Can HRT help with weight loss?

Hot flashes. Mood swings. Erratic periods. Menopause can feel like one long horror flick full of plot twists — like when an extra five or ten pounds attach themselves to your body out of nowhere.

If it feels as if someone rewired your metabolism and didn’t tell you, you aren’t imagining things, and you certainly aren’t alone. Menopausal weight gain isn't just a matter of willpower or aging. It's also a matter of hormones, the very things driving menopause in the first place. And that’s also why hormone replacement therapy (HRT) is emerging as a symptom solution.

In recent years, research has uncovered fascinating connections between HRT and weight management during menopause. Even more intriguing is growing evidence suggesting that when combined with newer GLP-1 medications, HRT could give your weight-loss efforts an extra boost. Here’s the science and strategies you need to know.

What is HRT?

Our hormones exist in a careful balance. When menopause arrives, lower levels of estrogen and progesterone can throw everything off (cue: symptoms). HRT can add back what’s missing, via pills, patches, creams, gels, and even a vaginal ring — and in synthetic or bioidentical forms. The goal? To alleviate disruptive menopause symptoms like hot flashes, night sweats, mood swings, sleep issues, etc.

But HRT isn't just about making hot flashes less... well, flashy. It's a comprehensive approach that addresses multiple aspects of menopause, including potential impacts on weight and metabolism.

The link between hormones and weight

To understand how HRT could possibly help with weight gain, you need to first understand how hormones affect weight. These powerful chemical messengers play a pivotal part in many of our body’s processes. Estrogen, in particular, has several crucial roles in regulating weight:

• It helps regulate your metabolic rate (how quickly you burn calories)
• It influences where fat is stored in your body
• It affects your appetite and feelings of fullness
• It impacts insulin sensitivity (how efficiently your body processes carbs)

When estrogen levels are optimal, they also help ensure that fat is distributed more evenly throughout your body, rather than concentrating around your abdomen. It also helps maintain muscle mass, which is essential for a healthy metabolism.

Progesterone, estrogen's hormonal partner, plays more of a supporting role in this metabolic dance. Together, they help maintain the delicate balance that keeps your weight relatively stable.

Menopause and weight changes

When menopause comes, your body’s old instruction manual goes out the window. “One of the biggest complaints I hear from my patients is about [menopausal] weight gain, and specifically, weight gain around the midsection,” says Stephanie Faubion, M.D., director of the Center for Women’s Health at Mayo Clinic, medical of the North American Menopause Society, and member of the WeightWatchers Scientific Advisory Board.

“Women commonly tell me that they haven't changed anything in terms of their diet and exercise, and yet, they are gaining weight,” says Faubion. “I say ‘exactly.’ If you haven't changed anything, you will gain weight in midlife. That's because our bodies are changing during this time, and what worked in the past isn't going to work now."

During the menopausal transition (which can last upwards of 10 years) women experience an average weight gain of 5–7 pounds due to several factors:

• Loss of muscle mass that further reduces calorie-burning capacity
• Sleep disruptions that affect hunger hormones
• Insulin resistance that makes it harder to process carbohydrates
• Age-related changes in physical activity
• Declining estrogen levels that slow metabolism

But what’s most frustrating for many women isn’t the number of pounds — it’s where those pounds end up.

Premenopause, estrogen encourages fat to settle in the hips and thighs — a pear shape. “A decline in estrogen can lead to an increase in belly fat, which is associated with a more ‘apple-shaped’ fat distribution,” notes Dr. Kameelah Phillips, M.D., OB/GYN, founder of Calla Women's Health and author of The Empowered Hysterectomy.

This isn't just a cosmetic concern — abdominal fat is metabolically active and associated with increased risks of cardiovascular disease, type 2 diabetes, and other health conditions, says Phillips.

Can HRT help with weight loss?

While HRT isn't marketed as a weight-loss treatment, research suggests it might have beneficial effects on body composition. "Women want to know whether using hormone therapy will reverse these changes,” says Faubion. “I wish it were that simple, but the reality is that these changes relate to the loss of ovarian hormones, but also to the aging process itself. Men gain weight in midlife too. For women who are experiencing menopause symptoms, there may be some benefit in terms of combating belly fat accumulation. But it's important to note that hormone therapy isn't a weight-loss drug."

