Your blood sugar is normal. Your A1c looks fine. But could your body already be working harder than it should to keep those numbers in range? Let's talk about insulin resistance, why it matters during midlife, and what we can do about it.
One of the things I love about preventive medicine is the opportunity to identify changes in health before they become a diagnosis.
Insulin resistance is a great example.
Most women are familiar with diabetes and, increasingly, prediabetes. But insulin resistance often begins long before either condition develops.
In fact, your blood sugar can remain perfectly normal for years while your body is working increasingly hard to keep it that way.
This is why I sometimes think of insulin as the canary in the coal mine of metabolic health. Changes in insulin levels may provide an early signal that your metabolism is becoming less efficient, well before your standard blood sugar testing identifies a problem.
But there's an important distinction between identifying an early risk factor and diagnosing a disease. And understanding that distinction is key to making good decisions about your health.
What Is Insulin Resistance, Anyway?
Insulin is a hormone produced by your pancreas. One of its primary jobs is to help move glucose (sugar) from your bloodstream into your cells, where it can be used for energy or stored for later.
Think of insulin as a messenger telling your cells, "There's energy available. Let's bring it inside."
When your cells respond appropriately to insulin, your pancreas only needs to release a relatively small amount to get the job done.
But with insulin resistance, cells in your muscles, liver, and fatty tissue become less responsive to insulin's signals.
Your pancreas compensates by producing more insulin.
Initially, this works remarkably well. Your blood sugar remains normal because your pancreas is keeping up with the increased demand.
Over time, however, some people can no longer produce enough insulin to compensate. Blood sugar begins to rise, potentially progressing to prediabetes and eventually type 2 diabetes.
Here's the important part: Insulin resistance can develop years before blood sugar becomes abnormal.
And that gives us an opportunity to intervene.
Why Does Insulin Resistance Matter Beyond Diabetes?
Insulin resistance isn't just about the possibility of developing diabetes someday.
It's closely connected to several other aspects of metabolic and cardiovascular health.
People with insulin resistance are more likely to develop:
Elevated triglycerides and lower HDL cholesterol
High blood pressure
Increased visceral fat, particularly around the abdominal organs
Metabolic dysfunction-associated steatotic liver disease (MASLD), sometimes called fatty liver disease
Prediabetes and type 2 diabetes
Cardiovascular disease
Chronically elevated insulin, sometimes called hyperinsulinemia, can be one sign that the body is compensating for insulin resistance.
However, insulin itself isn't a toxin, and having insulin rise after eating is completely normal. Insulin resistance, excess visceral fat, inflammation, and abnormal blood lipids often develop together, making it difficult to attribute every associated health risk to insulin alone.
The goal isn't to eliminate insulin or avoid every insulin increase. It's to help your body respond efficiently to the insulin it produces.
Why Is This Particularly Important During Perimenopause and Menopause?
The menopause transition brings some significant changes to body composition and metabolic health.
As estrogen levels decline, women tend to experience a shift in how fat is distributed, with more fat accumulating around the abdominal organs.
At the same time, aging and changes in physical activity can contribute to losses in muscle mass.
This combination matters because muscle is one of the body's most important tissues for taking up glucose, while excess visceral fat is closely associated with insulin resistance.
You may notice that your waistline is changing, even if your weight hasn't increased significantly.
And yes, this can happen to women who have always been active, maintained a healthy weight, and eaten a generally nutritious diet.
It's not necessarily that you're doing something wrong. Your physiology is changing.
The good news is that we have effective strategies to help protect muscle mass, improve insulin sensitivity, and support metabolic health during this transition.
How Do We Evaluate Insulin Resistance?
This is where things get interesting, because there isn't one perfect blood test that tells us everything we need to know.
I prefer to look at several pieces of information together rather than relying on a single number.
1. Hemoglobin A1c and Fasting Glucose
These are the most familiar tests.
Hemoglobin A1c estimates your average blood sugar over approximately the previous three months, while fasting glucose measures your blood sugar at one point in time after fasting.
