Jan 6

9 Things You Need To Know About Weight Gain With Perimenopause?

Updated: Nov 16

If you're curious about what causes weight gain with perimenopause you can find the answers here. You've probably guessed it has a lot to do with hormones and you are right.

As Anna* entered her early 40s, she noticed subtle changes in her body. Her clothing seemed tighter and the numbers on the scale were slowly inching upward despite her best efforts. Juggling a career and family, she initially attributed the weight gain to stress or lack of exercise.

She decided to clean up her eating and joing the gym. Frustration crept in as she discovered that shedding those extra weight had become an uphill battle. It wasn't until her periods started changing that Anna saw her doctor and realized that the hormonal changes of perimenopause were contributing to her weight gain.

Anna's story is common, and highlights the challenges women face during menopause, especially when it comes to managing weight. Weight gain may be a symptom of menoause that is challenging for you. But learning about the hormonal causes of menopause weight gain is the first proactive step to navigate this phase of life with knowledge and resilience.

1. Perimenopausal Weight Gain is Hormonal Weight Gain

Many women express disbelief that even when they are eating well and exercising regularly, they still experience perimenopause weight gain or that they are gaining weight despite no change to diet or exercise levels.

Perimenopause weight gain is hormonally driven. Remember how your body changed shape at puberty?

All weight gain occurs under the instructions of hormonal pathways in the body.

The decline in estrogen is associated with fat redistribution and body composition changes during perimenopause.

These changes in estradiol levels and increased visceral fat also contribute to insulin resistance.

Given the modern industrial food environment and our sedentary lifestyles in which we live, there can also be dietary and lifestyle drivers that compound hormonal perimenopause weight gain.

All weight gain is hormonal weight gain. And the good news is you can hack your own biology to support your hormones.

Dr Deborah Brunt, GP & Menopause Doctor

woman measuring her waist with a tape measure

2. Menopause Belly: Your Changing Body Fat Distribution

Menopause belly is the name given to the abdominal fat deposition that occurs during perimenopause.

Perimenopausal hormone changes cause the redistribution of body fat. It moves fat from under the skin (subcutaneous fat) from the buttocks, hips and thighs to the belly.

This transition of increased belly fat around the abdomen is a change in body composition from a GYNOID fat distribution (ie fat on hips, buttocks and thighs) to an ANDROID fat distribution with fat distributed around the abdominal organs. This fat is known as visceral fat and is pro-inflammatory and is metabolically active.

There is so much we yet need to understand about hormones and body fat changes in perimenopause. A study tracking body fat changes through perimenopause over 2-6 years found in white women:

a decline in estradiol (the main estrogen) and sex hormone binding globulin (SHBG)
For every 1% reduction in total testosterone, there was a 0.05% decrease in visceral fat.
an average 3 kg weight increase (an increase of 6% body fat and 9% increase in fat mass)
An average increase in 19% subcutaneous fat.
An average increase in 15% abdominal visceral fat.
The increase in abdominal visceral fat was associated with an increase in insulin resistance.
For every 1% increase in fat mass there was a 0.04% increase in glucose levels.

However among black women;

more black women started the study with some pre-existing visceral fat,
there was a significant decrease in total testosterone but not in their estradiol,
For every 1% decrease in total testosterone, visceral fat increased 0.05%
For every 1% increase in fat mass there was a 0.2% increase in glucose levels - indicating an exaggerated impact on blood glucose levels compared to white women.

To track your changing body shape:

take a tape measure and measure the smallest part of your waist and the largest part of your hips.
Divide your waist measurement by your hip measurement.

A waist/hip ratio less than 0.80 indicates lower visceral fat and a more gynoid fat distribution. A waist/hip ratio of more than 0.85 incicates more visceral fat in an android fat distribution and this is associated with increased metabolic disease risk.

Related: What is Metabolic Health?

3. Belly Fat Contributes To Insulin Resistance

Gaining weight with a gynoid to android shift in fat distribution has some major effects on the metabolic health of the body.

Increased belly fat (also known as visceral fat) produces more inflammatory cytokines. There is also fat deposition within the liver. Fatty liver induces insulin resistance, the precursor to diabetes.

Insulin resistance means that the body no longer responds to glucose signalling with the normal amounts of insulin and it needs to produce more insulin to be able to transport glucose from your blood and into your cells to be used or stored as energy.

The higher the level of insulin that is produced, the more energy the body decides to store as visceral fat.

