The Soulful GP Perimenopause Series | Part Five By The Soulful GP

Let’s talk about the thing that is making you want to throw your scales out of the window.

You are eating the same way you always have. You are exercising the same way you always have. But suddenly, your clothes do not fit. The weight is sitting differently — gathering around your middle in a way it never did in your twenties or thirties.

You go to the doctor, or you confide in a friend, and you are handed the oldest, most tired piece of advice in the world: “Eat less, move more.”

I want you to hear this clearly, from a doctor: You cannot simply willpower your way out of the hormonal and metabolic changes occurring during perimenopause.

The weight gain you are experiencing is not a moral failing. It is not because you are lazy. It is driven by a profound change in your biology. And until we talk honestly about what is happening inside your cells, you will keep fighting a battle you were never designed to win.

It is also worth saying this upfront: weight gain during perimenopause is common, but it is not inevitable. Small, consistent changes in nutrition, strength training, sleep, and — where appropriate — HRT can make a meaningful difference. There is genuine reason for hope.

Sarah, aged 47, told me: “I thought I was failing because everything I’d always done had stopped working.”

She wasn’t failing. Her biology had changed.

The Biology of the “Meno-Belly”

When you enter perimenopause, your body undergoes three major metabolic shifts. Understanding them is the key to changing how you respond to them.

1. The Insulin Resistance Shift

Oestrogen is a metabolic protector. Declining oestrogen contributes to reduced insulin sensitivity in many women — meaning the body has to work harder to move glucose out of the blood and into the cells where it can be used for energy.

Insulin helps regulate blood glucose and also promotes energy storage. When insulin levels are persistently elevated — as they are in those who are insulin resistant — the body increasingly favours fat storage, particularly visceral fat: the deep fat that gathers around your abdomen and organs. This is why the “meno-belly” is not simply about eating too much. It is a metabolic shift happening at a cellular level.

2. The Muscle Loss Shift (Sarcopenia)

Oestrogen helps maintain muscle mass. As it drops, you begin to lose muscle at an accelerated rate. Muscle is metabolically active tissue; it burns calories even when you are sitting still. Less muscle means a lower basal metabolic rate. If your metabolism has slowed but you are eating the same amount, your body will store the excess energy.

Here is something that often goes unnoticed: during perimenopause, the number on the scale often tells only part of the story. Many women lose muscle while simultaneously gaining fat, meaning body composition changes significantly even when overall weight changes very little. You can weigh exactly the same as you did five years ago and still feel entirely different in your body. That is not your imagination. That is biology.

3. The Cortisol Shift

Perimenopause is inherently stressful on the body. Add to that the sleep deprivation from night sweats, the anxiety from fluctuating progesterone, and the general load of mid-life, and your cortisol (stress hormone) levels can remain chronically elevated. Chronic elevations in cortisol are associated with increased abdominal fat deposition and worsening insulin resistance — a compounding effect on top of the hormonal changes already underway.

MYTH: Perimenopause weight gain is simply the result of eating too much.

FACT: Hormonal changes alter where fat is stored, how muscle is maintained, and how insulin works — independently of calorie intake.

Why “Eat Less, Move More” Fails Women

When women notice the weight creeping on, their instinct is usually to restrict calories and do more cardio. They eat salads. They run on treadmills. They push harder. And they are exhausted by the lack of results.

Here is why that approach so often backfires during perimenopause: excessive calorie restriction combined with prolonged endurance exercise may increase physiological stress and accelerate muscle loss. Your body, already navigating significant hormonal change, can respond by breaking down muscle for energy — worsening your metabolic rate — while holding onto fat for survival.

The result is exhaustion, persistent hunger, muscle loss, and continued fat gain. It is the exact opposite of what you are trying to achieve. This is not a failure of effort. It is a mismatch between strategy and biology.

How to Work With Your Body, Not Against It

If the old rules no longer apply, what are the new rules? How do we protect our metabolic health during this transition?

