In Episode 51, Dr. Sarkar welcomes Dr. Tina Zhang, who will be talking with us about diabetes and menopause. She’s an assistant professor of medicine at Johns Hopkins University School of Medicine. She currently serves as co-director of the Johns Hopkins Women’s Wellness and Healthy Aging Program, the co-director of the Medical Education Pathway for the Johns Hopkins, Osler and Bayview Internal Medicine Residency Programs. She also serves as the director of the Academic Women’s Health Track of the Johns Hopkins General Internal Medicine Fellowship. Dr. Zhang has primarily focused her clinical work, research, and educational efforts on improving women’s health education and care with a special focus on menopause. She is a Menopause Society certified menopause practitioner, and has created a women’s health consultative practice within the Johns Hopkins Division of General Internal Medicine to support women through the menopause transition. Her research has focused on various women’s health topics including menopause, women’s health curricula, and HPV vaccination.

Dr. Sudipa Sarkar, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Sudi Sarkar, at Johns Hopkins University. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.

This podcast is included in our Women’s Health series, where we focus on how diabetes impacts the lives of women.

Today we’re excited to welcome Dr. Tina Zhang, who will be talking with us about diabetes and menopause. She’s an assistant professor of medicine at Johns Hopkins University School of Medicine. She currently serves as co-director of the Johns Hopkins Women’s Wellness and Healthy Aging Program, the co-director of the Medical Education Pathway for the Johns Hopkins Osler and Bayview Internal Medicine Residency Programs.

She also serves as the director of the Academic Women’s Health Track of the Johns Hopkins General Internal Medicine Fellowship. Dr. Zhang has primarily focused her clinical work, research, and educational efforts on improving women’s health, education and care with a special focus on menopause. She is a Menopause Society Certified Menopause Practitioner and has created a women’s health consultative practice within the Johns Hopkins Division of General Internal Medicine to support women through the menopause transition. Her research has focused on various women’s health topics including menopause, women’s health curricula, and HPV vaccination.

Welcome, Dr. Zhang.

Dr. Tina Zhang, MD: Thank you so much Dr. Sarkar. It is so wonderful to be here.

SS: Thank you for joining us. I wanted to start off and ask you to please explain the terms: perimenopause and menopause—if you could help us understand what they are and the differences between the two.

TZ: Absolutely, I think that’s a great place to start. Menopause is a clinical diagnosis and it’s a retrospective diagnosis. We define menopause as the point where a woman has gone 12 consecutive months without a menstrual period. In the United States, the average age (of onset) is around 51. After they hit that 12-month mark of no menstrual cycle, they are in menopause and then after that period, they’re considered post-menopausal.

Perimenopause—we like to use the term “the menopause transition”—is the transitional phase leading up to the point of menopause. This is where a woman’s body is producing less estrogen, less hormones. This period can last many years, and you are going to see a lot of symptoms like mood swings, hot flashes, sleep disturbances, et cetera. But all of that is part of the menopausal transition that can start as early as in your mid-to-late thirties and it can transition all the way until a woman hits menopause.

SS: Dr. Zhang, how does diabetes impact age of menopause or even the symptoms of menopause?

TZ: On average, diabetes by itself does not impact the age of menopause onset, as I mentioned earlier the average age (of onset) is about 51. What we do see is that women who have diabetes, who may have a higher BMI or more adiposity, they do have more severe and more frequent symptoms of menopause, in particular the hot flashes and the night sweats, what we call our vasomotor symptoms of menopause. Those seem to be more severe in the pre- and peri- menopause stage in patients who may have more central fat distribution, which is interestingly reversed in the post-menopause period.

There is some data (that suggests) that type 1 diabetes patients may experience earlier menopause. We are still not sure why, but we think there may be an autoimmune component to it.

In general, diabetes by itself doesn’t impact the onset, but it can make symptoms worse. It is important to know what the symptoms associated with menopause are, and unfortunately there are a lot of them.

The most common symptoms associated with menopause are what we call vasomotor symptoms of menopause — these are your night sweats, your hot flashes, and night sweats that are really just hot flashes at night.

We also have what we call the genitourinary syndrome of menopause (GSM), and that is symptoms like vaginal dryness, vaginal irritation, discomfort, burning, increased risk of developing urinary tract infections (UTIs), urinary incontinence, et cetera. Those symptoms worsen with time. In women, the majority of the other symptoms will get better, but genitourinary symptoms do worsen as patients get older.

A hallmark of menopause are the menstrual irregularities, sometimes that’s the first thing patients present with — they aren’t having any hot flashes, they’re not having any night sweats, but they’re starting to notice that their menstrual cycles are starting to space out or become more irregular or all of a sudden they got really heavy one month and super light the next month. That can be one of the defining symptoms of menopause that we see.

