Diabetes Deep Dives: Menopause & T1D (What to expect & what you can do)

0:00 foreign0:03 hello and welcome to diabetes deep Dives0:06 my name is Candice and I am from0:08 diabetes Canada I'm so pleased that you0:10 are joining us today0:13 diabetes deep Dives is a series of0:15 videos designed to dive deeper and0:17 Beyond the surface of different areas of0:19 diabetes management we're exploring0:21 those burning questions you may have by0:24 featuring Dynamic and engaging guests0:26 with knowledge or lived experience on0:29 the topic0:30 our goal is to share information in ways0:33 that will spark continued interest and0:34 learning and leave you with practical0:36 tips and tools that you can easily use0:38 we'll be dropping a new video every0:40 month so subscribe to our YouTube0:42 channel and click on the notification0:44 Bell to be notified about new content0:46 you can also check us out on social0:48 media to find out when the next one will0:50 be posted on our YouTube channel0:52 just a reminder that the information0:54 shared in these videos in no way0:57 replaces the advice and direction that1:00 you have from your Healthcare team if1:02 you have questions about your care1:04 please speak to your healthcare provider1:06 and team to make sure that you are1:07 getting the best advice1:10 in this video we are going to hear from1:12 Dr Alice Chang about the intersection1:14 between type 1 diabetes menopause and1:17 Sexual Health we know that diabetes and1:19 Sexual Health are not topics that1:21 everyone talks about so we are happy and1:23 excited for this discussion1:26 Dr Chang is an endocrinologist at1:28 Trillium health partners and Unity1:30 Health Toronto as well as an associate1:32 professor at the University of Toronto1:35 she's been involved in the development1:36 of the diabetes clinical practice1:38 guidelines since 2003.1:41 in this video Dr Chang discusses the1:43 hormones involved in menstruation1:45 perimenopause and menopause how these1:48 hormones affect living with diabetes1:50 other health concerns related to1:52 menopause and how that impacts diabetes1:55 management and tips for living well1:57 during menopause and Beyond2:01 we hope that you find this discussion2:03 enlightening and that it helps you to2:05 successfully manage your journey with2:07 diabetes and now over to Dr Chang2:10 welcome everyone to this presentation2:12 entitled menopause in type 1 diabetes2:15 what to expect and what you can do2:18 presented by diabetes Canada my name is2:21 Dr Alice Chang an endocrinologist from2:23 the University of Toronto and it is my2:25 pleasure today to be sharing this2:27 information with you2:29 now if we think about the hormonal2:31 stages of life particularly in women we2:34 think about things such as puberty2:36 pregnancy2:38 perimenopause and menopause these are2:41 the hormonal stages that a woman may go2:44 through over the course of her lifetime2:47 now in all of these stages a common2:50 theme is that the hormones are changing2:53 so the question then becomes how do2:55 hormones sex hormones in particular2:57 affect diabetes3:01 well to answer that let's think about3:03 the menstrual cycle3:05 I'm going to take you back to biology3:07 class from high school to remind you3:10 about the hormones involved in the3:12 menstrual cycle occurring in the first3:14 place3:15 so here on the diagram on the right3:17 you'll see on the top two hormones3:19 listed LH and FSH those are the3:22 pituitary hormones the hormones that are3:24 coming from the brain to help sort of3:27 Mastermind the entire cycle3:29 the middle chunk is looking at estradiol3:32 and progesterone which are estrogen and3:34 progesterone which are hormones that3:37 come from the ovaries which is also very3:39 important in the cycling that occurs3:42 now day one of the cycle is actually the3:45 first day of bleeding and if we start at3:48 day one you'll notice in the middle3:50 panel that the red line the estradiol3:52 starts to rise over time and that rise3:56 over time is triggered by changes in FSH3:59 and LH in the pituitary and that rise in4:03 estradiol happens slowly over time and4:05 then suddenly around just before day 144:08 there's a surge in the estradiol4:11 and a surge in LH and that surge results4:15 in ovulation so ovulation is the popping4:18 out of the egg4:19 once the egg has popped out the4:22 remaining cells where the egg used to be4:24 in the ovary starts to transform and4:26 starts making a hormone known as4:28 progesterone as shown here in the orange4:30 dotted line and the progesterone levels4:32 start to rise rise rise after ovulation4:36 the progesterone hormone is responsible4:38 for the PMS symptoms that we experienced4:40 before a period4:42 now