How does menopause impact weight and metabolic health?
Weight gain is common during menopause, but we often miss the underlying relationship to insulin and other hormonal changes.
Hot flashes, mood changes, sleep disturbances, and changes in libido are common symptoms doctors and researchers directly attribute to the menopausal transition. But doctors often dismiss another common symptom: weight gain.
Doctors often pin the weight gain during menopause on aging. However, that explanation discounts the complex changes the female body undergoes during the midlife milestone of menopause, and it hinders people from addressing the root cause that’s impacting their health.
Research indicates many women in midlife experience more fat gain and changes in fat distribution, often with fat accumulating around the abdomen. These changes can be frustrating—when favorite clothes no longer fit or the same workout routines and nutritional efforts are less effective at maintaining the same body composition. But the concern about weight and bodily changes during menopause is not trivial. Weight gain and obesity are also risk factors for Type 2 diabetes, coronary heart disease, stroke, and other potentially deadly diseases. Meanwhile, menopause itself is a risk factor for heart disease and Type 2 diabetes.
Many women are told age slows their metabolism and are just advised to eat less and exercise more. Yet, research shows that hormonal changes during the menopausal transition drive insulin resistance—which directly relates to metabolism and fat distribution—and that the transition also leads to increased androgen production and lower adiponectin levels, which are linked to insulin resistance and weight gain.
To read more about how blood sugar and menopause symptoms are linked, you can read our deep dive here.
Stabilizing blood sugar levels and maintaining good metabolic health can help address menopausal weight changes and reduce the risk for chronic diseases. Read on to learn about weight gain during menopause and how focusing on your metabolic health can counteract these biological changes.
Weight and body changes during menopause
Natural menopause occurs after menstruation has ceased for an entire year. On average, this happens in the early 50s. The years leading up to menopause are called perimenopause or the menopausal transition. On average, perimenopause begins in one’s late 40s. It is marked clinically by changes in hormone levels that suggest declining ovarian reserve. Life beyond one year after the last menstrual period is considered postmenopause.
People tend to gain fat and lose muscle mass during the menopause transition and into postmenopause. These changes can have serious health consequences, putting people at risk for frailty (especially later in life), sarcopenia (age-related muscle loss and a decline in muscle function), osteoporosis, and osteoarthritis. They also impact overall quality of life and increase one’s risk of worsening metabolic health since muscle plays a role in preventing obesity and Type 2 diabetes. In contrast, fat mass plays a contributing role.
In a 2019 landmark study of menopausal women, titled the Study of Women’s Health Across the Nation (SWAN), researchers examined body mass metrics for 1,246 participants spanning the eight years before their last menstrual period and 10.5 years after. They found that lean and fat mass increased in the eight to two years leading up to the last menses. Then the rate of fat gain doubled from two years before to one and half years after the last period, while lean body mass decreased.
The researchers note that an increase in fat mass coupled with a decrease in lean mass demonstrates how body composition changes during this time, even when the number on the scale doesn’t. Yet, this is significant from a health perspective because of visceral fat accumulation. This fat surrounds abdominal organs and is associated with increased cardiovascular risk and other chronic diseases. Another study looking at SWAN data for 362 women found that visceral fat accumulation increased sharply at 8% per year in the two years before the participants’ last menstrual period. This increase was independent of aging. The rise in visceral fat also correlated with an increase in the thickness of the carotid artery. Greater thickness of this artery is a risk factor for heart disease.
So, what are the processes behind these changes in body mass composition?
The sex hormone and metabolic health relationship
Understanding the links between menopause and weight gain help us confirm we need to dig deeper into how sex hormones and metabolic health connect in the first place.
During the usual trajectory of a menstrual cycle, the hypothalamic-pituitary-gonadal (HPG) axis (also called HPO for ovarian) maintains a tightly controlled feedback loop. As one hormone level rises, it starts a set of chain reactions on other hormone levels. These hormone fluctuations occur across the two main phases of the menstrual cycle: the follicular and luteal phases, with ovulation happening between. Changes during menopause can alter these processes, impacting blood sugar and impairing weight management.
Hormonal Changes
The feedback loop of the HPG axis influences glucose regulation, which is how we use or store energy from the foods we eat. The hypothalamus helps control food intake, energy expenditure, and body mass distribution, and these are all affected by estrogen. For example, estrogen’s impact in this area of the brain helps limit food intake—likely working in concert with the hunger-suppressing hormone leptin—and helps stimulate physical activity. Estrogen also helps curb white adipose tissue (WAT) accumulation. The distribution of WAT is associated with metabolic dysregulation, including insulin resistance.
Estrogen also offers protection against insulin resistance—a risk factor for prediabetes and Type 2 diabetes and a root cause for weight gain—by enhancing insulin sensitivity. The exact reasons for this are still unclear. But some research points to estrogen’s potential role in increased glucose uptake in muscle.
