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During perimenopause and menopause, many women will find themselves gaining weight, especially around their midsection.
This is due to the metabolic effects of declining and fluctuating hormone levels (both oestrogen and progesterone). For example, one change is a decrease in muscle mass which leads to fewer calories being burned by the body. The impact of menopause symptoms also plays a role, as poor sleep, aches and pains, and hot flushes can zap you of energy, making you more sedentary and leading to poorer food choices.
Hormone replacement therapy (HRT) can help manage the symptoms of menopause, but can it contribute to weight loss or gain? In this article, we explore the answer to this question so that you can make an informed choice about whether it’s right for you.
What happens to weight during menopausal change?
Weight gain relates to many factors including changing physiology, lifestyle and also environmental factors. For lots of reasons, including hormonal change, the way we live may become more sedate and cravings for foods including refined sugars and simple carbohydrates (alongside a glass of wine or a gin and tonic) are common.
Another frustrating change most women notice is fat distribution moving to around the middle or the back and arms – that feeling of losing your waist, gaining a belly or ‘muffin top’ that no matter how hard you try, you just can’t shift.
The hormone 17 beta oestradiol encourages fat to be held around the hips and thighs – a healthier fat distribution – as this declines it naturally starts to change body shape. In fact, a major review by the International Menopause Society (IMS) stated that “menopause does not cause weight gain but does increase ‘belly fat’”. This increase in abdominal fat otherwise known as visceral fat is detrimental to our health in other ways and can form part of metabolic syndrome.
HRT and weight loss
We see many women for whom HRT is helpful in terms of weight management. There is limited evidence, but some studies confirm HRT helps with weight loss and less belly fat. One study found that HRT can prevent weight gain and encourage weight loss by significantly increasing lipid oxidation and positively influencing the insulin response and energy expenditure. Other research indicates that while HRT doesn’t contribute to weight loss, it can cause weight redistribution, meaning that abdominal fat reduces as deposits go elsewhere in the body.
Even if HRT doesn’t cause weight loss directly, many women do lose weight and feel considerably fitter and overall, better on HRT, which often means that they have the desire and motivation to look after themselves again.
This, in turn, makes it much easier to make healthier food choices with more fruit, vegetables, whole grains and protein whilst reducing processed foods, refined sugars and alcohol intake.
HRT often improves energy levels and with this comes the motivation to be active and enjoy exercise again. Together, this means it can be easier to maintain a healthy weight.
Sleep disturbances frequently improve with HRT, which is important when it comes to healthy weight and fat distribution. The science says that lack of sleep can drive weight gain through the stress hormone cortisol. So, improved sleep again often means it is easier to manage your weight.
All in all, if your menopausal symptoms are under control, this will mean it is much easier to manage your weight and build a healthier body as you move forward. HRT is not a magic fix, but it can certainly help.
What is the best HRT for weight loss?
HRT is not primarily intended nor prescribed for weight loss, but it can help indirectly by improving overall well-being. HRT doesn't work the same way for everyone so no one type of HRT is best for weight loss – this will largely depend on personal factors such as your menopause symptoms, lifestyle, and medical history.
Oestrogen
Some evidence suggests that oestrogen hormone therapy increases a woman's resting metabolic rate (energy expenditure). This might help slow weight gain.
One study found that taking oestrogen as part of menopausal hormone therapy increased resting energy expenditure, on average, by 222kcal per day.
Testosterone
Testosterone replacement therapy can be beneficial for women during menopause if they are struggling with low libido. However, it can also have an impact on body composition and weight. Testosterone is important for muscle growth and increasing lean muscle mass and directly influences metabolism, fat storage and energy levels.
There is a small amount of evidence that suggests that testosterone has a significant and positive influence on body mass index (BMI), body fat, weight, lean body mass and fat mass.
Thyroid hormone
The thyroid is a gland at the front of your neck. It produces hormones that regulate the metabolism of the body’s cells. However, the thyroid can be underactive, leading to the body’s metabolism slowing down and weight gain, or overactive, where the metabolism speeds up.
The risk of developing an underactive thyroid increases with age and is 10 times more common in women than men. Therefore, many women going through menopause are affected and it’s estimated that 12-20% of women over the age of 60 may have an underactive thyroid.
Thyroid and menopause symptoms can overlap, meaning the management of both is important. Thyroxine (or levothyroxine) is the thyroid hormone replacement recommended in the UK and is not a contraindication to HRT for menopause.
