I want to start by acknowledging the privileged position I hold as a mid-life woman who has a straightforward relationship with food and weight. I know from my consultations with thousands of women over the last 25 years how unusual that is.

Food is complex

Weight is complex

Women are complex

Menopause is complex

If you’re using or considering GLP-1s, this is what I want you to know to support you in making the right decision for you.

What are GLP-1s?

Glucagon-like peptide-1 receptor agonists (GLP-1s or GLP-1RAs) are medications that are similar to a natural hormone which is released after eating, influencing our hunger cues so we feel fuller, and slowing stomach emptying. Some types of these medications also act on another hormone involved in appetite and blood glucose regulation, GIP (glucose-dependent insulinotropic polypeptide).

In the UK, there are three licensed medications, the most common being semaglutide (Wegovy, Ozempic) and tirzepatide (Mounjaro). They are given as injections, either daily or weekly. They have been used for diabetes over the last 10 years, improving insulin sensitivity and glucose control, and some have also now been licensed for weight loss. NICE (National Institute for Clinical Excellence) has approved Tirzepatide (Mounjaro) for weight loss in adults where someone has a BMI over 35 and there is an associated health impact, such as heart disease. GPs in England will be starting to prescribe on the NHS for patients with the highest clinical need from this Summer. The NHS rollout to all patients currently eligible for these medications will be phased and is predicted to take place over the next 12 years.

Do they work?

People using these medications in clinical trials lost up to 20% of their body weight, and these results seem to be replicated in “real-life”. This isn’t always a guarantee, as the people in the clinical trials also received intensive support around nutrition and movement in addition to the medication. There were lots of women included in the trials, which is great, but less representation of different ethnicities and of people with pre-existing medical conditions.

People in the studies were shown to have improvements in blood pressure, cholesterol, and blood glucose, with lower levels of heart attacks and strokes. We are increasingly understanding that there are also impacts on other factors, such as inflammation levels.

What about side effects?

The most common side effects are gastro-intestinal with nausea, vomiting, bloating, and diarrhoea. There can also be skin reactions at the injection site, hair loss, and fatigue. All side effects should be reported, as the medications are “black triangle” and still relatively new. (See the resources below for how you can do this directly.)

The impact on mood and overall emotional wellbeing seems to be mixed, with some people reporting positive effects and others suicidal thoughts. This is being actively monitored by the European Medicines Agency.

They should not be taken by people with a personal history or family history of thyroid cancer, and are cautioned with a history of pancreatitis.

What about microdosing?

Some private clinics advocate micro-dosing with very small doses of the medication to minimise the side effects. This approach is not regulated, approved, or studied, so there are a lot of unknowns!

What about for women specifically?

Pre-menopausally, the medications are just as effective for women as they are for men. Post-menopausally, they are more effective for men, with oestrogen seeming to increase their effectiveness in women.

They directly affect the hypothalamus-pituitary-ovarian (HPO) axis, and particularly for women with polycystic ovarian syndrome (PCOS), this results in improved insulin sensitivity, lower testosterone levels, and more regular ovulatory cycles with improved fertility.

It is recommended, though, that they are not to be used when trying to conceive, during pregnancy, or during breastfeeding, as there is not enough data currently to know if this is safe. There are increasing reports of “Ozempic babies”, so real-life data is being collated.

Mounjaro can reduce the effectiveness of oral hormonal contraception, and so it is recommended to switch to a different method (like the coil) or not rely on the pill for 4 weeks after starting Mounjaro or increasing the dose.

In terms of HRT, the studies suggest that women see more weight loss when using GLP-1s with HRT and less when using GLP-1s with hormone blockers that suppress oestrogen. Again though, they can reduce the effectiveness of oral progesterone, so if you are using a micronized progesterone like Utrogestan or Gepretix in your HRT regime, the recommendation is to change to a Mirena or patch as the progesterone may not be giving enough protection to the womb lining (which is then a worry for the development of womb lining cancer).

What are the potential concerns?

There is a significant reduction in muscle mass with the weight loss from these medications, and this is a real worry for me for women at menopause. Muscle supports our metabolism, our heart health, brain health, and bone health, and is naturally declining at menopause. Similarly, there are reports of bone loss with the medications, which again is typically declining at menopause.

Many people using the medications are buying them online after answering a series of questions, and may not realise the medications interact with contraception and HRT, or can affect us if we have an operation. Another concern is the use by people who do not have a BMI over 30, particularly by those with disordered eating in a restrictive pattern.

In trials, people with health conditions are typically excluded, so we do not have much evidence at all on how they will impact someone with depression, for example.

What about longer-term?

GLP-1 medications generally work as long as you take them, and when stopped, typically weight is regained quickly, with this more commonly being fat, not muscle. The cost of the injections is not insignificant, at up to £300 a month.

What about lifestyle?

Appetite tends to be quite suppressed, so it’s really important to optimise what food is being eaten, with particular attention to protein levels. A general multi-vitamin may be appropriate.

In the studies, regular strength training was shown to mitigate against the loss of muscle mass and bone mass seen with the medications, so this is really key for women in mid-life to incorporate.

What next?

I’m very interested to see more data on whether they could be of particular benefit for people with ADHD, via modulating dopamine. There are now many anecdotal reports of people experiencing less “food noise” but also having fewer cravings for nicotine and alcohol. Similarly, there are anecdotal reports of improved cognitive function too.

There are also emerging reports of lower cancer risks, particularly with regards to breast cancer and ovarian cancer. Whilst this may be due to the direct weight loss, it has been postulated that there are other factors at play too. We will have to wait and see for now.

Conclusion

Most women in mid-life will gain weight despite the same nutrition and movement patterns, and this is linked with many other factors, including disrupted sleep. How that change in weight impacts us is very tied up with how society views both women and weight.

The evidence we have so far suggests that for women in mid-life using GLP-1s

using them alongside an appropriate type of HRT increases effectiveness
strength training is vital
ensuring adequate protein and nutrition is important
supplementing with vitamin D is important
long-term use is likely to be needed.

Here at Rethink, I offer holistic personalised menopause consultations, and am happy to advise on how to combine GLP-1s with HRT effectively, aswell as on how we can all optimise our physical and emotional health and wellbeing, whatever our weight.

GLP-1s, what mid-life women need to know