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Hormone Replacement Therapy and Weight Loss: Mostly Hype?

Written by Dr. Michael Ruscio, DC on July 30, 2024

Written by Dr. Michael Ruscio, DC on July 30, 2024 — Reviewed by Dr. Hannah Hamlin

Why Natural Therapies are a Better Option for Managing Your Weight

• Weight Gain During Hormonal Transitions|
• Gut-Hormone Connection|
• Hormone Replacement Therapy and Weight Loss|
• Gut-Healing Guide|
• Heal Your Gut to Improve Your Weight|

Weight gain during hormonal transitions like menopause can be frustrating. You may feel like you’re doing all the right things, but the number on the scale continues to creep up. Since declining estrogen levels in the years leading up to menopause are associated with increased abdominal fat and obesity, it’s tempting to consider hormone replacement therapy (HRT) as the silver bullet to curb this process [1]. But weight gain during this time for women is multifaceted, so it’s unlikely that one therapy alone will resolve the issue. 

And in fact, the research suggests that hormone replacement therapy and weight loss don’t usually go hand-in-hand, so HRT will likely have no significant impact on weight [2, 3]. This is good news if you’re using HRT for other reasons—you don’t have to worry about significant weight gain. 

So, what can you do if you’re in a hormonal transition and struggling with your weight? Before considering HRT, you’ve got to address the common underlying causes of weight gain like poor gut health, disrupted sleep, and lack of physical activity. Fortunately, these can all be tackled with natural therapies like diet, probiotics, and exercise. Let’s jump right in by looking at why weight gain can accompany peri-and postmenopause and how gut health factors in.

Weight Gain During Hormonal Transitions

Women tend to gain body fat and lose muscle during perimenopause (the 6–11 years prior to menopause). Once menopause is reached, the rate of fat gain doubles but then levels off about 2 years after the last menstrual cycle [4]. 

Declining estrogen levels, elevated levels of follicle-stimulating hormone (FSH), decreased physical activity, and a slower metabolism are thought to be culprits when it comes to weight gain during menopause [5, 6]. Since these could be contributing factors, you may be wondering if HRT is a good option for combating menopause-associated weight gain. 

Let’s take a look at the research. 

Hormone Replacement Therapy and Weight Loss

Since low estrogen levels are associated with weight gain and obesity, it would make sense that replacing estrogen and other hormones may help to prevent or reverse unwanted weight gain.  While both types of HRT (conventional and bioidentical) can be helpful for a variety of hormone-related factors like hot flashes, night sweats, osteoporosis, heart disease, mood swings, and insulin resistance [7, 8, 9, 10], when it comes to weight loss specifically, the research seems to indicate little, if any benefit. 

Meta-analyses of randomized controlled trials have found that typical menopausal hormonal therapy, consisting of synthetic or standardized bioidentical hormone replacement therapy, does not appear to affect body weight positively or negatively [2, 3]. This means if you’re hoping to use HRT to help with a weight issue, it’s not likely to give you the results you’re looking for. And it’s important to remember that starting HRT for weight loss alone is not advisable as it can disrupt hormone levels and come with side effects.

Some women choose to have another form of HRT using testosterone supplementation. This type of HRT can significantly improve sexual satisfaction, but it may also contribute to moderate weight gain with no improvement in body composition (the fat-to-muscle ratio), bone mineral density, or muscle strength [11].

If you’re already on HRT and you’re experiencing good relief from your symptoms and you’re also seeing weight loss, that’s great! But this doesn’t mean you need to stay on HRT forever. Working on the strategies I outline below can help ease the transition off of HRT and prevent unwanted rebound weight gain. 

Hormone imbalances and lack of exercise alone don’t tell the whole story when it comes to weight gain during hormonal transitions. In my experience in the clinic, poor gut health is an often overlooked component of stubborn weight gain for women during this time. Let’s take a look at how gut health factors into the equation.

The Gut-Hormone Connection

Research suggests there’s a connection between gut health and female hormones. Part of this relationship involves common gut imbalances like bacterial dysbiosis and inflammation, which are both experienced by your body as stress. If dysbiosis and chronic inflammation in the gut aren’t corrected, your body ends up using the materials it needs to produce sex hormones (like estrogen and progesterone) to instead keep the production of stress hormones (like cortisol) high [12]. 

Additionally, dysbiosis and chronic gut inflammation (whether related to physical or emotional stress) can increase intestinal permeability further exacerbating inflammation and the cascade of events leading to unwanted weight gain (especially belly fat) and hormonal disturbances [13]. Women with menopausal symptoms like hot flashes, night sweats, and weight gain have been found to have dysbiosis [14]. 

So, while estrogen levels naturally decline through the menopausal transition, keeping your gut health in check may help ease your body through this time with much less of an impact on your weight. 

HRT probably isn’t a good option for dealing with unwanted weight gain during the menopausal transition and for postmenopausal women, so what can you do? This is where addressing gut health with natural therapies and improving your lifestyle can really start to move the needle in the right direction.

Healing Your Gut: A Step-By-Step Guide

If you’re hoping to slow the weight gain that’s associated with perimenopause and menopause, I recommend starting with improving your gut health. I outline the gut-healing treatment plan I use in the clinic in Healthy Gut, Healthy You but I’ll take you through the initial steps here, which will likely be very effective. 

Step One: Reset

In this initial step, I recommend a quick gut reset with a modified fast for 2–4 days. The first day is often the most difficult and you may feel quite fatigued. By day 2, most people are starting to experience improved energy, mental clarity, better sleep and mood, and fewer digestive symptoms. If you are uncertain whether modified fasting is a good fit for you, checking with your trusted healthcare provider is a good idea. And if this type of protocol doesn’t meet your needs, that’s ok, you can continue on to healing your gut with an elimination diet like the ones I highlight below. 

