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Weight loss can be daunting, especially during menopause. Fluctuations and decline in ovarian hormones at perimenopause and menopause do contribute to weight gain via a number of mechanisms impacting metabolism.
Menopausal symptoms can limit your ability to exercise due to poor sleep, fatigue, and joint or muscle pain. Hormone therapy can help weight loss, reduce belly fat accumulation and increase lean muscle mass. It can be one strategy to support your weight loss journey in conjunction with nutrition, exercise, adequate sleep and stress management.
This article outlines how hormones influence metabolism and how HRT and other hormonal support may influence this and your body composition.
Understanding Hormones and Metabolism
Many hormones play a crucial role in regulating our body's metabolism, which is the process of converting food into energy and storing energy for later use by the body.
Some key hormones that influence metabolism and body composition at menopause that can be used to support weight loss and body composition during menopause include:
Estradiol
Testosterone
Melatonin
Insulin and GLP-1
Many more hormones influence your weight including thyroid hormones, cortisol, leptin and ghrelin.
Body Composition Changes at Menopause
One of the most noticeable changes during menopause is the shift weight that is associated with a change in body composition. Many women experience a decrease in skeletal muscle mass which is often less noticed but associated with the increase in belly fat.
As muscle is a metabolically active organ, less muscle mass contributes to a slower total metabolism at rest and with exercise and therefore weight gain.
Menopause Belly Fat
This accumulation of menopausal belly fat is primarily due to the decline in estrogen levels.
Estrogen helps maintain muscle mass and promotes fat distribution to the hips and thighs in the gynoid distribution that women typically gain from puberty onwards. It also helps maintain insulin sensitivity.
With lower estrogen levels, lower muscle mass and higher insulin levels, women tend to accumulate belly fat. It can be an aesthetic concern but from a medical perspective, this abdominal visceral fat or fat within and surrounding the abdominal organs is associated with inflammation-related health risks. This includes an increased risk of:
cardiovascular disease
type 2 diabetes
joint pain and arthritis and
chronic kidney disease.
Loss of Skeletal Muscle Mass
Furthermore, the reduction in lean muscle mass means you have less muscle that is capable of burning calories at rest, and during exercise. This means that even by maintaining the same nutrition and exercise prior to perimenopause, your metabolic output is reduced. This means less energy is used and more energy is stored, making it more challenging to maintain a healthy weight.
These changes can be frustrating and can negatively impact a woman's self-esteem, long-term health and overall quality of life.
Fundamentally, when we are talking about weight loss in menopause we are talking about maintaining and building metabolically active muscle.
Hormone Therapy for Weight Loss
Hormone replacement therapy (HRT) or menopausal hormone therapy (MHT) involves taking hormones like estrogen, progesterone and testosterone to add back a low amount of these ovarian hormones that decline in menopause.
There are also some other key hormones that can be utilized to help with weight loss and maintenance of muscle mass.
There is so much we have yet to learn about hormones, metabolism and menopause, but here are some key studies about some important hormones that impact body fat distribution and body composition.
1. Estrogen Replacement and Weight Loss
Estradiol enhances metabolism by enhancing the insulin receptor function (Estrogen: An Emerging Regulator of Insulin Action and Mitochondrial Function 2015) This hormone also has a direct effect on glucose uptake by the skeletal muscle and adipocytes, leading to the lowering of the blood glucose concentration (The emergence of the metabolic syndrome with menopause).
The Danish Osteoporosis Prevention Study provides valuable insights into the effects of Hormone Replacement Therapy (HRT) on body composition when initiated early during menopause.
About the Danish Osteoporosis Prevention Study
The study followed 2016 women who were randomized to HRT or placebo that was started 3 months to 2 years after menopause and they were followed up for 5 years.
Specifically, women with a uterus used oral estradiol/norethisterone combination (Trisequens) and women who had a hysterectomy used 2mg estradiol (Estrofem).
The study tracked body weight, bone mass density and body composition.
Danish Osteoporosis Prevention Study Outcomes
The study found that women who used HRT gained less weight than women who did not.