those cells that are making4:44 progesterone only live for 14 days4:46 so 14 days after the egg has been4:49 released and those cells start making4:51 progesterone 14 days later those cells4:53 die and when the cells die the4:55 progesterone level drops and that drop4:57 in progesterone level is what triggers4:59 the bleeding to occur5:01 so in the first phase of the cycle5:03 what's deemed the follicular phase5:05 what's happening is that the estrogen5:07 levels are rising slowly and that's5:09 building the lining of the uterus in5:12 preparation for potential pregnancy5:14 and then once progesterone is made after5:17 ovulation progesterone doesn't build the5:19 lining progesterone matures the lining5:21 prepares it for potential embedding of5:24 an embryo but then 14 days later if it's5:27 not used the drop in progesterone allows5:30 the shedding of that lining to occur so5:33 this is the menstrual cycle a reminder5:35 from high school biology class5:37 follicular phase is the first half of5:39 the cycle the middle is ovulation for a5:41 day and then you've got the luteal phase5:43 which is the phase with high5:44 progesterone5:46 okay so therefore how does this impact5:49 the glucose levels well there's a5:53 gradual increase in estrogen in that5:54 follicular phase which actually raises5:56 insulin resistance so you become more5:59 resistant to insulin slowly in that6:01 first half of the cycle but once6:03 progesterone starts to rise it's a very6:05 insulin resistant hormone and you find6:08 that your blood sugars tend to go higher6:10 and you need to give yourself more6:11 insulin but once that drop in6:13 progesterone occurs which triggers6:15 shedding of the lining or your period6:17 then that drop in insulin resistance6:21 means that you suddenly become more6:22 sensitive to insulin and your insulin6:24 requirements go down6:26 so this is what the pattern that I'm6:29 sure many of you have observed yourself6:31 with respect to your cycle6:34 so then therefore the impact on blood6:36 glucose is obviously different depending6:38 on what part of the cycle that you're in6:40 but the time period just before your6:43 period6:44 tends to be when your sugars are the6:46 highest and that could be just three6:48 days before or for some ladies it's up6:50 to 10 days or even 14 days before their6:53 period so as soon as the progesterone6:55 starts to go up they start to notice an6:56 impact on their blood sugars6:58 however once the period starts then7:02 there's an Abrupt drop in the blood7:03 glucose levels which of course have to7:05 be accounted for7:07 so from an insulin dose adjustment7:09 perspective during the PMS time which is7:13 the time when the progesterone levels7:15 are rising not only is it giving you7:17 insulin resistance but I think many of7:19 us can can attest to the fact that there7:22 are also cravings for food that may7:24 occur particularly carbohydrates so7:27 therefore one needs to account for that7:28 of course when you're carb counting and7:31 then also there needs to be an increase7:33 in the insulin and for those who are7:35 very regular you can actually predict7:36 that and have a different basal program7:39 for example for those of you on a pump7:41 to be able to account for that7:43 pre-period period of time and then you7:46 have to change that basal setting once7:49 the period starts7:51 so that's when you're cycling regularly7:54 but what happens in perimenopause and in7:58 menopause7:59 so I'm going to direct you to a fabulous8:02 website called menopause and you dot CA8:05 which is actually created by the Society8:07 of Obstetricians and gynecologists of8:09 Canada so a very credible Source8:11 well-designed website designed for8:14 people the general public and gives8:16 really up-to-date expert advice on8:20 menopause in terms of definitions and8:22 potential treatments etc etc so a great8:25 place to help guide you for any8:27 questions that you may have8:29 so what exactly is menopause so8:32 menopause is technically a clinical8:35 definition based on not having a period8:38 for 12 months8:40 now from a blood test perspective what8:42 you could identify is an elevated FSH8:45 which is one of the hormones that comes8:47 from the pituitary and the FSH is high8:50 in response to low estrogen from the8:53 ovaries that are pooping out and no8:56 longer working because they've run out8:57 of eggs8:58 and the official diagnosis of menopause9:02 though is having no period for 12 months9:04 and with that can come a high FSH 95 of9:08 the time it happens after the age of 459:10 and the average age is around 51 in9:13 North America9:15 but leading up to menopause there is a9:18 time period known as perimenopause9:20 perimenopause is usually