Once you start taking thyroxine, your hormones begin to rebalance, and this can lead to weight loss.
HRT and weight gain
There is little evidence that most types of HRT make you put on weight. Generally, the advantages of hormone replacement therapy far outweigh any negatives and risks, with many women finding that HRT helps them to manage their weight or even lose weight.
Does HRT cause weight gain?
Many women are concerned about weight gain during perimenopause and may also be concerned that HRT leads to further weight gain.
All of the evidence-based data that we currently have suggests that HRT does not cause weight gain and that it is, in fact, the metabolic changes associated with menopause that influence weight gain. Of course, in reality, weight gain is multifactorial and hormonal shifts are likely to be only part of the jigsaw puzzle.
If HRT is used to manage menopausal symptoms, many women actually find their weight easier to manage and may even lose weight. This is because the right HRT regime will gradually shift metabolism back towards a pre-menopausal metabolic state (leading to a healthier weight distribution).
Progesterone (and synthetic progestogens) can sometimes lead to fluid retention, which can mimic weight gain, but some alterations can be made to HRT regimes to minimise this impact.
Why am I gaining weight on HRT?
One side effect experienced by some women taking HRT is water retention and bloating. This experience can feel much the same as weight gain. This might relate to the type of progestogen used. Specialist adjustments to both the dose and type of HRT can often help.
Another reason some women may report slight weight gain relates to the easing of anxiety symptoms. Previous heightened anxiety may mean a reduced appetite over time, keeping weight a little lower than it would be naturally.
The positive impact of HRT often calms anxiety but the follow-on is a natural return of a better appetite and, with time, a naturally higher, often healthier weight. This type of weight gain generally plateaus quickly and can be very supportive of a healthy menopausal transition and better long-term muscular bone health.
Menopause weight and metabolic syndrome
The menopause transition induces adverse changes in many metabolic factors, leading to a type of metabolic syndrome. We see changes in blood fats (lipids and lipoproteins), glucose and insulin metabolism, body fat distribution (abdominal weight gain), blood pressure and blood clotting. This can be serious in terms of overall health, especially given that 50% of cardiovascular events in women are related to metabolic disorders.
What is metabolic syndrome and why is it important?
Metabolic syndrome is a collection of metabolic disturbances that are all interlinked. These include:
- High blood pressure
- Blood fat (lipid) abnormalities
- Abdominal weight gain (central obesity)
- Impaired glucose tolerance
- Coagulation disturbances (increased risk of blood clots)
These all increase your risk of developing heart and vascular disease and type 2 diabetes. Central to all of these is insulin resistance.
A woman's risk of developing metabolic syndrome and insulin resistance increases and she goes through menopause. Postmenopausal women, therefore, become more at risk of developing conditions such as cardiovascular disease and type 2 diabetes.
What is insulin resistance?
Insulin is a hormone released by our pancreas. It is released to help regulate our blood glucose levels when we eat food.
Insulin resistance occurs when your body’s tissues become resistant to insulin activity i.e. your tissues are no longer responding as effectively as they should to your own insulin.
When this happens, you compensate by producing more and more insulin. This causes sudden drops in blood glucose – still within the normal range, but this change in levels can lead to unpleasant symptoms. It also leads to weight gain and accumulation of fat centrally – tummy fat or a ‘spare tyre’ – as well as metabolic disturbances.
What causes insulin resistance?
Things that contribute to insulin resistance are obesity, high simple carbohydrate/sugar consumption (which leads to more insulin being released), and a sedentary lifestyle (not using up the glucose – ‘energy’ – that is available in the bloodstream.)
Symptoms associated with insulin resistance include:
- Generalised tiredness
- Central weight gain
- Carbohydrate cravings
- Mid-morning/mid-afternoon hypoglycaemic episodes (sudden marked fatigue, light-headedness, shaking/tremor)
Insulin resistance is also associated with conditions such as PCOS and gestational diabetes, as well as those mentioned above.
What can you do if you have metabolic syndrome?
The main thing you can do is to correct the changes that are happening. This includes reducing your body fat and getting your blood pressure to a normal range. This can sometimes be more difficult during the menopause transition.
A low glycaemic index, minimally processed, Mediterranean-style diet, as well as regular movement, is central to helping symptoms and improving metabolic status in women. HRT has also been proven to help with many of the changes we see at this time.
