Can menstruation precipitate diabetic ketoacidosis (DKA)?

Can Menstruation Precipitate Diabetic Ketoacidosis (DKA)?

Yes, menstruation can precipitate diabetic ketoacidosis in some women with diabetes, a phenomenon known as catamenial DKA. 1

Pathophysiological Mechanism

• The basic underlying mechanism for DKA is a reduction in the net effective action of circulating insulin coupled with a concomitant elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone) 2
• During the late luteal and early menstrual phases, hormonal fluctuations can lead to insulin resistance and altered glucose metabolism 1, 3
• Mean glucose levels increase from 8.2±1.5 mmol/L during the early follicular phase to 8.6±1.6 mmol/L during the late luteal phase, with corresponding decreases in time-in-range 3

Epidemiological Evidence

• A significant association between menstruation and ketoacidosis has been documented, occurring more frequently than would be expected by chance (p<0.01) 4
• In one study, 70% of patients aged 45 years or under with diabetic ketoacidosis seen in a diabetic clinic over five years were women 4
• Approximately 67% of women with diabetes experience changes in blood glucose levels premenstrually and 70% during the menstrual phase 5

Clinical Presentation

• Women may present with recurrent episodes of DKA that coincide with their menstrual cycle without other obvious precipitating factors 1
• The pattern of glucose control changes varies among women:
  • 53% experience deterioration in control with hyperglycemia during menstruation 4
  • 23% experience improved control with hypoglycemia being more common 4

Risk Factors for DKA (Including Menstruation)

• The most common precipitating factors for DKA include:
  • Infection (30-50% of cases) 6
  • Discontinuation or inadequate insulin dosing 2
  • Psychological stress 2
  • New-onset type 1 diabetes 2
  • Drugs affecting carbohydrate metabolism (corticosteroids, thiazides, sympathomimetic agents) 2
  • Menstruation (catamenial DKA) 1, 4

Management Considerations

• Women with diabetes who experience menstrual-related glucose fluctuations may require insulin dose adjustments during different phases of their cycle 3
• Median total daily insulin requirements increase from 37.4 units during the early follicular phase to 38.5 units during the late luteal phase 3
• Patient education should include awareness of potential menstrual-related changes in glucose control 6
• Blood glucose and ketone monitoring should be intensified during menstruation in women who have previously experienced catamenial hyperglycemia or DKA 1

Prevention Strategies

• Recognize menstruation as a potential precipitating factor for DKA in women with recurrent unexplained episodes 1
• Implement proactive insulin dose adjustments based on menstrual cycle phase 3
• Maintain consistent carbohydrate intake despite potential premenstrual cravings for sweet foods, which may contribute to hyperglycemia 5
• Ensure patients do not discontinue basal insulin during menstruation, even if food intake is reduced 2

Clinical Pitfalls to Avoid

• Failing to consider menstruation as a potential trigger when evaluating unexplained DKA in women of reproductive age 1
• Not accounting for menstrual cycle phase when adjusting insulin dosing in women with diabetes who report cyclical patterns in glucose control 3
• Overlooking the need for more intensive monitoring during menstruation in women with a history of catamenial DKA 1, 4