in your 40s and9:23 is associated with and this is the9:25 visual that I use in my head and when9:27 I'm explaining it to my patients just9:29 imagine it's like your ovaries are like9:31 a car running out of gas and it's sort9:33 of sputtering9:35 so every now and then it pops out an egg9:37 but it's not doing it in a in a in a9:40 regular fashion like it did previously9:42 and therefore your periods are just9:45 unpredictable9:46 they could happen two months later they9:49 could happen six weeks they could happen9:51 two weeks so it could be shorter it9:53 could be longer it's just no longer the9:56 regular cycle that many of you may have9:58 had previously which also means that10:01 during that time it becomes harder to10:03 predict when a period is going to show10:05 up and your hormones are doing funny10:07 things and it's just a potentially10:10 difficult time for many women and there10:13 are symptoms associated with those10:15 changes in hormones so there are10:18 potential menopausal slash10:19 perimenopausal symptoms and this is10:22 taken from the menopause and you website10:24 and I hate to share this part of the10:26 information with you but these symptoms10:27 can last between six months up to 1510:30 years depending on the individual and10:33 the symptoms are shown for you here in10:35 the red block Red Box10:37 the most common one that we tend to hear10:39 about of course is hot flashes night10:41 sweats however there are other things10:43 such as sleep disturbances which can be10:45 quite common fatigue is another one that10:48 people may describe just not thinking as10:50 clearly as they previously did some10:52 people can get mood swings joint aches10:55 and pains I mean there's a variety of10:56 symptoms that can come with the10:58 perimenopause slash menopause and it's11:01 usually a result of just fluctuating11:03 hormones and that reduction in estradiol11:06 or estrogen overall as well as the loss11:08 of progesterone11:10 now the challenge in diabetes is that11:14 the irregular menstrual cycles makes it11:16 very difficult for you to predict what11:18 your blood sugars are going to do11:19 whereas when your periods were regular11:21 you were able to say okay you know11:23 checking my calendars is about the time11:24 when I'm going to need to increase my11:25 insulin but then in the perimenopause11:28 because you cannot predict when your11:30 period is going to show up it's going to11:31 be harder to do that prediction the11:34 other thing is hot flashes become very11:36 difficult to differentiate from low11:39 blood sugar hypoglycemia11:41 and that becomes a confusing aspect as11:43 well so what can you do about it11:46 it's just check a lot frequent11:49 monitoring of blood glucose is going to11:50 be your best way certainly to11:52 differentiate vasomotor symptoms of hot11:55 flashes with that of the low blood sugar11:57 continuous glucose monitoring may be11:59 particularly helpful during this period12:01 of time when things are just wonky and12:03 you need to be able to make adjustments12:05 in a fairly quick manner12:07 increase insulin doses or reduce insulin12:10 doses as needed based on what's12:12 happening with your sugars12:14 and then living healthy so regular12:17 physical activity eating healthy all of12:19 these things can certainly help lessen12:22 some of those perimenopausal symptoms12:24 but it definitely is difficult to12:28 address12:30 hormone replacement therapy is of course12:32 on the table for those women who suffer12:36 a lot from perimenopausal slash12:38 menopausal symptoms and when I say12:40 suffer a lot meaning it's affecting12:41 their quality of life affecting their12:43 ability to function then hormone12:45 replacement therapy is something that12:47 could be discussed with your physician12:48 and certainly someone living with12:50 diabetes could still take it this would12:52 be the same advice we would give any12:53 woman who's having significant12:55 perimenopausal symptoms and that could12:58 come in the form of low-dose birth12:59 control or it could come in the form of13:02 low-dose hormone replacement therapy as13:04 we might use in menopause itself13:09 and then what about menopause and13:11 diabetes so that's sort of perimenopause13:13 and the symptoms that can go with it but13:15 once it's menopause menopause and13:16 there's been no period for 12 months the13:19 only good thing is that the hormonal13:21 fluctuations of the unpredictable Cycles13:23 there's no longer an issue so at least13:25 from that perspective things are stable13:28 however you may still experience hot13:30 flashes for many years to come and that13:33 is still hard to differentiate from13:35 hypoglycemia and therefore frequent13:37 