Contrary to what you might have heard, there's little evidence that HRT alone causes weight gain. In fact, some studies show quite the opposite — HRT has been linked to modest decreases in BMI and waist circumference, particularly in the early stages of menopause.

Here's how HRT may potentially influence weight:

1. Upping metabolic rate: By replacing some of the lost estrogen, HRT may help prevent the slowdown in metabolism that contributes to weight gain.
2. Improving fat distribution: HRT may help maintain the more favorable fat distribution patterns of premenopause, reducing the tendency toward abdominal fat accumulation.
3. Supporting muscle mass: Hormones play a role in maintaining muscle tissue, which is essential for a healthy metabolism. HRT may help slow the loss of muscle mass that occurs during menopause.
4. Promoting sleep: By reducing night sweats and improving sleep quality, HRT may normalize hunger hormones that get disrupted with poor sleep.
5. Boosting diet, mood, and energy: Managing depression and fatigue — often a downstream effect from lack of sleep — can make it easier to maintain healthy eating patterns and stay physically active.
6. Reducing inflammation: Estrogen may also decrease levels of inflammation in the body, notes Phillips. “Chronic inflammation is a risk factor for diseases such as heart disease, rheumatoid arthritis, and Alzheimer's."

It's important to note that while these effects are promising, they're generally modest. HRT isn't a magic weight-loss pill — rather, it may help create a more favorable internal environment for weight management when combined with healthy lifestyle changes.

Combining HRT with a GLP-1 for weight loss

Now, here's where things get really interesting. Growing research suggests that combining HRT with newer weight-loss medications, particularly GLP-1 receptor agonists like semaglutide (sold under brand names like Wegovy and Ozempic) and tirzepatide (sold under the brand names Mounjaro and Zepbound) might create a powerful synergy for weight management in menopausal women. “Using the both together can help support metabolic health, minimize menopausal symptoms that impact skeletal health, increase motivation to exercise, and support significant weight loss and maintenance,” says Phillips.

A recent study published in the journal Menopause found that postmenopausal women who used both hormone therapy and semaglutide experienced significantly greater weight loss compared to those using semaglutide alone. Specifically, over a 12-month period, the HRT group achieved an average total body weight loss of 16%, while the non-HRT group achieved 12% — approximately 30% greater weight loss in the HRT group. Dr. Faubion has additional research forthcoming, which will show similar results.

Why might this combination work particularly well? Several mechanisms could explain this hormonal harmony:

1. Restoration of estrogen levels: HRT helps restore estrogen, potentially improving metabolic rate and reducing fat accumulation.
2. Increased GLP-1 levels: Estrogen increases our natural production of appetite-controlling GLP-1, which declines as we age.
3. Improved insulin sensitivity: Estrogen influences glucose metabolism. HRT may enhance insulin sensitivity, complementing the glucose-lowering effects of GLP-1 medications.
4. Enhanced appetite regulation: Estrogen and GLP-1 act on overlapping areas of the brain to reduce food intake, and estrogen potentially sensitizes these areas of the brain to have a greater response to GLP-1. So, by stabilizing estrogen levels, HRT may amplify the appetite-suppressing effects of GLP-1 therapies.
5. Targeted reduction in visceral fat: HRT has been associated with decreased visceral (abdominal) fat, which is particularly responsive to GLP-1–induced weight loss.

This exciting area of research suggests that for menopausal women struggling with weight, the combination of hormone replacement and newer weight-loss medications might offer more effective results than either approach alone.

Role of lifestyle changes

"We all start to lose muscle mass during midlife, about 1% per year,” says Faubion. “Muscle burns more calories than fat, so we burn fewer calories both at rest and with exercise. Hormone therapy isn't going to reverse all of these changes. That's why lifestyle [modifications] during midlife are especially important and can set women up for staying healthy as they age."

During menopause, a combination of proper nutrition and regular physical activity remains essential. Research shows that improving diet quality and engaging in routine physical activity during menopause has been associated with improvements in body composition and reductions in waist circumference.

