Weight & Body Composition - Come Sit With Me

Your pants don’t fit. You haven’t changed how you eat. You’re doing the same exercise you’ve always done. And yet.

The weight conversation during perimenopause is loaded with shame and misinformation. So let me tell you what’s actually happening—because it’s not as simple as “eat less, move more,” and understanding the biology matters.

It’s Redistribution, Not Just Gain

Here’s what the research shows: the menopausal transition itself doesn’t necessarily cause significant weight gain. What it does cause is dramatic redistribution.

Visceral fat—the fat around your organs, the fat that makes your waist thicker—increases substantially. Studies show visceral fat can go from 5-8% of total body fat before menopause to 15-20% after. That’s not a small shift. That’s your body fundamentally changing where it stores energy.

Meanwhile, you’re likely losing muscle mass. This shift—more fat, less muscle—can happen even if the number on the scale barely moves. You weigh the same but your body is different. Your clothes fit differently. Your shape has changed.

This isn’t a failure of willpower. It’s biology.

Why This Happens

Estrogen affects fat distribution. When estrogen was higher, your body preferentially stored fat in hips and thighs (the “pear” shape). As estrogen declines, fat redistributes to the abdomen (the “apple” shape). This shift happens regardless of total body weight.

Your metabolism actually changes. Research shows activity energy expenditure drops significantly during perimenopause—in some studies, activity counts dropped by half in the years leading up to menopause. Your body is burning fewer calories doing the same activities.

Insulin sensitivity decreases. The same foods that didn’t affect your blood sugar before may affect it differently now. This contributes to fat storage, particularly abdominal fat.

Muscle loss accelerates. Without intervention, muscle mass declines—and muscle is metabolically active tissue. Less muscle means lower resting metabolism.

Sleep disruption compounds everything. When you’re not sleeping, your hunger hormones go haywire. Ghrelin (hunger) increases; leptin (satiety) decreases. You’re hungrier and less satisfied.

Why Visceral Fat Matters

This isn’t about appearance. Visceral fat is metabolically active in ways that subcutaneous fat (the fat under your skin) isn’t. It’s associated with:

Increased cardiovascular risk
Insulin resistance and type 2 diabetes
Inflammation throughout the body
Higher risk of certain cancers

The shift to abdominal fat distribution is one reason cardiovascular risk increases after menopause. Your heart is losing estrogen’s protective effects and gaining a metabolically problematic fat distribution.

What Actually Helps

I’m not going to give you a diet. Diets don’t work long-term for most people, and weight cycling (losing and regaining) may be worse for health than stable higher weight.

What I will say:

Movement—especially resistance training

Cardio is good for your heart. But for body composition during perimenopause, strength training is essential. It:

Builds and maintains muscle mass
Increases resting metabolism
Improves insulin sensitivity
Helps maintain bone density
Specifically targets the muscle loss that accompanies this transition

You don’t need a gym. Bodyweight exercises, resistance bands, or weights at home all work. What matters is progressively challenging your muscles.

Protein intake

Maintaining muscle requires adequate protein—more than you might think. Research suggests older adults need more protein than younger adults to achieve the same muscle-building effect. Distribute it throughout the day rather than loading it all at dinner.

Sleep and stress

These aren’t optional extras. Chronic sleep deprivation and chronic stress both drive visceral fat accumulation. Addressing sleep problems and stress isn’t just about feeling better—it directly affects body composition.

Hormone therapy

HT can help prevent the shift to visceral fat storage. Some research shows women on hormone therapy maintain more favorable fat distribution. This isn’t the only reason to consider HT, but it’s part of the picture.

GLP-1 Agonists: The New Landscape

If you’re considering or already using medications like semaglutide (Ozempic, Wegovy) or tirzepatide (Mounjaro, Zepbound), you’re not alone. These medications have become common among perimenopausal and postmenopausal women.

What the research shows:

They work across menopause stages. A study of tirzepatide found approximately 20% weight reduction regardless of whether women were pre-, peri-, or postmenopausal. Menopause doesn’t blunt the effect.

Combination with hormone therapy may enhance results. A 2024 study found postmenopausal women on both semaglutide and hormone therapy lost more weight than those on semaglutide alone—16% vs 12% after a year.

Muscle and bone loss are real concerns. Rapid weight loss from any cause—including GLP-1s—can result in muscle and bone loss. This is particularly concerning during perimenopause when you’re already losing both.

Resistance training becomes even more important. If you’re on a GLP-1, strength training isn’t optional—it’s essential for preserving muscle mass and bone density.

Adequate protein is critical. When eating less, getting enough protein to maintain muscle becomes even more important.

These medications aren’t magic, and they’re not right for everyone. They work best as part of a comprehensive approach, not as a replacement for other interventions.

The Emotional Weight

Weight changes during perimenopause often carry emotional weight beyond the physical. You may be grieving a body that felt more familiar. You may be struggling with a culture that equates thinness with worth. You may be exhausted from a lifetime of diet culture messaging.

All of this is real, and none of it is simple.

What I want you to know: your worth isn’t measured in pounds or inches. Health behaviors matter more than the number on the scale. And sometimes the most radical act is to care for your body without trying to shrink it.

Your body is changing because it’s supposed to change. The goal isn’t to prevent that change—it’s to support your health through it, in whatever body you have.