Type 1 & the Big "M" - So What Has Changed?
Information available about the typical female cycle and the impact of hormones on blood glucose levels suggests that for many women, the further into your cycle you go and post ovulation, progesterone levels rise and lead to increased insulin resistance. Although CGM was not available during my peak reproductive years, my general experiences from monitoring blood glucose levels regularly were that:
Blood sugars would often plummet on the last day of my cycle,
I required less insulin in the first three days of a cycle,
I had greater variability around ovulation, with a mixture of both less predictable lows and highs, and
Post ovulation, I tended to find that a new stability would only come with slightly higher doses of insulin.
It is already recognised that type 1 can interfere with the reproductive experiences in a number of ways. I had a very delayed menarche (just before my 18th birthday) which I understand can be common for girls diagnosed with type 1 before puberty, even where they have intensive insulin therapy.
I was very fortunate however in that from then onwards, I did not have any menstrual abnormalities, which can be more common with type 1. I had incredibly regular 28 day cycles and was very conscious of my predictable pattern of ovulation, due to the physical cramping that accompanied it for several hours. I conceived my son in the first month of trying at the age of 29 and daughter equally quickly, two years later.
My experiences through these various life stages will not be identical to those of others, so why talk about them? There is so little information and understanding that I am interested to see whether earlier experiences can help to identify the type of experiences you may have in navigating the peri-menopause.
People’s experiences in other areas – those of illness and exercise for example and how best to manage blood glucose levels through this - will be different. However, that hasn’t stopped discussion or research into what you might experience. And, all of this discussion helps to support people both practically and mentally, in knowing that they are not alone, whilst trying to navigate their way through the challenges presented. So, I’m starting to put some detail out there, which I hope will trigger further conversations and the appreciation that the same needs to be done for the perimenopause and menopause.
So what has changed for me?
I started to notice changes in my early to mid 40s. The length of my cycles began to reduce, initially to 26 days and then averaging at around 22 to 24 days in length. They were still very regular but just significantly shorter. From the age of 50, my cycle lengths began to increase slightly again, returning to the 26 to 28 day length. In the last three years I have had a total of three cycles that ranged from between 45 to 55 days in length but then I would return to my 26 to 28 day cycle after each longer one.
So what have been the specific problems of managing type 1 through these changes?
My basal insulin requirements are reducing. Not in a predictable constant way. The general trend is downwards but there are a lot of bumpy up and down movements around this general downwards trend leaving you struggling to decide the best background insulin rates to set. Not long ago I broke the 0.4u barrier and required a basal rate of 0.35u per hour for a significant period of the night to prevent hypos. I am currently back up to a mixture of 0.5u and 0.55u per hour through the night.
The typical pattern of greater insulin sensitivity in the early part of a normal cycle followed by variability around ovulation before hitting the greater insensitivity in the latter half of the cycle, is no longer as predictable. Although I have still experienced a regular cycle, albeit often shorter in length, there has been far less certainty over how blood glucose readings are likely to behave throughout my cycle. There has definitely been a less predictable pattern of ovulation. Sometimes I don’t seem to ovulate at all during a cycle yet other months, I seem to have my tell-tale cramping more than once, often up to two or three days apart.
I am no longer certain of the dawn phenomenon response that has been a regular companion to my mornings. Instead, mornings can now be split into three or four different patterns – dawn phenomenon; foot to floor rise when getting out of bed; or foot to floor drop when getting out of bed which could eventually turn into a delayed foot to floor rise, almost an hour after getting up.
Night sweats and hot flushes have led to quite rapid increases in blood glucose. These are impossible to predict so trying to tame the sudden blood glucose spike can be very difficult when you are playing catch up, recognising the time that it takes for insulin to peak post injection.
Exercise of any description has become more of a challenge, regardless of the level of intensity. Blood sugar crashes are much more likely now, even with the gentlest and shortest of walks and with no significant active insulin on board. The opposite can also be true. If I am undergoing a prolonged period of exercise, I can hypo more quickly without a reduction to background insulin rates but if I reduce background rates for several hours, I have also had some quite horrific blood sugar spikes.
The burden of managing all of this mentally has been huge. I think back to the relative stability I enjoyed post pregnancies and find it hard to remember that I had days where type 1 didn’t need to be the constant focus of my attention alongside whatever else I was doing. That is no longer the case.
I appreciate that many of my experiences will be different to those of others and as with everything related to type 1, you need to work out the pattern specific to you. However, having a reference point in relation to someone else’s experiences can hopefully help to reduce some of the feelings of helplessness and isolation that can accompany the situations, when tried and tested techniques are no longer working.
I have written a separate blog on many of the bullet points above, looking at how I have tried to deal with each situation. I wish you a less bumpy journey through the changes.
I am writing a series of blogs about my experiences of managing type 1 as I approach the menopause. I hope this will help others to understand the range of changes that may affect them. However, I am very aware that my experiences may well be very different to yours…. So please use this for ideas, discussion with HCPs and not as gospel. Please talk to your team before experimenting with techniques that have worked for me. Please experiment slowly and safely, to see how you react when trying to find techniques that may work for you. It has taken me nearly five years of self-funded CGM use and trial and error, to come up with my tool kit. Even then, it never works all of the time!