For the modified fast, I recommend using a formula like Elemental Heal, which is an easy-to-digest powder (mixed with water) that can help to improve dysbiosis and inflammation, which may be underlying your unwanted weight gain. Once you get through your fasting period, you can find your ideal gut-healthy diet. The purpose of this elimination-type diet is to:

• Reduce your exposure to allergens or food intolerances
• Improve your blood sugar (glucose) control
• Increase your intake of fresh, whole, unprocessed foods

There are several dietary plans that fit this description. If you’ve never changed your diet before, you may want to start with a Mediterranean or Paleo diet. If you follow one of these for a couple of weeks and feel great, then stick with it for a couple of months. However, if you don’t have noticeable improvements after a few weeks, then you may need a more restrictive plan like the low FODMAP diet, which reduces the amount of certain carbohydrates that feed intestinal bacteria.

In addition to what you’re eating, meal timing is an essential factor for gut healing. It’s important to avoid grazing and instead eat a balanced meal every 4 hours or so, [6, 15]. Protein is a key component of a balanced plate and is vital for weight loss and healthy aging.

Fine-Tune Your Routine

While you’re working on finding the right diet, there are other lifestyle factors to consider. Sleep disturbances, lack of physical activity, and excess stress can all contribute to weight gain and poor gut health [6, 12, 16]. Here’s a chart with research-backed lifestyle options and helpful tips when you’re trying to prevent weight gain or trying to lose weight:

You don’t need to incorporate every single one of these recommendations. Pick one or two from each category and filter them into your routine until you’re practicing them consistently. You can then branch out and try a few more. The goal here is to create a healthy foundation that will not only improve your gut (and metabolic) health to support a healthy weight but also improve your quality of life.  

I want to add that resistance training for women going through this hormonal transition may be very helpful since it can significantly improve body composition (meaning more muscle and less fat). In one small randomized controlled trial of 17 overweight postmenopausal women, 3 months of high-intensity interval training plus resistance training significantly reduced total abdominal and visceral fat mass and increased muscle mass [24]. 

If you’re not accustomed to this type of exercise, I encourage you to work with a personal trainer to develop a tailored routine that you would optimally perform 3 days per week and/or check out one of our articles on resistance training. 

Once you’ve laid a healthy foundation with diet and lifestyle, you can consider moving on to step two where you’ll add probiotics.

Step Two: Support

In this step, you’ll be supporting your gut and gut microbes with probiotics, which are live microorganisms that can provide you with a myriad of benefits:

• Increase the bacterial diversity of your gut microbiome [25, 26, 27]
• Fight harmful bugs and their toxins [25, 26, 28, 29, 30]
• Promote a more rapid recovery from dysbiosis [25, 26]
• Promote a healthy immune response in your gut [25, 26 31, 32, 33]
• Reduce gut inflammation [25, 26, 27]
• Encourage the growth of your “good” gut microbes [25, 26, 31]
• Reduce leaky gut [25, 26, 34, 35, 36]

Essentially, probiotic supplements help to improve the balance of microbes in your gut, reduce inflammation, and help modulate your immune system, all of which can help prevent and/or reverse unwanted weight gain. 

Now, there are literally endless probiotic products on the market, so how do you know which one to choose? In the clinic, I recommend the triple therapy probiotic approach (using three different categories of probiotics) because many people achieve better gut microbiome balance when taking more than one strain of probiotic. 

Here’s the process I use in the clinic:

1. Try a quality formula probiotic from category 1 (Lacto/Bifido blend), category 2 (Saccharomyces boulardii), and category 3 (soil-based) – take all three together.  
2. Monitor your symptoms for 3–4 weeks. If you’re improving, stay on this protocol until your improvements seem stable.
3. Once you’ve seen your maximum improvement, stay here for about a month to allow your system to calibrate to these new improvements. Then reduce your dose and find the minimal effective dose and stick with that to maintain.

If you’re feeling great after steps one and two, then it’s time to reintroduce some of the foods you’ve eliminated. Of course, it’s important to stick with a whole-foods meal plan but you don’t need to fear food. The goal is always to have the widest variety of food in your diet as possible. 

When addressing menopause-related weight fluctuations, research suggests getting plenty of fiber from fruits, vegetables, legumes, whole grains, and nuts may be helpful. In addition, you should prioritize protein from lean meats and good quality dairy products to promote muscle protein synthesis [6].

If you’re still struggling with weight loss after steps one and two, you may want to follow the entire Great-in-8 step-by-step plan outlined in Healthy Gut, Healthy You. 

Heal Your Gut to Improve Your Weight

Weight changes that happen during the menopausal transition can be disheartening. It’s tempting to think that weight gain or the inability to lose weight during this time is solely related to hormonal changes. While the natural decline in estrogen is a contributing factor, it’s not the only culprit when it comes to the number on the scale.

HRT can indeed be very helpful for many women experiencing the symptoms of menopause. However, I don’t recommend anyone base their decision to start HRT only on the hope that it will help with weight loss. Overall, the research suggests that both conventional and bioidentical HRT don’t have much of an impact on weight. The exception here is testosterone therapy, which may actually cause weight gain.

So, what can you do? The key is to address the underlying factors that are contributing to weight gain, which often include poor gut health, disrupted sleep, and reduced physical activity. When you address these factors, you naturally give your body the tools to make this a smoother transition and to improve your overall well-being. If you heal your gut and improve your lifestyle but are still unsatisfied with your results, contact us at the Ruscio Institute for Functional Health for a more personalized plan.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.