Perimenopause and type 2 diabetes are closely interconnected, with hormonal changes during the menopausal transition potentially increasing diabetes risk and complicating blood sugar control in women already living with the condition. Declining oestrogen levels during perimenopause can reduce insulin sensitivity, promote abdominal fat accumulation, and disrupt glucose metabolism. Women with existing type 2 diabetes may experience more variable blood glucose readings and find their condition harder to manage during this phase. Understanding how these conditions interact enables women and healthcare professionals to implement effective preventive strategies, optimise treatment, and maintain metabolic health throughout the perimenopausal years. This article explores the mechanisms linking perimenopause to diabetes risk and provides evidence-based guidance on management.

How Perimenopause Affects Blood Sugar and Diabetes Risk

Perimenopause, the transitional phase before menopause, typically begins in a woman's 40s (though timing varies) and brings significant hormonal fluctuations that may affect glucose metabolism and increase the risk of developing type 2 diabetes. During this period, declining and fluctuating oestrogen and progesterone levels create metabolic changes that can influence how the body processes and regulates blood sugar.

Key metabolic changes during perimenopause may include:

• Reduced insulin sensitivity, making cells less responsive to insulin's glucose-lowering effects

• Redistribution of body fat from peripheral areas to visceral (abdominal) deposits, which are more metabolically active and associated with insulin resistance

• Changes in appetite regulation and energy expenditure, potentially contributing to weight gain

• Disrupted sleep patterns due to night sweats and hot flushes, which can affect glucose regulation

Research suggests that women transitioning through perimenopause may face an elevated risk of developing type 2 diabetes compared to premenopausal women of similar age. Oestrogen is thought to play a protective role in maintaining insulin sensitivity and healthy lipid profiles; as levels decline, these protective effects may diminish.

Additionally, perimenopausal symptoms such as fatigue, mood changes, and sleep disturbances may reduce physical activity levels and affect dietary choices, further compounding diabetes risk. Women with risk factors should be particularly vigilant during this transitional period. These risk factors include:

• Family history of type 2 diabetes

• South Asian, Black African, or Black Caribbean ethnicity

• Polycystic ovary syndrome (PCOS)

• Previous gestational diabetes

• Overweight or obesity (BMI ≥25 kg/m² or ≥23 kg/m² for South Asian adults)

• History of prediabetes or impaired glucose tolerance

If you are at high risk of type 2 diabetes, your GP may refer you to the NHS Diabetes Prevention Programme, which offers evidence-based support including dietary advice, physical activity guidance, and weight management. Understanding these connections enables women and healthcare professionals to implement preventive strategies and maintain optimal metabolic health throughout the menopausal transition.

Managing Type 2 Diabetes During Perimenopause

Women with existing type 2 diabetes may find their condition more challenging to manage during perimenopause due to hormonal fluctuations affecting blood glucose control. Effective management requires a comprehensive, individualised approach that addresses both the diabetes and perimenopausal symptoms whilst maintaining cardiovascular and bone health.

Blood glucose monitoring becomes particularly important during perimenopause. Women may notice their usual patterns changing, with previously stable readings becoming more variable. More frequent self-monitoring of blood glucose can help identify these patterns and guide treatment adjustments. Flash glucose monitoring (intermittently scanned continuous glucose monitoring, isCGM) or real-time continuous glucose monitoring (rtCGM) may be offered to adults with type 2 diabetes on insulin therapy who meet specific NICE criteria, including those with problematic hypoglycaemia, impaired awareness of hypoglycaemia, or inability to self-monitor adequately. Discuss eligibility with your diabetes team.

Lifestyle modifications form the cornerstone of management:

• Dietary approaches: Following a balanced diet rich in vegetables, whole grains, lean proteins, and healthy fats can help stabilise blood glucose whilst supporting overall health. A Mediterranean-style eating pattern is one suitable approach. Limiting refined carbohydrates and sugary foods remains essential. Some women find that eating smaller, more frequent meals helps manage both blood sugar and perimenopausal symptoms. Your diabetes team can refer you to a dietitian for personalised advice.

• Physical activity: The UK Chief Medical Officers recommend at least 150 minutes of moderate-intensity aerobic activity weekly (such as brisk walking or cycling), combined with muscle-strengthening activities on two or more days. Exercise improves insulin sensitivity, aids weight management, supports bone density, and can alleviate perimenopausal symptoms such as mood changes and sleep disturbances.

• Weight management: Even modest weight loss (5–10% of body weight) can significantly improve glycaemic control and reduce cardiovascular risk. For some people with type 2 diabetes, substantial weight loss (typically 10–15 kg) may lead to remission of diabetes. Your GP can discuss whether referral to a specialist weight-management service or low-calorie diet programme is appropriate for you.

Structured education is an important part of diabetes care. If you have not attended a structured education programme such as DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed), ask your diabetes team about local availability.