Other things to be aware of, I mentioned mood fluctuations just associated with the hormonal changes; mood swings are very prominent; sleep disturbances — we see a lot of issues with sleep in menopause; hair loss and; skin changes, those are things we’re going to see as well. It can really impact libido, so women can have lower libido. One thing I see all the time is brain fog — feeling like you’re starting to not remember words or just feeling like it’s hard to concentrate and feeling like the job that they were doing at work that initially wasn’t so hard, all of a sudden it’s just becoming harder. They feel like their brain is not functioning the way it usually does — that is something we see very often as well. There are estrogen receptors everywhere in the body, anywhere it’s in the body; you’re going to see it impacted. But those are some regular and common symptoms that we see associated with menopause.

 It’s not fair, it’s like everything. But I will say I do think it’s very important, as providers, to make sure we’re ruling out other causes and making sure that we are being thorough and proactive and clarifying that symptoms are due to the menopause transition and not something else as well.

SS: Can you tell us a little bit more about how perimenopause or menopause might impact women with diabetes? Specifically, in terms of areas like heart health, blood pressure, or cholesterol?

TZ: In younger, healthier patients, estrogen has a protective effect on cardiovascular health. What we see during menopause is that as estrogen declines, that can lead to changes in cholesterol. It leads to the “bad cholesterol” or what we call the Low-Density Lipoprotein (LDL) gets higher. The “good cholesterol”, which we call the High-Density Lipoprotein (HDL) gets lower and it can also elevate blood pressures as well. Those changes combined with the risks associated with diabetes can then lead to a higher risk of developing heart disease.

In patients who have diabetes, we want to really be careful of monitoring the eyes every year. Changes in menopause can impact vision. Estrogen levels can lead to dry eyes, which can impact your vision as well. That is just another thing that I think is important for patients who have diabetes to be aware of as they’re going into the menopausal transition, that sometimes dry eye can be associated with menopause.

Then bone health becomes really important as well. Especially our type 1 diabetics where we know there’s an increased risk of osteoporosis and increased risk of fractures; estrogen’s really protective of the bones. As you go through menopause and your levels are going down, what we can see is that menopause and diabetes can negatively impact bone density as well.

SS: That’s very helpful. How does weight gain during menopause impact diabetes management? And is there an increased risk of developing diabetes in women after menopause?

TZ: Many women gain weight during the menopause transition. We see that all the time in our consultative practices and during menopause consultations. I think weight gain is one of the top three complaints that we see in clinic. Most women are gaining weight during menopause, not because of menopause itself, but more related to aging and lifestyle changes rather than menopause. That is one thing that I did want to clarify, one thing that we chat with patients about a lot is that weight gain is maybe more related to the aging process than the hormonal fluctuations.

That being said, what we do know is that estrogen plays a big role in how fat is distributed in the body. With menopause, we see an increase in central fat distribution or central adiposity. That can lead to worsening insulin resistance and therefore that really impacts women with diabetes because if you’re more resistant to insulin, it can make glucose management more difficult.

I will say that because of the fluctuations in hormones associated with menopause, particularly the menopausal transition, the hormones while estrogen’s going down, it’s a rollercoaster ride of hormone fluctuations. Those fluctuations can sometimes impact blood sugars. That can be one of the things that patients can see that there are more fluctuations in blood sugars to be aware of during that menopausal transition.

SS: Great. Then Dr. Zhang, I think you answered this, but do you see that in women post menopause, are they more at risk of developing diabetes?

TZ: Yes, and the reason for that is more related to the fact that we do see weight gain associated with the menopausal transition and just aging. A result of the weight gain that is then associated with more insulin resistance and a higher risk of developing diabetes.

But I will say that it is just one potential risk factor. It’s usually that other potential risks are also playing a role here as well. If they have a history of gestational diabetes in the past or a history of Polycystic ovary syndrome (PCOS), things like that could also impact their overall risk for developing diabetes. So those are things that we do monitor for during our menopause consultations, we’ll ask about their obstetric history and see if they have a history of PCOS or things like that, which can also affect their risk of developing insulin resistance or diabetes for patients.

SS: You touched a little bit earlier about heart disease and bone health in women during menopause and after menopause. Do you find that for women with diabetes in menopause or after menopause, are they more likely to be diagnosed with heart disease and or low bone densities?

