Perimenopause brings hormonal fluctuations that can make weight management particularly challenging, with many women experiencing shifts in fat distribution and metabolic changes. GLP-1 receptor agonists—medications such as semaglutide and liraglutide—have gained attention for their weight management properties, though they were originally developed for type 2 diabetes. Whilst these treatments may offer benefits for some perimenopausal women meeting strict eligibility criteria, they are not specifically indicated for hormonal changes and must be used alongside lifestyle modifications. This article explores how GLP-1 medications work, their safety profile, NHS prescribing criteria, and alternative evidence-based strategies for managing perimenopausal weight gain.

Understanding Weight Gain During Perimenopause

Perimenopause represents the transitional phase leading up to menopause, typically beginning in a woman's 40s but occasionally starting in the mid-30s. During this period, fluctuating hormone levels—particularly oestrogen and declining progesterone—trigger numerous physiological changes that can significantly impact body composition and weight management.

Hormonal influences on metabolism and fat distribution are notable during perimenopause. Oestrogen plays a role in regulating metabolism, insulin sensitivity, and fat distribution. As oestrogen levels fluctuate and eventually decline, many women may experience a shift in fat storage from the hips and thighs to the abdominal area, potentially increasing visceral fat. This central adiposity carries greater health implications, including elevated risks for cardiovascular disease and type 2 diabetes. Additionally, changing hormone levels may affect leptin and ghrelin—hormones that regulate appetite and satiety—potentially leading to increased hunger and reduced feelings of fullness.

Beyond hormonal changes, several interconnected factors may contribute to perimenopausal weight gain:

• Metabolic slowdown: Basal metabolic rate naturally decreases with age, meaning the body burns fewer calories at rest

• Muscle mass loss: Sarcopenia (age-related muscle loss) accelerates during perimenopause, further reducing metabolic rate

• Sleep disruption: Night sweats and insomnia, common perimenopausal symptoms, interfere with hormones regulating appetite and glucose metabolism

• Mood changes: Anxiety, depression, and stress during this transition may lead to emotional eating patterns

• Reduced physical activity: Fatigue, joint pain, and other symptoms may decrease exercise tolerance

Research suggests women may gain weight gradually during perimenopause, though individual experiences vary considerably. If you experience rapid, unexplained weight gain, particularly with symptoms like fatigue or swelling, consult your GP to rule out other medical causes such as thyroid disorders or medication effects. Understanding these multifactorial causes is essential for developing effective, personalised weight management strategies during this challenging life stage.

What Are GLP-1 Medications and How Do They Work?

Glucagon-like peptide-1 (GLP-1) receptor agonists represent a class of medications originally developed for managing type 2 diabetes but increasingly recognised for their weight management properties. These medications include semaglutide (marketed as Wegovy for weight management and Ozempic for diabetes) and liraglutide (Saxenda for weight management and Victoza for diabetes). In the UK, these treatments are regulated by the Medicines and Healthcare products Regulatory Agency (MHRA).

Mechanism of action: GLP-1 is a naturally occurring incretin hormone released by the intestines in response to food intake. GLP-1 receptor agonists mimic this hormone, binding to GLP-1 receptors throughout the body, particularly in the pancreas, brain, and gastrointestinal tract. The medications work through several complementary mechanisms:

• Appetite suppression: Acting on receptors in the hypothalamus to reduce hunger signals and increase satiety

• Delayed gastric emptying: Slowing the rate at which food leaves the stomach, prolonging feelings of fullness

• Enhanced insulin secretion: Stimulating glucose-dependent insulin release from pancreatic beta cells

• Reduced glucagon secretion: Decreasing the hormone that raises blood glucose levels

Clinical efficacy for weight loss has been demonstrated in clinical trials. In the STEP trials, semaglutide 2.4 mg weekly showed average weight reductions of 12–15% of body weight over 68 weeks, whilst in the SCALE trials, liraglutide 3 mg daily typically produced 5–8% weight loss. These medications are administered via subcutaneous injection, with dosing gradually increased to minimise gastrointestinal side effects.