What is even more important is that the reduced weight gain in the HRT user group was due to a lower increase in body fat.
A significant finding was that the strongest predictor of weight gain in the non-HRT user group was the decline in physical fitness. This suggests that in the HRT user group, HRT was protective against a decline in physical exercise, which resulted in less weight increase, specifically less increase in belly fat.
This is an important finding and there are a number of reasons why HRT use helped women to maintain their physical activity. Possible reasons include:
reduced tendon, joint and muscle pain,
less post-exercise pain and faster recovery,
reduced injury,
fewer hot flashes, night wakening that lead to improved sleep,
less urinary frequency, urination at night and better sleep,
improved sleep, less fatigue, and therefore more energy for activity.
By supporting estrogen levels, HRT likely helps counteract the decline in muscle mass and the increase in abdominal fat that typically accompanies menopause.
Estrogen Therapy Plus Resistance Training
A further study examined the use of transdermal estrogen therapy (estrogen via the skin). It looked at the impact of both estrogen and resistance training on skeletal muscle in the early post-menopause phase.
The study recruited women who had not had a period for at least 6 months, but whose last period was no longer than 5 years prior to starting the study.
The training program consisted of 1 5 min light cardio warm-up, followed by six resistance exercises. The exercises were built up progressively to avoid injury. They included:
leg press,
knee extension ,
knee flexion,
dumbbell triceps extension,
sit-ups and
back extensions.
The women receiving estrogen used a 100 microg patch of 17-β estradiol. Women receiving placebo had a placebo patch.
The study demonstrated that women who received estradiol patches combined with resistance training experienced greater muscle growth than resistance training itself in early postmenopausal women.
It also showed an increase in quadriceps muscle size via MRI and an increase in fat-free mass or lean body mass as measured via DEXA scan.
This shows that when estrogen therapy is combined with resistance training, women in early postmenopause can increase their metabolically active muscle to benefit their body composition and health.
Estrogen Therapy and Insulin Resistance
HRT can enhance the body's response to insulin, improving blood sugar control and reducing the risk of insulin resistance and metabolic syndrome. This is particularly important for women with a family history of diabetes, prediabetes, or who had gestational diabetes or have other features of metabolic dysregulation.
Does HRT Help With Weight Loss?
Although current guidelines do not yet advocate for the use of HRT to support weight stabilization, or body composition, the Danish study does suggest that estradiol +/- progesterone when initiated early during menopause may be beneficial for reducing belly fat gain and to help women to maintain their physical activity.
The benefit of adding in resistance training alongside HRT seems to enhance your ability to increase your lean muscle mass.
Additionally, if you are struggling to exercise due to some of your menopausal symptoms, HRT may be a strategy to minimise your symptoms such as fatigue, night wakening, hot flashes and joint and muscle pains that can interfere with exercising.
2. Tibolone and Testosterone for Menopausal Weight Loss
Tibolone is a steroid hormone which acts on estrogen, progesterone and testosterone receptors.
It acts as a selective estrogen receptor modulator (SERM) with exerting estrogenic effects on brain, bone, and vagina, while avoiding the undesired estrogenic effects on the endometrium and breast (Tibolone mechanism of action 2004)
In clinical trials, use of tibolone has been found to:
increase handgrip strength ,
increase isometric knee extension strength,
increased the lean body mass and
decreased the accumulation of body fat (Muscle strength and Tibolone 2002).
It is interesting that tibolone, which has androgenic effects (acts on testosterone receptors) improves lean body mass, whereas use of estrogen and progesterone without testosterone simply resists an increase in fat composition.
Testosterone has been validated as a treatment for hyposexual desire disorder in menopausal women. It would be great to get some studies on body composition in menopausal women who use estrogen and testosterone combinations to see if this has a similar effect of reducing belly fat, but increasing lean body mass.
This would be beneficial for preventing sarcopenia (muscle loss), loss of muscle strength and ultimately loss of mobility.