Some specific lifestyle recommendations for menopausal women include:

• Strength and resistance training: These exercises help build and maintain muscle mass, which naturally declines during menopause. More muscle means a higher metabolic rate. “Strength and resistance training is key to prevent menopausal bone loss as well as stimulate the metabolism and insulin sensitivity,” says Phillips. “I highly encourage my patients to pick up weight training 4-5 times a week. They will not “ bulk up” or become masculine with consistent training, but will reap the benefits of weight loss/maintenance, cardiovascular health, improved mood and sleep, as well as other mental health benefits.”
• Heart-healthy diet: Aim for 3–4 servings of vegetables, 1–2 servings of fruit, 30–45 grams of fiber, less than 1500 mg of sodium, and less than 10% of total caloric intake from saturated fats per day. “A diet rich in fiber and complex carbohydrates helps improve insulin sensitivity, gut health, and can help regulate your appetite,” says Phillips.
• Adequate protein intake: Consuming 1–1.5 g of protein per kg of body weight supports muscle maintenance and bone health.
• Mindful eating: Pay attention to hunger and fullness cues.
• Limiting trigger foods: Spicy foods, hot beverages, and alcohol (particularly red wine) may trigger hot flashes in some women.
• Proper hydration: Hormonal changes can affect thirst perception, so aim for about 33 mL of fluid per kg of body weight daily.

These kinds of principles form the foundation of the WeightWatchers Program, which can be tailored to your needs in a number of ways —including R.D. visits for extra nutrition support during this life stage. By combining lifestyle approaches with medical interventions like HRT and GLP-1s (when appropriate), you're creating a comprehensive approach to managing menopause-related weight changes.

Risks and side effects of HRT

Let's be real: Every medical treatment comes with potential risks and benefits, and HRT is no exception. It's not appropriate for everyone, and the decision to start HRT should always involve a careful discussion with your healthcare provider about your specific health profile.

Potential side effects of HRT can include:

• Breast tenderness
• Bloating
• Headaches
• Mood changes
• Nausea
• Vaginal bleeding

More serious risks that have been associated with certain types of HRT include:

• Increased risk for venous thromboembolism (blood clots)
• Potential increased risk of breast cancer with long-term use of combined estrogen-progestin therapy
• Possible increased risk of stroke

It's worth noting that many of these risks vary based on:

• The type of HRT (estrogen-only vs. combined)
• The delivery method (oral vs. transdermal)
• When HRT is started (early vs. late menopause)
• Your personal and family medical history

The current recommendation is that HRT should be prescribed primarily to alleviate menopause symptoms rather than for chronic disease prevention. The U.S. Preventive Services Task Force recommends against using HRT solely for the prevention of chronic conditions in menopausal women.

If HRT is used, it should be at the lowest effective dose and for the shortest duration needed to achieve symptom relief. Regular follow-up with your healthcare provider is essential to reassess the benefits and risks over time.

Phillips notes that early use of HRT (before age 60) is helpful to minimize the effects of vasomotor symptoms, preserve muscle, and manage insulin and lipid profiles.

Who HRT is best for

Who might be the best candidates for considering HRT as part of their menopause management strategy? Patients for whom the benefits clearly outweigh the risks.

HRT may be particularly beneficial for:

• Women experiencing moderate to severe menopause symptoms (hot flashes, night sweats, sleep disturbances)
• Women who are within 10 years of menopause onset or under age 60
• Women without contraindications, such as a history of breast cancer, endometrial cancer, or certain other estrogen-sensitive cancers; a history of blood clots or stroke; liver disease; or unexplained vaginal bleeding.

If weight management is a specific concern, the emerging research on HRT combined with GLP-1 medications suggests this approach might be particularly beneficial for:

• Postmenopausal women with obesity or overweight
• Women who haven't responded adequately to lifestyle changes alone
• Women without contraindications to either HRT or GLP-1 medications

Remember, the decision about whether to use HRT (with or without weight-loss medications) is highly individual. What works wonderfully for your friend might not be right for you, and vice versa. This is definitely a situation where personalized medicine — treatment tailored to your specific health profile and goals — is essential.

The bottom line

The relationship between menopause, hormones, and weight is complex but increasingly understood. While HRT isn't a weight loss treatment per se, emerging evidence suggests it may help create a more favorable metabolic environment, especially when combined with appropriate lifestyle changes and, in some cases, medications specifically designed for weight management.

If you're struggling with menopause-related weight changes, know that you're not alone, and there are evidence-based approaches that might help. The key is working with knowledgeable healthcare providers who can help you navigate the options and develop a personalized approach that addresses your specific needs and goals.

Remember: menopause isn't just about endings — it's also about new beginnings and opportunities to reimagine your approach to health and wellness. With the right information and support, you can write the next chapter of your health story with confidence and optimism.