Menstrual & Weight Changes

Menstrual and weight changes during menopause are primarily attributed to hormonal shifts, especially the reduction in estrogen. Perimenopause, the transition to menopause, begins when the intervals between periods lengthens, including missed periods and heavy periods, and ends with menopause, which is confirmed when you have not had a period for 12 consecutive months.

Specifically, menstrual related changes include breast changes, involving changes in size, shape, and the appearance of lumps, as well as breast pain (mastalgia), irregular menstrual cycles, manifesting as prolonged or shortened periods, heavier or lighter bleeding, or skipped periods, and menstrual disorders, such as dysmenorrhea, premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).

Complications can arise from heavy menstrual bleeding (menorrhagia) such as iron deficiency anemia (ferropenic). Body composition and weight fluctuations directly linked to menstrual symptoms including bloating, and both weight gain, particularly increased abdominal, or visceral, fat often called menopause belly or meno belly, and weight loss, are associated with the reduction in estrogen, specifically estradiol, which helps to regulate metabolism and body weight.

Menstrual and weight changes during menopause are largely driven by hormonal shifts and losing ovarian follicular function. These changes mark the perimenopausal and menopausal transition, characterized by irregular menstrual cycles, breast changes, and premenstrual symptoms followed by the eventual cessation.

The menstrual cycle is regulated by the hypothalamus and the pituitary gland, which oversee six essential hormones, including Gonadotropin-Releasing Hormone (GnRH), Follicular Stimulating Hormone (FSH), Luteinizing Hormone (LH), estrogen, progesterone, and testosterone. These hormones work in harmony to regulate the menstrual cycle, ensuring the development and release of eggs and influencing reproductive and physiological processes to prepare for potential conception. As levels of these hormones change during perimenopause and the body signals its end to fertility, a range of changes and symptoms ensue.

Estrogen and progesterone play a role in maintaining breast tissue, so as these hormones decline, breast tissue also changes. As estrogen, specifically estradiol, the major form of estrogen, helps regulate metabolism and body weight, its reduction, and estrone, another form of estrogen which is considered pro-inflammatory, increases, both contribute to bloating and weight gain, leading to increased fat storage, particularly in the abdominal area.

Other contributors to weight gain include age-related reduction in muscle mass, strength, and function (sarcopenia), thyroid disorders, increased food intake, decreased physical activity and a reduced metabolic rate. Weight loss, however, can be related to factors such as decreased appetite, oral changes, taste changes, digestive and gastrointestinal (GI) issues, loss of muscle mass, mood changes, and stress.

Hormonal fluctuations, primarily the reduction in estradiol and increase in estrone, underlie menstrual and weight changes during menopause, affecting various parts of a woman’s reproductive health and body composition.

The symptoms associated with menstrual and weight changes during menopause reflect the hormonal shifts that define this phase in a woman’s life. Menstrual symptoms encompass a spectrum of experiences, including irregular menstrual cycles, breast size, and shape changes, mastalgia, and a range of menstrual disorders such as dysmenorrhea, PMS, and PMDD. These changes often lead to challenges such as heavy menstrual bleeding, potentially resulting in ferropenic. Concurrently, weight-related symptoms manifest as fluctuations in body composition, leading to weight gain and bloating, particularly around the abdominal area, and, sometimes, weight loss. These symptoms are primarily attributed to the reduction in estrogen levels and age-related factors, setting the stage for a multifaceted journey through menopause.

Breast Pain (Mastalgia)

Mastalgia, characterized by breast discomfort and pain, is a common symptom experienced by many women during menopause in one or both breasts. The pain can range from mild to severe, often described as a heavy, tight, burning sensation or a dull ache. It may be cyclical, coinciding with the menstrual cycle, or non-cyclical, persisting throughout the month. Mastalgia may also come with breast tenderness, swelling, or lumps.

