Updated March 04, 2008

Menopause
What to Expect, How to Cope

by Pat Dougherty, C.N.M., M.S.N., and Joyce Green Pastors, M.S., R.D., C.D.E.

For most women, menopause—the cessation of menstrual periods—is a normal, natural occurrence. The average age at menopause is 51, although any time after 40 is considered normal. The years leading up to the menopausal transition—a time known as the perimenopause—may be characterized by changes in the menstrual period, hot flashes (a sudden feeling of warmth, sometimes accompanied by sweating), emotional ups and downs, sleep disturbances, and vaginal dryness. Some of these symptoms may continue after menopause. The severity of symptoms varies dramatically from person to person, ranging from barely noticeable menstrual changes to an experience described as debilitating. Women who experience menopause abruptly because of the surgical removal of their ovaries (called surgical menopause) typically have much more severe symptoms than women who experience a natural menopause.

Both the perimenopausal and postmenopausal periods may present additional challenges for women who have diabetes. For one thing, the hormonal fluctuations that are common to perimenopause can affect blood glucose levels. For another, some symptoms of menopause are the same as or easily confused with the symptoms of high or low blood glucose levels, so the cause must be determined before corrective action can be taken. In addition, both diabetes and menopause raise a woman’s risk of osteoporosis, so women with diabetes must be proactive about taking steps to keep their bones strong. Lack of sleep, whether related to menopause, stress, or something else, can disrupt diabetes control. And menopause is often associated with weight gain, which can make blood glucose control more difficult.

The menopausal process
A woman is said to be postmenopausal one year after her final menstrual period. Menstrual periods may be very irregular in the years leading up to the final period, sometimes with only one to three cycles occurring per year in the late perimenopause. A small percentage of women stop having periods abruptly without any cycle fluctuation. Although fertility declines sharply after age 40, perimenopausal women can become pregnant, so contraception is necessary for sexually active women who do not wish to become pregnant until menopause is confirmed. Once a woman has gone a year without a period, she can no longer become pregnant.

As the ovaries age, they become less responsive to the hormonal messengers on which they rely for regular function, and greater amounts of estrogen and progesterone are required for ovulation and menstruation to occur. The perimenopausal years are characterized by fluctuating, although not necessarily low, levels of these hormones. The unstable levels of estrogen and progesterone contribute to menstrual cycle irregularities and perimenopausal symptoms. They can also contribute to unstable blood glucose levels. While the effects of estrogen and progesterone on diabetes control are not entirely understood, in general, it appears that higher levels of estrogen may improve insulin sensitivity, while higher levels of progesterone may decrease insulin sensitivity. When insulin sensitivity decreases, more insulin is needed to get glucose into the cells.

The changes associated with perimenopause commonly begin about three to five years before a woman’s final menstrual period, although some women notice subtle changes as early as their late 30’s. Eventually, the ovaries become unresponsive and unable to ovulate (release eggs). Once the ovaries cease ovulating altogether, estrogen levels decline, and menstrual periods stop. However, hot flashes, night sweats, sleep disturbances, and mood fluctuations may continue for several years. Vaginal dryness due to low estrogen levels may persist if not treated.

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Pat Dougherty is a Certified Nurse Midwife and Nurse Practitioner in the Department of Obstetrics and Gynecology, Division of Midlife Health, in the University of Virginia Health System. She is also certified as a Menopause Practitioner by the North American Menopause Society. Joyce Green Pastors is a Diabetes Nutrition Specialist with the Virginia Center for Diabetes Professional Education and an Assistant Professor of Medical Education in Internal Medicine, Division of Endocrinology at the University of Virginia School of Medicine.

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