Perimenopause and Insulin Resistance: Symptoms, Testing, and Management

The Link Between Estrogen and Insulin Sensitivity

Insulin sensitivity describes how effectively your cells respond to insulin and take up glucose from the bloodstream. Estrogen supports this process in several ways: it improves glucose uptake in muscle cells, reduces liver glucose production, and promotes healthy fat distribution. When estrogen levels decline and fluctuate in perimenopause, insulin sensitivity worsens. Cells become less responsive to insulin, so the pancreas compensates by producing more. This state of elevated insulin with normal or near-normal blood glucose is called insulin resistance. Over time, if insulin resistance is not addressed, blood glucose rises and the risk of type 2 diabetes, cardiovascular disease, and metabolic syndrome increases substantially. For many women, perimenopause is the point at which insulin resistance first becomes a clinical concern.

Recognising the Symptoms

Insulin resistance rarely produces obvious early symptoms, which is one reason it often goes undetected for years. However, there are signs worth noticing. Increased fat accumulation around the abdomen (particularly a shift in fat distribution from hips and thighs to waist) is one of the most consistent early indicators. Persistent energy dips in the afternoon, difficulty concentrating after meals, strong sugar or carbohydrate cravings, and unusual hunger shortly after eating can all reflect poor glucose regulation. Some women notice darker skin in skin folds around the neck, armpits, or groin, a condition called acanthosis nigricans, which reflects chronically high insulin levels. Fatigue that does not improve with sleep is another pattern that overlaps significantly with insulin resistance. Many of these symptoms also overlap with general perimenopause symptoms, which makes testing particularly important for a clear picture.

Tests to Ask Your Doctor About

Dietary Approaches: Lowering Glycaemic Load

Reducing the glycaemic load of your diet is the foundation of dietary management for insulin resistance. This means choosing carbohydrates that raise blood glucose more slowly (wholegrains, legumes, vegetables) over refined carbohydrates (white bread, white rice, sugary drinks, pastries). Pairing carbohydrates with protein, fat, or fibre slows glucose absorption further. Eating protein at every meal, aiming for around 25 to 30 grams per meal, supports muscle maintenance and helps stabilise blood glucose. Minimising ultra-processed food, which tends to be low in fibre and high in refined carbohydrates and seed oils, supports both insulin sensitivity and weight management. Time-restricted eating has attracted attention as a potential tool for improving insulin sensitivity. While early evidence is promising, it is not appropriate for everyone, particularly those with a history of disordered eating or hypoglycaemia. Any significant dietary change is worth discussing with a healthcare professional first.

Exercise as the Primary Intervention

Physical activity is the single most effective lifestyle intervention for improving insulin sensitivity. Skeletal muscle is the primary site of insulin-stimulated glucose uptake, and exercise both acutely and chronically improves how efficiently muscle uses glucose. A single session of moderate-intensity aerobic exercise improves insulin sensitivity for up to 48 hours in insulin-resistant individuals. Regular exercise (at least 150 minutes per week of moderate aerobic activity) produces sustained improvements. Resistance training is equally important: building and preserving muscle mass directly increases the body's capacity for glucose disposal. A combination of aerobic and resistance exercise is more effective than either alone. Even breaking up prolonged sitting with short walks every hour has a measurable effect on postprandial (after-meal) blood glucose. Women who have been sedentary do not need to start with a structured gym programme. A consistent walking habit is a meaningful and sustainable beginning.

When Medication Comes Into the Picture

Metformin is a medication commonly used in type 2 diabetes and prediabetes that also improves insulin sensitivity directly by reducing liver glucose output. Some clinicians prescribe it off-label for insulin resistance in perimenopause, particularly for women who are at high risk of progressing to type 2 diabetes or who have polycystic ovary syndrome. It is generally well tolerated, though gastrointestinal side effects (nausea, loose stools) are common when starting and can be reduced by starting at a low dose with food. GLP-1 receptor agonists, such as semaglutide, have become widely discussed for metabolic health and weight management. These are powerful medications with clear evidence in type 2 diabetes and obesity but are not appropriate for everyone and carry their own side effect profiles. Medication decisions should always be made in partnership with a prescriber who knows your full health history.

Putting It Together: A Practical Starting Point

The evidence consistently points to the same starting framework: whole-food diet that is low in refined carbohydrates and high in protein and fibre, daily movement with both aerobic and strength components, good sleep (poor sleep acutely worsens insulin sensitivity), and stress management. These are not quick fixes but rather sustainable shifts that compound over months and years. Getting baseline tests done gives you data to measure progress and motivation to stay consistent. Tracking how you feel after meals, your energy across the day, and your exercise alongside these test results helps you and your clinician understand what is working. Perimenopause is an ideal window to address insulin resistance proactively, before it progresses, and the habits built now protect your metabolic health through menopause and into later life.