Hormonal fluctuations, particularly the decline in estrogen and progesterone, play a significant role in causing mastalgia. Before your period, fluid builds up in your breasts, making them feel more swollen, tender, or painful than other times of the month. Because the hormonal changes of perimenopause make your cycle irregular, breast soreness can occur unpredictably. Breast pain may originate from the chest wall or arthritis of the spine, and where the pain is persistent or severe, consultation with a healthcare professional is recommended to ensure it is not related to other health conditions, such as cancer.

Breast Size and Shape Changes

During perimenopause, hormonal shifts can trigger various breast changes. Glandular breast tissue reduces, causing the skin to lose moisture and elasticity, resulting in reduced density and increased fat content. This can lead to stretching, flattening, sagging, and noticeable decreases in breast fullness, sometimes requiring a change in bra cup size. You might also experience increased tenderness and mastalgia, nipple positioning changes, stretch marks, and a widening gap between the breasts.

During menopause and part of the aging process, there is an elevated risk of breast cysts, fibroids, and other abnormal growths. You may detect lumps in your breast. Fibrocystic changes can lead to lumpy, painful breasts with rubbery areas. These changes and cysts typically reduce post menopause, are typically benign (non-cancerous) and don’t significantly increase the risk of breast cancer. You may also notice raised white bumps on the nipple and surrounding areola called Montgomery tubercles, or Montgomery glands also common during pregnancy, or symptoms associated with mammary duct ectasia.

Mammary duct ectasia, also called ductal ectasia, periductal mastitis, and comedomastitis, is where one or more milk ducts beneath your nipple widens. This can result in fluid accumulating in the ducts leading to inflammation, swelling, tenderness, redness, pain, nipple discharge, nipple retraction where it pulls inward, and a lump or thickening near the nipple.

While menopausal breast changes are typically normal, it is important to conduct regular self-examinations and undergo screenings like mammograms. Consult with a healthcare professional where you are uncertain about breast changes, experience a lump (particularly one that remains the same size or increases in size), firm areas, nipple discharge, inverted nipples, skin alterations like redness, dimpling or ridges, or unexplained breast swelling or shrinking, especially affecting one breast.

Irregular Menstrual Cycles

Irregular periods are a hallmark of perimenopause ending with menopause, when you have not had a period for 12 consecutive months. Your period is irregular if the gap between them is less than 21 days or over 35 days. During this phase, menstrual cycles may be unpredictable with variations in period length and intervals between periods, spotting or bleeding between periods, variances in blood flow and missed periods. These irregularities can be attributed to fluctuations in hormone levels, particularly a decrease in ovarian steroid secretion and production.

Anovulation, when an egg does not release or ovulate from a woman’s ovaries, may be linked with irregular menstruation because of reduced ovarian steroid production.

Modifiable risk factors, such as smoking, obesity, and stress, are associated with irregular menstrual cycles and early menopause. Smoking, for example, can lead to hypoestrogenism, while high stress levels can affect the activity of the hypothalamic-pituitary-adrenal axis. Similarly, a high body mass index (BMI) can influence various hormone levels, emphasizing the importance of lifestyle changes.

Menstrual Disorders

Menstrual disorders encompass a range of conditions that affect a woman’s menstrual cycle, leading to various symptoms. Disorders include dysmenorrhea, PMS, PMDD, menorrhagia, metrorrhagia, amenorrhea, oligomenorrhea, and hypomenorrhea.

Dysmenorrhea, characterized by painful cramps during menstruation, and PMS, involving physical and psychological symptoms such as bloating, breast tenderness, fatigue, changes in sleeping and eating habits, mood changes, and anxiety, are common experiences. Less common is PMDD, which is a more severe form of PMS. Menorrhagia, which involves heavy and prolonged menstrual bleeding, and metrorrhagia, bleeding at irregular intervals between expected periods, are also part of this spectrum. Amenorrhea signifies the absence of menstruation, while oligomenorrhea refers to infrequent periods and hypomenorrhea to light menstrual flow.