Both are well-established tools for identifying prediabetes and diabetes.
For reference, prediabetes is defined by an A1c of 5.7–6.4% or a fasting glucose of 100–125 mg/dL. An oral glucose tolerance test can also identify abnormal glucose and regulation.
But here's their limitation: Neither test tells us how much insulin your body needed to produce to maintain those glucose levels.
A normal A1c is reassuring. It just doesn't necessarily mean that your insulin sensitivity is optimal.
2. Fasting Insulin: An Earlier Clue?
A fasting insulin test measures how much insulin is circulating in your bloodstream after an overnight fast.
If your fasting glucose is normal but your insulin is relatively elevated, it may suggest your pancreas is working harder to maintain that normal glucose level.
This can provide information that an A1c alone doesn't capture.
However, fasting insulin is not a standardized diagnostic test for insulin resistance. Levels vary between individuals, laboratory methods differ, and there isn't a universally accepted cutoff that defines healthy versus unhealthy insulin sensitivity.
It's also possible to have insulin resistance without elevated fasting insulin, particularly when insulin production is declining.
I think fasting insulin can sometimes be a useful additional piece of information, especially when there are other signs of metabolic dysfunction.
But it needs to be interpreted in context.
3. HOMA-IR: Putting Glucose and Insulin Together
You may have heard of a calculation called HOMA-IR, which stands for Homeostatic Model Assessment of Insulin Resistance.
Rather than looking at fasting glucose or fasting insulin alone, HOMA-IR combines the two measurements to estimate insulin resistance.
The calculation is:
HOMA-IR = (Fasting Insulin × Fasting Glucose) ÷ 405
This formula uses insulin measured in µIU/mL and glucose measured in mg/dL.
For example, someone with a fasting glucose of 90 mg/dL and a fasting insulin of 10 µIU/mL would have a HOMA-IR of approximately 2.2.
Higher values generally suggest greater insulin resistance.
You may see online sources suggesting specific cutoff values, often around 2 or 2.5. But there's an important caveat: HOMA-IR does not have a universally accepted diagnostic threshold.
It's a useful research tool and can sometimes help us understand metabolic patterns, but it is not currently recommended as a routine diagnostic test for insulin resistance.
In other words, it's a piece of information, not a diagnosis.
4. Continuous Glucose Monitoring (CGM)
This is one of the newer technologies generating a lot of interest in metabolic health.
A continuous glucose monitor is a small wearable sensor that tracks glucose levels in the fluid just beneath your skin throughout the day and night.
Instead of seeing your blood sugar at one moment, you can observe how it changes in response to meals, exercise, sleep, and daily activities.
This can be incredibly informative information.
For example, you might discover that eating a particular breakfast results in a much larger glucose rise than eating a different breakfast with more protein and fiber.
Or you may notice that a short walk after dinner changes your glucose response to a meal.
But we need to be careful about how we interpret these results.
A CGM measures glucose, not insulin. It cannot diagnose insulin resistance.
And while CGMs have substantial benefits for many people with diabetes, we don't yet have strong evidence that routine CGM use improves long-term health outcomes in otherwise healthy people without diabetes.
Some glucose fluctuations after eating are entirely normal. A brief glucose spike is not automatically a sign of disease, and we don't have validated targets for eliminating glucose spikes in people without diabetes.
Used thoughtfully, a CGM may be an educational tool that helps some women better understand their responses to food, movement, and sleep.
Used without appropriate context, it can lead to unnecessary food restriction and anxiety over perfectly normal glucose patterns.
5. Looking at the Bigger Metabolic Picture
Some of the most useful information comes from tests and measurements we already have available.
These include blood pressure, triglycerides, HDL cholesterol, waist circumference, glucose levels, and sometimes liver enzymes or additional testing for fatty liver disease.
Together, these can help identify metabolic syndrome, a cluster of risk factors associated with diabetes and cardiovascular disease.