1. Prioritise Protein Over Restriction

You do not need to starve; you need to restructure. Because you are losing muscle mass, your protein needs increase during perimenopause. Aim for a substantial source of protein at every meal — roughly 25 to 30 grams per sitting is a practical target for many women. Protein stabilises blood sugar, keeps you full, and provides the building blocks your body needs to maintain and rebuild muscle.

For a woman weighing 70 kg, the recommended intake during perimenopause is approximately 70–84 grams of protein per day (1.0–1.2 g per kg of body weight). Spread across three meals, that means aiming for roughly 25–30 g per meal. The table below shows how easy it is to reach that target with everyday foods:

A practical example for a 70 kg woman: Breakfast — 3 eggs with smoked salmon (≈ 30 g). Lunch — a large chicken salad (≈ 30 g). Dinner — lentil dahl with Greek yoghurt on the side (≈ 25 g). That is roughly 85 g across the day — job done, without obsessing over numbers.

You do not need to track every gram meticulously. Simply asking yourself “where is my protein?” before each meal is enough to shift the habit.

A note for women with chronic kidney disease: If you have been diagnosed with CKD or any kidney condition, please seek individual advice from your GP or dietitian before significantly increasing your protein intake, as higher protein loads may not be appropriate for everyone.

2. Muscle Is Your Metabolic Superpower

If there is one non-negotiable change to make to your exercise routine, it is this: incorporate resistance training. Lifting weights, using resistance bands, or doing challenging bodyweight exercises is the most effective way to arrest the muscle loss of perimenopause. Aim for two to three sessions per week. You do not need to become a bodybuilder — “heavy” simply means a weight that feels genuinely challenging by the last few repetitions. Building muscle improves insulin sensitivity and raises your metabolic rate. It is the most powerful metabolic medicine available to you.

A word on creatine: While not essential, creatine is one of the best-studied supplements and the evidence supporting its use alongside resistance training — for preserving muscle mass, strength, and physical function in perimenopausal women — is becoming increasingly persuasive. It is worth a conversation with your GP or a sports medicine professional, particularly if you are already strength training.

3. Flatten the Glucose Curve

Because insulin sensitivity is reduced, you need to be strategic about carbohydrates. You do not need to eliminate them, but you do need to manage how they affect your blood sugar. Pair carbohydrates with protein or healthy fats. Eat your vegetables first, protein second, and carbohydrates last. A ten-minute walk after a heavy meal can help your muscles absorb glucose more efficiently. These are small habits with a meaningful cumulative effect.

4. Feed Your Gut: The Case for Fibre

Fibre is one of the most underrated tools in perimenopausal metabolic health, and most women are not getting nearly enough of it. The recommended intake is around 25–30 grams per day, yet the average adult in the UK consumes closer to 18 grams.

Fibre works on multiple levels during perimenopause. Soluble fibre — found in oats, lentils, apples, flaxseed, and chia seeds — dissolves in water to form a gel that slows glucose absorption, blunts blood sugar spikes, and helps lower LDL cholesterol. Insoluble fibre — found in wholegrains, vegetables, and nuts — supports gut motility and feeds the beneficial bacteria in your microbiome.

This matters more than many women realise. The gut microbiome changes significantly during the menopause transition, and these shifts are linked to changes in oestrogen metabolism, inflammation, and weight regulation. A diverse, fibre-rich diet supports the gut bacteria that help process and recirculate oestrogen — a system sometimes called the estrobolome, though research in this specific area is still emerging. What is more established is that higher fibre intake is associated with lower risk of metabolic syndrome in postmenopausal women, and that soluble fibre in particular has been shown to help reduce insulin resistance — the very mechanism driving visceral fat accumulation in perimenopause.

Practically, the goal is simple: aim for at least five different plant foods per day, and try to eat the rainbow. Vegetables, fruit, wholegrains, legumes, nuts, and seeds all count.

5. Manage Your Stress — Actively, Not Passively

We have already discussed how chronic cortisol elevation drives visceral fat storage and worsens insulin resistance. But it is worth being direct: stress management is not a soft lifestyle suggestion. It is a metabolic intervention.