Hormonal imbalances play a significant role in premenstrual symptoms, contributing to mood swings, irritability, bloating, breast tenderness, and food cravings. Causes of amenorrhea and oligomenorrhea can include pregnancy, breastfeeding, hormonal contraception, and perimenopause. Functional hypothalamic amenorrhea, marked by disrupted hormone secretion and hypothalamic-pituitary-adrenal axis dysregulation, can lead to menstrual irregularities.

Abnormal bleeding should prompt consultation with a healthcare professional to rule out underlying conditions such as polycystic ovary syndrome (PCOS), eating disorders, sexually transmitted infections (STIs), uterine growths, hormonal problems, or thyroid issues. Bleeding once menopause has been diagnosed requires medical attention.

Weakness (Ferropenic)

Weakness is a common symptom of iron deficiency anemia (ferropenic). In premenopausal women, heavy menstrual bleeding, or menorrhagia, is a leading cause of this condition. Typically, losing more than 2.7 oz (80 ml) of blood per menstrual cycle can lead to ferropenic. This is the most common type of anemia occurring when the body does not have enough iron to produce sufficient healthy red blood cells. This type of anemia hampers the transport of oxygen in the blood to body tissues, causing symptoms like weakness, dizziness, lightheadedness, pale skin, fatigue, cold hands, and feet, and chest pain.

Menstrual fluid contains approximately 48% or 50% (for menorrhagia) menstrual blood and the remaining includes endometrial tissue, uterine lining, and mucus. Women taking oral contraceptives experience withdrawal bleeding during their sugar pill cycle, which is not a regular menstrual period. This bleeding, lighter and shorter than normal periods, occurs when hormone levels drop, causing a thinner uterine lining to shed. This is the result of the synthetic hormones in the contraceptives preventing significant buildup of the uterine lining during the cycle.

Other less common symptoms include inflammation or soreness of the tongue, brittle nails, reduced appetite, and cravings for non-nutritious substances such as ice, clay, or dirt, in an attempt to extract nutrients.

Some symptoms may be subtle and not immediately associated with ferropenic, and if left untreated, can lead to heart complications. Other causes include a lack of iron in your diet, an inability to absorb iron because of gastrointestinal and other diseases or surgical procedures, and pregnancy.

Conversely, post-menopausal women may experience iron toxicity or overload, as they no longer regularly menstruate and release iron. In addition, iron toxicity may result from dietary supplements. Symptoms include abdominal pain, diarrhea, nausea, vomiting, arrythmia, joint pain, fatigue, and brain fog.

Weight Gain (including bloating)

Weight gain, often accompanied by bloating, is a common and frustrating symptom experienced during menopause. This shift in body composition, especially noticeable around the midsection (also called menopause belly or meno belly), can lead to feelings of fullness and abdominal tightness. Hormonal fluctuations play a pivotal role in these changes, disrupting metabolism and fat storage patterns.

Weight gain in the midsection involves increased abdominal, or visceral, fat, which increases the likelihood of health conditions such as respiratory issues, cardiovascular disease, type 2 diabetes, and certain cancers like breast, colon, and endometrial cancers. Weight gain can lead to obesity, if not already a factor, which is associated with a variety of adverse health conditions and more severe menopausal symptoms, including vasomotor. Bloating, a common companion of menopausal weight gain, can be intensified by water retention, digestive issues, and menstrual symptoms.

While being overweight introduces a range of health challenges and increased health risks, it can postpone or reduce menopausal symptoms due to increased endogenous estrogen stored in body fat (adipose tissue). Adipose tissue is found under the skin (subcutaneous fat), between internal organs (visceral fat), and in the inner cavities of bones (bone marrow adipose tissue).

Weight gain typically becomes noticeable during perimenopause, along with other symptoms, and can manifest up to a decade before menopause. Stretch marks may also be noticed as the skin stretches. The root causes of menopausal weight gain lie in the declining levels of estrogen and progesterone, coupled with the natural aging process. These changes trigger metabolic shifts, leading to reduced muscle mass and calorie burning, contributing to fat accumulation. Genetics, sleep patterns, sedentary lifestyles, and other medical conditions, like PCOS, further exacerbate this cycle, with muscle tone lost to reduced hormone production replaced by fat deposits, primarily around the midsection.

