Key findings:

Menopause commonly shifts body composition toward more abdominal fat and less muscle — changes that increase cardiometabolic risk — and the best current strategy is resistance training, good sleep and nutrition, daily movement, plus individualized clinical options (including menopausal hormone therapy) when appropriate.

1. More belly fat, different shape.
   Many women shift fat from hips/thighs to the abdomen during the menopause transition — increasing visceral (deep abdominal) fat and changing overall body shape.
2. Muscle falls while fat rises.
   Menopause is associated with gains in fat mass and declines in lean mass (muscle), a combination that worsens metabolic health and function.
3. Aging + menopause both matter.
   Some midlife weight gain is due to aging and lifestyle, but menopause independently contributes to the distribution of fat (more central/visceral fat) and to accelerated muscle loss.
4. Likely biological drivers:
   • Estrogen decline — loss of estrogen signaling promotes visceral fat accumulation and influences energy balance.
   • Gonadotrophins (e.g., follicle-stimulating hormone, FSH) — there is some evidence these hormones may have independent metabolic effects.
   • Lower energy expenditure and activity — resting metabolic rate and spontaneous daily activity often decline in midlife.
   • Other contributors — poor sleep, changes in appetite and gut hormones, and the gut microbiome are plausible contributors but need more research.
5. Health consequences:
   The shift toward more visceral fat and less muscle increases cardiometabolic risk (insulin resistance, type 2 diabetes, cardiovascular disease), can affect physical function and bone/muscle health, and may influence long-term disease risk.
6. Management options:
   • Lifestyle first: resistance training to preserve or rebuild muscle, regular aerobic activity, daily movement, adequate protein intake, sleep hygiene, and balanced diet.
   • Menopausal hormone therapy (MHT): MHT can modestly reduce the tendency to accrue abdominal fat and help preserve lean mass for some women. It is not a weight-loss therapy and must be considered alongside individual risks and benefits.

The Results

• Menopause is linked to redistribution of fat toward the abdomen and to loss of muscle, more than to dramatic sudden weight gain.
• Multiple interacting mechanisms (estrogen loss, possible FSH effects, reduced energy expenditure/activity, sleep and gut changes) probably explain these shifts, but exact causal pathways need more study.
• These composition changes matter because they raise cardiometabolic and functional risks.
• Combining lifestyle measures with individualized clinical options (including MHT when appropriate) is the most practical approach today.

Practical implications

• Focus on muscle and movement: prioritize resistance training, keep daily non-exercise movement high, and aim for sufficient dietary protein to protect muscle mass.
• Watch waist, not just scale: waist circumference and strength tests are often more informative than the bathroom scale for health risk.
• Consider MHT carefully: for some women, menopausal hormone therapy can modestly protect body composition, but it should be a personalized decision made with a clinician.
• Address sleep and lifestyle: improving sleep, reducing prolonged sitting, and managing stress are practical ways to limit unfavorable changes.