TZ: Absolutely. I think menopause, independently, can increase the risk of heart disease and osteoporosis, but then in combination with diabetes, I think these risks really magnify. I think patients who do have diabetes have a higher risk of developing heart disease because diabetes by itself is a risk factor for heart disease. Then you add the aspect of menopause to that, and both can definitely negatively impact bone density because, again, estrogen is protective of the bones. During the postmenopausal phase, where you’re losing estrogen, you end up losing bone mass. With type 1 diabetes, in particular, we see it associated with increased risk of osteoporosis and fractures.

SS: You talked a little bit about changes in estrogen in the perimenopausal period, then in menopause and then in post menopause and how they impact blood glucose in women with diabetes. Are the changes in blood glucose and those fluctuations similar in those three phases? Could you comment on that?

TZ: During the perimenopausal transition, like before they’ve hit menopause, there are very wide fluctuations in hormones. As a result it can impact blood sugars more. Once patients hit menopause and then are in the postmenopausal stage, some things tend to even out a little bit. But even within the post menopause phase, we have different stages. There’s early post menopause and late post menopause, we do still see some more fluctuations during the early post menopause phase and patients usually have still more menopausal symptoms. Whereas once they’re in that late post menopause phase symptoms really are very stable and those vasomotor symptoms like the hot flashes and the night sweats, by then, those symptoms are hopefully mostly gone.

As a result, blood sugars, typically the fluctuations that can be seen with that, you will stabilize a bit, but once you get into post menopause, then you have the risks associated with more insulin resistance, higher risk of weight gain, changes in your cholesterol, blood pressure, that can lead to higher risk of developing heart disease or metabolic syndrome.

SS: What options are out there for women, that are not medications, that might help manage blood glucose changes in the perimenopausal period during menopause and even after menopause?

TZ: Great question. In particular, for non-medication options, I think the most important thing that we counsel patients about almost every single day is about the importance of exercise. I think that’s something that we all know, I personally feel like I need to exercise more. I tell my patients to exercise more and I’m like, I need to exercise too. I think in this particular case, exercise is really important for menopause. There is data that shows that exercise can help to reduce the severity of menopausal symptoms. We know for a fact that aerobic activity is really important for heart health. We know for a fact that strength and weight training is really important for bone health. Exercise in general is not only going to help with menopausal symptoms, it’s going to protect your bones, it’s going to protect your heart, and it’s going to help with weight loss. Overall that is probably the most important non-medication strategy for managing menopause and blood, health,and diabetes, et cetera.

Then nutrition plays an important role here, obviously in diabetes, just being very careful about eating a balanced diet, not having too much sugar in the diet. Then thinking about limiting really refined carbohydrates, limiting added sugar, et cetera. But we also can see that sometimes spicy foods can cause worsening hot flashes or night sweats at night, there are certain foods that can trigger menopausal symptoms for some of those patients. Identifying what those triggers are can be really helpful.

SS: Can you discuss more about treatments for menopause and how this could impact glycemic management?

TZ: When it comes to menopause treatment, I like to bucket them into three categories. The first one we discussed already, more lifestyle modifications and mind-body techniques. Those things include exercise, a healthy diet, and things like cognitive behavioral therapy.

But in terms of medication specific I think about them in two buckets. The first one is hormone treatment options, and then the second bucket is our non-hormonal treatment options. Of the two, hormone therapy is going to be the most effective treatment for our menopausal symptoms, in particular, night sweats and hot flashes. When it comes to hormone therapy, there is a lot of controversy about it. There has been research in the past that have associated hormone therapy was with elevated risk of heart disease and breast cancer. It has led to a lot of women not being able to get hormone therapy. It has led to a lot of providers not feeling comfortable prescribing it or managing it. That has really impacted care for women who are going through the menopausal transition, unfortunately.

What we know now is that in patients who are less than the age of 60 or within 10 years of menopause onset who don’t have clear contraindications to being on hormone therapy, the benefits could outweigh risks in those patients who are having moderate to severe symptoms of night sweats and hot flashes. We have so many different options for hormone therapy. My preference is to choose the transdermal options because they are safer than the oral estrogen options. There are a lot of nuances that come with hormone therapy and management for menopause that could be a whole podcast in and of itself. I think the main takeaway is that hormone therapy is the most effective treatment for patients who are going to qualify for hormone therapy, and a lot more women do qualify than we think. This is where I think it’s equally important for us to educate providers about which patients would be the best candidates for hormone therapy, for menopausal symptoms, and we always use evidence behind everything we do here at Hopkins.