Metabolic syndrome is generally diagnosed when at least three of the following five features are present:
Increased waist circumference
Elevated triglycerides
Low HDL cholesterol
Elevated blood pressure
Elevated fasting glucose
Certain medication treatments also count toward these criteria.
The reason we care is that these findings often occur together and provide a more complete picture of cardiometabolic risk than any one test alone.
Why Body Composition Matters More Than the Number on the Scale
One of the limitations of traditional weight-based assessments is that they don't tell us what your body is actually made of.
Two women can have the same height, weight, and BMI but very different amounts of muscle and visceral fat.
And those differences matter.
Visceral fat is the fat stored deep within the abdomen, surrounding internal organs. It's metabolically different from the fat located just beneath the skin and is more strongly associated with insulin resistance and cardiovascular risk.
Meanwhile, muscle is enormously important for metabolic health.
Skeletal muscle is a major site of glucose disposal, meaning it helps your body take up and use glucose from the bloodstream.
More importantly, improving the strength, quality, and function of your muscle can improve insulin sensitivity.
This is why I think body composition assessments can sometimes be valuable, particularly during midlife.
Depending on the technology, these measurements may provide estimates of:
Total body fat percentage
Skeletal muscle mass or lean mass
Visceral fat
Changes in fat and muscle over time
Tools such as DXA and bioelectrical impedance analysis can provide additional information beyond weight alone, although their accuracy and ability to measure visceral fat vary.
These assessments aren't necessary for everyone, and no single body fat percentage defines metabolic health.
But for women who want to monitor how their bodies are changing during menopause, body composition can be a helpful way to assess progress without focusing exclusively on weight loss.
Sometimes maintaining your weight while gaining muscle and losing abdominal fat represents meaningful improvement.
What Can You Actually Do to Improve Insulin Sensitivity?
Here's where I want to spend the most time, because insulin resistance is often responsive to changes in daily habits.
And fortunately, the strategies that improve insulin sensitivity are also some of the most effective things we can do for long-term cardiovascular, bone, and brain health.
1. Prioritize Strength Training and Muscle Mass
If I could encourage women in midlife to embrace one form of exercise, resistance training would be very high on my list.
Muscle isn't just about strength or appearance. It's metabolically active tissue that plays a central role in glucose regulation.
During exercise, contracting muscles can take up glucose through pathways that don't require insulin. Over time, regular resistance training also improves insulin sensitivity.
This means your body can handle glucose more efficiently.
I generally encourage women to aim for at least two to three resistance training sessions per week, appropriately challenging their major muscle groups.
The goal should be progressive improvement in strength, not simply going through the motions.
And remember that adequate nutrition, including sufficient protein, is important for building and maintaining muscle.
Especially during midlife, muscle is an investment in your future health.
2. Don't Overlook High-Intensity Interval Training
High-intensity interval training, or HIIT, involves alternating brief periods of vigorous activity with periods of recovery.
And yes, there's evidence supporting its metabolic benefits.
Research suggests that HIIT can improve insulin sensitivity, reduce some measures of insulin resistance, and improve cardiovascular fitness.
Some studies have found greater improvements in fasting insulin or HOMA-IR with HIIT compared with moderate-intensity continuous exercise. However, the evidence is variable, and HIIT isn't consistently superior for every metabolic outcome.
That means it's a useful tool, but not a requirement.
A practical approach might involve short intervals of harder effort on a stationary bike, followed by easier recovery periods.
You don't need to sprint until you're exhausted, and you certainly don't need to do HIIT every day.
For women who enjoy it and can participate safely, one or two sessions per week can be a reasonable complement to resistance training and regular aerobic exercise.
For others, brisk walking, cycling, swimming, or other moderate-intensity activities are excellent choices.
The most effective exercise program is one you can do consistently.
3. Move After Meals
This is one of my favorite recommendations because it's simple, free, and doesn't require changing what you're eating.
Take a walk after a meal.
Even a short period of walking can help your muscles take up glucose and reduce the rise in blood sugar after eating.
If you've been sitting at your desk all afternoon, getting up and moving also helps interrupt prolonged sedentary time.
