Why Diabetes Is More Challenging for Women and Girls

Managing type 1 or type 2 diabetes is challenging regardless of your gender, but there are a variety of challenges unique to those with female reproductive systems.

It comes down to hormones. From the start of puberty, the female body endures a nearly constant fluctuation of hormone levels. Those fluctuations occur every single day with more dramatic changes evolving over years depending on the person’s age. 

Those hormonal fluctuations significantly impact blood glucose levels, insulin sensitivity, weight management, and more.

Diabetes & Girls: The Facts

Recent research presented at the 2022 European Association for the Study of Diabetes (EASD) highlighted the facts that demonstrate girls with type 1 diabetes (T1D) have an overall more difficult experience.

Higher A1C levels: Research says girls have higher A1C levels at diagnosis and beyond compared to boys.
Higher risk of DKA: Girls are more likely to experience diabetic ketoacidosis, and DKA events are more severe, compared to boys.
Higher insulin needs: Girls generally need more insulin than boys, which isn’t surprising considering the many hormones explained throughout the rest of this article!
Higher risk of complications & comorbidities: Girls tend to develop more diabetes-related complications and autoimmune conditions, like thyroid disease and celiac.
Higher rates of diabetes distress: Girls tend to report higher levels of diabetes distress than boys — though one could wonder if that’s because boys, in general, are less likely to express how they feel in the first place.

Research about women with T1D and type 2 diabetes (T2D) highlights notable differences, too:

Lower quality of life: Women with T1D showed an overall lower quality of life (QoL) compared to men with longstanding diabetes.
More likely to struggle with mental health: Women with T1D experience more depression and anxiety symptoms compared to men.
Higher A1c levels: Women with T1D tend to have higher A1c levels compared to men.
Higher risk of diabetes risk due to stress: Research finds women face a higher risk of T2D due to higher levels of psychosocial stress.
Higher risk of insulin resistance: Women experience greater hormonal fluctuations like menopause, that can impair overall metabolic function and promote weight gain.
Higher risk of heart health concerns: Compared to men, women with T2D have a higher risk of heart attack. Women with T2D are also less likely to be treated promptly for heart disease and heart attack compared to men. 

Conclusions: Adult women with long-standing DM1 showed lower QoL probably related to higher frequency and severity of psychopathological syndromes. Depressive and anxious symptoms and, among women, exposure to glycemic excursions were identified as modifiable, QoL-related variables. Educational, technological, and psychological interventions are needed in order to improve QoL in DM1 patients.

Here’s a closer look at the unique challenges of living with T1D or T2D as a woman.

Puberty

As if middle school isn’t hard enough, puberty is challenging for everyone. For young women, the hormonal changes at this phase of life can work against diabetes management. 

Testosterone: Testosterone is well-known for its positive impact on muscle growth and utilizing body fat more efficiently for fuel. While women of all ages certainly produce testosterone, it pales in comparison to how much testosterone teenage boys are producing. Increased muscle mass and decreased body fat improve overall insulin sensitivity — making it easier to combat insulin resistance.
Estrogen: Meanwhile, estrogen levels rise significantly during puberty in teenage girls. Estrogen is well-known for promoting fat storage! In other words, estrogen encourages your body to store fat because healthy body fat levels are essential for fertility and pregnancy. Higher levels of body fat decrease insulin sensitivity, which means teenage girls will need more insulin to manage blood glucose levels. (We’ll chat about the impact of menstrual cycles in a bit!)
Growth hormone: Evening the playing field here, most teenagers will see insulin needs rise dramatically during puberty thanks to growth hormone. Growth hormone is a critical part of human development but is well-known for decreasing your overall insulin sensitivity.

Menstrual Cycles

The 28-day cycle of menstruation can be a constant challenge for women with diabetes — particularly those taking insulin. Attempting to fine-tune your insulin doses based on the constant fluctuations of four different menstrual hormones is like shooting an arrow at a moving target. Let’s not forget that menstrual cycles don’t exactly work like clockwork, either, and they can vary dramatically from one gal to another.

Some research suggests the impact of menstruation on red blood cells might actually lessen the accuracy of A1C testing in women, too! 

Four hormones are fluctuating nearly every day within this 28-day cycle and each hormone has its impact on insulin sensitivity and blood glucose levels.

Progesterone
Estrogen
Luteinizing Hormone (LH)
Follicle Stimulating Hormone (FSH)

These four hormones fluctuate based on four phases within the 28-day cycle. (To keep you on your toes, the number of days per phase can vary by a few days.)

Phase 1: Menstruation (Day 1 – 7) — The start of your period is when progesterone and estrogen levels are lowest, but many women experience the most significant insulin resistance during this phase or in the days right before. For some, there’s a dramatic spike in your blood sugar the moment you start bleeding — which is nearly impossible to predict! That insulin resistance might last only one day or several. By the time you figure it out and get your insulin doses adjusted, the temporary insulin resistance stops and you’re back to your normal doses. 

