Localised fat in the menopause: why the body changes and what helps

“I haven't changed anything, but my belly has grown.” It is one of the phrases most often heard from women in their mid-40s to mid-50s. The waist widens, trousers stop fitting, the arms and back change, and what used to work (eating a little less, walking more) seems to have no effect.

It is not a lack of effort or imagination. The transition to the menopause changes the way the body stores fat and maintains muscle, and this change begins before the last period. The good news is that there is a lot that can be done, especially if you understand what is happening.

What changes in the body: what studies show

The transition is the key moment

The menopause is defined as the last period, confirmed after 12 months without periods. In Portugal, as in Europe, it occurs on average at around 50 to 51 years of age. But hormonal changes begin years earlier, in the perimenopause (or menopausal transition), with irregular cycles and, often, hot flushes and sleep changes.

The SWAN study

The Study of Women's Health Across the Nation (SWAN) followed women of different backgrounds in the United States for more than two decades, with regular measurements of body composition. An analysis published in 2019 (Greendale et al., 2019) showed that:

• At the start of the transition, the rate of fat mass gain more than doubled compared with the previous phase.
• At the same time, lean mass (especially muscle) began to decline.
• These changes continued until about two years after the last period and then stabilised.
• The weight on the scales did not always reflect the size of the change, precisely because fat is gained and muscle is lost at the same time.

Fat changes place

Before the menopause, oestrogens favour the accumulation of fat on the hips, thighs and buttocks (“gynoid” distribution). As they fall, the distribution moves closer to the male pattern (“android”), with more fat in the abdomen. Imaging studies (Lovejoy et al., 2008) showed an increase in visceral fat during the transition, even in women without a large weight gain.

In practice, many women notice:

• A more protruding belly and a less defined waist.
• Fat on the flanks and back, next to the bra.
• Arms with more volume and less firmness.
• Less fat in the legs, in some, with slimmer legs and a bigger belly.

Why it happens

There is no single cause (Davis et al., 2012). Several factors add up:

1. The fall in oestrogens

Oestrogens influence where fat accumulates, insulin sensitivity and energy expenditure. Their fall favours abdominal and visceral accumulation and may slightly reduce resting energy expenditure. Studies have also shown a reduction in fat oxidation and spontaneous physical activity during the transition.

2. Loss of muscle mass

With age, muscle is lost, and the menopausal transition accelerates that loss. Less muscle means lower energy expenditure, less strength and a body with less firm “structure” beneath the fat.

3. Sleep

Hot flushes and night sweats fragment sleep. Short, poor-quality sleep is associated with greater appetite, a preference for higher-calorie foods, less energy for exercise and more abdominal fat.

4. Life changes

This stage often coincides with more stress (work, children, elderly parents), less time for exercise, more meals out and, sometimes, more alcohol.

5. Age

Some of the changes would also happen with ageing, regardless of the menopause. The SWAN study helped to show that the transition itself has an effect of its own that adds to that of age.

It's not just aesthetic: what it means for health

The shift of fat to the abdomen is not just a question of clothing. Visceral fat is associated with:

• Insulin resistance and type 2 diabetes.
• Increase in LDL cholesterol and triglycerides.
• Hypertension.
• Cardiovascular disease, which is the leading cause of death in women after the menopause.
• Fatty liver.

At the same time, the loss of muscle and bone increases the risk of falls, fractures and loss of independence later on.

What is worth measuring

• Waist circumference: from 80 cm the risk increases and from 88 cm it increases greatly (reference values for European women, WHO, 2008).
• Waist-to-height ratio: above 0.5 suggests excess abdominal fat.
• Blood pressure, blood glucose and lipid profile, with the family doctor.
• Bone density, when indicated.

If these values are abnormal, the first step is to speak to your doctor, before any aesthetic treatment.

What helps

1. Strength training: the priority

If there is one measure that makes a difference at this stage, it is this. Strength training (weights, machines, bands, bodyweight exercises), two to three times a week, working the large muscle groups:

• It slows and may reverse part of the loss of muscle mass.
• Improves insulin sensitivity.
• Protects bone.
• Improves body contour, even when weight changes little.

It is never too late to start. If you have never trained, seek guidance to learn the technique and progress safely.

2. Aerobic exercise

Brisk walking, cycling, swimming, dancing. It reduces visceral fat, even with little weight loss, and protects the heart. The general recommendations (Bull et al., 2020) point to at least 150 minutes a week of moderate intensity.

3. Sufficient protein

It helps to preserve muscle, especially combined with strength training. Spreading protein across the day's meals (rather than concentrating it at dinner) seems to be more effective. The exact needs depend on weight, activity and kidney health; speak to your doctor or dietitian.

4. Adjusting your diet to the new stage

With less muscle and slightly lower energy expenditure, the same diet as before can lead to weight gain. Favouring vegetables, fruit, pulses, wholegrain cereals, fish and olive oil (the Mediterranean pattern) and cutting back on ultra-processed foods and sugar helps without requiring restrictive diets.

5. Sleeping better

Treating hot flushes, when they disturb sleep, is an indirect way of helping with weight. Sleep hygiene, a cool bedroom and, when indicated, medical treatment of the symptoms.

6. Less alcohol

Alcohol adds calories, worsens sleep and is associated with more abdominal fat and poorer control of hot flushes in some women.

7. Hormone therapy: what is known

Menopausal hormone therapy is indicated mainly to treat symptoms such as hot flushes and night sweats (NAMS, 2022). Studies and meta-analyses (Salpeter et al., 2006) have shown that it tends to reduce the accumulation of abdominal fat and to improve insulin sensitivity, but it is not recommended for weight loss. The decision to start hormone therapy is individual, made with the doctor, weighing symptoms, age, time since the menopause and risks (such as a history of breast cancer, thrombosis or cardiovascular disease).

Body contouring and skin at this stage

When the foundations are in place (health assessed, exercise, diet, sleep), some women seek help for specific areas that continue to bother them. Two important notes:

The fat that is treated is not the fat that is a health concern

Body contouring treatments (cryolipolysis, radiofrequency, ultrasound, among others) act on subcutaneous fat, the kind you can pinch. They do not reduce visceral fat or cardiovascular risk. They may improve the contour of areas such as the flanks, lower abdomen, back or inner knees, in women close to their healthy weight. See also Flanks and belly that resist diet and exercise: why.

The skin has changed too

In the first years after the menopause, the skin loses collagen more rapidly, becoming thinner, drier and less firm (Brincat, 2000). This has two consequences:

• Laxity becomes more visible, especially on the belly, arms and inner thighs.
• Reducing fat on loose skin may make the appearance worse. That is why, at this stage, skin-firming treatments (such as radiofrequency) and body skincare gain importance, on their own or combined with fat reduction.

Care for the skin of the body

• Daily moisturising with creams rich in lipids and humectants.
• Short, lukewarm baths, without harsh soaps.
• Sunscreen on exposed areas.

This article is for information purposes and does not replace a medical consultation. Decisions about hormone therapy should be made with your doctor.

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