You don't need to turn every meal into a workout.
Sometimes a 10- to 15-minute walk after dinner is a great place to start.
4. Think About What You Eat—and the Order You Eat It
We know that dietary patterns influence insulin sensitivity.
But I don't think women need to become afraid of carbohydrates or spend their lives trying to avoid every blood sugar increase.
Instead, consider a few relatively simple strategies.
Start with vegetables and protein.
Research suggests that eating fiber-rich vegetables and protein before carbohydrate-rich foods can reduce the immediate glucose rise after a meal.
For example, you might begin with a salad and a protein source before eating bread, rice, or potatoes.
The effect on long-term diabetes prevention is less certain, but it's an easy strategy that doesn't require eliminating foods you enjoy.
Pair carbohydrates with protein, fiber, and healthy fats.
A piece of toast by itself may produce a different glucose response than toast eaten with eggs, avocado, or another source of protein and fat.
Similarly, fruit paired with yogurt or nuts can be a satisfying snack that provides more nutritional value than carbohydrates alone.
Focus on dietary quality.
Mediterranean-style eating patterns, rich in vegetables, legumes, whole grains, nuts, olive oil, and other minimally processed foods, have strong evidence supporting cardiometabolic health.
Other dietary patterns, including appropriately planned lower-carbohydrate diets, can also be effective.
There's no single ideal diet for every woman.
What matters most is finding a sustainable pattern that supports your metabolic health, provides adequate nutrition, and works for your life.
And please don't interpret this as a recommendation to stop eating fruit, whole grains, or other nutritious carbohydrate-containing foods. They absolutely can belong in a metabolically healthy diet.
5. Take Sleep Seriously
Sleep is one of the most underappreciated factors in metabolic health.
And this is particularly relevant during perimenopause, when night sweats, insomnia, and other sleep disturbances can make getting sufficient rest more difficult.
Research has demonstrated that even relatively modest sleep restriction can worsen insulin sensitivity.
In one randomized study of healthy women, reducing sleep from approximately 7.5 hours to 6.2 hours per night for six weeks increased insulin resistance, with a particularly pronounced effect among postmenopausal women.
Importantly, this occurred even without changes in body fat.
In other words, poor sleep can affect metabolism independently of weight gain.
Most adults should aim for approximately seven to nine hours of sleep per night, recognizing that sleep needs vary.
If hot flashes, insomnia, or possible sleep apnea are interfering with your rest, addressing those issues isn't just about feeling better tomorrow.
It's part of protecting your long-term health.
6. Consider Visceral Fat Reduction When Appropriate
For women who have excess visceral fat, reducing it can meaningfully improve insulin sensitivity and cardiometabolic risk.
And this doesn't always require dramatic weight loss.
Relatively modest, sustained weight reduction in people with excess body fat can improve insulin sensitivity and decrease the risk of developing type 2 diabetes.
But, not every woman with insulin resistance needs to lose weight.
Insulin resistance can occur in women with a normal BMI, and we shouldn't overlook it simply because someone appears lean. Likewise, a woman with higher body fat may have excellent metabolic health and minimal visceral fat.
Our goal is better metabolic health, not achieving an arbitrary weight.
Can Menopausal Hormone Therapy Improve Insulin Resistance?
This is a reasonable question, particularly given estrogen's role in fat distribution and glucose metabolism.
Research suggests that menopausal hormone therapy can have favorable effects on insulin sensitivity and may reduce the incidence of type 2 diabetes in some populations.
However, hormone therapy is not currently recommended solely for diabetes prevention or the treatment of insulin resistance.
Its primary indications remain the treatment of menopausal symptoms and, in appropriate women, prevention of bone loss.
That said, for a woman considering hormone therapy for menopausal symptoms, the potential metabolic effects can be part of a broader conversation about benefits and risks.
As with most decisions in menopause medicine, individualization matters.
Do You Need Medication for Insulin Resistance?
Not necessarily.
For many women, lifestyle changes are the appropriate first step.
