Understanding Weight Gain in Women During Perimenopause

Women in midlife commonly come to Beverly Tchang, MD, with concerns about gaining weight, even though their diet and exercise routines have not changed.

The patients are frequently frustrated about the uncontrollable changes and are usually experiencing a range of hormonal shifts as they go through perimenopause, said Tchang, an endocrinologist and associate professor of clinical medicine at Weill Cornell Medical College, New York City.

“Perimenopause is a natural phase of a woman’s life, but because so much of it is out of our control, it’s frustrating because many women feel like they can’t fix it,” she said. “They can’t get back to where things were in their prior decades. A second source of frustration is that often, when they do see a healthcare professional, the professional doesn’t know how to help them because they identify this as something that naturally happens.” 

Studies show women in midlife generally experience a change in body composition around perimenopause, primarily faster accumulation of fat around their waistline.

Aging-related changes — such as decreased energy expenditure and less physical activity — are common culprits for weight gain in midlife women, according to Maria Hurtado, MD, PhD, an endocrinologist at the Mayo Clinic in Jacksonville, Florida.

Hurtado analyzed this subject in the journal Current Obesity Reports.

“Weight gain affects the majority of midlife women, irrespective of race or ethnicity,” Hurtado said in an interview with Medscape Medical News. “However, evidence suggests that women with lower socioeconomic status and those from racial and ethnic minority groups, such as African American and Hispanic women, tend to have higher baseline body weight and may be more vulnerable to weight gain and its clinical ramifications in the long term.”

The health consequences for such body changes in midlife include the development of cardiometabolic diseases, osteoarthritis, and cancer, as well as the worsening of cognition, mental health, and menopause symptoms, according to Hurtado’s analysis.

Although perimenopause is normal, Tchang said it doesn’t mean women have to suffer through the experience without help or intervention.

“I think we need to have more open conversations about what women are experiencing during this time and to be open to intervening on it to improve that quality of life, even though what they’re experiencing may not be considered pathological,” she said.

Treating Weight Gain in Midlife Women

When women in midlife share their worries about weight gain, Wisconsin-based obesity specialist Leslie Golden, MD, first normalizes what they’re experiencing, she said.

Patients should understand the problem is not a failure of willpower — it’s physiology, said Golden, founder of Weight In Gold, a clinic specializing in sustained weight health using health coaching and the latest medications.

“Then, we take a step back and look at the full picture,” she said.

Some questions to consider are: Is the patient eating sufficient protein? Are they preserving muscle mass through resistance training? How is their sleep? Are there signs of metabolic conditions, such as insulin resistance or early changes in blood sugar?

At her practice, Golden takes a science-based, whole-person approach that may include medication, shifting the type of movement patients are doing, or improving the quality of patients’ nutrition, she said.

“It’s rarely about doing more,” Golden said. “Often, it’s about doing things differently and supporting the body instead of fighting it.”

Tchang noted that some healthcare professionals may not feel comfortable intervening on menopausal management. If so, it’s important to direct patients to trusted resources, or if time allows, to educate themselves on this period in women’s lives, she said.

She recommends The Menopause Society’s website, which has information and education that can be helpful for both patients and providers.

Clinicians may also want to consider initiating preventative treatment for women with normal or overweight BMI to prevent excess weight gain, ideally starting in their 30s, Hurtado said. This approach should proactively address potential weight gain through four key pillars:

• Consciously adjusting caloric intake, emphasizing a diet rich in fruits, vegetables, and lean protein
• Encouraging regular and optimized exercise to combat age- and menopause-related lean mass loss
• Addressing menopausal symptoms, such as sleep disruption and vasomotor symptoms
• Providing mental health support and stress management resources

Hurtado said that while early counseling focusing on tailored nutrition, exercise, and behavioral strategies is essential, many patients will require additional support due to metabolic and behavioral adaptations that hinder sustained weight loss.

“For those who do not achieve desired results with initial interventions, second-line therapies — such as obesity medications, endoscopic interventions, or bariatric surgery — should be considered within a multimodal and individualized approach that prioritizes the patient’s health, contraindications, and preferences,” said Hurtado.

How Sleep and Stress Impact Weight Management

If patients in midlife are doing “everything right” and still not seeing progress on their weight loss, sleep and stress are often the missing pieces, Golden said.

Chronic sleep deprivation and stress can promote fat storage, particularly in the midsection, by disrupting hunger and fullness signals, increasing cravings, and raising cortisol levels, she said.

One study found that nearly 52% of postmenopausal women have a sleep disorder.

When women in midlife report sleeping problems, Golden looks at their daily routines, talks through what’s realistic, and sets small goals. Sometimes, it’s about creating a nighttime schedule, reducing screen time or caffeine, or identifying stressors and figuring out what’s in their control, she said.

When needed, Golden brings in a behavioral health or coaching team to help them build skills in these areas.

“Very often, it also means challenging some deeply held beliefs — especially the idea that rest is a luxury or that taking care of themselves is somehow selfish,” she said. “I remind them: You’re on the list of people you take care of. Giving yourself permission to rest, to pause, to protect your energy; those aren’t indulgences. They’re essential parts of healing and sustainable change.”

With sleep problems, it’s also critical to make sure you’re not missing an actual disease diagnosis, such as constructive sleep apnea, Tchang said.

“This is something that I am particularly cognizant of because many of my patients also come in with obesity,” she said. “The obesity, plus the age, midlife, and these hormonal changes, are associated with increased risk of sleep apnea. So when someone comes to you with a sleep concern, it’s important to investigate a sleep disorder or refer to a sleep specialist who can do that.”

In addition to hormonal changes, women may be developing a new career, or they may have more family responsibilities at this point in their lives. “Multiple needs are often converging in this fourth decade of life that can add to stress,” Tchang said.

For many women in this phase, it’s a good time to reassess personal boundaries and redefine what self-care looks like, Golden said. That might mean making space for rest without guilt, saying ‘no’ more often, or investing in their own health in ways they may have deprioritized for years, she said.

“When those shifts happen alongside medical and behavioral support, that’s where we see real, sustainable change,” Golden said.