Perimenopause and menopause: understanding what changes

Menopause occurs on average around the age of 51 years old. It is confirmed after 12 consecutive months without menstruation, in the absence of another cause.

But the hormonal changes begin well before that. We now know that perimenopause is a transitional period that can last for several years, sometimes up to ten years before the last menstrual periods.

During this period, estrogen levels fluctuate, ovulation becomes less regular, and menstrual cycles may change. After menopause, estrogen levels decline permanently while FSH increases.

So the most common symptoms that appear are: hot flashes and night sweats, sleep disturbances and frequent awakenings, mood changes, irritability and difficulty concentrating, vaginal dryness and gynaecological and urinary discomforts, and changes in body fat distribution.

Up to about 80 % women experience vasomotor symptoms (hot flashes, night sweats) during this transition. In some, these unpleasant signs persist for about seven years or more.

A practical tip: Noting your periods and symptoms in a calendar for two or three months helps you better understand their progression. Some symptoms may be more pronounced before your periods, but they can also occur at any time during the cycle.

Obesity and menopause: what are the health risks?

Menopause does not necessarily lead to weight gain. However, with age, muscle mass tends to decrease and energy needs may change. The decline in estrogen primarily promotes the accumulation of fat in the abdominal area.

This visceral fat, located around the organs, is associated with several metabolic risks. This is fat that can increase waist circumference and worsen already present or emerging abdominal obesity. This fat can harm women’s health during the perimenopause.

In a woman living with obesity, this menopausal transition can also exacerbate certain health problems: the Type 2 diabetes (increased risk of insulin resistance), Cardiovascular diseases (hypertension, dyslipidemia and accumulation of risk factors), Sleep apnea (which can worsen fatigue and sleep disorders), Gynecological health  (increased risk of hyperplasia and endometrial cancer), Muscle health  (progressive decrease in muscle mass and strength, sarcopenia).

Or, obesity can also be associated with more frequent or intense hot flashes in some women.

It is then particularly relevant to pay attention to their metabolic health during this transitional period of menopause, even when weight does not change much.

Obesity and hormonal treatment: what risks?

One of the main hormonal concerns concerns the risk of venous thrombosis, that is, the formation of a blood clot in a vein, which can sometimes lead to pulmonary embolism.

Obesity already increases this risk, especially due to changes in coagulation and chronic inflammation.

However, estrogens taken by mouth to treat menopause can stimulate the production of coagulation factors by the liver. The combination of these two factors can further increase the risk of thrombosis.

That is why the way in which hormones are administered is as important as the choice of hormones themselves in obesity in transition during the menopause.

Oestrogens administered by the skin, in the form of gel or patches, prevent the hormones from passing directly into the liver, which makes them safer to use. Observational studies show that they are associated with a lower risk of thrombosis than oral estrogens.

This does not mean that these estrogenic creams applied by the skin are risk-free, but these estrogenic creams are generally a preferable option for women living with obesity when hormone therapy is indicated.

To better understand the importance of preserving your muscles, read our article on physical activity and muscle mass in the management of obesity.

Bioidentical hormones and menopause: are they safer?

Bioidentical hormones have a molecular structure identical to that of hormones naturally produced by the body.

Among the bioidentical medications approved in Canada are, among others, the transdermal estradiol, such as Estrogel, and the micronized progestin, such as Prometrium.

These treatments can have certain advantages:

The transdermal estradiol is associated with a more favorable thromboembolic profile than oral estrogens.

Micronized progesterone It appears to present a lower risk of thromboembolism than some synthetic progestins.

The approved medicines offer standardized doses and controlled quality..

However, bioidentical does not automatically mean safe. The risks also depend on the dose, the route of administration, the duration of the treatment, and the medical history.

To learn more about bioidentical hormones and the precautions associated with their use, consult the recommendations of the Society of Obstetricians and Gynecologists of Canada (SOGC).

Next, it is also necessary to distinguish these drugs from the so-called «personalized bioidentical» hormone preparations, which have not demonstrated better safety and the absorption or dosage of which may be less predictable.

Can I receive hormone treatment with a BMI above 30?

Yes. A BMI above 30 is not, in itself, a contraindication to hormonal treatment for menopause.

Systemic hormonal treatment remains the most effective treatment for hot flashes and night sweats. It can reduce their frequency by about 75 % and significantly reduce their intensity.

It can also improve sleep when awakenings are associated with vasomotor symptoms.

In women with obesity, transdermal estradiol is generally preferred. When the uterus is present, a progestogen or another suitable progestin must be added to the treatment to protect the endometrium from the proliferation of abnormal cells. Therefore, a combined estrogen and progestogen treatment is chosen.

Even so, hormonal treatment can help limit some accumulation of abdominal fat associated with menopause. However, it is not a weight-loss treatment and does not guarantee stable weight loss.

The decision to prescribe is still based on an individual assessment of the relationship between the expected benefits and the risks.

When are hormones not recommended or contraindicated? Let's get a health and safety overview!

Certain situations require special precautions, or even the avoidance of systemic hormonal treatment.

Special attention should be paid to abnormal uterine bleeding, since obesity increases the risk of certain pathologies of the endometrium.

