The third meeting of the herea Expert Board took place in December 2023. Dr. Susanna Weidlinger, Senior Physician at the University Clinic for Gynecology in Bern and President of the Swiss Society for Gynecological Endocrinology, Contraception and Menopause, presented her paper "Impact of estrogens on resting energy expenditure: A systematic review" on the topic of "Menopause and weight change". The review deals with the influence of medication with natural and synthetic estrogens on the resting energy expenditure (REE) of healthy normal to overweight women.1
The authors examined the relationship between HRT and energy balance. Animal studies suggest a possible link between estrogen and brown adipose tissue (BAT) activation, which may increase resting energy expenditure (REE) and contribute to negative energy balance.1
Contrary to widespread concerns, HRT could counteract age-related weight gain by reducing energy intake, increasing energy expenditure through physical activity and, most importantly, increasing resting energy expenditure. Large randomized controlled trials such as PEPI and DOPS showed less weight gain in postmenopausal women after 3-5 years in women that had received HRT compared to placebo.2–4
In addition to the potential effects of decreasing estrogen levels on weight, studies suggest that the increase in follicle-stimulating hormone (FSH) levels during perimenopause may lead to fat redistribution and drive lipid biosynthesis.5 While most contraceptives have a lowering effect on FSH levels, a similarly pronounced decrease in gonadotropins is not seen with HRT.6
Overall, the widespread assumption that HRT leads to weight gain has been refuted in studies.1–4 The review by Dr. Weidlinger emphasizes that HRT can even potentially lead to a slight reduction in age-related weight gain. The fear of weight gain as a result of HRT is therefore unwarranted.
Resting energy expenditure decreases consistently in the pre- to postmenopausal phase of life (40-60 years).1 However, it is difficult to accurately determine the change in resting energy expenditure. Studies on the change in REE with HRT or contraceptives (COC) show either an increase in REE or no difference between the HRT/COC groups versus the placebo-treated groups.
For patients who are not considering HRT or for whom HRT is contraindicated due to medical history, the non-hormonal drug fezolinetant offers an alternative.7 In animal studies and human studies, no weight gain was observed with fezolinetant treatment.8
Overall, the experts agree that more data is needed to better understand the relationship between the hormonal changes associated with menopause and weight gain.
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