A 45-year-old woman with no previous medical history presents with a chief complaint of weight gain. She reports gaining weight rapidly over the past 2-3 years without any changes to her diet or physical activity. She now weighs over 180 lb with a body mass index (BMI) of 30. She also notes fatigue, brain fog, difficulty sleeping, and anxiety. Upon further inquiry into her weight history, she becomes tearful and expresses frustration at how she feels she is losing control of her own body and no longer feels like herself. Her physical exam and laboratory data are normal despite the severity of her symptoms.
Have you ever told a female patient, "You just need to exercise" or walked out of a patient encounter and thought, She needs a therapist?
If so, pause. If the number and vagueness of complaints seem overwhelming, ask yourself: Could this be menopause or perimenopause?
Menopause is a normal physiologic phase of a woman's life caused by fluctuations in and the eventual loss of endogenous estrogen, manifesting in patients as any number of symptoms, including vasomotor, genitourinary, and/or psychological symptoms.
Unfortunately, menopause, or the period immediately preceding it — perimenopause — is rarely on the curriculum in medical school. This absence could be attributed to a few potential factors:
It's not a "disease" per se.
Clinicians lack knowledge and experience in managing menopause.
Systemic biases have historically dismissed female concerns, especially among people with obesity.
We must break down these barriers. Things to consider:
Just because a condition is "normal" doesn't mean it must be suffered.
Anyone can find trustworthy information via the North American Menopause Society, an organization that credentials physicians in providing safe and exceptional menopause care.
As a society, we must become more comfortable with discussing menopause openly. We must acknowledge how hormonal imbalances that can make someone feel "not themselves" can have consequences for that person's career, relationships, and self-development. And we must recognize that treatment with hormone replacement therapy (HRT) can be immensely therapeutic.
Today we offer HRT to women in the menopausal transition who are experiencing worsening quality of life due to hot flashes and associated symptoms (eg, fatigue, brain fog, anxiety, and poor sleep quality). In this case, the patient did not explicitly report hot flashes, but upon inquiry, she acknowledged that she feels "warmer" all the time.
💡TIP: The "hot flash" is a misnomer and can manifest for some women as a near-constant sensation of elevated body temperature. Also, not everyone experiencing menopausal symptoms suffers from hot flashes.
Remember that the patient came in with a chief complaint of weight gain. Menopause can be a trying time to lose weight or even maintain a healthy weight. A multitude of factors can contribute:
Nighttime hot flashes ("night sweats") can result in sleep disruption, which has been associated with increases in the hunger hormone ghrelin.
Anxiety related to hot flashes and mental changes (eg, brain fog) can increase cortisol, a stress hormone that causes weight gain.
Estrogen suppresses appetite, and fluctuations in estrogen levels like those experienced in the menopausal transition can result in varying levels of hunger and cravings.
Increases in visceral fat and decreases in lean muscle mass as a result of hormonal changes can predispose a person to higher insulin resistance and lower energy expenditure.
Many women find it harder to make healthier food choices or engage in exercise when they are experiencing discomfort and anxiety related to menopausal symptoms.
Fortunately, we have HRT with estrogen (and progesterone if the woman has a uterus) readily available in our menopause treatment tool kit. HRT is effective for managing vasomotor symptoms like hot flashes and night sweats. Because HRT is weight-neutral, we can use estrogen and progesterone to make it easier for women to lose weight with conventional methods such as diet and lifestyle changes.
As endocrinologists, we often manage multiple hormone-related conditions concurrently. In this patient with both perimenopausal symptoms and obesity, there are some special considerations:
Because obesity is independently associated with an increased risk for venous thromboembolism (VTE), we use transdermal estrogen in the form of a patch or gel. While the overall VTE risk in HRT users is quite rare (around 1 in 1000 women), transdermal preparations are associated with a lower risk for VTE compared with oral estrogen. Transdermal HRT is also more lipid-neutral whereas oral estrogen can raise triglyceride levels.
In a woman with a uterus who may still be producing significant amounts of endogenous estrogen (eg, perimenopause/early menopause or obesity, because adipose tissue also produces estrogen), estrogen with daily progesterone (continuous-combined therapy) is preferred over intermittent progesterone (continuous-cyclic therapy) because continuous-combined therapy is associated with less breakthrough bleeding. Progesterone is required to prevent increased risk for uterine cancer associated with unopposed estrogen in those with an intact uterus.
Practice caution with some nonhormonal treatments for vasomotor symptoms, like paroxetine, which can be associated with significant weight gain.
Some antiobesity or antianxiety medications can potentially worsen hot flashes, due to the increase in norepinephrine (eg, phentermine, bupropion).
💡TIP: Cardiovascular exercise, which increases adrenaline, can worsen hot flashes too.
After a careful history to exclude contraindications to HRT (personal history of breast cancer, cardiovascular disease, deep vein thrombosis/pulmonary embolism) and a thorough discussion of the potential risks and benefits, we started this patient on transdermal estrogen plus daily progesterone. She returned 3 months later with significant improvement in all of her symptoms and has been able to increase her exercise. She feels that she is gaining back control of her life. She has stopped gaining weight and is hopeful that further lifestyle interventions, and potentially antiobesity pharmacotherapy, will help her achieve her goals.
Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA. 2013;310:1353-1368. Source
Renoux C, Dell'aniello S, Garbe E, Suissa S. Transdermal and oral hormone replacement therapy and the risk of stroke: a nested case-control study. BMJ. 2010;340:c2519. Source
Roberts H. Type of hormone replacement therapy and risk of venous thromboembolism. BMJ. 2008;336:1203-1204. Source
The North American Menopause Society. Menopause Practice. A Clinician's Guide. 5th edition. The North American Menopause Society; 2015.
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Cite this: Beverly Tchang, Jessica R. Starr. Menopause May Cause Weight Gain; Is Hormone Replacement the Answer? - Medscape - May 02, 2023.