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 and hot flashes. Night sweats are hot flashes that happen at night. They can interfere with sleep, leaving a woman feeling tired and irritable.

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

For women with diabetes going through menopause, it is very important to monitor blood glucose regularly. Diabetes medication or insulin can then be adjusted as needed.

On average, women go through menopause around age 51. A woman can expect to live another third, or more, of her life after menopause. Healthy habits before and after menopause will have a dramatic effect on her years after menopause. 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 an example of how cardiovascular disease can affect the body. More women die of cardiovascular disease than all of the other cancers combined.
The bad news about having diabetes is that it is a risk factor for cardiovascular disease. Other risk factors include high blood pressure, high cholesterol, and a family history of cardiovascular disease. Some risk factors are inherited, while others such as smoking, a poor diet, and an inactive lifestyle can be changed.

The good news is that ways to reduce the risk of cardiovascular disease exist. 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 percent. Use recommended guidelines as targets for controlling blood pressure and cholesterol. For women with diabetes, a good target for blood pressure is below 130/80 mm Hg. LDL (bad) cholesterol should be less than or equal to 2.0 mmol/L.
Many resources are available to help quit smoking. Eat foods that are heart healthy and get regular physical activity to maintain cardiovascular health.

Osteoporosis

In osteoporosis, the bones become fragile and break more easily. The risk of fracture due to osteoporosis increases if there is a family history of the disease, low bone density, and a previous fracture due to osteoporosis. A woman reaches her maximum bone mass during her twenties. After that, bone mass gradually declines. For about ten years following menopause, the lower amount of estrogen in the body means bone loss happens more quickly.
Prescription medications can help stop bone loss, and even build bone in women with osteoporosis. These drugs are used to prevent or treat osteoporosis. They have also 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. Talk to your doctor or pharmacist if you have questions about medications used to treat osteoporosis.

Women can reduce their risk of osteoporosis in other ways than taking drugs. Getting enough calcium and vitamin D is critical.

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.

Regular weight-bearing activity and strength training prevent bone loss and can help to prevent falls by promoting balance, strength and flexibility.
Finally, avoid smoking or drinking too much caffeine and alcohol, as those habits also affect bone health.

Osteoporosis Society of Canada Recommended Daily Intake (RDI)
	Vitamin D	Calcium
Women under age 50	400 - 1000 IU	1000 mg
Women over age 50	800 – 2000 IU	1200-1500 mg

Cancer

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

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

All women should be aware of what is normal for their breasts. Tell your doctor about any unusual changes. The Canadian Cancer Society recommends that women aged 40 to 49 talk with their doctor about breast cancer risk, as well as the benefits and risks of mammography. They recommend that women aged 50 to 69 have a mammogram once every two years. For more information, go to cancer.ca and enter "Breast Screening Recommendations" into the search box.

Diabetes can increase the risk of cancer of the uterus, also called endometrial cancer. Abnormal bleeding from the vagina (bleeding that occurs at unexpected times) is the most common symptom. Discuss any unusual bleeding with your doctor.

Hormone replacement therapy – good or bad?

Hormone replacement therapy (HRT) is used to treat menopause symptoms like hot flashes and vaginal dryness. It is used at the lowest effective dose for a much shorter time than previously recommended (about three to five years). The risk-to-benefit ratio is positive for women who start HRT close to menopause, but becomes riskier with time. On the positive side, HRT can protect against fractures due to osteoporosis and can help with hot flashes. Some of the risks associated with HRT include blood clots and increased risk of breast 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 (about three to five years) may still be a good way to treat severe symptoms of menopause in some women. Sometimes hot flashes and night sweats can be so bad that a woman feels very miserable. It can be difficult to function on a daily basis. When quality of life is affected, 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. In tablet form, estrogen can change the lipid (cholesterol or triglyceride) levels in the body. It helps to lower LDL (bad) cholesterol and increase HDL (good) cholesterol. However, it also increases triglycerides. Since high triglycerides are already common in people with diabetes, adding estrogen in tablet form may make matters worse. Estrogen patches placed on the skin do not have this effect on triglyceride levels. For this reason, they may be a better choice for women with diabetes who also have high triglycerides. Natural progesterone (Prometrium) is preferred to synthetic progesterone (Provera or medroxyprogesterone acetate) because the effect on lipids is better.

Prescription medications

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

Dixarit (clonidine) stabilizes blood vessels, and so relieves hot flashes. It can cause drowsiness or dizziness, and may also lower blood pressure in some women.

The antidepressants Effexor (venlafaxine) and Paxil (paroxetine) 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. The most common side effect is drowsiness, which can be managed by taking the medication at bedtime.

Natural health products

Many women try natural health products for menopause symptoms because they are easy to pick up and may seem safer than prescription medications. Remember, these products contain biologically active substances that can cause side effects and may interact 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. It is thought that eating one or two servings per day of soy foods like soybeans, soy milk and tofu may help to relieve mild hot flashes.

In some studies, herbal supplements like black cohosh have been found to improve mild hot flashes.

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. Exercise, yoga, tai chi, massage and meditation are all good methods. Dressing in layers may help, as clothing can be removed when a hot flash starts. Keep room temperatures cool, especially at night.

For a woman with diabetes, the primary goal is to maintain the best possible blood glucose control while reducing 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 fibre. Keep in mind that good nutrition and physical activity can help manage body weight. In fact, regular physical activity is the single most effective way to maintain good health. It assists with blood glucose, cholesterol and blood pressure control, promotes bone health, and even reduces hot flashes. However, avoid smoking and alcohol.

After learning more about menopause and diabetes, Debbie 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. Debbie has discovered that menopause is a great time to make positive changes to keep herself healthy for the rest of her life.

Menopause and Diabetes What to expect with the change of life

At 50 years of age, Debbie is going through menopause. Although her type 2 diabetes is under good control, she wonders how the process might affect her health. She is also trying to decide whether she should start taking hormones.

The ‘change of life’