testing is necessary as well some women13:40 may find over the course of13:42 perimenopause into menopause a weight13:44 gain or it's harder to lose weight13:47 so with weight changes that could also13:49 impact your insulin resistance so again13:51 the main strategy Is frequent testing of13:53 the sugars and being aware of what might13:55 happen13:57 the other thing with menopause though is13:59 to remember other health issues that may14:01 come independent of diabetes with14:04 menopause so asking about getting your14:07 bone marrow density testing checking for14:09 osteoporosis making sure you're getting14:11 proper mammograms based on approved14:13 timings to rule out any breast masses or14:16 breast cancer and also recognizing that14:18 cardiovascular risk factor control is14:21 critical throughout your life of14:22 diabetes but particularly as you enter14:24 menopause because one is older at that14:27 time so making sure that things like14:29 blood pressure and cholesterol are well14:31 controlled that you're not smoking and14:33 then of course again the healthy14:35 lifestyle and the body weight14:37 but in terms of treatment of menopause14:39 itself it's no different for those with14:42 diabetes and without so if hormone14:44 replacement therapy is right for you and14:46 it's a discussion you've had with your14:48 team then by all means you can go ahead14:50 and use it it may impact your blood14:52 sugars because again that treatment will14:55 involve estrogen and progesterone but14:57 now you know how those two hormones can14:58 impact your blood sugars and then you15:00 can just check and adjust your insulin15:03 requirements accordingly15:05 but what about sexual function because15:07 that's the other aspect that can15:09 certainly change in the context of15:12 menopause but frankly even before15:15 menopause sexual function and female15:17 sexual dysfunction is more common than15:20 perhaps we realize15:22 so if we think about female sexual15:23 dysfunction these are some of the15:25 statistics that are out there in terms15:27 of how common it can occur15:29 and it's common as you can see here and15:33 these can be grouped into things like15:34 hypoactive sexual desire disorder female15:37 arousal disorder orgasmic disorder or15:40 sexual pain disorder so this is15:41 referring to the different phases of the15:44 sexual response that a woman may have15:47 now specifically in diabetes though15:49 female sexual dysfunction may be common15:51 because of other things that can come15:54 with diabetes that can of course impact15:56 sexual function so if there are15:58 blockages and arteries that could affect16:00 circulation if there is damage to16:02 nervous system then that could reduce16:04 sensation16:06 high blood sugars can reduce lubrication16:09 can result in yeast infections which of16:10 course would not be very pleasant from a16:12 sexual function perspective there may be16:14 issues around body image or fear of16:17 hypoglycemia and then of course the the16:20 mental health aspects are critical in16:22 diabetes and depression and anxiety can16:25 obviously impact sexual function and16:27 then there may be medications that some16:29 are using not necessarily specific to16:31 diabetes but other medications that can16:34 impact sexual function16:36 but what about specific to menopause16:38 well specific to menopause the two big16:40 ones that often come up as vaginal16:42 dryness or reduced sex drive16:46 now strategies to address this so16:49 hormone replacement therapy is probably16:50 one of the best strategies to address16:52 the vaginal dryness and that could be16:54 just local treatment so vaginal creams16:57 that could then reintroduce some16:59 estrogen to the vaginal wall which would17:01 then help with lubrication and avoid the17:04 dryness or perhaps systemic treatment17:06 pills if hot flashes and other systemic17:11 symptoms are a major issue of course17:14 lubricants would be very useful to make17:17 the sexual experience more enjoyable and17:20 again the the usual motherhood17:21 statements of regular physical activity17:23 and lifestyle interventions just giving17:25 you more energy and feeling good about17:27 yourself and and those endorphins and17:29 just feeling happy overall is obviously17:31 going to also be helpful for sexual17:34 function17:35 now in terms of the reduced sex drive I17:37 mean the female sex drive is very17:39 complicated it would be like looking at17:41 the cockpit of an airplane and there are17:44 multiple components there's the17:45 biological there's the psychological17:47 there's the social and there's also the17:50 contextual so it's not as simple as17:52 replace a hormone and boom the sex drive17:54 