However, medication can be useful in certain situations, particularly when someone has prediabetes with elevated risk of progression, type 2 diabetes, or obesity with associated metabolic complications.
Metformin, for example, can help reduce progression from prediabetes to diabetes in selected higher-risk individuals.
GLP-1–based medications and other evidence-based obesity treatments can also significantly improve metabolic health when clinically appropriate.
These aren't medications that everyone with an elevated fasting insulin or HOMA-IR needs.
A single abnormal insulin measurement should not automatically lead to a prescription.
The decision depends on your overall medical history, metabolic risk, treatment goals, and the strength of the evidence for the intervention.
The Bottom Line
Insulin resistance is important because it can be an early sign that your metabolic health is changing, often long before diabetes develops.
But understanding insulin resistance requires more than ordering every available test or trying to eliminate every glucose spike.
I prefer to consider the whole picture: glucose regulation, insulin when appropriate, body composition, visceral fat, cardiovascular risk factors, sleep, movement, and muscle health.
For many women, the most effective interventions are surprisingly straightforward: lift weights, build and preserve muscle, move regularly, eat a nutrient-dense diet, prioritize sleep, and address excess visceral fat when present.
And perhaps most importantly, don't wait for a diagnosis of diabetes before you start paying attention to your metabolic health.
A More Personalized Approach to Metabolic Health at Evermore Women's Health
At Evermore Women's Health, metabolic health is an important part of comprehensive preventive care for women in perimenopause, menopause, and beyond.
We look beyond a single blood sugar result to consider your individual risk factors, body composition, muscle health, cardiovascular health, hormonal changes, and long-term goals.
Depending on your needs, that may include additional metabolic testing, body composition assessment, or a discussion about whether continuous glucose monitoring would provide useful information.
Because the goal isn't simply to avoid diabetes. It's to help you maintain strength, vitality, and long-term health throughout midlife and beyond.
Interested in a more personalized approach to your midlife health? Learn more about care at Evermore Women's Health.
References & Further Reading
American Diabetes Association. Standards of Care in Diabetes—2026: Diagnosis and Classification of Diabetes. Diabetes Care. 2026.
https://diabetesjournals.org/care/article/49/Supplement_1/S27/163926/2-Diagnosis-and-Classification-of-DiabetesNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Insulin Resistance & Prediabetes.
https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/prediabetes-insulin-resistanceMuniyappa R, Madan R, Varghese RT. Assessing Insulin Sensitivity and Resistance in Humans. Endotext. Updated 2024.
https://www.ncbi.nlm.nih.gov/books/NBK278954/American Diabetes Association. Standards of Care in Diabetes—2026: Prevention or Delay of Diabetes and Associated Comorbidities. Diabetes Care. 2026.
https://doi.org/10.2337/dc26-s003Johansson M, Dower JA, Lipska KJ. Continuous Glucose Monitoring for Persons With and Without Diabetes. JAMA Internal Medicine. 2026.
https://doi.org/10.1001/jamainternmed.2026.2769American Heart Association. What Is Metabolic Syndrome?
https://www.heart.org/en/health-topics/metabolic-syndrome/about-metabolic-syndromeChronic Insufficient Sleep in Women Impairs Insulin Sensitivity Independent of Adiposity Changes: Results of a Randomized Trial. Diabetes Care. 2024.
https://pubmed.ncbi.nlm.nih.gov/37955852/Lu Y, et al. Effects of Practical Models of Low-Volume High-Intensity Interval Training on Glycemic Control and Insulin Resistance in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. Frontiers in Endocrinology. 2025.
https://pubmed.ncbi.nlm.nih.gov/39917538/Food Order Has a Significant Impact on Postprandial Glucose and Insulin Levels. Diabetes Care. 2015.
https://diabetesjournals.org/care/article/38/7/e98/30914/European Society of Endocrinology. Clinical Practice Guideline for Evaluation and Management of Menopause and the Perimenopause. European Journal of Endocrinology. 2025.
https://academic.oup.com/ejendo/article/193/4/G49/8281862
