The menopausal transition can highly disrupt one’s quality of life, making this milestone feel more like an upheaval than a rite of passage.
Worldwide, about 47 million people per year enter menopause, and 60 percent seek support from their healthcare provider for symptom management. Menopause symptoms include changes throughout the entire body, including hot flashes, weight gain, loss of libido, mood changes, and more. In a survey of more than 8,000 women aged 40 to 64, those with menopause symptoms reported significantly lower quality-of-life scores, higher work impairment, and higher healthcare utilization than those without symptoms.
Unfortunately, researchers have yet to find a cure-all for the frustrating menopause symptoms that women have endured for, well, forever. Over the years, treatments for menopause symptoms have included antidepressants, blood pressure-lowering medications, anticonvulsants, and more.
Although not a cure-all, improving metabolic health—specifically, keeping glucose (blood sugar) levels more stable and improving insulin sensitivity—may mitigate some undesired effects from perimenopause through postmenopause.
Focusing on tighter blood sugar control may not only help lessen menopause symptoms, but it may also help reduce the risk for chronic conditions associated with this stage of life. People in postmenopause—and in some cases even perimenopause—are at a greater risk for cardiovascular disease, Type 2 diabetes, Alzheimer’s disease, and other forms of dementia.
Read on to learn more about the interplay between metabolic health and menopause and how focusing on blood sugar can help to manage both symptoms and risks.
What are perimenopause, menopause, and postmenopause?
Menopause simply defines the threshold mark between perimenopause and postmenopause. Understanding all three of these terms is critical for learning how to manage the changes associated with them.
Perimenopause, or the menopausal transition, refers to the years leading up to menopause. This is an “ill-defined” period, meaning it’s unclear exactly how long it lasts. On average, perimenopause begins in one’s late 40s but can begin as early as one’s 30s.
What happens during perimenopause? First, we have to go back to when we ourselves were in the womb. At 6–9 months of pregnancy, the ovaries develop their non-growing follicles—millions of them, and they become our only reserve. A follicle is where an oocyte (immature egg) develops. (The follicles also secrete key hormones.) The amount of these follicles declines as we age, meaning our ovarian reserve diminishes. And it is this declining ovarian reserve that eventually initiates perimenopause. Ultimately, one reaches their final menstrual period when only about 1,000 follicles remain.
You might notice the beginning of a transition when things like sleep and mental health begin to shift and then progress to changes in menstrual irregularity, such as skipping periods. But clinically, perimenopause is observed via changes in hormone levels that indicate declining ovarian reserve. An anti-Mullerian hormone (AMH) test can indicate where you are on the trajectory. AMH is a hormone produced inside follicle cells, so it’s a good indicator of how many eggs are left in your ovarian reserve.
Natural menopause occurs when you’ve stopped menstruating for an entire year. Until that point, you’re still in perimenopause, even if you’ve started missing periods. And after the menopause threshold mark, you’re in postmenopause. Various factors contribute to when one reaches menopause, but many studies say it happens on average in one’s early 50s. However, people who have had a bilateral oophorectomy (removal of both ovaries) or take certain medications (such as for cancer treatments) undergo induced menopause soon after receiving this medical care.
Meanwhile, postmenopause is defined as the time beyond the first year after you’ve stopped menstruating. Symptoms that begin in perimenopause may persist up to a decade into being postmenopausal.
How does menopause impact metabolic health?
Metabolic health and menopause symptoms are linked because glucose levels and sex hormone levels are linked.
Metabolic Health 101
First, it’s essential to understand what blood sugar is, as well as its closest linked condition, insulin resistance.
Glucose is a primary form of energy for all of the cells in the body. When we eat certain foods, our body converts them to glucose (aka blood sugar), causing blood sugar levels to rise. Glucose levels also change based on other behaviors such as exercise and sleep.