is back so when there is reduced sex17:57 drive it's important to determine all17:58 the things that may in fact be affecting18:00 that18:01 there could also be a an official18:04 diagnosis of something called hypoactive18:07 sexual desire disorder18:09 which is officially defined as an18:11 absence of sexual fantasies absence of18:13 desire for sexual activity but very18:16 importantly causing distress and a18:19 minimum of six months18:21 many women may experience the first two18:23 but it doesn't really bother them it18:25 doesn't bother their partner but in that18:26 case it's not a disorder however if it18:29 is causing distress and it is chronic18:32 then this could be defined as hypoactive18:34 sexual desire disorder and there18:37 actually is this screener that exists18:40 online that you could look for where if18:43 you answer yes to the first four18:45 questions but more importantly no to the18:48 question number five then it could be18:51 diagnosed as generalized hypoactive18:54 sexual desire disorder and the no to18:56 number five is important so it needs to18:58 not be secondary to a recent operation19:01 mental health considerations medications19:04 pregnancy19:06 etc etc etc so it needs to not have19:08 another explanation then in that case it19:11 could be defined as hypoactive sexual19:13 desire disorder19:16 but what are the strategies to address19:18 reduced libido whether it's in the form19:20 of hsdd or just generally speaking19:22 reduce libido I think discussing it with19:25 your Healthcare team is important19:26 because there may be certain tests that19:28 need to be done to rule out other causes19:30 if the thyroid is not working properly19:32 if the blood sugars are very high19:34 if there are psychosocial things that19:36 are going on that are impacting it then19:39 all of those things could potentially be19:42 treated or reversible so it's important19:44 to check out other potential causes and19:46 then if there's not much to find then19:48 cognitive behavioral therapy can be very19:51 helpful Sex Therapy can be helpful and19:53 of course things like vaginal lubricants19:55 because painful sex is obviously not19:57 going to be enjoyable and then only in19:59 those who are post-menopausal women then20:01 testosterone low dose could be20:03 considered if it's officially diagnosed20:05 as hypoactive sexual desire disorder20:10 so to summarize hormones affect diabetes20:13 a lot and we went through the menstrual20:16 cycle and a reminder that there's an20:18 increase in insulin requirements20:19 particularly for the up to two weeks20:21 prior to a period but the perimenopause20:25 then is that transition time when things20:27 are fluctuating considerably and that's20:29 also when symptoms can be quite strong20:32 and therefore the only strategy you20:35 really have is to test a lot and then to20:38 adjust your insulin accordingly to20:41 smooth things out one can try things20:43 like low-dose birth control pills or20:45 low-dose hormone replacement therapy but20:48 again that's a discussion with your team20:51 to see if it's appropriate for you it's20:53 the same discussion we would have with20:54 any woman even outside of diabetes and20:57 the presence of diabetes would not20:59 exclude you so of course you could use21:01 those if necessary menopause is21:04 officially No period for 12 months and21:06 at that point make sure that you're21:08 considering other things that can come21:09 with age which would be checking for21:12 osteoporosis ensuring that your21:14 cardiovascular health is well managed21:17 and of course mammograms to screen for21:19 breast cancer and then finally sexual21:22 dysfunction is an issue that women may21:24 have even before menopause but certainly21:26 with menopause and is an important21:29 discussion to have with your health care21:30 team21:32 so thank you very much for your kind21:34 attention and I hope that this21:36 presentation was useful for you21:38 thank you so much for joining us to dive21:40 deeper into diabetes and menopause21:42 please take the opportunity to let us21:44 know what you learned what you liked and21:47 how we can do better in the comments21:48 section below21:50 if you have ideas for other topics you'd21:52 like to learn more about you can include21:54 that in your comments as well21:56 if you are looking for more resources21:58 about diabetes management please visit22:01 our website at diabetes.ca you can also22:03 email us at info diabetes.ca or call our22:07 info line at 1-800-benting that's22:12 1-800-226-8464 and speak to one of our22:15 information and support Specialists who22:17 can address your needs thanks again for22:19 joining us and see you next time22:21 foreign22:23 [Music]