Clinical review: Menopause hormone therapy in weight management

Background: This document provides clinicians with an evidence-based overview of menopause hormone therapy (MHT) and its role in weight management for perimenopausal and postmenopausal women with obesity or overweight. Methods: This clinical review was developed using a structured, evidence-informed process designed to synthesize current knowledge about menopause hormone therapy (MHT) and its relationship to weight regulation in perimenopausal and postmenopausal women with obesity or overweight. The methodology incorporated a targeted literature review and expert clinical interpretation of the author. Results: The menopausal transition is associated with significant changes in body composition - including increased total body fat, visceral adipose tissue accumulation, and decreased lean body mass that occurs independent of chronological age. While these changes are primarily driven by estrogen deficiency and evidence from randomized trials and meta-analyses demonstrates that MHT may attenuate central fat accumulation and preserve favorable body composition, it is not indicated as a primary weight loss intervention. Furthermore, although recent observational data suggest potential synergistic effects when MHT is combined with obesity medications (OMs), these findings are limited by small sample sizes, retrospective design, and potential confounding, requiring validation through rigorous clinical trials. Conclusion: Following individualized risk-benefit assessment, MHT should be prescribed based on established clinical indications: moderate to severe vasomotor symptoms, prevention of osteoporosis, treatment of hypoestrogenism, or treatment of vulvovaginal symptoms. While MHT may provide indirect benefits for weight management through improvements in cardiometabolic health and improvement of menopausal symptoms that interfere with lifestyle interventions, it should not be marketed or prescribed for weight loss or obesity treatment. Comprehensive obesity treatment should focus on the four pillars: nutrition, physical activity, behavioral modification, medical interventions, including metabolic and bariatric surgery and appropriate use of FDA-approved obesity medications when indicated.