A summary from the current Editorial from the AMS Society, April 2025

Menopause is a natural life stage, yet for many women, it brings a cascade of bodily changes that feel anything but natural, particularly when it comes to weight gain. For many, the experience feels sudden and uncontrollable: “I eat the same, I move the same — and yet the weight creeps on.”

The relationship between menopause and weight is not just a perception. It’s a physiological reality. Weight gain during and after menopause iscausative, not merely associative. Understanding the underlying changes in metabolism, body composition, and hormonal function can help demystify this transition and empower women to manage it with greater awareness.

A Calorie is Still a Calorie — But the Story is More Complex

In his recent book,A Calorie is a Calorie, Professor Keith Frayn unpacks the enduring truth of human energy balance. Despite the array of popular diets and weight-loss strategies — intermittent fasting, time-restricted eating, ketogenic plans — all roads lead back to the same principle: reducing total energy intake.

However, menopause complicates this equation. Not because calories suddenly mean something different, but because how our body processes them begins to change. During menopause, women experience a shift in fat distribution (from hips and thighs to the abdomen), an increase in visceral fat, and a loss of lean muscle mass. These changes directly impact metabolic rate and how efficiently the body uses energy.

Energy Balance: Precision and the Role of Underreporting

Energy balance — the relationship between calories consumed and calories burned — is astonishingly precise. For example, a 5 kg weight gain over 20 years equates to an average surplus of just 5 kcal per day. That’s less than half a cracker.

Interestingly, studies show that most people — especially those with larger body sizes — underreport their food intake by up to 30%. This isn’t necessarily due to dishonesty; rather, it reflects the challenge of accurately estimating portion sizes, ingredients, and hidden calories.

Menopause, Metabolism and Muscle

One of the most significant changes at menopause is the reduction in resting energy expenditure. This decline is driven by hormonal shifts — specifically the drop in oestrogen — which impact the sympathetic nervous system and reduce thermogenesis in brown adipose tissue (a type of fat that burns calories to produce heat). As oestrogen receptors in the brain become less active, the body becomes less efficient at burning energy, even at rest.

Lean muscle mass also decreases, which further lowers basal metabolic rate. Since skeletal muscle plays a vital role in insulin sensitivity and glucose metabolism, this loss can predispose postmenopausal women to insulin resistance and, eventually, type 2 diabetes.

Visceral Fat and Its Health Implications

The increase in abdominal fat that often accompanies menopause is not just a cosmetic concern. Visceral fat — fat stored around the organs — is metabolically active and pro-inflammatory. It contributes to the development of insulin resistance, type 2 diabetes, cardiovascular disease, and even certain types of cancer, such as hormone-receptor-positive breast cancer.

In fact, postmenopausal women are 2–3 times more likely to develop metabolic syndrome compared to their premenopausal peers. This constellation of conditions — including increased waist circumference, high blood pressure, elevated triglycerides, and impaired glucose tolerance — significantly raises the risk of chronic disease.

Hormonal Therapy and Metabolic Health

Research suggests that Menopause Hormone Therapy (MHT) may have a protective effect against some of these metabolic changes. Large-scale studies and meta-analyses have shown that MHT is associated with a reduction in fasting glucose and insulin levels, as well as improvements in insulin sensitivity.

For example, the Heart and Estrogen/Progestin Replacement Study (HERS) demonstrated a 35% reduction in the incidence of diabetes among women using MHT compared to those who were not. These findings were consistent even when changes in body mass index were accounted for, suggesting that oestrogen may act directly on tissues like the liver, muscle, and pancreas to enhance metabolic function.

However, MHT is not suitable for everyone, and decisions around its use should always be made collaboratively between a woman and her healthcare provider, considering her individual health history and preferences.

Behavioural and Lifestyle Factors: Small Changes, Big Impact

Despite the physiological hurdles, lifestyle changes can have a profound impact. Frayn points out that even small adjustments — like reducing daily intake by 50 kcal (half a slice of bread) — can significantly affect long-term weight trends. Regular physical activity, particularly strength training, is critical for preserving lean mass and boosting resting metabolic rate.

Non-exercise activity thermogenesis (NEAT), which includes things like fidgeting, maintaining posture, and household tasks, also contributes to daily energy expenditure. Cold water immersion and other methods to activate brown fat may offer additional metabolic benefits, although more research is needed in this area.

Diet quality matters, too. Reducing energy-dense processed foods, eating more fibre, and focusing on whole foods can support both weight management and gut microbiome health — another factor increasingly recognised for its role in metabolic function.

A New Body, A New Strategy

It’s important to recognise that menopause may require a shift in expectations and strategies. What worked at age 35 may not work at 55 — not because of a lack of effort, but because the playing field has changed. Accepting and adapting to these changes, rather than resisting them, can lead to more sustainable outcomes.

Michael Pollan’s oft-quoted advice —“Eat food. Not too much. Mostly plants.”— remains relevant. But for women in midlife, a more tailored mantra might be:“Eat less. Move more. Lift weights. Sleep well. Show compassion to yourself.”

How We Support Women Through Menopause

At Beyond, we work with women at every stage of menopause to help them better understand and navigate these physiological changes, particularly in relation to energy, weight, and wellbeing.

Our multidisciplinary team, including pelvic health physiotherapists, exercise physiologists, and osteopaths, who may help address many of the challenges that arise during this life stage:

• Support for weight changes through movement plans tailored to energy levels, joint health, and muscle preservation.

• Exercise programs that prioritise resistance training and functional fitness to counteract muscle loss and boost metabolic rate.

• Management of pelvic floor issues, including incontinence or prolapse, which may become more common due to hormonal changes.

• Pain and mobility care, especially in response to joint stiffness, posture changes, or altered activity levels.

• Education around lifestyle factors such as sleep, stress management, and physical activity to improve overall metabolic health.

• Referrals and collaboration with GPs or menopause specialists when hormonal therapy or further investigation may be helpful.

Menopause is a natural part of life, not a diagnosis. But understanding its impact on the body and having access to the right support can make a profound difference in how women experience this transition.

This blog was written from the Current Editorial from the AMS Society April 2025