Weight gain is a common occurrence during menopause — and often an unwelcome one.
According to Mayo Clinic, women tend to notice some weight gain starting in the years leading up to menopause, a period called perimenopause, and it’s common for women to gain about 1.5 pounds (lb) each year of her fifties.
Extra fat usually appears around the belly, and it’s harder to shed these new extra pounds than it is earlier in adulthood, says Disha Narang, MD, the director of obesity medicine at Northwestern Lake Forest Hospital in Evanston, Illinois.
Dr. Narang says weight loss medication can help some people safely manage menopausal weight gain when exercise and eating a healthy diet may not be enough.
“I see a lot of women in this phase of life who have worked out and been healthy their whole lives and are frustrated with the weight gain they’re experiencing now. Starting medication is not a failure,” she says.
What Causes Menopausal Weight Gain?
Several factors cause weight gain during the menopause transition.
“Our metabolism starts to slow down, but also when our estradiol [estrogen] levels drop, it also increases belly fat in our midsection,” Narang explains.
Menopause causes a significant — and permanent — shift in hormones. The big ones are estrogen and progesterone, two hormones produced by the ovaries. Testosterone also decreases, but not as much as estrogen, according to the North American Menopause Society.
This skewed ratio is why menopausal weight gain usually collects around the belly, says Joanne Dushay, MD, an endocrinologist at Beth Israel Deaconess Medical Center in Boston.
“That type of central distribution of body fat is associated with your body being less responsive to insulin, and that can contribute to trouble with weight loss,” she says.
According to Dr. Dushay, normal aging is associated with a slower metabolic rate — the number of calories your body burns to sustain normal function — in both men and women. A slower metabolic rate means your resting body burns fewer calories, which can contribute to weight gain.
This normal process may actually be protective as the body ages, she adds: “There may be advantages to having a slower metabolic rate as you get older.”
Can Semaglutide Help With Menopausal Weight Gain?
These days when people talk about weight loss drugs, they’re usually talking about a class of medications called glucagon-like peptide-1 receptor agonists (GLP-1s). These include the three most common injectable medications: Wegovy — the only GLP-1 agonist approved by the U.S. Food and Drug Administration (FDA) for weight loss — and Ozempic, which are both semaglutide; and Mounjaro, which activates both the GLP-1 and gastric inhibitory polypeptide (GIP-R) receptors. Ozempic and Mounjaro are approved medications for type 2 diabetes.
These medications help people lose weight by suppressing the appetite and lowering blood sugar levels by prompting the pancreas to produce more insulin, slowing the rate at which food moves through a person’s digestive system and keeping them full longer.
Studies suggest they are effective.
A double-blind clinical trial published in 2021 in the New England Journal of Medicine included nearly 2,000 adults with obesity who took semaglutide every week for over a year in addition to exercising and eating well. Three-quarters of the participants were female, and the same number were white. Their average age was 46, they had an average BMI of about 38, which is considered obese, and none of the participants had diabetes. Those in the semaglutide group shed an average of 15 percent of their body weight after 68 weeks compared with less than 3 percent in a placebo group.
Another trial, published in 2022 in the journal Nature Medicine, included just over 300 participants with an average age of 47 and showed similar results. All the participants in this study were either overweight or had obesity, along with one weight-related medical condition, including some who had type 2 diabetes. Their average BMI was 38.5, nearly 80 percent were female, and more than 93 percent were white. Those who took semaglutide once weekly for about six months lost about 15 percent of their body weight, compared with just over 2.5 percent in the placebo group.
Because there isn’t any data specifically on how post-menopausal women responded to the drug, and most studies on semaglutide are predominantly on white women, it’s hard to say for sure how people in these groups may respond differently to GLP-1s. “I wouldn’t say there is a physiological argument for post-menopausal women responding in a less robust way to GLP-1 agonists,” Dushay says.
There is one caveat: “[These drugs] don’t typically help with weight that is centrally distributed,” she says. That means the drugs may not help decrease fat deposits in specific areas, such as the belly fat associated with menopause weight gain.
Older women who have gone through natural menopause also may not be part of a group Dushay calls “super responders.”
In her own clinical experience, she thinks of people as super responders if they are able to lose 10 percent or more of their body weight with semaglutide. From there, average responders typically lose about 5–10 percent of their body weight, and non-responders either see no change or lose less than 5 percent.
“I would say the post-menopausal women I treat are not typically super responders,” she says.
A review of FDA adverse events, published in 2022 in Frontiers in Public Health, which included nearly 5,500 people who took semaglutide, found that people ages 18–65 were more likely to experience digestive problems like nausea and vomiting than people who were older than 65. The data did not determine if a person was taking semaglutide for weight loss or for type 2 diabetes, but the data was collected after Wegovy was approved for weight loss, meaning some of these people may have been taking semaglutide as a weight loss medication.
But a 2018 clinical trial that included nearly 3,000 people taking semaglutide for type 2 diabetes found that people over 65 were more likely to experience nausea and vomiting, and were more likely to stop taking semaglutide because of these side effects.
Regardless of whether they experience gastrointestinal side effects, Dushay says older people need to be particularly careful about bone and muscle loss.
Body composition changes with age. People tend to have more fat and less muscle and bone density as they age, than when they were younger. According to Dushay, bone density peaks in our thirties. After that it steadily declines along with muscle mass as well as strength.
“You have to take active steps to maintain your muscle mass as you age,” she says. “That is especially true with a medication such as a GLP-1 agonist that has the potential to cause significant and at times rapid weight loss.”
Narang says when a person loses a substantial amount of weight, they don’t just lose fat. They also lose muscle in particular, which means weight loss drugs can exacerbate natural muscle — and bone density — loss in post-menopausal women.
“Something we emphasize with medical weight management is the importance of resistance exercise,” she says. Adding weight training or body weight exercises to your workout routine as you age is important for everyone, but especially people who use weight loss drugs.
Who Can Use Wegovy?
The FDA has approved Wegovy for anyone who has both a BMI of over 27, which falls in the Centers for Disease Control and Prevention’s overweight or obese ranges (BMI of at least 25), as well as one obesity-related health condition, such as prediabetes. This means not everyone will qualify for the medication. But there may be other conditions your doctor can take into consideration.
“An attentive physician will take everything into account, not just those established metabolic risk factors,” says Dushay, noting that conditions such as depression and osteoarthritis may be reasons someone may benefit from weight loss medication.
The high cost of the semaglutide — about $1,400 for a month’s supply — can make it difficult to access. There’s also a shortage, which means that even if someone is prescribed Wegovy for weight loss, they may not be able to fill the prescription, Narang says.
“At the end of the day, the medication is just a resource and the lifestyle aspect — exercising and eating well — is incredibly important to sustain over time,” she says.