Importantly, these medications are indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, not as standalone treatments. For perimenopausal women specifically, there is no official link established between GLP-1 medications and hormonal changes during perimenopause. However, the weight loss achieved may help address metabolic complications associated with this life stage, including insulin resistance and cardiovascular risk factors. GLP-1 treatments do not directly address hormonal fluctuations or other perimenopausal symptoms beyond weight management.

Safety Considerations and Side Effects of GLP-1 Treatments

Whilst GLP-1 receptor agonists have demonstrated efficacy for weight management, understanding their safety profile is essential for informed decision-making. These medications are prescription-only in the UK and require careful medical supervision, particularly when used in perimenopausal women who may be managing multiple health considerations.

Common adverse effects are predominantly gastrointestinal and typically emerge during dose escalation:

• Nausea (affecting 20–50% of users initially)

• Vomiting and diarrhoea

• Constipation

• Abdominal pain and bloating

• Reduced appetite (therapeutic effect but may be excessive)

• Fatigue and headache

• Injection site reactions (redness, swelling or itching)

These effects usually diminish over several weeks as the body adjusts. Eating smaller, more frequent meals and avoiding high-fat foods can help manage symptoms. Maintaining adequate hydration is important, as dehydration from gastrointestinal side effects can lead to acute kidney injury in severe cases.

Serious but rare complications require immediate medical attention:

• Pancreatitis: Severe, persistent abdominal pain radiating to the back warrants urgent assessment

• Gallbladder disease: Rapid weight loss increases gallstone risk; right upper quadrant pain should be evaluated promptly

• Hypoglycaemia: Particularly when combined with other diabetes medications

• Thyroid concerns: Animal studies showed thyroid C-cell tumours; human relevance is unknown, but patients should be advised to seek medical attention for symptoms like a lump in the neck or persistent hoarseness

• Diabetic retinopathy complications: Rapid glucose improvement may temporarily worsen retinopathy in diabetic patients

Special considerations for perimenopausal women include:

• Pregnancy planning: Stop semaglutide at least 2 months before planned pregnancy; liraglutide should be discontinued at least one month before

• Pregnancy and breastfeeding: These medications should be avoided during pregnancy and whilst breastfeeding

• Mood changes: The MHRA advises monitoring for new or worsening depression or suicidal thoughts

• Heart rate increases: These medications may cause modest increases in heart rate

Patients should contact their GP immediately if experiencing severe abdominal pain, persistent vomiting, signs of allergic reaction, or visual changes. Regular monitoring of weight, blood pressure, and metabolic parameters is recommended throughout treatment. Report any suspected side effects to the MHRA Yellow Card Scheme (yellowcard.mhra.gov.uk).

Alternative Weight Management Strategies During Perimenopause

Whilst GLP-1 medications may offer benefits for some women, comprehensive lifestyle approaches remain the foundation of weight management during perimenopause. NICE guidance emphasises multicomponent interventions addressing diet, physical activity, and behavioural factors as first-line strategies.

Nutritional approaches tailored to perimenopausal physiology include:

• Protein optimisation: Moderate protein intake (around 1.0–1.2 g/kg body weight daily for most women) may help preserve muscle mass and enhance satiety. Higher intakes should be discussed with a healthcare professional, particularly for those with kidney disease

• Mediterranean dietary pattern: Rich in vegetables, fruits, whole grains, legumes, nuts, and olive oil, this approach supports cardiovascular health and weight management

• Calcium and vitamin D: Essential for bone health as oestrogen declines; aim for 700 mg calcium daily and consider a 10 mcg (400 IU) daily vitamin D supplement, particularly during autumn and winter months, as recommended by NHS guidance

• Phytoestrogens: Foods containing plant oestrogens (soya, flaxseeds, legumes) may modestly help some perimenopausal symptoms, though evidence for weight management is limited

