pumps, also known as sensor-augmented pump therapy with automated insulin delivery, integrate insulin pump technology with continuous glucose monitoring (CGM).³ These insulin pumps adjust insulin delivery automatically based on real-time CGM data, providing a degree of automation in insulin management.³

Menopause-related hormonal fluctuations can cause unpredictable changes in insulin sensitivity and blood glucose levels. Hybrid closed-loop insulin pumps help stabilise glucose levels by continuously monitoring glucose and adjusting insulin delivery accordingly, reducing both the frequency and severity of glucose fluctuations.

The automated nature of these insulin pumps also helps reduce the risk of hypoglycaemia by adjusting insulin delivery in response to falling glucose levels, even suspending insulin delivery until glucose returns to the target range. 

By automatically adjusting insulin delivery to maintain target glucose levels, hybrid closed-loop insulin pumps aim to increase the glucose time in range, promoting better overall glucose control and helping reduce the risk of long-term complications.³

Case study: Managing type 1 diabetes and menopause with a HCL insulin pump

A 52-year-old female with type 1 diabetes for 37 years has been managing her condition with multiple daily injections and despite her efforts, her time in range (TIR) on a CGM fluctuated between 55-65%. She has also experienced hypoglycaemia unawareness since her last pregnancy 20 years ago, making her condition difficult to manage, particularly after entering menopause in the past year. Since beginning HRT, blood glucose fluctuations have become more challenging and have significantly impacted her quality of life.   

Objective

The primary objectives were to improve her TIR, reduce the fear of hypoglycaemia, and achieve more stable glucose levels during menopause to reduce long-term risk of diabetes complications.

Intervention

This patient had previously completed the Dose Adjustment for Normal Eating (DAFNE) education programme. She was also commenced on an HCL insulin pump paired with a CGM. This advanced technology allowed for automatic adjustments of insulin delivery based on real-time glucose readings, addressing the challenges posed by hormonal fluctuations during menopause.

Outcome

The transition to the HCL insulin pump led to significant improvements. Her TIR increased to 75-85%, indicating better overall glucose control. Furthermore, the pump’s ability to reduce hypoglycaemia has significantly helped reduce her fear of hypoglycaemic events, making diabetes management more manageable and less stressful for her. 

The HCL insulin pump effectively minimised glucose fluctuations associated with hormonal changes. This change has been effective in managing diabetes during menopause with the patient commenting that the HCL insulin pump was a game changer.

HCL is an option that should be considered for our female patients with type 1 diabetes during menopause. Much has been written on HCL insulin pumps for females planning a pregnancy and their pregnancy journey. Menopause is another hormonal challenge where HCL insulin pumps can benefit our female patients.

Conclusion

Incorporating hybrid closed-loop insulin pumps into diabetes management during menopause offers significant advantages in glucose control, hypoglycaemia prevention, and overall quality of life. 

By utilising advanced technology to personalise care and manage the challenges of hormonal fluctuations, these insulin pumps empower women to navigate menopause while maintaining optimal health and wellbeing.

Education and support are essential for successfully using hybrid closed-loop insulin pumps during menopause. Users should be trained in the pump operation, interpretation of CGM data, and troubleshooting techniques. Ongoing support from their diabetes team can help optimise pump settings and address any concerns or challenges that arise.

There is plenty of information on menopause itself but not an abundance of resources specifically addressing the intersection of type 1 diabetes and menopause. Menopause can be a challenging time for women, especially with type 1 diabetes, so let’s try and make the journey as smooth as possible and help reduce long-term complications.