Functional Medical Approach to Weight Gain in Menopause Including Citations and Evidence-Based Solutions

Dr. Liz Bartman

Weight gain is often viewed as an inevitable and frustrating part of menopause. Weight gain during and after the menopausal transition is multi-factorial, but numerous studies have identified that the common root cause of this weight change is a result of a combination of hormonal changes, decreased metabolism, and lifestyle factors (1, 2). Although weight changes may be expected, this change in weight can have a negative impact on a woman’s physical and mental health. But there is hope. Evidence-based solutions exist that can help women manage their weight and feel their best during this transitional phase. From herbs to hormone therapy, we will explore the unspoken truth about weight gain in menopause and provide practical strategies for maintaining a healthy lifestyle.

Weight gain is a common concern among women going through menopause. In fact, studies have shown that up to 80% of women experience weight changes during this transitional phase of life. On average, a woman between the age of 45-55 can expect to gain between 5-8% of their baseline body weight during this transition, or roughly 1.5 lbs per year (3). This can be attributed to the hormonal changes that occur during menopause, specifically the decline in estrogen and progesterone levels levels. 

Estrogen and progesterone play a crucial role in regulating metabolism and fat distribution in the body (4). As estrogen levels decrease, the body tends to redistribute fat from the hips and thighs to the abdomen, resulting in an increase in belly fat. Additionally, decreased muscle mass, increasing risk for insulin resistance and a slowing metabolism can further contribute to weight gain, as can an elevation in ghrelin, a hormone linked to appetite and demonstrated to elevate as women enter their post-menopausal years compared to their premenopausal counterparts of similar body mass (2).

It is important to note that weight gain during menopause is not solely due to hormonal changes. Lifestyle factors such as poor diet, lack of physical activity, thyroid health, stress, poor sleep and even genetics can also play a role. Therefore, it’s essential to address these factors to effectively manage weight gain during menopause.

To effectively manage obesity during menopause, tailored comprehensive care is essential. Engaging women in weight regulation before menopause is crucial, and healthcare providers should counsel women about the potential association between changes in their menstrual cycle and weight gain. Entering peri-menopausal years at an ideal weight and with optimal diet and sleep strategies already in place can improve symptoms of the menopausal transition and decrease weight changes associated with changing hormones (7).

What is the average weight gain during menopause? 

The average weight gain during menopause varies depending on the stage of the menopausal transition. Women aged 35-64 years tend to experience higher weight gain in general than men of the same age, suggesting that when hormones begin to fluctuate, metabolic activity is influenced. Body composition studies reveal that the average and expected change to the percent body fat in a woman in transition is between 2-5% (3). 

Through the menopausal transition, women will simultaneously experience a decrease in basal metabolic rate and a loss of lean muscle tissue which increases the risk of weight gain and obesity [5]. Sarcopenia (muscle loss) develops and is highly prevalent during menopause and is primarily due to an imbalance between muscle protein synthesis and breakdown, contributed to by an increase in oxidative stress, pro-inflammation markers, and hormonal changes (6). In the SWAN cardiovascular study, a cross-sectional and longitudinal study examining cardiovascular fat in pre-, peri- and post-menopausal woman, it was identified that independent of total body fat percent, women in their post-menopausal years and those with lower estradiol in general (regardless of age) had greater cardiovascular fat distribution when compared to premenopausal cycling women independent of weight, obesity and other comorbidities. The authors concluded that the percent of cardiovascular fat was directly associated with low levels of estradiol (8). 

Postmenopausal women have been found to have increased markers consistent with chronic systemic inflammation and oxidative stress, as well as increased abdominal visceral adipose tissue, dyslipidemia and blood sugar dysregulation [9]. A systematic review found that the menopausal transition is associated not only in a decline of estradiol, but also a decline in growth hormone, insulin-like growth factor (IGF-1), and dehydroepiandrosterone (DHEA), as well as a decrease in muscle protein synthesis, and an increase in catabolic factors such as the pro-inflammatory cytokines, and tumor necrosis factor alpha (TNF-α) or interleukin 6 (IL-6) [10]. Another study found that weight-adjusted lean body mass (LBM) and skeletal muscle area were protective against weight-associated insulin resistance and metabolic abnormalities [11] suggesting that women with lower muscle mass, higher body fat and fewer estrogen receptors are at greater risk for metabolic complications as they transition into their peri- and postmenopausal years [12]. Decreased LBM has been found to be the most important contributor to changes in metabolism for postmenopausal women as it correlates to low whole-body fat oxidation and energy expenditure which in turn are associated with high visceral fat mass and low insulin resistance [13]

