Unwanted weight gain is a common problem for women after menopause. Primary care clinicians have likely heard from patients that attempts at shedding extra pounds are not working.
Nearly three fourths of women aged 60 years and older in the United States are overweight. Some may blame menopause for this trend. But the life stage itself does not cause weight gain. Aging does: Women gain about 1.5 pounds per year on average starting almost a decade prior to menopause to a decade after their final menstrual cycle, according to research.
"A lot of women are in tears because they have gained 10 or 15 pounds," said Stephanie Faubion, MD, medical director of The Menopause Society and director of the Mayo Clinic Center for Women's Health in Jacksonville, Florida.
A shortage of obesity and menopause specialists means primary care clinicians must understand the intersection of weight management and how the body functions after menopause.
"The importance of weight management in midlife cannot be overemphasized," Faubion said. "Excess weight around the middle increases the risk of diabetes and heart disease and that is directly related to the loss of estrogen."
The loss of estrogen due to menopause also causes the redistribution of fat from the thighs, hips, and buttocks to the midsection, which can be more difficult to trim. And women naturally lose muscle mass as they age, in part because the hormone is important to muscle functioning, according to Maria Daniela Hurtado Andrade, MD, PhD, assistant professor of medicine at Mayo Clinic Alix School of Medicine in Jacksonville, Florida.
"Menopause compounds the changes associated with aging: It makes them worse," Hurtado Andrade said.
Mounting evidence has linked obesity-related systemic inflammation with an increased risk for cardiovascular disease, including heart attacks and vascular damage.
Michael Knight, MD, clinical associate professor of medicine and a weight loss specialist at the George Washington University in Washington, DC, estimated that more than half of his patients are postmenopausal women.
He recommended clinicians look for adipose tissue dysfunction, which can cause localized insulin resistance and affect metabolic health. Research suggests clinicians can perform a basic metabolic panel, in addition to testing for triglyceride, low-density lipoprotein, and renal function levels. Several other recent studies have pointed to using waist circumference, insulin resistance, or presence of metabolic syndrome to diagnose adipose tissue dysfunction.
Beyond Diet and Exercise
Physicians should ask their patients about physical activity, the type of foods they are eating, and changes in day-to-day movement, Knight advised.
Pharmacotherapy or surgical options should be considered for some patients, according to Karen Adams, MD, clinical professor of obstetrics and gynecology and a lifestyle medicine specialist at Stanford Medicine in Palo Alto, California. Postmenopausal women who want to lose more than 5%-10% of their body weight likely will need another modality in addition to diet and exercise.
"What's important is transitioning the patient from feeling like they've failed to a mindset of seeking help or seeking care for this condition," she said. Adams, a certified menopause specialist, uses the idea of "good enough" with her patients and suggests they think of weight loss as a journey, which may require different tools at various points.
Glucagon-like peptide 1 receptor agonists like semaglutide or tirzepatide are some of the most effective drugs for obesity, according to Knight.
In addition to these drugs, hormone replacement therapy in combination with the weight loss drug semaglutide may improve weight loss and reduce cardiometabolic risk in postmenopausal women compared with semaglutide alone, as recently reported in a study Hurtado Andrade and Faubion recently coauthored. Improving vasomotor symptoms improved sleep, physical activity, and quality of life, which all can affect efforts to lose weight.
Most patients who struggle to lose weight using diet and exercise methods alone usually do not maintain a healthy weight long term, according to Knight. Physicians need a comprehensive strategy to introduce options like medications or surgery when indicated for long-term, weight management solutions.
Tips for primary care clinicians in helping postmenopausal women lose weight:
- Develop an effective solution that works for your patient's lifestyle. If you don't have one, make a referral to a weight loss specialist.
- Educate patients about obesity and postmenopausal weight loss challenges, to help destigmatize the condition. Explain that obesity is a chronic disease, like hypertension or diabetes.
- Exercise suggestions should consider issues like walkable neighborhoods, access and affordability of gym membership, and home broadband access.
- Strength training should be recommended to counter loss of muscle mass that comes with aging.
- Consider a patient's culture when discussing healthier alternatives to their usual diet.
- Suggest simple changes to start, like eliminating simple carbohydrates — white bread, pasta, and white rice — as a good place to start.
- Body mass index was not designed to be a clinical tool and does not fully assess weight in many populations. Risk for chronic diseases and obesity varies depending on whether a person carries weight centrally or on the hips and thighs.
But well before menopause, clinicians can educate their female patients on what body changes to expect and be more mindful about which medications to not prescribe.
People in menopause or perimenopause are frequently prescribed weight-promoting drugs like antidepressants for mood swings or gabapentin for hot flashes. Clinicians should conduct a medication review and look for alternatives to drugs that are associated with weight gain.
The best approach is to try to avoid weight gain in the first place, which can be easier than trying to lose later, Faubion said. "You can't just exercise your way out of it," she said.
Adams, Faubion, and Hurtado Andrade reported no disclosures. Knight is a former consultant with Novo Nordisk.
Liz Seegert is an award-winning freelance health journalist based in New York's Hudson Valley.
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