Rising glucose induces insulin production, as insulin helps facilitate glucose uptake to the cells to be used as energy (or stored as fat). However, when blood sugar levels consistently remain elevated, cells can become unresponsive to insulin’s signaling, leaving higher glucose levels in the bloodstream. This is called insulin resistance, and half of US adults may have it. If left unchecked, it can progress to prediabetes or Type 2 diabetes. Insulin resistance also plays a role in the development of high blood pressure, high cholesterol and triglycerides, and obesity.
Hormones and metabolic health
The shifts that occur in perimenopause and menopause put people at increased risk for insulin resistance because hormones affect how well the metabolic processes of glucose and insulin function.
During your reproductive years, estrogen enhances insulin sensitivity. However, estrogen declines in perimenopause and menopause and reduces the production of sex hormone binding globulin (SHBG), a protein made in the liver. SHBG binds to androgens, or “male” hormones. When there is less of it, androgens increase. Higher levels of androgens are associated with insulin resistance in older women.
Furthermore, estrogen loss is associated with increased total body fat, especially visceral fat. Visceral fat is linked to a reduced level of adiponectin, which also affects glucose metabolism and insulin sensitivity. The loss of estrogen and increased insulin resistance are both linked with increased inflammation, as well.
Ultimately, insulin resistance and other factors of metabolic disease are more prevalent in perimenopausal and postmenopausal women than in those who haven’t entered the transition yet. For example, one 2010 study looked at data from more than 1,500 women from three cities in Iran and split them into premenopausal, perimenopausal, and postmenopausal groups. Metabolic syndrome, a cluster of conditions including insulin resistance, was found in nearly 45% of those who were premenopausal, almost 58% of those who were perimenopausal, and more than 64% of those who were postmenopausal, compared to 26.5% of females of reproductive age.
The relationship between blood sugar and menopause symptoms
Not only are insulin resistance and impaired blood sugar control more prominent in women with menopause but they are also linked to many of the top menopause symptoms. The association is stronger for changes in body composition—such as weight gain, fat gain, and muscle loss—as well as for hot flashes. However, the links to insulin resistance and other symptoms—such as mood changes, increases in stress, and loss of libido—need further research to be fully understood.
Many women in midlife will gain about 1 pound per year. Studies attribute this weight gain to age rather than to menopause. However, women in midlife also tend to experience increased fat gain and notice changes in fat distribution, usually with fat accumulating around the abdomen. These body composition changes are associated with the menopause transition. The decreases in estrogen and adiponectin are risk factors for insulin resistance (as mentioned above), which then drives fat gain. Plus, obesity and insulin resistance perpetuate one another.
In addition to fat gain, muscle loss tends to occur in menopause. Researchers theorize that muscle loss during the menopause transition could be a result of estrogen and progesterone depletion. The muscular system contains estrogen receptors, and estrogen plays a role in skeletal muscle development and regeneration. Declining progesterone may also disrupt protein synthesis. Protein synthesis is crucial for increasing muscle mass. Meanwhile, fat gain and muscle loss contribute to a lower metabolic rate, which is a risk factor for developing insulin resistance.
Hot flashes are one of the most common and troubling symptoms of menopause. During a hot flash, the hypothalamus, which helps control body temperature, causes an abnormal heat-releasing response. Researchers partially attribute this reaction to the increase in FSH (follicle stimulating hormone), a decline in estrogen levels, and even a decline in serotonin. But hot flashes are also associated with higher levels of insulin resistance.
One possible reason for this link is that insulin resistance disrupts the hypothalamic-pituitary-gonadal (HPG) axis, which is the messenger system for reproductive hormones. Plus, the hypothalamus regulates body temperature. The autonomic nervous system may also play a role. Overactivation of the sympathetic nervous system (a branch of the autonomic nervous system) is linked to higher circulating glucose levels and lower insulin production. Some research also indicates that blood sugar levels and glucose transport in the brain may also be factors in hot flash symptoms.
