The Connection Between Menopause & Belly Fat

August 24, 2023

Many older women notice that they start gaining belly fat, especially in the years leading up to and following menopause.

“Like so many things related to women’s health, it’s complicated,” says University Hospitals OB/GYN and menopause specialist Rachel Pope, MD, MPH. “Research tells us that the number one reason for increased belly fat for the general population is a lack of physical activity, but for women in the menopause transition, the same active lifestyle can still result in fat redistribution to the belly. This is due to metabolic changes incited by hormone fluctuations. Other aspects of perimenopause like dysfunctional sleep patterns don’t help.”

Dr. Pope explains why abdominal weight gain is so common in older women and what can be done about it.

Hormonal Changes

During menopause and the years leading up to it (perimenopause), women undergo complex hormonal changes. The balance of estrogen, progesterone and testosterone – which work together during the reproductive years to trigger ovulation and support pregnancy – begins to shift, with levels of estrogen and progesterone dropping sharply. These changes trigger other hormonal changes that can contribute to weight gain, including:

Fat storage changes. Estrogen, particularly estradiol, influences where the body prefers to store fat. During the reproductive years, estrogen promotes fat storage in the hips, thighs and buttocks as subcutaneous fat. As estrogen levels decline during the menopause transition, fat storage shifts toward the abdomen, favoring visceral fat, the deeper fat that surrounds internal organs. Visceral fat is associated with higher risk for insulin resistance, cardiovascular disease, and type 2 diabetes, which is why this shift matters beyond appearance alone.
Loss of muscle mass slows metabolism. Aging itself drives a gradual loss of skeletal muscle mass known as sarcopenia. Lower estrogen accelerates this process, since estrogen receptors are present in muscle tissue and support muscle protein synthesis. Because muscle is more metabolically active than fat, less muscle mass means a lower resting metabolic rate. Even without a change in diet or activity level, women often find they burn fewer calories at rest during perimenopause, which can contribute to fat gain, particularly in the abdominal region.
Changes in insulin sensitivity and cortisol regulation. Estrogen also plays a role in maintaining insulin sensitivity. As levels fluctuate and then decline, many women experience a degree of insulin resistance, meaning the body needs more insulin to manage blood sugar. Insulin resistance is closely tied to increased visceral fat storage, creating something of a feedback loop.
Changes in production of the hunger hormones, leptin and ghrelin. Less estrogen causes a decrease in leptin (a natural appetite suppressant) and, when sleep patterns are disrupted, an increase in ghrelin, a hormone that signals hunger and prompts the body to hold onto excess weight.

Increased Stress & Mood Swings

Perimenopause is often a time of increased sleep disruption and stress, which can elevate cortisol, Dr. Pope explains. Chronically elevated cortisol has a well-documented association with central fat accumulation, compounding the hormonal shifts already underway.

“In addition, women at this stage of life are often dealing with significant life challenges, including children leaving home, the demands of caring for aging parents and relationship changes with a spouse or partner,” says Dr. Pope. “The emotional and physical stress that often accompanies these changes can lead to changes in sleep and eating habits and weight gain.”

Changing Sleep Patterns

“Lower estrogen levels in menopausal women, combined with common mood disorders like anxiety and depression, may make it more difficult to fall or stay asleep and increase the risk of sleep apnea,” says Dr. Pope. “Women who are not getting enough sleep feel tired the next day, are less likely to be active and more likely to reach for comfort foods – most often simple carbohydrates which can lead to weight gain.”

How to Battle the Belly Bulge

“The good news is that there is treatment for all of these factors,” says Dr. Pope. "Addressing each factor will cumulatively help the belly fat, but it’s not easy.”

Dr. Pope advises women to stick to healthy eating and consult a dietitian or nutritionist if they need help to meet the protein and fiber needs of perimenopause and menopause.

Nutrition. When the metabolism slows during menopause, it is important to cut back on processed and fatty foods to avoid weight gain. The Mediterranean diet has consistently been shown to be the best for cardiovascular health, says Dr. Pope.

Exercise. Increased strength training to combat muscle loss is helpful as muscle burns surrounding fat. Menopausal women should focus on both aerobic exercise for heart health and weight training to build lean muscle and protect bones.

Hormone Therapy. Menopause hormone therapy (MHT) does not cause weight loss directly, but in an indirect way, it can help with weight loss. MHT can help women sleep better, have more energy and fewer negative mood changes and less joint pain – all of which support weight loss efforts. Women who are perimenopausal or within 10 years of their last menstrual period are usually the best candidates for hormone therapy,” says Dr. Pope.

Stress Management. Keep your stress levels under control using a combination of better nutrition, exercise and integrative health approaches, including acupuncture, meditation, yoga and massage therapy. Sometimes behavioral health counseling may also be useful.

Surgery/Medications. For women with risk factors for weight-related illness or complications, bariatric surgery or weight loss medications may be an option.

“Above all else, I encourage my patients to embrace the changes in their body and not rely on the numbers on the scale for their self-esteem,” says Dr. Pope. “Women can be really hard on themselves and our culture has very strict beauty standards – try to show yourself a little love and compassion during this new stage of life. The goal for all of this should be strong and healthy, not skinny.”