How Can Women Control Their Weight During Menopause?

Salma, a 52-year-old woman who is 2 years past her final menstrual period, is frustrated.1 She walks daily, counts calories, and has never struggled with belly fat until now. Despite maintaining her routine, she has gained 10 pounds over the past year and asks her clinician if hormone therapy can help.

“She asks you the bombshell question because she's been on social media and she thinks pharmacotherapy can help her melt the belly fat,” said Ekta Kapoor, MBBS, FACP, MSCP, associate professor of medicine at Mayo Clinic College of Medicine. “Hormone therapy can actually result in weight gain. It's best avoided.”

Besides highlighting the need for better patient education on treatment types, Salma’s question also captures a common midlife concern: many women feel they are “doing everything right” but still gain weight as menopause progresses. The appropriate response, Kapoor said, is to not dismiss the concern but rather investigate the underlying symptoms that may be sabotaging healthy habits, such as sleep loss, hot flashes, and mood changes.

At The Menopause Society 2025 Annual Meeting, Kapoor explained how menopause symptoms can directly interfere with weight-management efforts and why lifestyle modification remains the foundation of care.

How Common Is Weight Gain During Menopause?

In a Mayo Clinic survey of nearly 5000 women aged 45 to 60 years, weight gain was cited as the most frequent concern, reported by about 80% of participants, followed by sleep problems, exhaustion, and hot flashes.2

“Weight gain is a very common concern in midlife women, it has been studied forever,” Kapoor said.1 “Seven out of 10 women going through midlife, going through the menopause transition, will have either overweight or obesity.”

Midlife women gain an average of 0.4 to 0.7 kg per year, driven largely by a decline in muscle mass and energy expenditure that comes with chronologic aging. There are also certain changes in body composition that happen during the menopausal transition that are primarily linked to hormonal changes.

“Those include an increase in the visceral and sexual fat as well as a decrease in lean tissue and bone mass at the same time,” Brooke Aggarwal, EdD, MS, FAHA, associate professor of medical sciences at Columbia University Irving Medical Center, explained in her session right before.3 “That's why a woman's weight may be stable according to the scale, but her composition actually worsens throughout the menopausal transition, and these changes are distinct from chronological aging alone.”

Weight gain is a common concern in midlife women. | Image credit: New Africa – stock.adobe.com

These changes can feel disproportionate to lifestyle habits, leaving women discouraged and even more uncomfortable in their bodies. However, Kapoor emphasized that addressing other bothersome symptoms of menopause can make weight management more feasible.1

Treating Symptoms That Prevent Lifestyle Change

The first treatment option: eating in a calorie deficit. Kapoor typically advises a 500-calorie daily deficit, translating to roughly 1300 to 1500 calories per day for many midlife women.

“Calorie restriction is key,” Kapoor said plainly. “Unless there is calorie restriction happening, weight gain is inevitable.”

Physical activity should also be encouraged for its mental and metabolic benefits, but Kapoor warned that patients often fall into “all-or-nothing” thinking. For example, a patient who doesn’t have time to hit 10,000 steps in a day may be so overwhelmed by the effort that she doesn’t even make it, but even modest activity supports body composition, mood, and sleep quality.

“The key message has to be, something is better than nothing,” she said. “Setting lofty goals for them is setting them up for disappointment and frustration with themselves.”

However, symptoms like vasomotor instability, sleep disturbance, and anxiety can make adherence to a calorie-deficit diet and regular exercise much more difficult. Kapoor underscored that clinicians should first identify which symptom cluster—hot flashes, poor sleep, or mood disorders—is most disruptive, and that treatment choice should follow that hierarchy. When vasomotor symptoms are prominent, hormone therapy can be considered first-line for eligible women.

“Estrogen-based hormone therapy is the most effective for treatment of vasomotor symptoms, assuming there is no contraindication, but there is no direct effect on weight,” she said. “Hormone therapy is to be considered weight neutral. Then again, you can imagine if a woman's hot flashes go away and she's sleeping better, there's probably an indirect effect, but no direct effect.”

If hormone therapy is contraindicated, nonhormonal approaches such as cognitive behavioral therapy and clinical hypnosis have strong evidence, Kapoor noted. Among pharmacologic options, she advised choosing weight-neutral or weight-favorable agents—venlafaxine, desvenlafaxine, oxybutynin, or fezolinetant—and avoiding drugs like paroxetine, gabapentin, or escitalopram, which may promote weight gain in patients.

Can Sleep Help Women Control Weight?

Sleep disturbances affect roughly 70% of women during menopause and can occur even in the absence of hot flashes. Kapoor cautioned that clinicians often underestimate this issue, noting two-thirds of women with increased wakefulness don’t experience vasomotor symptoms.

“That's a very important thing to recognize, because we just tend to club the 2 together,” she said. “But you will see many women in your offices who will come with isolated sleeping difficulties in the absence of vasomotor symptoms. Why is that important to know? Because it impacts management.”

Poor sleep contributes to weight gain by disrupting ghrelin and leptin signaling, increasing daily energy intake by 250 kcal or more. Chronic sleep deprivation of fewer than 5 hours per night is linked to a 32% higher risk of major weight gain over time.

For women whose main complaint is sleep disruption, Kapoor recommended screening for obstructive sleep apnea, even when classic symptoms like snoring are absent. Cognitive behavioral therapy for insomnia remains a first-line option, and although hormones can help if hot flashes are the driver, they have limited benefit when vasomotor symptoms are absent.

References

1. Kapoor E. Managing menopause symptoms to optimize weight loss. Presented at: The Menopause Society 2025 Annual Meeting; October 23, 2025; Orlando, FL.
2. Weight gain in women at midlife: Unique issues in management and the role of menopausal hormone therapy. Mayo Clinic. February 25, 2017. Accessed October 23, 2025. https://www.mayoclinic.org/medical-professionals/endocrinology/news/weight-gain-in-women-at-midlife-unique-issues-in-management-and-the-role-of-menopausal-hormone-therapy/mac-20431465
3. Aggarwal B. Body composition changes in menopause. Presented at: The Menopause Society 2025 Annual Meeting; October 23, 2025; Orlando, FL.