Diabetes risk

Type 2 diabetes is when the hormone insulin does not work properly or there is not enough of it, so the sugar in your blood climbs too high. That is how the NHS website's overview page describes it. At home, most of us just call it sugar.

Before diabetes there is often insulin resistance, when the body stops responding well to its own insulin. The Pakistan Menopause Society lists insulin resistance and metabolic syndrome among the longer-term changes that can follow menopause, along with weight around the middle and unhealthy blood fats (Table 1).

Often, nothing: the NHS website says not everyone with type 2 diabetes has symptoms. When they come, it lists feeling very tired, peeing more than usual, feeling thirsty all the time and losing weight without trying, as well as blurred vision, cuts that are slow to heal, and itching around the vagina or repeated thrush.

Some of those overlap with perimenopause: the tiredness, the night-time trips to the toilet, the itching. That overlap is a reason to ask for a sugar test rather than put it all down to the change.

The NHS website lists the things that raise the risk: age, family history, being overweight and not very active, conditions such as high blood pressure, and ethnic background. It says people from a South Asian background may be at higher risk from the age of 25, where for white people it is 40.

The European Menopause and Andropause Society (EMAS) adds two more to the list: having had diabetes in pregnancy, and polycystic ovary syndrome (PCOS). The NHS website says diabetes in pregnancy raises the risk of type 2 diabetes in the future.

The menopause guidance points the same way, as the British Menopause Society line at the top of this page shows.

The NHS website also says weight gain is common in perimenopause and menopause, often around the stomach and upper body. That is the same weight the diabetes guidance worries about. More in weight gain.

• Food. The Pakistan Menopause Society names sweetened drinks and colas as drivers of weight around the middle and metabolic risk, and asks doctors to talk about food in the context of Pakistani eating habits (Table 5). Women's Health Concern says refined starches such as white rice and white bread can be part of a healthy diet and need not be avoided, though more wholegrain is the aim. More in nutrition.
• Movement. The same recommendations list aerobic activity such as brisk walking, and strength and weight-bearing exercise, and say regular activity helps protect the heart (Table 6). See aerobic exercise.
• Weight. They say that losing a modest share of body weight is enough to improve many of the problems linked to insulin resistance (Table 6). See weight management.

Diabetes treatment is for your own doctor. The menopause guidance covers how diabetes and HRT fit together.

NICE NG23 recommends: "Consider HRT for menopause-associated symptoms in people with type 2 diabetes after taking comorbidities into account and seeking specialist advice if needed." (1.5.27) Its table of HRT effects adds that generally no adverse effect on blood glucose control is reported, and that the risk of developing type 2 diabetes is the same whether HRT is taken by mouth or through the skin.

The Pakistan Menopause Society asks doctors to investigate and refer women with diabetes, and to get it under control before starting systemic treatment (Table 4).

The NHS website says to see a GP if you think you may have type 2 diabetes or if you are at higher risk. It counts a South Asian background over the age of 25, and a parent, brother or sister with type 2 diabetes, among the things that raise the risk.

Ask for a sugar test at a menopause appointment. The Pakistan Menopause Society describes a fasting glucose test or an HbA1c blood test as options for doctors to consider (Table 4). In England, the NHS Health Check for people aged 40 to 74 without an existing condition can flag a higher risk.

Ramadan with diabetes raises real questions. Women ask whether they should fast, how to time their medicines, and what to do if their sugar drops before Maghrib. Whether to fast is a question for a qualified scholar, with your doctor's view of your health in hand. Medicine timing belongs with whoever prescribes it. More in Ramadan and fasting.

At home, sweetness is hospitality. Turning down the second cup of sweet chai or the plate of mithai can feel rude. You are allowed to protect your own health at someone else's table.