Menopause probably isn’t anyone’s idea of fun. Although it does have its advantages — many women are more than happy to say goodbye to menstruation — the menopausal transition in particular brings a variety of physiological and psychological changes that can range from mildly annoying to downright debilitating.
Many of the most common side effects, such as hot flashes and night sweats, for example, are caused by hormonal fluctuations and thus appear primarily during perimenopause; these symptoms usually decrease and eventually disappear at some point after a woman reaches menopause (defined as the absence of menses for more than one year). However, some of the symptoms caused by lower levels of estrogen and progesterone may continue.
One of these longer-term side effects may be menopause-related weight gain.
Some studies suggest that weight gain during menopause is due primarily to the normal aging process rather than the menopausal transition specifically, and many women do not gain weight at all. But menopause does cause a number of physiological changes that can affect weight, including increased fat mass (total body fat and especially visceral fat), decreased muscle mass, and reduced energy expenditure (up to an 8% decrease in resting metabolic rate).
These changes in body composition and metabolism can represent an unwelcome new reality for some women who never before had a tendency to gain excess weight. And for those already struggling with their weight, especially women with obesity, these additional challenges can further increase the risk of weight-associated health conditions.
Hormone- and weight-related physiological changes
Menopause leads to a decrease in the body’s production of both estrogen and progesterone. While the loss of progesterone affects weight partially through increased water retention, the decrease in estrogen levels has more widespread and lasting effects. For example, loss of estrogen can weaken the brain’s “fullness” signals, increase susceptibility to binge eating and reduce energy expenditure (calories burned both at rest and during activity).
“Normal” hormone-related metabolic slowing during menopause is sometimes compounded by the presence of subclinical hypothyroidism, which also decreases energy expenditure. Estrogen and thyroid hormones interact and affect each other in a variety of ways, and subclinical hypothyroidism often remains undiagnosed because many of the symptoms (such as fatigue, sleep disturbances and mood swings, for instance) are instead attributed to the menopausal transition. One study found subclinical hypothyroidism to be present in 18% of perimenopausal women. According to my endocrinologist colleague, Dr. Leon I. Igel, “Immediate treatment might not be warranted, but thyroid levels should be monitored closely, as subclinical hypothyroidism may be a precursor to overt hypothyroidism.”
Menopause-related hormonal changes are also associated with insulin resistance, which leads to higher levels of blood sugar and increased fat storage. This creates something of a vicious circle, as visceral fat promotes further insulin resistance — which in turn raises the risk of type 2 diabetes and cardiovascular disease, two of the most widespread and serious weight-related health issues.
Treatment options
So how do we treat menopause-related weight gain? Perhaps counterintuitively, hormone replacement therapy, one of the most common treatments for many menopause symptoms, has not been shown to affect weight significantly (causing neither gain nor loss). We do have other options, however, and weight gain is not inevitable.
Diet and physical activity are bedrock components of any weight management program, but to overcome the body’s resistance to weight loss — particularly when it comes to treating people with obesity — these lifestyle elements must be part of a comprehensive approach. This means not only providing ongoing support and assistance to foster sustainable lifestyle change, but considering the full range of underlying factors and potential treatment tactics, including medical interventions.
Insulin resistance can be counteracted with a wide variety of eating plans; low-carb and Mediterranean diets, for example, have proven effective. The most important strategy is to find a way of eating that is sustainable, so it becomes part of a long-term healthy lifestyle change rather than a temporary measure that will be abandoned at the first sign of difficulty. This means the food must be both tasty and satisfying, and the plan can’t feel too restrictive or rigid.
Physical activity also helps reduce insulin resistance and support weight loss. The ideal activity plan combines aerobic exercise, which burns calories and improves cardiovascular health, with resistance training, which builds muscle and reduces fat. Again, sustainability is key: physical activity should be enjoyable and fit in with the individual’s lifestyle and schedule constraints — it doesn’t necessarily need to involve traditional “exercise” or going to the gym.
Women whose weight doesn’t respond to changes in diet and physical activity and who have a BMI over 30 kg/m2 or over 27 kg/m2 with comorbidities may benefit from anti-obesity pharmacotherapy. On- or off-label medications — such as metformin, liraglutide, phentermine/topiramate, naltrexone/bupropion, and semaglutide — can help counteract the effects of insulin resistance. As an adjunct to lifestyle modifications, these medications can help surmount some of the hormonal, metabolic and neurobehavioral mechanisms (manifested as plateauing or the development of cravings, for example) the body has evolved to prevent weight loss.
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This important contribution by Medika author Dr. Saunders was co-authored by Leon I. Igel, MD, FACP, FTOS, DABOM. Dr. Igel is an Assistant Professor of Clinical Medicine at Weill Cornell Medical College, and an Attending Endocrinologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. He is Director of the West Side division of the Comprehensive Weight Control Center, as well as the former Program Director for Weill Cornell’s Obesity Medicine and Obesity Medicine/Bariatric Endoscopy fellowships. Dr. Igel is board certified in Internal Medicine, Obesity Medicine, and Endocrinology, Diabetes & Metabolism.