3. Does Melatonin Help With Weight Loss?
Melatonin is rhythmically synthesized in the pineal gland. It has important roles for the body's circadian rhythm, immune system, cancer inhibition, and even energy metabolism.
Melatonin production declines through life, and low melatonin in midlife can coincide with low ovarian hormone levels at menopause. Both loss of estrogen and melatonin impacts sleep, which also can enhance weight gain with menopause. Poor sleep also hinders weight loss efforts as increased fatigue lowers capacity for exercise.
Sleep deprivation is common in menopause due to a variety of perimenopausal symptoms that impair sleep. Sleep disturbances mediate increases in body mass index (BMI) through dysregulation (imbalanced):
stress hormones like cortisol which raises insulin, and
hunger hormones: meaning elevated ghrelin, suppressed leptin and disturbed appetite.
Adequate sleep quality and quantity is vital for overall health and plays a crucial role in weight management.
Melatonin can be a helpful supplement for improving sleep quality.
Studies in menopausal women show that melatonin treatment improves EEG patterns and subjective sleep quality in postmenopausal women with sleep impairment (Melatonin and the health of menopausal women: A systematic review- 2021).
It is likely the positive impact on sleep, and the flow on positive effect on stress hormones, metabolic hormones and appetite hormones are important mechanisms whereby women see a beneficial impact on their BMI.
Clinical trials using 5-8 mg of melatonin per night have show menopausal women both experience weight loss and an improvement in bone mineral density (BMD) (Melatonin supplementation on psychosomatic disorders in postmenopausal women 2018, Effect of melatonin on the quality of sleep and weight status in postmenopausal women 2014).
4. Exploring GLP-1 Agonists Like Saxenda
Glucagon-like peptide-1 (GLP-1) is a hormone that is made in the gut (intestines). GLP-1 works by a number of mechanisms:
enhances feelings of fullness,
reduces appetite, and
slows gastric emptying.
Impacts of GLP-1 Agonists & Weight Loss
GLP-1 agonists are a class of medications that perform the action of GLP-1.
GLP-1 medications are commonly used to manage type 2 diabetes but they are also effective for weight loss. They are typically used to treat weight loss in people with a BMI of over 30 or those with a BMI of over 27 with weight related medical complications such as high blood pressure, insulin resistance, PCOS, fertility difficulties, or arthritis.
There are a number of GLP-1 agonist medications, which have varying availability, and they include:
Dulaglutide (Trulicity)
Exenatide (Byetta)
Liraglutide (Victoza)
Semaglutide (Ozempic)
Tirzepatide (Mounjaro)
Liraglutide (Saxenda).
Use of these GLP-1 agonists leads to decreased calorie intake and, ultimately, weight loss.
In addition to its appetite-suppressing effects, Saxenda and other GLP-1 medications improve insulin sensitivity and blood sugar control, making it a valuable tool for managing weight and metabolic health.
For menopausal women, who are often developing early insulin resistance and weight gain, GLP-1 agonists like Saxenda can be particularly beneficial alongside lifestyle healthy habits.
Optimizing use of GLP-1 medications in menopausal women
One small study showed that among postmenopausal women who used semaglutide, those who also used hormone therapy had an improved weight loss response at 12 months compared to those using placebo.
More women who used hormone therapy alongside semaglutide were able to achieve both loss of 5 percent of body weight and 10 percent of body weight.
It is also important to note this is not a long-term medication so lifestyle support is of ongoing important.
GLP-1 Weight Loss Medications & Lifestyle Support
It's important to note that GLP-1 agonists should be used under close guidance of a healthcare provider. They are typically prescribed as part of a comprehensive weight management plan that includes support for nutrition and physical activity.
Without adequate nutrition and protein intake you may be at risk of loss of muscle mass which contributes to sarcopenia which is not desirable or healthy.
5. Lifestyle Medicine for Weight loss During Menopause
We are passionate about helping you incorporate lifestyle changes to support successful weight management during menopause. Healthy lifestyle habits are always a step towards optimal health and even small steps can support your metabolism.