By the final menstrual period, estrogen will have declined by about 50% compared to the reproductive years. A cascade of other hormone changes, including declining inhibin B and rising FSH, lead to a shortening of the follicular phase of the menstrual cycle and more rapid ovulation. These shifts further contribute to hormonal swings during the luteal phase and subsequent cycles, specifically: higher FSH, erratic changes in estrogen, and lower progesterone.
Research shows that the decline in progesterone may lead to a more “androgenic pattern” of fat distribution, with accumulation around the abdomen, as discussed below. And the inevitable decline in estrogen from menopause can worsen metabolic health, driving insulin resistance and, therefore, weight gain. Insulin resistance and obesity are connected, with each potentially driving the other in a complex relationship. Hyperinsulinemia, or high insulin levels, promotes glucose to be stored as fat. Likewise, weight gain and obesity further impair insulin signaling, creating a vicious cycle. Research demonstrates that insulin resistance and other factors of metabolic syndrome (a cluster of conditions including insulin resistance and central obesity) are more prevalent in those who are perimenopausal and postmenopausal than in people who haven’t entered the transition yet. Metabolic syndrome is a risk factor for mortality.
Higher Androgen Levels
Complicating matters is that insulin resistance can hinder estrogen production and synthesis, leading to even less estrogen when the hormone is already declining during the menopause trajectory. Estrogen loss reduces the production of sex hormone-binding globulin (SHBG), a protein made in the liver. As SHBG decreases, testosterone, which binds to this protein, increases in the bloodstream. Moreover, insulin drives testosterone production from the ovaries’ theca cells, which have insulin receptors.
Increased androgens, or “male” hormones like testosterone, can cause abnormal uterine bleeding, shorten or lengthen the menstrual cycle, and cause infrequent or skipped ovulation. Furthermore, increased androgens can cause weight gain and changes in fat distribution, such as increased visceral fat. And high levels of androgens are linked to insulin resistance.
Lower Adiponectin Levels
Excess androgen levels are associated with lower levels of adiponectin during perimenopause. Adiponectin is a protein produced by fat cells that aids in insulin sensitivity. It also appears to play a role in the prevention of atherosclerosis and has anti-inflammatory properties. One study of more than 300 participants found that adiponectin declined to its lowest level during perimenopause before increasing again after menopause. Low adiponectin levels are associated with metabolic syndrome, especially in menopause. Since adiponectin is crucial for energy homeostasis, a lower level can increase insulin resistance. A low adiponectin level is also associated with weight gain. Weight loss, however, increases adiponectin.
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What can you do about menopausal weight gain?
The changes to ovarian hormones, androgen levels, and adiponectin levels associated with the menopause transition all have links to decreased insulin sensitivity, which in and of itself can drive weight gain. Several strategies can help make the body more insulin sensitive, which can, in turn, help with weight management.
Hormone replacement therapy
In some cases, hormone replacement therapy may help mitigate the effects of hormone decline. Clinical trials have shown estrogen replacement boosts insulin sensitivity while lowering glucose levels. Those who use hormone therapy also have a reduced risk of Type 2 diabetes. Other studies have shown cardiovascular health benefits. However, only some will be candidates, often depending on underlying conditions, age, and medical and family history.
Focus on metabolic health
Aiming for stable blood sugar is a natural way of increasing insulin sensitivity. Seven levers that significantly impact how your body handles blood sugar include:
- Eating a metabolically healthy diet.
- Aiming for more micronutrients.
- Exercising.
- Reducing stress.
- Improving sleep.
- Boosting the gut microbiome.
- Preventing exposure to environmental toxins.
Even simple changes, like taking short walks after meals, can help improve blood sugar control and mitigate fat storage. When it comes to diet, aim for whole foods while avoiding processed foods and added sugar as much as possible. Try to limit high glycemic variability, characterized by blood sugar spikes and crashes. Aim for glucose stability instead, which will help keep insulin levels in check and maintain insulin sensitivity.
Incorporate exercise, particularly strength training
Strength training can also help. Muscle mass tends to decline during the menopausal transition, but muscle mass in premenopausal women has enhanced insulin sensitivity. Focusing on preserving and building muscle may offer some protection against insulin resistance. It can also help prevent musculoskeletal issues that often arise later in life, including osteoporosis, osteoarthritis, sarcopenia, and frailty. Aerobic activities can also help your body use glucose more efficiently and protect against insulin resistance.
The bottom line
Menopause is no longer an ordeal that the 47 million people per year going through the transition must endure without the appropriate care. The world is finally discussing and researching menopause and the root causes of some of its most frustrating symptoms. Hopefully, more public awareness will continue to shed light on the links between menopause and weight gain later in life. Even if your healthcare provider doesn’t tie your midlife weight gain to the menopausal transition, focusing on metabolic health may help alleviate the weight gain and body composition changes often accompanying menopause and reduce the risk for associated chronic diseases.