Phase 2: Follicular Phase (Day 1 – 14) — This phase overlaps with menstruation. Estrogen levels start rising again. Your body is preparing to release an egg, also known as “ovulation”. The exact timing is just as tricky to predict and why many women use ovulation prediction kits when trying to get pregnant. Fortunately, this phase doesn’t seem to have as much of an impact on insulin sensitivity for most women.

Phase 3: Ovulatory Phase (Day 14 – 15) — This very quick phase includes rising LH levels when you release an egg, which also tells your body to produce more of other hormones like testosterone. There can be slight changes in insulin sensitivity during this phase. Your body is hoping, during this phase, to become pregnant, preparing a hormonally cozy spot for that potentially fertilized egg.

Phase 4: Luteal Phase (Day 16 – 30) — This is when the lining of your uterus begins thickening when progesterone levels drop quickly. This can be the start of the insulin resistance many women experience in the days before they start bleeding.

There’s nothing quite as fun as the joys of menstruation! Period tracking apps can be helpful by at least giving you some sense of what phase you’re in, and the ability to take notes on insulin needs during those phases, too. (And we didn’t even talk about birth control!)

Pregnancy

If you’d like to go for a wild insulin management journey, try pregnancy! From the moment your egg is fertilized, your insulin needs start changing. 

The first few weeks of pregnancy can lead to insulin resistance.
The next couple of months can lead to dramatic insulin sensitivity. 
By month 5, insulin needs gradually start climbing as the baby starts growing, the placenta secretes hormones that contribute to insulin resistance. 

The tricky part, however, is that you don’t know exactly when or by how much your insulin needs will change. While diabetes pregnancy guides (I wrote one myself!) can help you predict what weeks or months will call for the biggest changes, every pregnancy is different. 

Some weeks, you might make several adjustments to your basal/background or mealtime insulin doses. In other weeks, you might make no changes at all. Fine-tuning insulin doses throughout pregnancy relies on daily monitoring with a blood glucose monitor or continuous glucose monitor and plenty of support from your healthcare team.

What makes this especially difficult is that, at the same time as you’re dealing with all this uncertainty, your doctor will probably ask you to manage your blood glucose levels even tighter than usual — striving for a range of 80 to 130 mg/dL as much as possible.

The overall goal, of course, is to ensure that both mom and baby are healthy and safe on delivery day. Pregnancy is inevitably one of the most challenging journeys a woman with diabetes can pursue.

Breastfeeding

When your baby is born, the fun doesn’t stop there. Next is breastfeeding.

Did you know the work of producing breastmilk is similar to the work of going for a 30-minute powerwalk? Producing breast milk can lower your blood sugar. Many postpartum women experience a lot of low blood sugars during the months of breastfeeding because it’s incredibly hard to predict exactly when that “milk production powerwalk” is going to strike.

And it could easily be when your baby is done nursing and has now fallen asleep on your lap. Can you reach the carbohydrates you use to treat lows without waking up the baby? It’s not easy.

Breastfeeding may be mother nature’s most natural method of feeding newborn babies, but it can be remarkably challenging if you have diabetes and take insulin. Work closely with your healthcare team to adjust your insulin dose, and ideally, prevent low blood sugars as much as possible!

Menopause

You might hope that the challenges of menstruation simply go away when menopause starts, but it’s truly just a different version of hormonal ping pong. 

Menopause is the very gradual decline of estrogen and progesterone levels while LH and FSH gradually increase!

Adding to the fun is the fact that menopause occurs in three phases:

Peri-menopause: This is the very gradual start of menopause and it can take nearly a decade before you’re actually in menopause. Periods become irregular and unpredictable, varying in length of bleeding and days between bleeding. Oddly enough, bleeding can get heavier instead of lighter at times. Most women see their insulin needs rise during this phase, especially with heavier bleeding.
Menopause: Menopause officially starts when you’ve gone a full year without bleeding.
Post-menopause: After that full year without bleeding, you are officially in post-menopause. 

Fortunately, the biggest benefit of menopause is that you become a bit more insulin-sensitive thanks to the decreased levels of estrogen and progesterone! Overall, your insulin needs should be more predictable without the constant fluctuations of that 28-day menstrual cycle.

The downside of menopause is the potential of decreased muscle mass and increased body fat which can lead to insulin resistance. The number one tip from medical experts is to hone in on those lifestyle habits — eating whole foods and getting plenty of exercise — to combat insulin resistance associated with menopause.

The bottom line…

Women are amazing! Being a woman, however, is pretty darn complicated. Being a woman with diabetes? That is beyond complicated.

Editorial Sources & Fact-Checking