To learn more about the different therapeutic options for menopause, consult the Clinical recommendations from NICE on menopause.

The choice of hormonal treatment must therefore take into account the woman’s overall health, and not just her weight.

Menopause: What non-hormonal treatments are possible?

A contraindication to hormonal treatment does not mean that one has to endure the symptoms without help.

Several non-hormonal treatments can reduce hot flashes and night sweats.

Fezolatinate (Veozah): a new non-hormonal option

Fetzolimod is a recently approved non-hormonal treatment in Canada to relieve moderate to severe vasomotor symptoms of menopause.

It acts directly on the temperature-regulating mechanisms in the brain, without providing any estrogen.

It represents a particularly interesting option for women who cannot or do not want to take hormones.

However, this medication requires medical evaluation and monitoring of liver function with blood tests during the first 9 months of treatment (at 3, 6, and 9 months), due to a rare but potentially serious risk of liver damage.

Other non-hormonal treatments

Other medications have also shown effectiveness against hot flashes:

Some antidepressants from the SSRIs or SNRIs family, prescribed at appropriate doses.

Gabapentin is particularly interesting in certain situations of nocturnal symptoms.

Other options exist depending on the symptoms, medical history, and contraindications.

Cognitive-behavioral therapy and structured clinical hypnosis can also help reduce the impact of symptoms and improve quality of life.

For vaginal dryness, Hydrators and lubricants can provide relief. Low-dose vaginal estrogens may also be considered in these situations where systemic hormones are not suitable, after medical evaluation.

There are therefore different ways to improve comfort and quality of life, even without systemic hormonal treatment.

Why treat obesity during perimenopause and menopause?

This period is an important opportunity to take care of one's weight, body composition, and metabolic health.

An appropriate approach includes several key elements to support:

A balanced diet, With sufficient protein intake to preserve muscle mass.

Muscle strengthening, associated with regular cardiovascular activity.

Attention to sleep, especially by looking for nocturnal hot flushes and sleep apnea.

Behavioral and psychological support, To support lasting changes without blame.

Medical treatment for obesity, When indicated, especially certain medications that act on digestive hormones such as GLP-1 agonists.

To learn more about obesity treatments and their follow-up, read our article on GLP-1 treatments and the importance of medical follow-up.

Why link the treatment of obesity with that of menopause?

Perimenopause and menopause are particularly relevant times for simultaneously acting on hormonal and metabolic health.

When indicated, hormonal treatment can improve hot flashes, sleep, and help limit certain changes in fat distribution. In turn, treatment of obesity can improve several cardiometabolic risk factors, promote a reduction in visceral fat, and contribute to better long-term health.

These two approaches do not replace each other; they complement each other. 

Because health isn’t just about the number on the scales; discover our article too: Liberating yourself from the weight of the body.

By improving sleep, energy, body composition, and metabolic health, joint care can help women navigate this transition in better condition.

That is why a consultation in obesity medicine can be particularly beneficial at this stage of life. At CoAttitude, female hormonal health is an integral part of the assessment. Perimenopause symptoms, sleep, gynaecological and urinary health, and treatment options are discussed when relevant, in a holistic, personalized, and non-judgmental approach.

Which examinations and tests are important for the obesity and menopause treatment team?

Perimenopause and menopause are also opportunities to take stock of one’s preventive health.

Depending on the age, history and risk factors, the doctor may suggest:

• A measure of blood pressure and an assessment of cardiovascular risk.
• A metabolic profile, including blood glucose or HbA1c and cholesterol levels.
• A check of the screening tests for breast and cervical cancer.
• An evaluation of abnormal menstrual bleeding.
• An assessment of bone health and the risk of osteoporosis.
• A screening for sleep apnea when symptoms suggest it.

After 45 years, the symptoms and the course of menstruation are often sufficient to recognize the menopausal transition. A systematic measurement of FSH or estrogens is usually not necessary. Monitoring of hormonal menopause treatment generally relies on symptoms, tolerability, and clinical evaluation, rather than systematic hormone measurements.

What can you do right now?

A few simple steps can help prepare you better for this transition:

• Note your menstrual cycles, your hot flashes, and the quality of your sleep.
• List the symptoms that disrupt your daily life the most.
• Take stock of your metabolic and cardiovascular health.
• Gradually incorporate muscle-strengthening exercises.
• Make sure you get enough protein and eat a variety of foods.
• During a consultation regarding obesity medicine, discuss possible hormonal and non-hormonal treatments.
• Don’t wait until the symptoms become unbearable to consult and take care of your menopause treatment along with that of obesity.

Taking care of your health, beyond weight and hormones

Perimenopause and menopause are natural stages of life, but their impact on health and quality of life deserves to be taken seriously.

Living with obesity may require more caution when choosing hormonal treatments, but that does not mean that you have to give up on them automatically.

Taking care of one’s weight, hormonal health, sleep, and psychological well-being means acting on several essential dimensions of one’s health.

At CoAttitude, we prioritize this holistic approach so that every woman can navigate this transitional period with more comfort, confidence, and serenity.

Every woman deserves an individualized assessment, clear information, and unbiased support in choosing the solutions that suit them.

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