Perimenopause may be best time to prevent poor body composition, metabolic outcomes
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Lifestyle intervention may be most effective in perimenopause, as women experience the onset of poor body composition and metabolism associated with menopause, according to a study.
“I have a passion for improving the health and well-being of women,” Abbie Smith-Ryan, PhD, associate professor of exercise physiology at the University of North Carolina, Chapel Hill, told Healio. “So many women buy into misinformation, or information on how to be healthy and feel good is unclear.”
Postmenopause may encompass up to 40% of a woman’s life, according to the study, which was published in Menopause.
“The length and cost of this transition to menopause is characterized by the onset of vasomotor symptoms, accelerated adverse changes in body composition and increased risk of chronic diseases including osteoporosis, cardiovascular disease and metabolic syndrome,” the researchers wrote. “Ultimately, the burden of this transition known as perimenopause is associated with decreased quality of life, productivity and potentially hindered personal and intimate relationships.”
To examine the onset of these changes throughout the menopausal transition, Smith-Ryan and colleagues conducted a cross-sectional study of 72 women aged 35 to 60 years who were premenopausal, perimenopausal or postmenopausal. They measured participants’ body composition using a four-compartment model — which evaluated bone mineral content, total body water, fat mass and body mass — resting energy expenditure (REE) and metabolic flexibility during sub-maximum physical activity at in-person visits.
Participants completed lifestyle behavior surveys prior to the visits.
‘Much larger change from pre- to perimenopause’
Although height, weight and BMI were similar between all three groups, premenopausal women had a significantly lower body fat percentage than perimenopausal women. This remained significant when controlling for estradiol and progesterone.
Android-to-gynoid ratio was also significantly lower in premenopausal women than in perimenopausal women. Again, the difference remained significant when controlling for hormones.
“We anticipated somewhat of a linear change in body composition and metabolism,” said Smith-Ryan, who is also an adjunct associate professor in the department of nutrition, director of the Applied Physiology Laboratory and co-director of the Human Performance Center. “For example, an increase in fat mass, decrease in muscle and lowered metabolic rate with age. However, we identified that there is a much larger change from pre- to perimenopause. Additionally, the changes that we saw were more than would be seen when attributed to aging alone.”
Visceral adipose tissue, extracellular content and waist-to-hip ratio were similar across groups, as was REE.
During moderate intensity exercise, fat oxidation was significantly greater in premenopausal women compared with postmenopausal women. However, the difference was no longer significant when the researchers controlled for hormone use.
An analysis of overall metabolic flexibility — measured as change in resting exchange ratio (RER) — showed there were significant differences for RER during moderate exercise. Premenopausal women had significantly lower difference in RER than perimenopausal women and postmenopausal women.
Survey responses
Self-reported survey responses revealed that sleep quality, physical activity and diet were similar between groups.
Compared with premenopausal women, perimenopausal and postmenopausal women reported significantly more menopause symptoms, and peri- and postmenopausal women reported symptoms at similar rates. When controlling for hormone use, those findings remained significant between pre- and peri-menopausal women only.
“To prevent unwanted changes in resting metabolism, as well as metabolic flexibility, it is possible that menopausal women should engage in activities that help maintain lean mass (ie, resistance exercise) as well as retain or increase oxidative capacity (ie, moderate to high intensity exercise),” Smith-Ryan and colleagues advised.
Since each participant attended only one visit, the researchers warned that some of the hormone variability and lower RER values seen in perimenopausal women may be due to unpredictable hormone fluctuations. Other limitations included self-reported data and the study’s longitudinal design.
“We are planning and hoping to explore some mechanistic views of what is happening to the muscle during this transition, as some other data from our lab (that is in review) suggests that muscle and protein kinetics are driving a lot of these changes,” Smith-Ryan said. “Additionally, we are exploring the impact of hormonal contraception on some of these same outcomes.”
The researchers called perimenopause the “most opportune” time for lifestyle intervention.
“Ultimately, future cross-sectional investigations and longitudinal interventions should be designed to target perimenopausal women to determine if menopause-related shifts in body composition and metabolism are preventable with sustainable nutrition and exercise modifications,” Smith-Ryan and colleagues wrote.
Perspective
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This study by Smith-Ryan and colleagues demonstrated that unfavorable body composition and metabolic changes start in perimenopause rather than after menopause. As expected, resting energy expenditure declined across the menopause transition. Also important to note is that unfavorable body composition changes occurred in peri- and postmenopausal women despite increased reported physical activity in these two groups compared with premenopausal women. Additionally, there were adverse changes in exercise metabolism in peri- and postmenopausal women compared with premenopausal women, meaning that peri- and postmenopausal women weren’t getting the same metabolic impact from exercise as premenopausal women. The authors suggested that because these changes appear to begin in perimenopause, interventions in this group of women might be needed to mitigate some of these changes, specifically an increase in percent fat and abdominal adiposity.
These results are entirely consistent with what I hear from my patients. That is, that they haven’t changed anything — they are eating like they always have and exercising like they always have (or more) and are still fighting body composition changes and can’t seem to lose weight. I usually start the conversation by validating what my patients are noting and further affirming that they won’t be able to utilize exercise alone to combat the issue. Some of these changes are related to aging (both men and women lose muscle mass and gain weight starting in midlife), but some of these changes are related to menopause and the loss of estrogen, particularly the body composition changes.
So, what is the solution? It’s important to level set the expectation that our bodies are not the same at age 55 as they were at age 20. So, should we just give up and accept all of these changes? That’s not a great answer either, as abdominal adiposity is dangerous and represents a significant cardiovascular risk, even in normal weight women. Further, it is important to remember that heart disease is the number one killer of women. What I typically suggest is maximizing fruit and vegetable intake; cutting caloric intake overall, particularly simple carbohydrates (don’t forget to include alcohol in this category); and maintaining or increasing aerobic activity. Resistance training is also helpful in maintaining muscle mass (muscle burns more calories than fat does). Even small changes can make a big difference in overall health, such that going down a pant size is a win, even if the scale doesn’t change.
Finally, I agree with the authors in suggesting that we should start education and lifestyle measures before women hit menopause, but I would go a step further and advocate for education on the menopause transition and initiation of lifestyle changes while women are still premenopausal. These changes catch most women off-guard, and we need to be more proactive with anticipatory guidance given that menopause is a universal event for women.
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