To achieve and maintain a healthy weight, we always recommend the following these 5 lifestyle health habits alongside any hormone support:
1. FOOD
A balanced whole-food patterns of eating that includes plenty of lean protein, fiber-rich fruits and vegetables and plants, and healthy fats. These include the Mediterranean diet, a whole food plant-based diet and many other traditional eating patterns.
2. MOVEMENT
Regular physical activity, including cardiovascular exercise and strength training to preserve muscle mass.
Exercise has MANY beneficial health outcomes, above and beyond weight loss including: improved mood, reduced risk of many diseases including cardiovascular disease, type 2 diabetes and some cancers, better cardiovascular fitness, and builds a stronger, more resilient body.
3. SLEEP
Adequate sleep quality and quantity through practices such as maintaining a consistent sleep schedule, limiting screen time before bed, and avoiding caffeine after midday.
Adequate refreshing sleep is essential for metabolic hormone balance.
4. STRESS MANAGEMENT
Managing stress and therefore lowering stress hormones via mindfulness techniques, yoga, nature walks or any activity that helps your mind and body relax.
Adequate rest and recovery supports the metabolic hormones.
5. AVOID HARMFUL SUBSTANCES
Avoiding smoking and excessive alcohol consumption that can contribute to metabolic health problems such as heart disease and cancers is important. Both these substances trigger inflammatory responses in the body that contribute to disease.
The Takeaways: Hormone Therapy For Weight Loss During Menopause
Hormones alter your metabolism and body composition. Supporting your body with hormone therapy is one strategy that can be utilized alongside the pillars of lifestyle medicine to support you as you go through the menopausal transition.
With appropriate medical support, HRT can help maintain muscle mass, reduce abdominal fat, and enhance metabolic health.
Specific hormone therapies that may be helpful include:
estrogen (+ progesterone which is necessary if you still have a uterus)
testosterone
melatonin
GLP-1 analogues
If you're struggling with weight management during menopause, consider discussing hormone therapy and other treatment options with your healthcare provider.
By taking a proactive approach, you can achieve lasting results and enjoy a healthier, more vibrant life.
For personalized guidance and support, book a consultation with one of our expert healthcare providers today. Together, we can create a tailored plan that meets your unique needs and weight loss goals.
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Dr Deb Brunt @ Ōtepoti Integrative Health would love to support you to navigate perimenopause and menopause.
She is a menopause specialist and women's health doctor. She has a passion for supporting women adapt to their changing female physiology for optimum health and wellbeing.
Book an appointment with Dr Deb Brunt | Ōtepoti Integrative Health | Book now
Join our Meno Thrive program to optimise your health and wellbeing during perimenopause and menopause.
References
Jensen LB, Vestergaard P, Hermann AP, et al. Hormone replacement therapy dissociates fat mass and bone mass, and tends to reduce weight gain in early postmenopausal women: a randomized controlled 5-year clinical trial of the Danish Osteoporosis Prevention Study. J Bone Miner Res. 2003 Feb;18(2):333-42.
effects. Maturitas. 2004 Aug 30;48 Suppl 1:S1-3.
Meeuwsen IB, Samson MM, Duursma SA, et al. Muscle strength and tibolone: a randomised, double-blind, placebo-controlled trial. BJOG. 2002 Jan;109(1):77-84.
Gupte AA, Pownall HJ, Hamilton DJ. Estrogen: an emerging regulator of insulin action and mitochondrial function. J Diabetes Res. 2015;2015:916585.
Treister-Goltzman Y, Peleg R. Melatonin and the health of menopausal women: A systematic review. J Pineal Res. 2021 Sep;71(2):e12743.
Chojnacki C, Kaczka A, Gasiorowska A, et al. The effect of long-term melatonin supplementation on psychosomatic disorders in postmenopausal women. J Physiol Pharmacol. 2018 Apr;69(2).
Dam TV, Dalgaard LB, Ringgaard S, et al. Transdermal Estrogen Therapy Improves Gains in Skeletal Muscle Mass After 12 Weeks of Resistance Training in Early Postmenopausal Women. Front Physiol. 2021 Jan 18;11:596130.
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