Related: Menopause and Inflammation

4. Insulin resistance & Perimenopause Weight Gain

Insulin resistance is a process where your body cells are not as responsive to insulin messages. It precedes diabetes by approximately a decade.

With insulin resistance, your cells are no longer responding to insulin as they used to and so the body needs to produce more insulin in order for glucose to be taken up by your energy producing cells.

The higher insulin levels signal to the body that there is plenty of energy coming in, so it should store more of the energy as fat.

Even though the body is getting energy, it cannot access it very well and so hunger signals continue, which means you may actually gain weight in perimenopause because your cells are hibernating due to not being able to use all the energy that is coming in.

A significant proportion of women become insulin resistant through perimenopause.

A study of 900 women from Prague found that 30% of premenopausal women had insulin resistance, and 57% of women postmenopausal had insulin resistance.

Considering that insulin resistance and metabolic syndrome have major impacts on long-term health outcomes, knowing if you have insulin resistance is an important biomarker of your health.

One additional important point is that hot flashes are related to insulin resistance in women with 'normal' body mass index, which is another reason why the conversation needs to move away from using BMI categories as healthy and towards using measures of body composition and metabolic biomarkers as indicators of health.

5. Menopausal Body Composition Changes

Through the 7-10 year perimenopausal period, estrogen levels gradually decrease, and this is associated with changes in how energy is utilised and stored in the body.

In addition to increasing total body fat and visceral fat, these hormonal changes in estradiol and testosterone levels also cause changes to muscle mass including:

reduced muscle regeneration,
increased programmed cell muscle death.

The long term result of this is weakness, which impacts mobility and independence.

You may be surprised to know that muscle mass is a marker of longevity, while body mass index is not. We need to talk more about the adverse impacts of loss of muscle mass and encourage women to build and maintain muscle in midlife.

Healthy weight is not based on your body mass index, but on your body composition and your metabolic hormonal status.

Strong not skinny, this is the marker of menopausal health.

Dr Deborah Brunt, GP & Menopause Doctor

The decline in estrogen also causes altered bone turnover (dynamic breakdown and re-building). This means bones rebuild at a slower rate than they breakdown. Over the ensuing decades your bones gradually become more fragile and prone to fracture.

The body composition changes in perimenopause are best measured using dexa or bioimpedence scanning rather than BMI which does not differentiate between lean and fat body mass.

6.Increased Cortisol Is Hormonally Driven in Perimenopause

A study specifically looked at overnight cortisol and it's relationship to other hormones and stress levels during perimemenopause.

It found a relationship between estrone, testosterone and FSH levels with cortisol levels, ie the higher these hormones were, the higher cortisol levels were.

Interestingly cortisol levels were not associated with perceived stress levels or social stressors or perimenopause symptom severity. This indicates the raised cortisol in perimenopause is more biologically driven by ovarian aging than by social factors.

Additionally higher cortisol levels were also significantly related to epinephrine and norepinephrine levels. These hormones are indicators of sympathetic nervous system arousal/activation.

Obviously additional unmanaged stress such as stress from life events, chronic stressors such as finances or discrimination, or untreated trauma can exacerbate the hormonally driven high cortisol and other stress hormones, driving them even higher.

High cortisol contributes to weight gain in perimenopause in the following ways:

higher cortisol cause sleep disturbances - raising insulin,
higher cortisol directly raises insulin, contributing to more energy storage and weight gain,
higher cortisol stimulates appetite driving craving for salty snacks and sugary foods.

Managing your stress is important during perimenopause, to reduce the impacts of these elevated cortisol levels on gaining weight.

7. Important Hormones in Perimenopausal Weight Gain

There are more hormones that contribute to perimenopause weight gain.

Leptin Is One Hormone That Affects Weight Gain

Leptin is a hormone that signals to your brain to regulate feelings of hunger and fullness. It is made by fat cells.

Another important function of leptin is to modulate the metabolism. Leptin tells your body whether it needs to conserve or expend energy, by signaling for changes in appetite, food intake, and physical activity levels.

Leptin resistance is common where women gain weight during perimenopause and menopause, and this contributes to weight gain. If the body becomes resistant to leptin, it can no longer receive the signal that you are full and need to stop eating.

This leads to overeating, which then causes a spike in insulin production. Insulin stores excess energy as fat, leading to an increase in visceral fat and insulin resistance.

Ghrelin

Ghrelin is a peptide hormone that increases food intake and decreases burning energy.

