For women with overweight/obesity trying to lose weight, perimenopause and menopause bring special challenges. Hormonal changes can wreak havoc physically and emotionally, making it more difficult to stay on track — even women whose weight tends to stay in the normal range may put on extra pounds during this time.

For insights into how menopausal changes affect patients and evidence-based strategies to help them stay motivated and focused on their weight-loss goals, Medscape Medical News interviewed two obesity medicine experts: Courtney Younglove, MD, founder and medical director of Heartland Weight Loss in Overland Park, Kansas, and Sandra Christensen, a nurse practitioner and owner of Integrative Medical Weight Management in Seattle.

Both experts recently presented on this topic at the Obesity Medicine Association meeting.

‘Triple Whammy’

The key change during perimenopause/menopause is a decline in estrogen. With respect to weight loss, “that’s pretty much a triple whammy,” said Younglove.

First, insulin resistance increases, which drives fat storage, especially visceral fat. Second, muscle mass starts to decline more rapidly, which results in worsening insulin resistance and a decreased metabolism, because an individual’s metabolic rate is primarily determined by the amount of muscle mass they have. And third, cortisol levels rise directly and indirectly due to sleep disruption, which drives fat storage, she explained.

In this state, calorie restriction results in low energy and increased hunger and food cravings, creating a vicious cycle, she added.

Emotional challenges that can drive overeating are also common. “Almost everything has the potential to create emotional challenges,” Younglove said. Mood is often disrupted around the time of perimenopause due to the drop in estrogen or, indirectly, due to sleep deprivation.

Also at play are “all of the many things that women are coping with around midlife unrelated to estrogen levels, such as redefining their place in the world, navigating relationship shifts that occur as children leave home, taking on caretaking roles for aging parents, navigating glass ceilings and ageism in the workplace, and coping with their aging bodies in a culture where women are valued for being young and thin.”

“It’s hard to implement lifestyle improvements when we feel like we are already drowning,” Younglove underlined.

‘Musculoskeletal Syndrome of Menopause’

Another recently defined and relevant result of diminished estrogen is called the “musculoskeletal syndrome of menopause,” said Christensen.

A “revolutionary article” by Vonda J. Wright, MD, of the University of Central Florida College of Medicine, Orlando, Florida, and colleagues coined the term and categorized the aches and pains that women get during this period — that is, issues with ligaments, tendons, and cartilage breakdown. Together, they can make it more difficult to engage in physical activity, a key to weight loss with or without anti-obesity medications.

About 70% of women will experience the syndrome, and 25% will be disabled by it through the transition from peri- to postmenopause, according to the research. In addition to musculoskeletal inflammation and arthralgias, the syndrome includes loss of muscle mass and bone density, which may already be affecting women taking weight-loss medications or following restricted diets.

Furthermore, medications prescribed to treat the symptoms and complications of menopause may also be weight-promoting, Christensen noted.

Validate Symptoms, Treat Appropriately

Physicians need to be aware that the symptoms women experience around menopause are “completely legitimate,” Younglove said. “When we dismiss women’s complaints, we force them to seek advice elsewhere, and sadly, there are a ton of smarmy companies out there preying upon women’s need to be heard and helped through this time of life, and they’re promising quick-fixes. It’s gross.”

Christensen added, “There’s much more interest in these topics these days, and women are coming in and talking to me about menopause and what happens around that time before I even bring it up. Many are more educated and want to learn more.”

Nevertheless, clinicians should be prepared to ask patients who don’t volunteer information about their feelings and symptoms and be ready to address those issues, she said.

Younglove and Christensen suggested the following evidence-based treatments:

Menopausal hormone therapy (MHT). Both experts agreed that MHT is a safe and effective option for many women, after ensuring that the patient is an appropriate candidate (eg, no history of blood clots, stroke, or breast cancer and no high blood pressure or liver dysfunction, among other risks).