Weight Loss

Weight loss during menopause can manifest as a response to hormonal fluctuations, reduced muscle mass, and changed metabolism. Significant and abrupt weight loss, however, may be an indicator of underlying health issues that require medical attention.

Symptoms related to weight loss may include fatigue, reduced appetite, and mood alterations. Weight loss can be linked to conditions such as osteopenia and osteoporosis, which is common following menopause. Any significant weight loss should be assessed by a healthcare professional.

While hormonal fluctuations during menopause may not directly affect appetite regulation, they can indirectly influence dietary habits due to sleep disturbances, fatigue, and irritability. Other factors like digestive issues, muscle mass loss, mood fluctuations, and oral and taste changes can contribute to reduced food intake, thus causing weight loss.

Diagnosing menopause-related menstrual and weight changes involves a comprehensive evaluation. It involves a thorough review of your medical history, focusing on menstrual patterns and weight fluctuations. You may also be referred to a gynecologist, a specialist who focuses on female reproductive health.

Thyroid function blood tests exclude thyroid disorders as a cause of weight changes. Transvaginal ultrasonography may assess endometrial thickness where you are experiencing postmenopausal bleeding.

For menstrual disorders, evaluations may include questions about menstrual cycles, family history, pelvic pain, medications, diet, contraceptives, and stress. Based on your symptoms and age, blood tests, ultrasounds, a hysteroscopy (to view the cervix and uterus), and pelvic exams may be recommended to help diagnose endometriosis, fibroids, polyps, structural abnormalities of the reproductive organs, or other related conditions.

A combination of medical history, physical examinations, and specialized tests helps healthcare professionals in accurately diagnosing menopause-related menstrual and weight changes, supporting aligned treatment and management.

Treatment for menopause-related menstrual and weight changes involves a combination of medications, therapies, and dietary supplements.

Hormone Replacement Therapy (HRT) may help slow weight gain by increasing a woman’s resting metabolic rate. Woman have had mixed results with HRT. Some have experienced bloating and others have noticed redistribution of abdominal fat to other areas, such as thighs and glutes. HRT may also help in managing weight by regulating sleep. High-dose estrogen therapy (HDE) (or pseudopregnancy when given in combination with a high dose of progestogen as hormone levels mimic those in pregnancy) may be prescribed to women with endometriosis, premenstrual syndrome (PMS), and premenstrual dysphoric disorder (PMDD).

Medications to manage menstrual disorders and their symptoms include oral contraceptives, hormonal intrauterine devices (IUD), progesterone injections, nonsteroidal anti-inflammatory drugs (NSAIDs) and pain medications. Injectable iron may be considered, where other forms of iron are ineffective. Weight-loss drugs for people with a BMI over 27 and a serious medical condition, or over 30, include bupropion-naltrexone, liraglutide, orlistat, phentermine-topiramate, semaglutide, and setmelanotide.

Surgical procedures for women with heavy menstrual bleeding, painful cramps, and other menstrual symptoms that interfere with daily functioning include endometrial ablation which removes a layer of the uterine lining, uterine artery embolization to remove uterine fibroids and obstruct blood supply to the uterus, and hysterectomy which removes the uterus. These procedures are not suitable if you wish to have children. Surgical procedures for weight loss include malabsorptive procedures, restrictive procedures, and mixed procedures like bariatric surgery. Procedures to remove stretch marks like laser and light therapy, microdermabrasion, microneedling, radiofrequency techniques, and acid peel treatments, may be considered if prescription and non-prescription ointments and creams and collagen injections are ineffective.

Conventional therapies, such as cognitive-behavioral therapy (CBT) can give women coping strategies and techniques to handle symptoms and change negative thought patterns. Additionally, motivational interviewing (MI) can help women enhance self-efficacy and personal control, to find and sustain the motivation to manage weight gain during menopause. Natural therapies such as acupuncture can help manage menstrual symptoms by increasing endorphins and weight management by reversing mechanisms associated with appetite and energy metabolism.

