by Allison Sayre, MSN, WHNP
Blood sugar management is a critical therapeutic target for whole-person health during perimenopause.
When people think of perimenopause, they often think of hot flashes, night sweats, and irregular periods. However, perimenopause is much more than just a set of bothersome symptoms; it is a complex neuroendocrine transition that affects every system in a woman's body. Among its less discussed, yet highly consequential effects, is the impact perimenopause has on glucose metabolism. As healthcare practitioners guiding women through this critical life stage, we must recognize that managing blood sugar during perimenopause is not merely about preventing diabetes. It is about supporting metabolic resilience, hormonal balance, and overall vitality.
The Metabolic Storm of Perimenopause
Perimenopause is a time of hormonal chaos, characterized by fluctuating estrogen and progesterone levels. While these sex hormones play an important role in this transition, insulin cannot be negated. So here is what is happening beneath the surface:
- Estrogen’s Role in Glucose Regulation: Estrogen enhances insulin sensitivity by promoting glucose uptake in muscles and modulating fat distribution. As estrogen levels decline, insulin resistance can increase, even in women without previous metabolic issues. Estrogen also plays a role in the downregulation of inflammation. The decrease (and fluctuation) of estrogen during perimenopause leads to a pro-inflammatory state, only further exacerbating insulin resistance.[1]
- Progesterone’s Effects: While progesterone is often viewed as a reproductive hormone, it also impacts insulin sensitivity and energy consumption. As it fluctuates, it creates a see-saw effect that contributes to variable blood sugar control.[2]
- Cortisol's Uninvited Role: Perimenopause is often accompanied by heightened stress and disrupted sleep, leading to increased cortisol level. Chronic cortisol elevation induces glucogenesis and can worsen insulin resistance and increase central fat deposition, increasing the risk for metabolic dysfunction.[2]
The Hidden Effects of Insulin Resistance in Perimenopause
Insulin resistance not only precedes type 2 diabetes, but also acts as a complex disruptor, worsening typical perimenopausal symptoms:
- Weight Gain: Many women report unexplained weight gain during perimenopause. This is because insulin resistance promotes fat storage, particularly around the abdomen. Especially for women, there is a favorable link between increasing waist circumference and worsening cardiovascular health.[2]
- Energy Crashes and Fatigue: Fluctuating blood sugar levels can trigger post-meal energy crashes, leaving women feeling fatigued and less likely to engage in exercise and other health-promoting activities.
- Mood Disturbances: Blood sugar instability is linked to mood swings and mood disorders such as depression- issues that can only amplify perimenopausal emotional challenges.[3]
- Inflammation and Cardiovascular Risk: Insulin resistance is a pro-inflammatory state that increases the risk of cardiovascular disease which is a leading cause of mortality in postmenopausal women.[1][2]
- Vasomotor Symptoms: Insulin resistance has been linked to an increase in vasomotor symptoms, such as hot flashes and night sweats.[4]
Going Beyond the Standard Glucose Screening: Clinical Considerations
Routine fasting glucose and hemoglobin A1c (HgbA1c) tests may miss early signs of insulin resistance. Consider a deeper dive with these tests:
- Fasting Insulin: Elevated fasting insulin is an early marker of insulin resistance, often preceding glucose dysregulation by years.
- 2-Hour Oral Glucose Tolerance Test (OGTT): This can uncover postprandial hyperglycemia not seen with fasting glucose tests.
- Advanced Markers: Also be on the lookout for elevated triglycerides, reduced HDL cholesterol, and increased waist circumference which are hallmarks of metabolic syndrome.[5]
Therapeutic Strategies: Beyond Blood Sugar Control
Blood sugar can be affected by many factors including diet, activity, cortisol levels, and hormone imbalance. That is why managing blood sugar during perimenopause requires a multifaceted approach that addresses underlying mechanisms rather than simply targeting glucose levels. Here are some therapeutic strategies to get you started:
- Personalized nutrition: Focus on low glycemic eating and prioritizing nutrient-dense, whole foods that stabilize blood sugar, such as fiber-rich vegetables, lean proteins, and healthy fats. Balanced meals at regular intervals can also put less stress on the hypothalamic-pituitary-adrenal axis.[6]
- Exercise: Living an active lifestyle and exercising regularly can have profound effects on blood sugar regulation. Exercise should include resistance training to build muscle mass, which increases glucose uptake, as well as aerobic activity, as it enhances insulin sensitivity and promotes cardiovascular health.[6]
- Stress management: Interventions may include mind-body practices such as yoga, meditation, or breathwork. Supplements can also be utilized to target cortisol and the hypothalamic-pituitary-adrenal (HPA) axis.[6]
- Sleep management: Interventions can include lifestyle changes, such as regular exercise and sleep hygiene, as well as targeted supplementation. Hormone replacement therapy, in some women, can also be an effective method for treating sleep issues.[6][7]
- Hormone Replacement Therapy (HRT): In select patients, HRT has been shown to play a mitigating role in insulin resistance.[8] Transdermal estrogens appear to be more protective against fat mass growth and android fat distribution.[2]
- Targeted supplementation: May support mechanisms underlying insulin resistance, stress, and mood.
- Continued glucose monitors (CGM): The proper and consistent use of CGMs has demonstrated efficacy in terms of improving HgbA1c as they provide real-time updates on blood sugar levels, helping users make informed decisions about factors such as diet and activity.[9]
A Call to Action for Clinicians
The stakes are undeniably high. Blood sugar dysregulation and insulin resistance in perimenopause can snowball into full-blown metabolic syndrome, type 2 diabetes, and cardiovascular disease, if left unchecked. By recognizing the link between hormones and glucose metabolism, we can intervene earlier and more effectively. It’s time to challenge the idea that blood sugar management is only about diabetes prevention. It is central to the health span of perimenopausal women affecting their energy, mood, cognitive function, and long-term vitality. The time to act is now. By reframing perimenopause as a window of metabolic opportunity rather than a hormonal descent, we empower both practitioners and women to navigate this transition with strength, clarity, and resilience.
Allison Sayre, MSN, WHNP specializes in women's health and functional medicine, blending both traditional and integrative approaches. With over 17 years of experience, she has empowered women to reclaim their health through personalized nutrition and supplementation, hormone balancing, and lifestyle modifications. She received her Bachelor of Science from Mount Carmel College of Nursing and her Master of Science from the University of Cincinnati. She has been a certified women’s health nurse practitioner since 2014 and has continued her education and training in functional medicine from both the Institute of Functional Medicine as well as the American Academy of Anti-Aging Medicine.