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2025-05-24

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Special Edition: Missing Pieces in Diabetes Care Design

Published on 24 May 2025.

In this Special edition:

Insights on Women's Health from ATTD 2025

This special edition of News from Loop and Learn spotlights top insights on women’s health from ATTD 2025 sessions. Thank you to Miroslava Calegari for weaving these insights together and to Dawn Adams for contributing her research.

Historically, research often ignored sex differences. Greater awareness can help reshape priorities and foster more inclusive, effective care. Understanding sex-specific factors means challenging outdated assumptions and building care that’s truly personalized.

Several sessions underscored the need to tailor diabetes care to biological sex and hormonal changes across the lifespan. These insights aren’t just relevant for women— they matter to everyone involved in diabetes care: clinicians, educators, partners, parents, and researchers.

Men have an important role to play, too. Diabetes doesn’t happen in isolation—it unfolds within relationships, families, and teams. Recognizing how menstruation, pregnancy, or menopause affects glucose and insulin can lead to better support and reduced stigma.

Who should read this?

Everyone.

A lot of women get excited to see men caring for babies. We get excited to see men in the diabetes community talking about glucose differences during menstrual cycles!

Updates on Diabetes Management and Female Health

Differences in sex and gender are fundamental in diabetes care. They play a crucial role in everything from cardiovascular risk and metabolic function to how people use wearable technology. To improve outcomes, diabetes care must embrace the full range of diversity in sex, age, and individual experiences. This session brought together five speakers.

Leveraging Technology to Address Gender Differences in Diabetes Care

Dr. Eda Cengiz

Critical disparities in diabetes care exist, one of the most alarming of which is that women with type 1 diabetes face a 40% higher risk of early death, increased rates of stroke and other severe complications. Yet diabetes treatment remains largely “one-size-fits-all,” with care that rarely accounts for women’s health needs except during pregnancy. Most studies still don’t report sex-specific data, limiting progress in personalized care.

Dr. Cengiz highlighted tech tools like smart rings designed for women and MedRing, an app-controlled intravaginal ring that collects data and delivers medication.

“We can’t treat what we don’t understand.” Without better gender-specific data, even the most advanced tools won’t meet women's needs. Closing the gender data gap is essential for making diabetes care smarter, more precise, and more equitable.

The Role of Estradiol in Glucose-Insulin Homeostatis

Dr. Lia Bally

Dr. Lia Bally highlighted the important role of the hormone estradiol in metabolism. It boosts insulin secretion and sensitivity, enhances GLP-1 function, curbs appetite, and raises energy use. Despite its relevance, most research is based on animal models, with limited studies involving women with diabetes. Bally stressed that hormonal changes from menstrual cycles, menopause, or contraception significantly affect glucose management. For example, estradiol dips have been linked to increased hypoglycemia in insulin pump users, though automated systems can help. She called for better hormone monitoring, more inclusive clinical trials, and more advanced tools to close the gender gap in diabetes care.

“We still have strong patient voices calling for better tailored support —even with AID.”

Impact of Sex on the Control of Type 2 Diabetes

Dr. Chiara Fabris

Clinical evidence shows that females typically have a lower risk of cardiovascular disease. However, when it comes to T2D, women fare worse compared to men. They tend to have higher A1c, LDL cholesterol, and BMI. Unique health factors, such as gestational diabetes, PCOS, early menopause, thyroid issues, and different responses to medication, further increase their risk. Despite these known differences, women are less often offered recommended treatments and tend to face more challenges with long-term medication use. This highlights the urgent need for sex-aware treatment guidelines and precision medicine to address the unique risks women face in T2D.

"We really have a need for precision medicine for treatment and treatment guidelines that take into consideration sex differences."