MHT is “vastly underused,” Christensen said, despite its demonstrated efficacy in reducing an array of menopausal symptoms, including depression, insulin resistance, hot flashes, and vaginal dryness. In addition, in postmenopausal women, when combined with semaglutide, hormone therapy is associated with greater weight loss.

Anti-obesity medications. All anti-obesity medications, not just GLP-1s, have the potential to help women start and continue on a weight-loss journey, Younglove said. But if they’re used inappropriately — that is, without robust nutritional support and strength training — “we run the risk of worsening the loss of muscle mass, thus further lowering metabolism and setting women up for sarcopenia and frailty as they age.”

Nutrition. Getting adequate protein is critical to maintaining and building muscle mass and to maintaining bone mass or reducing its decline, Christensen said. Protein requirements for menopausal women should be around 1.5 g/kg of body weight, and older women might need as much as 2 g/kg. That level of intake is also associated with the “protein leverage effect,” meaning when individuals eat more protein, they eat less unhealthful foods.

Data also suggest that a low-fat diet is associated with an increased risk for weight gain in women who are normal weight or living with overweight/obesity, whereas a reduced carbohydrate diet may decrease the risk for postmenopausal weight gain, she noted.

Physical activity, body composition. Loss of muscle mass is a concern with any kind of weight-reduction program, “so the combination of some strength training and cardio with weight-loss medication is really beneficial,” Christensen said. “It can also help relieve some of the aches and pains that people get when they become more physically active.”

But if women specifically have knee or hip pain, for example, it’s important to acknowledge and address the pain by referring the patient for imaging or to a physical therapist or orthopedist to be evaluated. “The important thing is not to dismiss these concerns when a woman brings them up.”

Younglove underscored the importance of tracking body composition instead of focusing solely numbers on the scale. “We track body composition and celebrate loss of fat mass without loss of muscle mass and pivot treatment plans quickly if it appears as though people are losing lean mass,” she said.

Sleep therapy. If a woman is having problems sleeping, Christensen advises talking to her about sleep hygiene, referring her cognitive behavioral therapy for insomnia, and helping her reduce her stress “because all those things can impact weight,” she said. To reduce stress, help her learn delegate if, for example, she has family responsibilities as well as a professional life. Otherwise, “her own personal needs and health habits can go by the wayside.”

Motivation and focus. To support patients in making changes, dig down to discover what factors are motivating them to lose weight. “Don’t lecture them and don’t impose your goals on them,” Christensen said. “Ask questions like, ‘how do you want to be functioning in 10 years?’ A classic answer is that they want to be able to get on the floor and play with their grandkids. Or they may want to be ballroom dancing or go to Europe — whatever the goal might be. Then say, ‘Let’s talk about what you’re willing to do to make that happen,’ and then break that down into small steps.”

If they haven’t been exercising, ask them what physical activity they are most likely to engage in, Christensen suggested. “Once they’ve picked the thing that they’ll most likely do, ask if there’s there a way they could do that for 10 minutes, three times a week? If you already know that they couldn’t do 10 minutes, then just say could you do it for 5 minutes? Or negotiate with them to get them to do it.”

With regard to eating, “[i]t’s too overwhelming to give a patient a diet plan and say, ‘go home and do this,’” she said. Instead, help them choose one thing in their diet they’re willing to change, and when they reach that small step or milestone, move on to the next. “I will often say, ‘what’s one change you could make between now and when I see you next?’”

It’s important to be encouraging and complimentary when patients make changes because usually they’re so hard on themselves, she said. “I’ll often tell a new patient, ‘I can give you expertise on treating overweight and obesity, but really, my job is to help you stay on your own side.’”

If they fall back on old habits, Christensen tries to help patients get back on track. “I ask them to think about their goal and regain their focus, understanding that when they veer off course, it’s because they lost focus and that’s normal. It’s all part of the process.”

Christensen reported being a speaker on obesity for Eli Lilly and Novo Nordisk and being on an advisory board for Novo Nordisk. Younglove declared having no conflicts of interest.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.