Then the other bucket is our non-hormonal treatment options. Actually there’s a whole toolkit, there are so many options out there. Many of the options are things that we use all the time as internists that we forget about. Things like our antidepressants, our Selective Serotonin Reuptake Inhibitors (SSRIs), which are antidepressants, can be very effective for helping manage symptoms. We have medications like gabapentin, which I know a lot of diabetics use because it can help with diabetic neuropathy, but it’s also very effective for helping with sleep disturbances associated with menopause. It helps to reduce both the frequency and the severity of night sweats associated with menopause. Gabapentin is an option that I use very often in menopause consultation clinics.

We also have some newer agents out there, like our neurokinin three receptor antagonists, those were FDA approved in 2023. It is a new medication to help manage hot flashes, but it’s really well tolerated, and patients do well on it. There are quite a few options out there that are non-hormonal as well.

That’s how I think about the two medication buckets, hormone therapy, and non-hormone therapy. Then, with regard to blood sugar in particular, hormone therapy is not going to really raise blood sugar. That is usually not something that we will be worried about. There is some newer evidence out there, I think there was a new meta-analysis that was published, that shows that it may improve insulin sensitivity. Again, it is not really going to impact blood sugar per se, in terms of concerns that it may make your blood sugar worse.

SS: How do diabetes and menopause intersect to impact mental health?

TZ: I think that mental health is really important during the menopausal transition, just because, number one, the symptoms of  menopause are just so uncomfortable that women are going through a lot, and I think that can really impact your quality of life; your relationships, at work, at home; your ability to focus; it can cause brain fog, et cetera. But the other thing to be aware of is there are so many hormonal fluctuations that are associated with the menopausal transition, and that leads to a lot of mood fluctuations. The hormone changes lead to mood changes, so the mood swings, we see that often. We see worsening anxiety; we see worsening depression. Then on top of that, in patients who have diabetes, that can be a really big psychological burden as well. The fear of complications, having to monitor your blood sugar all the time. The combination can feel quite overwhelming. Living with diabetes and then adding all the hormonal changes associated with menopause, that can lead to mood fluctuations as well. Thatis something that, number one, patients need to be aware of that, these mood changes we are going to see in menopause and that you are not alone. We expect this and we have ways to help manage it. I think open communication with their primary care practitioners (PCPs) or gynecologists or their menopause providers is going to be really important. Also knowing that there are ways to help manage their physical symptoms, but also their mental health as well. Especially because, as I mentioned earlier, our antidepressants can be used not only to help with mood, but can also be used to help alleviate menopausal symptoms. That is something that is going to help patients who may have issues with mental health and struggles.

Sometimes support groups can be really helpful, just whether it’s a diabetes support group or a menopause specific support group, just to help normalize the experience of what they’re going through, can provide some support and some guidance, and I think that can be really helpful as well.

Rita Kalyani, MD: It’s interesting for people with diabetes you think that the recent evidence doesn’t suggest they go through menopause earlier, but the symptoms could be worse, right?

TZ: Absolutely.

RK: Is that something you think we should be educating our patients with diabetes about, ahead of time?

TZ: I definitely think so. It is more related to insulin resistance and weight. The majority of the data that looks at severity and frequency of menopausal symptoms looks more associated with the weight side of things, and I think that goes hand in hand with diabetes. If you are overweight, that is definitely going to cause worsening symptoms in the pre- and peri- menopausal transition. Post menopause, interestingly, and I think it is because when you have more adiposity, there’s more peripheral conversion into estrone because you have more estrogen levels than someone who has a lower BMI, but post menopause, your symptoms actually lessen. It’s a little bit convoluted and confusing. But I do think regardless, I think women, even if they didn’t have diabetes, should be informed about menopause. But in our diabetic patients, in particular, knowing that they already have a risk factor for heart disease, now adding on the risks associated with menopause, that kind of compounds their risk — I think that is important to educate our patients about.

SS: Dr. Zhang, as we finish up our conversation, are there any thoughts that you’d like to share with our audience?

TZ: I think the main takeaway is that menopause is something that all women are going to go through. It’s a natural progression of aging, but unfortunately, I feel like a lot of women are not prepared for this transition. I don’t think we talk about it enough. I don’t think we were prepared to go through the menopausal transition enough, and I don’t think providers are educated enough to support women going through the transition and to be knowledgeable about what all of the options are to help them through this. I think the main thing I would say to the patients who are listening is that if you want to learn more or if you are going through menopause and having symptoms, just know that there are so many resources out there that are evidence-based that are really helpful, both here at Hopkins, but also at other places.

We’d be happy to help connect you with resources if needed.

SS: Dr. Tina Zhang, thank you so much. This has been a really informative discussion.

TZ: Thank you so much Dr. Sarkar.

SS: I am Dr. Sudi Sarkar, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit hopkinsdiabetesinfo.org.

We love to hear from our listeners. The email address is [email protected].

Thanks for listening and see you next time.