HRT can help to lower central fat accumulation. It also lowers the ‘bad’ fats in the blood and increases the ‘good’ fats. HRT lowers insulin resistance and often lowers blood pressure too. Treating menopausal symptoms may, therefore, improve metabolic syndrome and reduce the future risk of conditions such as cardiovascular disease and type 2 diabetes, which are leading health issues for women as they age.
Often women feel better when they are on HRT and are more able to address nutritional and lifestyle issues that can impact metabolic health and reduce their risk of future health conditions.
Will I lose weight if I stop HRT?
Stopping HRT is unlikely to result in weight loss and weight changes during menopause or as a natural consequence of ageing are likely to happen whether HRT is taken or not.
If you feel you’ve gained weight on HRT and are considering stopping it to lose weight, other factors may be at play. Diet, exercise, sleep, and stress levels are equally critical in managing weight during menopause.
What to do if struggling with weight gain on HRT
Taking steps to manage your weight during menopause and when on HRT can be pivotal in helping you feel your best. Most actions that can help you to maintain or lose weight also contribute to overall well-being.
Eat a balanced diet
A menopause eating plan is key to managing weight on HRT. A diet rich in vegetables, fruits, whole grains, and lean proteins can stabilise blood sugar, which prevents energy dips and reduces cravings for high-sugar snacks.
Protein is particularly important as it helps maintain muscle mass, which naturally declines during menopause and contributes to a healthy metabolism.
Healthy fats from sources like olive oil, nuts, and avocados are also beneficial, as they provide satiety and support hormone production.
Consider portion control and mindful eating techniques, like eating without distractions, which can help with recognising fullness.
Stay hydrated
Staying hydrated can play a surprising role in weight management as water is essential for digestion, metabolism, and appetite control. Sometimes, thirst can be mistaken for hunger, leading to unnecessary snacking.
Drinking a glass of water before meals can help you feel fuller and may reduce overall calorie intake. Aim for at least 8-10 glasses per day and consider herbal teas or no added sugar squash rather than fizzy drinks if you want something with flavour.
Exercise regularly
Exercise is crucial for managing weight, supporting muscle health and reducing the risk of menopause heart problems.
Aim for a combination of cardio, strength training, and flexibility exercises. Cardio, like brisk walking, cycling or even cold water swimming during menopause, burns calories and boosts cardiovascular health, while strength training preserves muscle mass and promotes a higher resting metabolism, helping you burn more calories even at rest.
Aim for at least 150 minutes of moderate-intensity exercise weekly, plus two days of muscle-strengthening activities. Incorporating exercise not only aids in weight control but also enhances mood, energy, and sleep quality.
Reduce stress
Chronic stress can lead to weight gain, especially around the abdominal area, due to increased cortisol levels.
Managing stress can prevent this hormonal imbalance and help with weight maintenance on HRT. Try incorporating relaxation techniques like menopause yoga, meditation, or deep breathing exercises to support stress relief.
Making time for hobbies or social connections can also lower stress and improve overall well-being. Lowering cortisol not only helps with weight control but also enhances mood, helping you feel more positive and in control of your health journey.
Optimise your sleep
Quality sleep is essential for weight management, as it regulates hunger hormones like ghrelin and leptin, which control appetite. Poor sleep can increase cravings for high-calorie foods, disrupt metabolism, and make it harder to stick to health goals.
Aim for 7-8 hours of sleep each night, and establish a calming bedtime routine, like dimming the lights, reading a book, or practising relaxation exercises. Avoid caffeine and screen time close to bed. Consistent, restful sleep supports healthy body weight, energy levels, and a balanced mood, all of which are crucial while managing weight on HRT.
Menopause, HRT and weight changes
Ultimately weight changes during menopause, whether taking HRT or not, are complex and often the result of several factors rather than one direct cause. As everyone is different, the best way to manage menopause symptoms and weight gain should be tailored to each individual.
Knowing which doctor to consult for menopause isn't always easy, but choosing a dedicated menopause doctor with experience in supporting women through this transitional life stage can be invaluable.
At Menopause Care, we have specialists who can talk to you about your HRT options, develop a treatment plan that works for you and give you evidence-based advice. This includes our consultant dietician Marcela who provides nutritional guidance and plans based on your experiences and needs. Book a consultation with a menopause doctor to get started.
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