Dietary supplements like iron in ferrous form are useful for ferropenic. Chasteberry (Vitex Cagnus), dong quai (Angelica sinensis), and Ginkgo biloba can help manage menstrual symptoms. Green tea extract (Camellia sinensis) containing Epigallocatechin gallate (EGCG), green coffee bean extract (Coffea arabica or Coffea canephora), and L-carnitine can help with weight management. Cinnamon (Cinnamomum verum or Cinnamomum cassia), can also help with weight management, as well as reducing fasting blood glucose levels, increasing insulin sensitivity, and boosting metabolism. Iodine can support weight management and thyroid health, especially in cases of iodine deficiency. Phytoestrogens, plant-based compounds that mimic estrogen in the body, can be an alternative to HRT.

The effectiveness of these treatments varies among individuals and should be discussed with a healthcare professional.

Menopause-related menstrual and weight changes can be managed and prevented through lifestyle modifications and behavioral changes.

Mind-body exercises like yoga and Tai Chi and mindfulness practices like meditation and deep breathing can help reduce stress, which can exacerbate symptoms, and help reduce the intensity of symptoms. Embracing bodily changes that come with menopause can support a positive mindset and outlook.

Behavioral changes include wearing a correctly fitted and comfortable bra to help reduce breast discomfort and pain. Also, for breasts, refraining from squeezing any raised glands or using harsh soaps on the nipples can be effective. Applying heat as a heating pad, warm compress or taking a warm bath can help relieve the pain from menstrual cramps. Massaging areas with stretch marks helps boost circulation. Donating blood, assuming you have adequate hemoglobin and vitamin B12 (cobalamin), can help to remove excess ferritin for iron toxicity.

Consuming a diet with nutrient-dense foods that contain iron, particularly heme iron found in fish, shellfish, pork, poultry, and red meat, including organ meat like liver, and vitamin C to enhance the absorption of iron can help manage ferropenic and menstrual symptoms. A diet that supports weight loss includes minimal sugar, refined carbohydrates, processed and genetically-modified organism (GMO) foods, refined vegetable oils, alcohol, and caffeine. Additionally, kelp seaweed, cod fish, oysters, yogurt, eggs, and beef liver are all rich in iodine. Unrefined salts such as Himalayan, Celtic, and Kosher are beneficial, as they contain more trace minerals than table salt. Staying hydrated with purified water can help suppress appetite, boost metabolism, and remove waste from the body.

Regular physical exercise, including cardiovascular and strength (or resistance) training, can help boost mood, manage weight, strengthen bones, and reduce risk of other diseases like cardiovascular disease. Exercise can also help reduce menstrual symptoms, keep the body toned, promote sleep, improve sleep quality, and reduce sleep disturbances. Being overweight can exacerbate menstrual symptoms and sleep disturbances and introduce sleep disorders.

Nonrestorative sleep creates a hormone imbalance in the body that can encourage overeating and weight gain. Hormones leptin and ghrelin that regulate appetite are changed when sleep is disrupted, resulting in increased feelings of hunger. Smoking can lower estrogen levels further, cause dehydration, and impact circulation, so reducing use is recommended.

Menstrual and weight changes during menopause are driven by hormonal fluctuations starting in the perimenopausal stage. These changes manifest as breast pain, breast size, and shape changes, irregular menstrual cycles, menstrual disorders, ferropenic, weight gain, bloating, and weight loss. The diagnostic process involves assessing a woman’s medical history and symptoms, supported by blood tests, physical examinations, and tests. Treatment options HRT, medications for menstrual symptoms like oral contraceptives and progesterone injections, surgical procedures, therapies, and dietary supplements like chasteberry, dong quai, and Ginkgo biloba. Symptoms can be managed through stress-reduction techniques, eating nutrient-dense foods rich in iron and protein, regular physical exercise, and activity, and deep restorative sleep. These approaches not only ease menopausal symptoms but also enhance overall well-being.