HbA1c targets should be individualised. NICE recommends:

• A target of 48 mmol/mol (6.5%) for adults managed by lifestyle and diet alone or with a single drug not associated with hypoglycaemia

• A target of 53 mmol/mol (7.0%) for adults on drugs associated with hypoglycaemia (such as sulphonylureas or insulin)

• Individualised targets based on factors such as likelihood of complications, treatment side effects, comorbidities, and life expectancy

During perimenopause, more frequent reviews (every 3–6 months) may be beneficial to optimise diabetes management and address menopausal symptoms. Regular review appointments with your GP or diabetes specialist nurse are essential to adjust medication regimens, monitor for complications, and address emerging concerns.

Sick-day rules: If you become acutely unwell (with vomiting, diarrhoea, fever, or infection), continue taking insulin if prescribed, maintain hydration, monitor blood glucose more frequently, and contact your diabetes team or NHS 111 for advice. If you take an SGLT2 inhibitor (such as dapagliflozin, empagliflozin, or canagliflozin), you should stop this medication during acute illness and seek medical advice.

Hormone Changes and Insulin Resistance in Perimenopause

The relationship between reproductive hormones and glucose metabolism is complex. Understanding the mechanisms that may underlie increased insulin resistance during perimenopause helps explain why this life stage can present particular metabolic challenges for some women.

Oestrogen's metabolic roles are thought to be multifaceted and protective. This hormone is associated with enhanced insulin sensitivity in muscle and adipose tissue, favourable fat distribution, support of pancreatic beta-cell function, and regulation of appetite. As oestrogen levels decline and fluctuate during perimenopause, these beneficial effects may diminish. The loss of oestrogen's influence on insulin signalling pathways may mean that cells become less responsive to insulin, requiring the pancreas to produce more insulin to maintain normal blood glucose levels—a state known as insulin resistance.

Progesterone fluctuations may also contribute to metabolic changes, though human data are mixed. The irregular hormonal patterns characteristic of perimenopause may cause variable glucose control in some women. Some women notice that blood sugar control varies throughout their menstrual cycle during the perimenopausal years, which may reflect these hormonal shifts.

Visceral adiposity (central abdominal fat) tends to increase during the menopausal transition, even without overall weight gain. This central fat accumulation is particularly problematic because visceral adipose tissue is metabolically active, releasing inflammatory substances and free fatty acids that may further impair insulin sensitivity. The shift from gynoid (pear-shaped) to android (apple-shaped) fat distribution represents a key mechanism that may link perimenopause to increased diabetes risk.

Additionally, age-related changes in body composition, including reduced lean muscle mass (the primary site of insulin-mediated glucose disposal), may contribute to insulin resistance. Vasomotor symptoms (hot flushes and night sweats) and sleep disturbance during perimenopause can also indirectly affect glucose control through effects on stress hormones, appetite, and physical activity levels.

It is important to note that not all women develop significant insulin resistance during perimenopause; individual variability is considerable. These interconnected hormonal and metabolic changes emphasise the importance of proactive management during the perimenopausal transition for women at risk of or living with type 2 diabetes.

Treatment Options for Women with Both Conditions

Managing the dual challenge of perimenopause and type 2 diabetes requires careful consideration of treatment options that address both conditions whilst minimising potential interactions and maximising overall health benefits.

Diabetes medications may require adjustment during perimenopause. Treatment should follow NICE guidance (NG28):

• Metformin remains the first-line pharmacological treatment for type 2 diabetes and offers additional benefits including weight neutrality or modest weight loss, which can be particularly valuable during perimenopause when weight gain is common.

• SGLT2 inhibitors (such as dapagliflozin, empagliflozin, or canagliflozin) should be considered early, alongside metformin, for people with established cardiovascular disease, chronic kidney disease, or high cardiovascular risk. These medicines offer cardiovascular and renal protection alongside weight management benefits. However, they carry important risks: genital mycotic infections (thrush), urinary tract infections, volume depletion (especially in older adults or those on diuretics), and a rare but serious risk of diabetic ketoacidosis (DKA), which can occur even when blood glucose is near normal. If you take an SGLT2 inhibitor, you should stop it during acute illness, maintain hydration, and seek medical advice if you develop nausea, vomiting, abdominal pain, or feel generally unwell. If ketone testing strips are available, check ketones and contact your diabetes team or NHS 111 if ketones are raised.

• GLP-1 receptor agonists (such as semaglutide, dulaglutide, or liraglutide) may be used according to NICE criteria, typically when HbA1c remains above target despite other therapies and BMI is ≥35 kg/m² (or ≥32.5 kg/m² for South Asian and some other minority ethnic groups), or if insulin is contraindicated or not tolerated. These medicines support weight loss and have cardiovascular benefits but commonly cause gastrointestinal side effects (nausea, vomiting, diarrhoea), which usually improve over time. Specialist advice is often needed.

• Sulphonylureas (such as gliclazide) and insulin carry a risk of hypoglycaemia, which may be more difficult to recognise during perimenopause when symptoms can be confused with hot flushes or other menopausal manifestations. If these medications are necessary, careful dose titration and patient education about distinguishing hypoglycaemic symptoms are essential.