Higher levels promote weight gain.

Ghrelin levels appear to contribute to weight regain after weight loss in menopausal women. This is one of the reasons women experience rebound weight gain after weight loss. However a study found ghrelin levels are lower in women who use hormone replacement therapy compared to those who do not.

This suggests that hormone replacement therapy, ie the use of estradiol and progesterone supports weight management by reducing ghrelin which has the effect of reducing food intake and increasing energy expenditure.

Neuropeptide Y (NPY)

Neuropeptide Y is a neuropeptide that stimulates appetite.

It increases food intake, preferentially carbohydrates and promotes the storage of energy as fat. NPY levels increase in postmenopausal women, which contributes to weight gain during this time.

Glucagon-like peptide-1 (GLP-1)

GLP-1 is a hormone that is released after eating and signals to the brain to decrease appetite. It is produced by L-cells in the small intestines, the pancreas and the central nervous system.

It also slows down gastric emptying which leads to increased feelings of fullness or satiety.

GLP-1 levels have been shown to decrease in postmenopausal women, contributing to weight gain and an increase in abdominal fat. Studies have also found that hormone replacement therapy can increase GLP-1 levels , helping to regulate food intake and energy expenditure.

8. Should I eat fewer calories and exercise more?

This is a really simplistic and outdated model of weight gain that does not take into consideration the complexity of the hormonal milieu that is occuring in perimenopause. It also fails to consider that a calorie of donut and a calorie of salad impact hormones differently. The types of nutrients we consume are instructions to our hormones.

If you eat fewer calories but are insulin and leptin resistant, or have high cortisol, or excess estrogen or testosterone for your estrogen, this will drive android weight gain DESPITE restricting calories. It will also make you more tired, less likely to exercise and crave more food. It is a negative cycle you will get into.

Rather than restricting calories, you should aim to eat a healthy diet that supports your changing hormones. This means working with your hormones nutritionally, providing nutrients that support lower insulin and leptin levels, such as:

adequate protein to build and maintain muscle, and to avoid blood sugar spikes,
adequate fiber for micronutrients and phytonutrients and to keep blood sugars well managed.
time-restricted eating: eating sufficiently so that you can go 12-16 hour without food, allowing the body to mobilise and burn fatty acids when you are not eating.

With regards to exercise, building muscle is the number 1 habit you need to build. Muscle is metabolically active and the more of it you have and use, you can mitigate insulin resistance. Start strength training today. If this is new to you, start with body weight exercises such as squats and push-ups.

Lifestyle factors play an important role in maintaining a healthy body composition and metabolic health, but not in the ways that have traditionally been promoted.

9. Thyroid hormone depends on estrogen

Many aspects of thyroid health and function depends on estrogen. Lower estrogen levels means less effective production of essential proteins in the thyroid needed for thyroid cell function and thyroxine production.

With estrogen declining in perimenopause, there is a decrease in the production of thyroid-binding globulin (TBG) which binds with thyroid hormones. This can result in more bound thryoid hormone, and less unbound thyroid hormone. WIth lower unbound thyroid hormone, cells have less thyroid hormone available to utilise so metabolism can be slower.

Any women experiencing weight gain during perimenopause should have their thyroid function and thyroid antibodies checked to ensure your thyroid is functioning adequately.

Changes in your ovarian hormones can influence your immune system, causing autoimmune conditions including Hashimoto's thyroiditis which can reduce your thyroid hormone and cause weight gain.

Seeking Medical Guidance

Consulting Experts for Personalise Weight Management Plans

If you have noticed a sudden increase in weight, it is important to discuss this with a healthcare provider who understands the complex interplay between hormones, food, activity, sleep, stress and changes in body composition.

They can help determine what factors may be contributing to your weight gain and provide personalised recommendations for managing your weight. In some cases, hormone replacement therapy may be recommended to help balance hormones and reduce visceral fat.

Frequently Asked Questions

Can I prevent weight gain during perimenopause?

While some weight gain during perimenopause is likely, significant weight gain is not inevitable. By maintaining a healthy lifestyle and seeking guidance from healthcare professionals, you can manage your weight and prevent excessive weight gain. This may include incorporating strength training, time-restricted eating, and menopause hormone therapy into your routine.

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Dr Deborah Brunt is a women's health and menopause specialist in Dunedin, New Zealand. She can help you to combat perimenopause weight gain.

Book a consult with Dr Deb Brunt | Ōtepoti Integrative Health | Book Now

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