Menopause and Obesity

Highlights

• Menopause is associated with increased abdominal and visceral obesity.

• Abdominal and visceral obesity increases cardiometabolic risk and mortality.

• The increased obesity occurs in both obese and non-obese women.

• Abdominal adiposity is best measured by waist circumference and waist to hip ratio.

• Lifestyle modifications can ameliorate the increased menopausal adiposity.

• Menopausal hormone therapy (MHT), hitherto known as hormone replacement therapy, is the most effective treatment for menopausal symptoms but requires careful assessment and management of risks.

• Diet and exercise strategies can attenuate menopause related metabolic changes.

  
  

Overview

The transition from late reproductive years to menopause is associated with increased obesity, especially in the trunk, upper body and within the organs which not only changes body shape but increases cardiometabolic risks. With the current life expectancy, women spend about half of their life in perimenopause and menopause state. This article was published in 2023 and focuses on the impact of menopause on obesity and the effect of available treatment options.

Introduction

Many women wonder about testing their hormone levels. Menopause is only diagnosed retrospectively after having no menses for 12 months. Many women do not have menses due to surgery. In that case, after menopause has already happened, an FSH level will be high, but that is still only after ovaries have stopped functioning for a period. But, we know without any blood test, that changes in hormone happen as a transition from late reproductive years. These changes cause sleep and mood changes, genitourinary symptoms and affect  lipid metabolism, energy consumption, insulin resistance, and body fat composition, with a transition from a gynecoid to an android body shape and increased abdominal and visceral fat accumulation associated with increased CVS and metabolic risks.

Menopause Transition

Menopausal transition (MT), defined as a critical period of physiologic change leading up to the final menstrual period. Menopause transition (MT) can last from 4 to 10 years before menopause. The younger this happens, the more impact it has over time. Women who have an earlier age at natural menopause have a higher risk of obesity and women with later menopause have lower rates of obesity in the postmenopausal time. This is probably because of more time in the perimenopause/menopause state with its unfavorable characteristics. 

Menopause Symptoms

The deficiency of  estrogen causes depression, sleep disruption, decreased appetite, and hot flushes.

Menopause Effects on Metabolism

Starting with menopause transition, fat accumulation in the abdomen and within the organs is accelerated. This can be caused by an increase in follicle stimulating hormone, a decrease in estradiol, and the resulting increase in adipokines secreted by visceral fat. These changes cause abnormal lipid metabolism and increased cardiometabolic risk. Importantly, these changes can happen in women with a normal BMI who have obesity by body fat percentage. Appetite tends to decrease, and with reduced appetite, women eat less, lose more muscle and this worsens metabolic changes., which leads to worsening of the loss of skeletal muscle mass and lean body.

Metabolic Effects of Visceral Fat

Abdominal and visceral fat is metabolically active, producing “adipokines” which circulate and have adverse effects throughout the body. In fact, increased visceral fat may be the main driver of all the increased cardiometabolic risk factors, including lipid profiles, blood pressure, inflammation, insulin resistance, metabolic syndrome and Type 2 Diabetes. Why does this happen? Most visceral fat is drained by the vein that goes into the liver. This exposes the liver to the high concentration of free fatty acids which then impairs healthy liver metabolism and glucose intolerance. 

Mechanism 

Studies suggest that reduced concentrations of estrogen causes insulin resistance in peripheral tissues and affects insulin production and insulin disposal in muscles, which are conditions that further exacerbate the risk of diabetes. This may be why decreased skeletal muscle mass worsens menopause related obesity. 

The balance between estrogen and testosterone shifts during menopause and may be a cause. A higher baseline testosterone-to-estradiol ratio and its increase over time were strongly associated with a higher risk of obesity and metabolic syndrome during menopause transition. In addition to estradiol decreasing, the availability of testosterone increases. Testosterone, while bound to sex hormone binding globulin (SHBG), is inactive. During menopause, SHBG concentration decreases.  This causes an increase in active testosterone. 

Treatment!

Menopausal hormone therapy (MHT) is the most effective treatment for menopausal symptoms.  Current evidence supports its use in young, healthy menopausal women younger than 60 years and within 10 years of menopause, with benefits typically outweighing risks. 

Symptoms are more common in perimenopausal women with obesity. But, there is a higher risk of blood clot, cardiovascular complications, and breast and endometrial cancers that need to be considered. So, it should be undertaken with assessment and management of these risks. Treatment with the lowest dose of ethinyl estradiol and micronized progesterone should be used. Topical forms of estrogen (patches or creams) have lower risk of blood clot.  

Estrogen replacement has been shown in both animal and human studies to reverse the estrogen depletion associated with weight gain and body fat redistribution. Several studies have shown a beneficial effect of hormone therapy in the reduction of central adiposity and preservation of lean body mass, including the Women's Health Initiative Study.  Current advice is not to use MHT to prevent or treat MT-associated weight gain and visceral adiposity because the risks outweigh the benefits. 

Exercise

There is clear evidence that lifestyle changes, such as regular physical activity and dietary management, have a positive effect on health and prevention of chronic diseases. 

Age-related declines in resting energy expenditure are not seen among women who exercise regularly. In both humans and rodents, increasing physical activity is an effective strategy to protect against metabolic dysfunction after ovarian hormone loss, and physical inactivity, therefore, is an imperative modifiable risk factor that may prevent or attenuate adverse metabolic changes during menopause .

Summary

I recommend monitoring of blood work and body composition and visceral adipose in women starting with the late reproductive years and then long term, with attention to visceral and abdominal adiposity and skeletal muscle mass in the arms and legs. These parameters are shown clearly on the InBody report. Awareness of changes then allows treatment, including targeting nutrition, exercise, and prescription medications, when appropriate, for any observed changes. Typical screenings of basic blood work and body mass index are insufficient to detect changes before they become serious clinical issues. The current standard of care tends to focus on waiting until BMI is 30 or above, diabetes occurs, or simply treating high blood pressure or cholesterol with blood pressure or cholesterol medications without targeting the underlying issue.

After all, these are supposed to be the most fun years of our life; let’s feel and look our best!

Take Back Your Second Half,

Valerie Hope-Slocum Sutherland, MD

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Example:

Notes:

• visceral fat is 18. Normal is 7-10

• Skeletal muscle mass is relatively lower than body fat mass.

• Weight is mostly distributeed in the trunk and upper body.