Mood changes, like depression, irritability, and anxiety, are widespread during menopause. More research is needed, but some researchers theorize that menopausal mood concerns are associated with glucose dysregulation.
One theory suggests that reductions in glucose in the brain may be to blame. Plus, a decrease in estrogen causes a reduction in serotonin, which is a mood-boosting neurotransmitter. It’s also worth noting that insulin resistance is linked to mitochondrial dysfunction in the brain, which can also impact mood, potentially making menopausal mood symptoms even worse.
Stress also factors into the menopausal transition. Levels of the stress hormone cortisol are elevated during the late stages of perimenopause. Cortisol also rises during a hot flash, and cortisol levels might have a connection with hot flashes, but the potential associations are still unclear.
Cortisol prompts the liver to produce glucose so we can respond to a threat. Meanwhile, the stress hormone also decreases glucose uptake in muscles. These factors are why elevated cortisol is associated with increased glucose levels.
Up to 85 percent of postmenopausal women report sexual dysfunction, whether with declining vaginal lubrication, ability to orgasm, or desire, according to estimates from a 2021 study.
Sexual dysfunction in menopause may be attributed to multiple factors, including hormonal changes and mood changes. But sexual dysfunction and blood sugar dysregulation are also linked.
Sexual function requires adequate blood flow to the clitoris and the peripheral nerves that control sexual function, like the pelvic ganglia. But both glucose and insulin affect blood vessel diameter. The low estrogen levels associated with menopause also harm nitric oxide levels, which dilate blood vessels during arousal. At the same time, insulin resistance can impede the processes in the brain that signal nitric oxide’s release.
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How can you stabilize blood sugar for menopausal symptoms?
The good news is that lifestyle changes—such as diet and physical activity—help to increase insulin sensitivity and promote stable glucose.
Researchers are still learning about the potential links and exact mechanisms between menopause symptoms and metabolic health factors. Based on what is known so far, taking steps to improve your metabolic health may improve menopause symptoms.
A foundational approach to improving metabolic health involves keeping blood sugar more stable. High glycemic variability—when blood sugar spikes and falls dramatically—is linked to insulin resistance.
Here are some strategies to consider.
- Reduce consumption of refined grains, like pasta and rice, and opt for alternatives that won’t spike your blood sugar and focus on adding healthy fats, like oily fish, to your diet. This will help stabilize glucose. And it may even help delay natural menopause if you haven’t gone through the transition, according to a first-of-its-kind study from 2018.
- Walking after a meal has beneficial effects on blunting a blood sugar spike. And getting regular exercise can help increase insulin sensitivity.
- Focus on reducing stress, which can help lower cortisol levels and potentially improve menopausal mood symptoms.
- Add more fiber to your meals. Fiber helps you feel fuller longer. It can also blunt glucose spikes and promote the production of short-chain fatty acids in the gut that can help foster metabolic health.
- Focus on getting at least seven hours of sleep, maintaining a consistent sleep schedule, and getting natural light exposure in the morning—all of which are important for glucose control, hunger and satiety hormone signaling, and more.
- Incorporate strength training into your workout routine. Doing so can help mitigate the muscle loss that occurs with menopause and boost your resting metabolic rate and provide additional glucose disposal.
The bottom line
Unfortunately, modern medical research has yet to find a cure for the host of menopausal symptoms that have plagued women since the dawn of their existence. While emerging research and clinical data is showing that hormone replacement therapy can be a support for the right patient, there are many things you can do that put the locus of control back within yourself. Thus, aiming for tighter blood sugar control may help ease some of these bothersome symptoms that crop up midlife and negatively impact quality of life.
Interested in using continuous glucose monitoring to manage menopause?
Levels, the health tech company behind this blog, helps people improve their metabolic health by showing how food and lifestyle impact your blood sugar, using continuous glucose monitoring (CGM), along with an app that offers personalized guidance and helps you build healthy habits. Click here to learn more about Levels.