by Dr. Charles Mok
The obesity and overweight trend that has developed over recent years is an alarming public health concern. About 13% of Americans were overweight between 1960 and 1980. Between 1980 and about 1998, the rates of obesity almost tripled.
For women, obesity rates peak between the ages of 40 and 59, with about 42% of women being obese at age 40, and about 75% of women being overweight or obese at this age (59).
There are clearly several causes for overweight and obese trends. There are changing lifestyles with regard to activity and changing food choices, and there’s also evidence that our gastrointestinal microbiota (the complex community of microorganisms that live in our digestive tract) have an impact on weight. But in this article let’s take a minute to talk specifically about our hormones.
Hormone replacement therapy was once commonly used for women entering or in menopause. Hormone placement therapy was shown to protect the cardiovascular system, improve mood and energy, improve sleeping ability, and improve the quality of life.
In 2002 and 2004, a couple of studies came out that suggested health risks associated with hormone replacement therapy, particularly breast cancer and heart disease. These were subsequently found to be not valid for the practice of medicine, but just an observation of studies that were flawed.
We now know that with proper hormone replacement therapy, cardiovascular events and breast cancer rates are actually reduced by over 50% when women take hormone replacement the way we prescribe it today at Allure, and there’s reduced mortality from all causes.
But what about weight? Does hormone replacement therapy limit weight gain or cause it?
Let’s look at clinical studies. I’m going to go into this in a few phases. The first is evidence from over a decade ago on observations made based on hormone replacements of the time. Then we’ll go through evidence of more modern hormone replacement and its effect on weight.
An observational study was conducted between 1972 and 1991. The women who lived in Rancho Bernardo, California, were surveyed regarding their weight and lifestyle choices such as smoking, alcohol consumption, exercise, and diet, as well as their use or nonuse of hormone replacement therapy.
At that time hormone replacement therapy was typically Premarin, which is an oral horse-based estrogen.
This long-term study found the hormone replacement therapy, whether used intermittently or continuously for more than 15 years, was not associated with the weight gain that is commonly observed in postmenopausal women. (JAMA, Jan 3, 1996, Vol 275 No.1. pp 46-49)
A study done at the University Hospital of Geneva Obesity Center recruited women who were overweight (BMI greater than 25 kg/mg) and in menopause for at least six months.
Women were given estrogen patches, which deliver medication through the skin, as well as a progestin, which is used to prevent the uterus from being stimulated when exposed to estrogen. Another group of women was not given estrogen nor progestin.
The women, who had an average age of 52, were trained on dietary modification and given a diet journal. After three months, the women on the diet and hormone replacement lost about 4 ½ pounds. The women on the diet only lost less than a quarter of a pound.This was a significant linear relationship. In the absence or the reduction of sex hormones, weight loss is very difficult in middle-age women. (Maturitas 32 (1999) 147-153)
A study done in Australia sought to evaluate different forms of estrogen and its relative role in weight loss or weight gain.
Researchers randomized postmenopausal women into taking oral estrogen. As I noted earlier, at the time the main oral estrogen was Premarin, a horse-based estrogen. It is still used today, surprisingly, compared to an actual human estrogen patch, which allows estrogen to transmit to the skin. The patches are still used today, but we now use tiny pellets that are inserted under the skin that give a more reliable delivery than you will receive through a patch.
This is called a crossover study, which means that all the women went through both arms of the study. That is to say, they were treated at one time with oral estrogen, discontinued it and waited, and then used the topical skin patch estrogen.
The women, who were overweight, were instructed not to change their normal diet and exercise patterns. They found that the transdermal (skin-based) estrogen had favorable effects on lean body mass as well as fat mass, while oral estrogen had negative effects on both. (J. Clin. Invest, Vol 102, No. 5, Sept 1998, 1035-1040)
A study in Macedonia evaluated hormone replacement therapy in women who were postmenopausal and had type 2 diabetes. They were put on human estrogen in a synthetic progestin and followed for 12 months. Standard diabetes medications were continued. Compared to those not taking hormone placement therapy, the addition of estrogen improved insulin sensitivity and markers of diabetes. (Maced J Med Sci. 2016 Mar 15; 4(1):83-88)
A study out of the University of Alabama at Birmingham used radiological imaging to assess visceral fat. Visceral fat, or belly fat, is the most unhealthy fat in the body. It is associated with more metabolic syndromes, diabetes, and cardiovascular disease.
They followed the women for two years, and all had their average belly fat increase by 10%, which is typical of postmenopausal women. (As I mentioned, menopause is associated with persistent weight gain.)
However, women on estrogen replacement were less likely to gain belly fat and more likely to lose belly fat.
Additionally, there was an association to low testosterone and belly fat. Women with low testosterone had a more acute relation of belly fat and women with higher testosterone levels had less accumulation of belly fat. (Obesity (Silver Spring). 2012 May ; 20(5): 939–944. doi:10.1038/oby.2011.362)
If estrogen replacement reduces the simulation of belly fat, and low testosterone is associated with the growth of belly fat, what about testosterone replacement therapy and belly fat?
A study done at the University of Vienna in Austria evaluated post-menopausal women who were gaining weight. They put them on testosterone replacement or placebo.
The women were instructed to make no lifestyle changes with regard to diet and exercise, even though they presented because they had been gaining weight. The only intervention was testosterone replacement or placebo. At the time they used topical gel, while currently we use testosterone in the form of a pallet inserted beneath the skin; it breaks down over a few months and thus gives a more consistent study of delivery on testosterone in women.
The women were followed for six months. The women on placebo gained a little bit of weight. The woman on testosterone gel lost a little over five pounds.
(Maturitas 29 (1998) 253-259)
Weight gain and obesity are frequent concerns for women as they age and enter menopause. Lifestyle modification is, of course, mandatory for healthy living, but hormones also play a role.
Hormone replacement, when done in the contemporaneous fashion with actual hormone replacement, as opposed to using synthetic hormone-like drugs, leads to better body composition, better ability to maintain and lose weight, and better quality of life. There are no known adverse events associated with physician-monitored hormone placement therapy in the fashion that we are performing it today.
If you would like to learn more about hormone replacement therapy, call 586-992-8300 and schedule a consultation with one of our experienced providers.