Contributor: Contributor: Jennifer Smith, RD, LD, CDCES
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As a woman, you deserve the best, including the best information for self-care when living with diabetes. You may feel like things can be a bit of a roller coaster up and down. You've likely brought this concern to your healthcare team, who may tell you to make some adjustments, or that all looks great and to keep it up. It can be frustrating knowing that what you are doing is a bit of an up-and-down roller coaster that you try to ride without much direction on the course. Even if it translates into in-range glucose levels or the A1C that is in target, it doesn't show all the work you've done to achieve that level of management.

I have found, personally and professionally working with so many women of all ages, that the navigation of diabetes for a woman is not well discussed. Education is lacking regarding what to expect related to where you are in your life cycle – pre-teen/teen, pre-conception, postpartum, or perimenopause/menopause. The frustrations you bring into a medical appointment may never touch on why you see things work one way during one week of the month vs. another way, with different settings or medication needs, at another time of the month. Hormones are a significant factor as we age. Understanding why you seem more or less sensitive at certain times in life would be helpful as you navigate the other variables that can impact your day-to-day glucose management strategy.

MENSTRUAL CYCLE:
The menstrual cycle for women includes many hormones that impact blood glucose in each stage of the month. You may have received information from your care team about paying attention to the time right before your menstruation begins, but this is just a portion of the hormones at work. Did you know your menstrual cycle is really an entire month long? It includes about a 4-week span where some key hormones play a role in moving you through a time of potential conception (ovulation) into actual menstruation if no pregnancy has occurred.

What hormones are at play monthly, and what can you expect to change related to your diabetes management? If you are not taking any birth control or using a hormone-based IUD, then the hormones that shift through a month and in each phase are:

Week 1 – The Menstrual Phase

• The start of week 1 begins with the first day of your period. Hormones are at their lowest at this time of the month as the body realizes it is not pregnant. Estrogen begins a slow climb, but overall, this is a low time in hormone impact.
• Blood glucose management may seem “easy,” and insulin sensitivity may be at its highest until the days leading to ovulation.
• If you are using insulin, your needs may go down some, and you may be the most sensitive in the 24-72 hours after your period starts before things even out to a baseline of need. That is the best time of the month to work with your diabetes care team to establish your baseline insulin needs in order to adjust up when hormones are hitting hard at other times of the month.

Week 2 – The Follicular Phase

• This phase starts at almost the same time as the start of your period. The brain begins to send signals for another hormone release – follicle-stimulating hormone (FSH).
• FSH tells the ovaries to create a small sac called a follicle with an immature egg. One of these will be deemed the healthiest, and this follicle will mature. Estrogen levels will rise even more in this phase allowing the lining of the uterus to get thicker and be nutrient dense to support a fertilized egg.
• If you are using insulin, you might find that your needs are pretty stable at this stage, OR they may increase slightly. You may need to increase your basal or bolus insulin just before this phase or at the next phase – 2 days before ovulation.

Week 3 – The Ovulation Phase

• The follicular phase ends when ovulation takes place. Rising estrogen levels tell the body to release another hormone (oh joy!) called luteinizing hormone (LH), which tells the ovary to release the egg.
• If you use insulin, this time of the month, just before and at ovulation, can mean your needs go up. Your basal insulin may increase, as well as your bolus doses for food and corrections. This stage is short, but with the high hormone spike, you will likely find sticky elevated blood glucose levels.

Week 4 – The Luteal Phase

• Progesterone is the key hormone in this stage of your monthly cycle – usually days 22-28 (in a 28-day cycle). It helps to ensure the thickened uterine wall stays thick to allow for implantation if an egg has been fertilized.
• Energy levels may take a nosedive as these hormones rise and change. You may have an increase in appetite as well as a fall in energy level.
• If you use insulin, you are likely to notice a rise in blood glucose levels at this time of the month and resistance to insulin about 3-7 days before your period starts.
• Talk to your healthcare team about adjusting your basal insulin dose, as it is typical at this stage. Amounts may continue to shift up as you move closer to the start of your period.

Pregnancy

• If pregnancy has occurred, progesterone levels stay high, and another hormone enters the picture, human chorionic gonadotropin (hCG). This helps to ensure the lining of the uterus stays thick to allow the egg to develop further into an embryo. Both will keep blood sugar levels elevated and increase insulin needs.
• Pregnancy management takes a lot of navigation, and you may decide to work with a maternal-fetal management team and a knowledgeable CDCES who specializes in diabetes during pregnancy.

PERIMENOPAUSE AND MENOPAUSE
Hormone changes persist through our next stage in life. During early perimenopause, levels of estrogen and FSH become variable, and your menstrual cycle may be irregular. Your cycle length may shorten or lengthen, and symptoms of menopause may start to show up.

During the latter part of this stage, which could be for several years, estrogen levels continue decreasing, and FSH increases. The length of time between cycles will increase and become more irregular.

Menopause is defined as having no menstrual period for 12 months or more. It often includes a host of common symptoms that may have started in perimenopause, including:

• night sweats/hot flashes
• insomnia
• changes in mood/depression
• potential weight gain
• more achy joints
• vaginal dryness

These symptoms are a result of estrogen levels decreasing considerably. With changes in energy levels, a decrease in exercise may follow, making weight gain more likely and impacting glucose levels and medication needs too. Work with your doctor as you start to experience changes. Weight-bearing exercise in this period of life can be important to ensure bone health and decrease the chance of osteoporosis. It will also assist with keeping energy levels, mood, and blood glucose levels more stable.

HOW TO EVALUATE AND PLAN
Tracking your month-to-month cycle can be helpful to see how changes can keep things in the target you are aiming for long term. Find a good care team that can help you track what you see happening and provide suggestions for adjustment. You may have less mental burden once you can go back to your notes and adjust from a place that worked in the months past. While each month may not be consistent, regular cycles, for the most part, will require about the same adjustment in medication and strategy unless other variables have changed significantly. Be sure to go into your healthcare visits with a list of questions and concerns that can help direct that visit and address what is important for you as you navigate life with diabetes and women’s hormones.

Jennifer Smith, RD, LD, CDCES, Director of Lifestyle and Nutrition, has lived with diabetes since childhood and has first-hand knowledge of diabetes management. She is passionate about achieving healthy nutrition and fitness goals while living with diabetes. In 2009 she completed her first 70.3 triathlon, which brought a deeper understanding of athletic training requirements and the importance of nutrition to realize athletic goals. Jennifer has a keen interest in women's health as she works with women with diabetes through all stages of life. As a mother of two, she works in depth with women during preconception, pregnancy as well as postpartum times to ensure safe and healthy outcomes for mother and child.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin-Green Bay. She is a Registered (and Licensed) Dietitian, Certified Diabetes Care and Education Specialist, and is an active member of the American Diabetes Association and the Association of Diabetes Care and Education Specialists. She is a contributing author for DiabetesSisters and Diabetes Daily and a contributor to the Juicebox podcasts. Jennifer has co-authored a book - Pregnancy with Type 1 Diabetes: Your month-to-month guide to blood sugar management to provide assistance to women who are navigating pregnancy with diabetes in an easy-to-use format.