Cardiovascular risk reduction is a core part of diabetes management. In addition to glucose control, optimising blood pressure and lipids is essential. Most adults with type 2 diabetes should be offered a statin (typically atorvastatin 20 mg) for primary prevention of cardiovascular disease, and antihypertensive treatment if blood pressure is persistently above target (typically 140/90 mmHg or lower if appropriate). Smoking cessation support should be offered to all smokers.

Hormone Replacement Therapy (HRT) can be considered for managing troublesome perimenopausal symptoms in women with type 2 diabetes. Type 2 diabetes is not a contraindication to HRT. Some evidence suggests that oestrogen therapy may improve insulin sensitivity and glycaemic control, though individual responses vary. Decisions about HRT must be individualised through shared decision-making, considering cardiovascular risk factors (which are often elevated in women with diabetes), venous thromboembolism (VTE) risk, breast cancer risk, blood pressure, and smoking status.

Transdermal oestrogen preparations (patches or gels containing regulated 17β-oestradiol) are generally preferred over oral formulations in women with diabetes and cardiovascular risk factors, as they avoid first-pass hepatic metabolism and have more favourable effects on lipid profiles, blood pressure, and VTE risk. Women with an intact uterus require progestogen alongside oestrogen to protect the endometrium; micronised progesterone or dydrogesterone are often preferred due to their neutral metabolic effects.

Important HRT cautions and contraindications include current or previous breast cancer, active or recent VTE, uncontrolled hypertension, active liver disease, and unexplained vaginal bleeding. Your GP or menopause specialist will assess your individual risk-benefit profile.

Only use regulated, MHRA-licensed HRT products. Avoid unregulated compounded 'bioidentical' hormones, which are not subject to the same safety and quality standards.

Complementary approaches may help manage symptoms:

• Cognitive behavioural therapy (CBT) for troublesome hot flushes and night sweats

• Vaginal oestrogen (cream, pessary, or tablet) for genitourinary symptoms such as vaginal dryness or recurrent urinary tract infections (minimal systemic absorption; can be used long-term)

• Stress management techniques to support both glucose control and menopausal symptom management

Regular medication reviews ensure treatments remain optimally effective and well-tolerated as women progress through perimenopause. A collaborative approach involving GPs, diabetes specialists, and where appropriate, menopause specialists, provides comprehensive care addressing all aspects of health during this transition.

Reporting side effects: If you experience a suspected side effect from any medicine, you can report it via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk or using the Yellow Card app.

When to Seek Medical Advice

Recognising when to contact your healthcare provider is crucial for maintaining health and preventing complications when managing both perimenopause and type 2 diabetes. Certain symptoms and situations warrant prompt medical attention.

Call 999 or go to A&E immediately if you experience:

• Severe hypoglycaemia with confusion, loss of consciousness, or seizures

• Symptoms of diabetic ketoacidosis (though uncommon in type 2 diabetes): excessive thirst, frequent urination, nausea, vomiting, abdominal pain, fruity-smelling breath, confusion, or rapid breathing. Note: if you take an SGLT2 inhibitor, DKA can occur even when blood glucose is near normal.

• Chest pain, severe breathlessness, or symptoms suggesting a heart attack or stroke

• Sudden vision loss or severe eye pain

• Signs of severe infection, particularly with poor glucose control, foot ulcers, or spreading skin infection (cellulitis)

Contact NHS 111 or your GP urgently (same day or next day) if you notice:

• Persistent deterioration in blood glucose control despite medication adherence

• Frequent hypoglycaemic episodes or difficulty recognising warning symptoms

• Symptoms of acute illness (vomiting, diarrhoea, fever) whilst taking diabetes medication, especially SGLT2 inhibitors

• New or worsening symptoms of diabetic complications (numbness, tingling, visual disturbances, non-healing wounds)

• Recurrent urinary tract infections or genital thrush

• Concerns about medication side effects

Contact your GP or diabetes team within a few days if you notice:

• Unintentional weight loss or rapid, significant weight change

• Perimenopausal symptoms significantly affecting quality of life, sleep, or ability to manage diabetes

• Persistent low mood, anxiety, or mood changes interfering with daily activities

• Questions about HRT or managing menopausal symptoms alongside diabetes

Routine monitoring and reviews are equally important. Women with type 2 diabetes should have structured annual reviews including:

• HbA1c measurement (typically every 3–6 months until stable, then at least annually)

• Blood pressure monitoring

• Lipid profiles

• Kidney function tests (eGFR and urine albumin-creatinine ratio)

• Foot examinations

• Retinal screening through the NHS Diabetic Eye Screening Programme (annual digital retinal photography; attend every appointment even if you have no symptoms)

During perimenopause, more frequent reviews (every 3–6 months) may be beneficial to optimise diabetes management and address menopausal symptoms.

Don't hesitate to discuss concerns about the interaction between perimenopause and diabetes with your healthcare team. Open communication enables personalised management strategies that address your individual circumstances, preferences, and health goals. Many areas have specialist menopause clinics or diabetes services with expertise in managing women through this transition, and your GP can facilitate appropriate referrals if needed.

Frequently Asked Questions