Sex Differences in Diabetes Management in the Primary Care Setting

Dr. Natalie Bellini

Women with T2D are less likely to receive recommended screening and treatment in primary care, including lower rates of metformin use, statin therapy, and lipid screening. They experience more adverse drug effects (such as gastrointestinal issues with metformin), have a higher risk of hypoglycemia due to metabolic differences, and face added challenges from caregiving demands and missed meals. The benefits of integrated, cross-specialty care, education, and the positive influence of peer support groups like DiabetesSisters in improving health outcomes were emphasized. Bellini urged us to “act today.” Primary care can’t wait—when the problem is visible, it’s time to act. Managing insulin pumps isn’t enough; blood pressure, lipids, weight, and real-life challenges all demand attention.

"Ignoring factors like metabolism, hormonal shifts, autoimmune disorders and medication side effects is really not okay."

Sex Differences in Cardiovascular Risk Factors

Dr. Darja Šmigoc

Women with T1D have significantly higher cardiovascular risks than men, especially if diagnosed before age 10, and may lose up to 18 years of life due to early atherosclerosis. Key risk factors include traditional ones such as hyperglycemia, hypertension, albuminuria, obesity, and dyslipidemia, as well as psychosocial and behavioral factors. Although many of these risks are highly preventable, they are often under-recognized and undertreated.

In a Slovenian study, we see that by 2016, with the use of insulin pumps, the gender gap in HbA1c disappeared. However, the girls still had a less-than-optimal lipid profile. Šmigoc stressed the importance of biomarkers like Apolipoprotein B and C-reactive protein in early atherosclerosis.

Most cardiovascular risk is preventable, yet interventions often begin too late or are insufficient, particularly in young women. Starting primary prevention early with gender-specific strategies is crucial to address this serious health disparity.

"Further studies are needed to help update guidelines — especially since women have historically been underrepresented in cardiovascular trials."

Menstruation and Diabetes

Although women with diabetes report changes in glucose control across their menstrual cycle, this area is dramatically underrepresented in diabetes research and technology development. This spotlight on Carson Wedding’s work demonstrates that the same behaviors can lead to very different glycemic outcomes depending on the hormonal context. Carson’s work represents a powerful blend of scientific curiosity, technical innovation, and lived experience — exactly the kind of voice the diabetes community needs more of.

Using Cycle-Based Pattern Analysis To Improve Insulin Dosing For Women With Type 1 Diabetes

Carson Wedding, an undergraduate researcher with type 1 diabetes—and daughter of Nightscout Foundation’s James Wedding—presented a standout project exploring how the menstrual cycle impacts blood glucose outcomes. Motivated by personal challenges in managing her own diabetes, Carson sought to uncover patterns in glucose, insulin, and food intake data that shift with hormonal changes across the menstrual cycle

Using a model she developed, based on a method called Block Recurrence Quantification Analysis (Block RQA), she identified behavioral patterns in diabetes management data and examined how these patterns varied between menstrual phases, especially the follicular and luteal phases. Her most striking finding: glycemic risk increases by nearly 200% during the luteal phase. She also found that meals without a bolus were significantly more likely to cause hyperglycemia during this time.

These insights offer critical evidence for something many have long suspected, but few studies have explored in depth: hormonal fluctuations can dramatically alter how the body responds to the same diabetes management strategies. Carson’s work lays the groundwork for more advanced, individualized diabetes technologies that account for hormonal context. Her project highlights the value of combining lived experience with scientific inquiry- and brings attention to an area that deserves much more focus in diabetes research and technology design.

Pregnancy and Diabetes

Here we highlight sessions on technology use by pregnant women with diabetes. Current Automated Insulin Delivery (AID) technologies may not fully meet the unique needs of pregnancy, and their effectiveness relies heavily on timely initiation, clinical support, and equitable access. Starting AID early in pregnancy can make a meaningful difference- and it’s effective!