Healthcare providers working with peri- and postmenopausal women should engage their clients in weight regulation before the onset of menopausal transition. Opportunistic screening of weight and health status should be initiated in a women’s late 30’s, followed by customized weight management programs. Dietary and physical activity modifications are essential for managing weight and addressing other health issues related to menopause.

What is a functional medical approach to weight gain during menopause? 

A functional medical approach to weight gain during menopause involves several key strategies:

1. Understanding the complex interplay: This approach recognizes the relationship between aging, menopausal transition, and weight status in women. It emphasizes the importance of screening and managing weight before menopause through opportune interventions.

2. Education about the menopausal transition: Women should be informed about potential weight gain during the perimenopausal phase and its association with changes in menstrual cycle.

3. Opportunistic screening and tailored strategies: Screening for weight and health status should be conducted in a women’s 30s, followed by personalized weight management strategies involving dietary and physical activity modifications.

4. Addressing other menopause-related health issues: Besides weight management, this approach focuses on psychological distress, sarcopenia (muscle loss), heart health, and bone health for overall well-being during menopause.

5. Hormone balancing: Estrogen deficiency can contribute to weight gain and is associated with increased risk for cardiovascular disease and bone loss (14), so hormone replacement therapy or other hormone-balancing treatments should be considered. It is important to keep in mind that timing of estrogen therapy is as equally important as dose of therapy. Numerous studies have demonstrated that women who initiate bio-identical estrogen in the first 10 years of their postmenopausal transition have greater benefit to bone health and vascular health than those who remain hormone naïve and initiate estrogen more than 10 years after menopausal transition (15). That is not to say you cannot use estrogen later in transition, but the risk to benefit ratio must be more closely examined.  

6. Nutritional guidance: A nutritious diet emphasizing whole foods, adequate protein intake, healthy fats, portion control, and avoidance of processed foods, refined sugars and trans-fats is encouraged.

7. Regular exercise: Engaging in a combination of cardiovascular exercises, strength training, and flexibility exercises helps manage weight during menopause.

8. Stress management: Techniques like mindfulness, meditation, yoga, or counseling can help manage stress levels and avoid emotional eating.

9. Sleep optimization: Adequate sleep positively impacts hunger hormones and metabolism, making it crucial for maintaining a healthy weight during menopause.

10. Individualized approach: Each person’s experience with menopause and weight gain is unique, so personalized assessment and treatment plans are important to address individual needs. Additional endocrine risk factors that can negatively impact weight include development of insulin resistance or frank diabetes, low vitamin D status, and hypothyroid disorders. Testing for these conditions may be considered as part of a truly wholistic and comprehensive approach when working with women in their peri-menopausal transition or who are in menopause.

It is important to note that these recommendations are based on studies conducted on midlife women in the western population. More research is needed to refine recommendations specifically for Indian women.

What long-term risks are associated with continuing to sustain increased weight after menopause? 

Continuing to sustain increased weight after menopause can have significant long-term risks for a woman’s health. This includes negative effects on overall well-being, quality of life, sleep disturbances, psychological distress, cardiovascular disease and issues with bone and joint health. Engaging in weight regulation strategies before the menopausal transition is crucial.

Women often feel overwhelmed when they experience weight gain during menopause. However, with evidence-based solutions and professional guidance, this transitional period can be managed more effectively. It is important to work with your client to create a personalized treatment plan that takes into account individual needs and circumstances.

Hormone therapy may be recommended but is not suitable for everyone. It’s important to assess the potential benefits and risks with your patient to determine the best course of action. Additionally, nutrition, exercise, and other lifestyle changes play a vital role in managing weight gain during menopause.

Empowering clients and helping to guide them through this transformative phase with confidence and ease.