• Mindful eating practices: Addressing emotional eating patterns common during this transition

Physical activity recommendations should combine multiple modalities, in line with UK Chief Medical Officers' guidelines:

• Resistance training: Two to three sessions weekly to combat muscle loss and maintain metabolic rate

• Cardiovascular exercise: 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity activity weekly

• High-intensity interval training (HIIT): May help with fitness and metabolic health for some women, though evidence for superior effects on visceral fat is still emerging

• Flexibility and balance work: Yoga or Pilates can address stress whilst improving functional fitness

Hormone replacement therapy (HRT) deserves consideration primarily for symptom management, though it may have modest effects on body composition:

• HRT is not licensed for weight management and should not be prescribed specifically for weight loss

• It may help reduce the tendency toward central fat deposition in some women

• By improving sleep, mood, and other symptoms, HRT may indirectly support healthy lifestyle behaviours

• NICE guidelines support HRT for perimenopausal symptom management when benefits outweigh risks

Additional supportive measures include:

• Sleep hygiene optimisation: Addressing night sweats and insomnia through environmental modifications and, when appropriate, medical interventions

• Stress management: Cognitive behavioural therapy (CBT), mindfulness, or other evidence-based approaches

• Behavioural support programmes: NHS-funded weight management services or commercial programmes meeting quality standards

These integrated approaches address the multifactorial nature of perimenopausal weight gain and support overall health beyond weight management alone.

Speaking to Your GP About GLP-1 Treatment Options

Discussing GLP-1 medications with your GP requires preparation and understanding of NHS prescribing criteria. These treatments are not routinely available for weight management alone and must meet specific eligibility requirements outlined in NICE guidance.

Current NHS eligibility criteria for semaglutide 2.4 mg (Wegovy) for weight management, according to NICE TA875, include:

• Body Mass Index (BMI) ≥35 kg/m² with at least one weight-related comorbidity (such as type 2 diabetes, hypertension, dyslipidaemia, obstructive sleep apnoea)

• For people from certain high-risk ethnic groups (such as South Asian, Chinese, Black African, or African-Caribbean), lower BMI thresholds apply (typically reduced by 2.5 kg/m²)

• Treatment must be prescribed within specialist weight management services only

• Treatment is limited to a maximum duration of 2 years

• Must be used as an adjunct to a reduced-calorie diet and increased physical activity

Liraglutide 3 mg (Saxenda) availability varies significantly across NHS regions and is not routinely commissioned in many areas. Your GP can advise on local pathways and eligibility.

Preparing for your consultation:

Before your appointment, document:

• Your weight history, including previous weight loss attempts and outcomes

• Current medications and medical conditions

• Perimenopausal symptoms and their impact on daily life

• Dietary habits and physical activity levels

• Family history of obesity, diabetes, or thyroid conditions

• Specific concerns about weight gain and health goals

Questions to discuss with your GP:

• "Am I eligible for referral to specialist weight management services that might consider GLP-1 medications?"

• "What are the realistic expectations for weight loss with these treatments?"

• "How would this medication interact with any HRT or other treatments I'm taking?"

• "What monitoring would be required during treatment?"

• "What happens when I stop the medication—will weight return?"

• "Are there local NHS weight management services that might help?"

• "Would addressing my perimenopausal symptoms with HRT potentially help with my overall health?"

Setting realistic expectations is crucial. GLP-1 medications are not a standalone solution but work best alongside sustained lifestyle modifications. Treatment through NHS specialist services typically continues for up to 2 years, and discontinuation often results in weight regain. Your GP will assess whether the benefits justify the risks in your individual circumstances.

If NHS prescription isn't available or appropriate, your GP can discuss alternative evidence-based approaches, referral to specialist weight management services, or consideration of other medications like orlistat (which has different eligibility criteria under NICE guidance). Remember that perimenopausal weight management is a marathon, not a sprint, and multiple strategies may be needed to achieve sustainable results whilst supporting overall health during this transitional phase.

Frequently Asked Questions