Review of Trials

Dr. Helen Murphy spotlighted ten key studies from over 4,000 diabetes-related publications of the past year, focused on pregnancy in type 1, type 2, and gestational diabetes. Two major randomized controlled trials evaluated hybrid closed-loop (HCL) insulin delivery systems: the AiDAPT trial (CamAPS FX system) & the CRISTAL trial (MiniMed 780G). Real-world data reveal that not all HCL systems perform equally in pregnancy, emphasizing the importance of both the technology and how it’s used. While new tools hold enormous promise for improving outcomes, successful implementation depends on clinical expertise and equitable access, not just the devices themselves.

Medtronic AID

Medtronic AID were compared to MDI in Spain. Prof. Rosa Corcoy shared challenges: off-label use, often introduced later in gestation, and typically reserved for more complex cases such as individuals with elevated HbA1c or additional health conditions. Variations in clinical practice and access made outcomes harder to assess consistently.

CRISTAL Trial

Dr. Katrien Benhalima shared results of the CRISTAL trial - the first trial to assess Medtronic’s 780G system in pregnancy. It was shown to be safe and well-received, with better overnight glucose control and fewer low blood sugar events than standard insulin therapy. Improvements were greatest in those new to automated insulin delivery and in women entering pregnancy with lower HbA1c, likely reflecting established proactive diabetes management practices.

Guidelines for Glucose Control in Pregnancy

Dr. Yariv Yogev emphasized that clear guidelines for blood sugar control in pregnancy, especially with gestational diabetes (GDM), remain a challenge. Definitions of “well-controlled” vary, and most studies rely on indirect markers like HbA1c, with less than 1% reporting actual glucose data, limiting real-world relevance. Higher or unstable glucose levels have been linked to large birth weight, preeclampsia, and birth defects. Experts suggest using CGM and data from healthy pregnancies to guide targets, aiming for <105 mg/dL with minimal variability. Obesity during pregnancy increases insulin resistance and risk, even without a diabetes diagnosis, and often overlaps with GDM, making care more complex.

Perimenopause and Menopause in Diabetes Care

Dawn Adams shared her insights- she is a midwife and part of the #dedoc° voices program- an international initiative that brings lived experience into the heart of scientific conversations. At events like ATTD, voices like hers help uncover missing pieces in diabetes care, in this case, especially for women navigating under-discussed phases such as perimenopause and menopause.

More in-depth information from Dawn Adams can be found here.

The Use of Diabetes Technologies During Perimenopause and Menopause in Women with Type 1 Diabetes

Despite widespread preparation for pregnancy in girls and women with type 1 diabetes (T1D), menstruation and the transition through perimenopause and menopause- inevitable stages- receive far less attention and support. As hormone levels shift, many women experience increased insulin resistance and glucose variability. Diabetes technologies such as continuous glucose monitors (CGM), insulin pumps, connected pens, and Automated Insulin Delivery (AID) systems have revealed critical gaps in education, guidance, and research around these life stages.

Symptoms of menopause, such as fatigue, hot flashes, mood swings, and weight gain, often overlap with or mask dysglycemia, complicating diabetes management. While technologies offer personal insights into how hormonal changes, physical activity, dietary adjustments, and menopause hormone therapy (MHT, formerly known as hormone replacement therapy, HRT) affect glucose control, few formal studies and no agreed-upon recommendations exist. A small global study of 90 women with T1D in menopause showed that many reported decreased insulin sensitivity and reduced time in range, despite using CGM and/or AID. MHT was seen by many as helpful for both glucose stability and psychological well-being.

Women from underserved communities or with lower incomes faced even more challenges. Many didn’t have access- or had limited access- to diabetes technology, menopause hormone therapy (MHT), or healthcare providers who understood their needs. These missing pieces made it harder to manage diabetes and left many women feeling stressed and unsupported.

To improve outcomes, there is a clear need for integrated, culturally sensitive care that bridges endocrinology, gynecology, and mental health. Incorporating menopause into diabetes care pathways- as has been done with pregnancy- could improve health, longevity, and quality of life for women with T1D during midlife and beyond.