The problem is that most women in perimenopause are managing enormous loads — careers, ageing parents, teenagers, relationships, and the physiological stress of the transition itself. Telling someone to “just relax” is not helpful. What the evidence does support are specific, practical approaches:

Mindfulness-Based Stress Reduction (MBSR): A meta-analysis of mindfulness-based interventions in menopausal women found significant improvements in anxiety, depression, and stress scores. Mindfulness practice has been associated with reductions in cortisol levels in some studies, which may support better body composition during the transition. Even five to ten minutes of daily practice — breathwork, body scanning, or guided meditation — is a reasonable and low-risk starting point.

Meditative movement: Yoga, tai chi, and qigong have emerging evidence for improving body composition in perimenopausal women, likely through their combined effect on cortisol reduction and gentle resistance on the musculoskeletal system.

Identifying and reducing chronic stressors: This sounds obvious, but it is worth naming. Chronic low-grade stress — a difficult relationship, a relentless workload, financial strain — keeps cortisol elevated in a way that no amount of exercise or dietary change can fully overcome. Addressing the source, not just the symptoms, is part of the metabolic picture.

6. Rethink Alcohol

This is the section many women would rather skip. But it deserves an honest conversation.

Alcohol is uniquely problematic during perimenopause for several reasons that go beyond simple calorie counting:

It disrupts sleep architecture. Even moderate alcohol consumption fragments sleep and suppresses REM sleep — meaning that the glass of wine that feels like it helps you wind down is actually reducing sleep quality. Given that poor sleep is already a major driver of insulin resistance and cortisol elevation in perimenopause, this is a significant compounding factor.

It interacts with oestrogen metabolism in a complicated way. Alcohol can impair the liver’s ability to metabolise oestrogen, which may temporarily affect circulating oestrogen levels. The clinical significance of this during perimenopause is not fully established, but the broader picture is clearer: multiple large studies have found an association between alcohol consumption and increased risk of oestrogen receptor-positive breast cancer — a risk that is worth factoring in, particularly for women considering or already taking HRT.

It is calorically dense and metabolically disruptive. Alcohol provides 7 calories per gram — more than carbohydrates or protein — with no nutritional value. It also temporarily suppresses fat oxidation, meaning your body prioritises burning alcohol over burning fat. For women already dealing with reduced insulin sensitivity, this is an additional metabolic burden.

What does the evidence say about quantity? The relationship between alcohol and weight in postmenopausal women is genuinely complex — some studies suggest light to moderate intake is not strongly associated with weight gain, while heavy intake clearly is. However, the broader health picture — sleep disruption, breast cancer risk, liver metabolism, and cortisol interaction — points toward the same conclusion: less is better during perimenopause, and none is fine.

If you drink regularly, even reducing by one or two drinks per week can have a meaningful impact on sleep quality, which in turn improves insulin sensitivity, cortisol regulation, and energy levels. It does not have to be all or nothing.

7. Protect Your Sleep

Sleep deprivation drives insulin resistance and cortisol up. Treating perimenopausal insomnia — whether through HRT, CBT-I (Cognitive Behavioural Therapy for Insomnia), or consistent sleep hygiene — is not just about feeling rested. It is a metabolic intervention in its own right.

8. Consider HRT

HRT should never be prescribed solely for weight loss. However, by replacing declining oestrogen where clinically appropriate, it may reduce visceral fat accumulation and improve insulin sensitivity in some women. If you are experiencing symptoms that affect your quality of life, it is worth having an honest conversation with your doctor about whether HRT is appropriate for you.

Did you know? Muscle tissue burns approximately three times more calories at rest than fat tissue. Every kilogram of muscle you build raises your resting metabolic rate — meaning you burn more energy around the clock, not just during exercise. This is why resistance training is the single most important exercise change you can make during perimenopause.

Managing Cravings: Why Your Brain Is Working Against You (And What to Do About It)

One of the most distressing and least-discussed aspects of perimenopause is the sudden, overwhelming nature of food cravings — particularly for sugar, refined carbohydrates, and ultra-processed foods. Many women describe a feeling of being out of control around food for the first time in their lives. This is not weakness. It is neurobiology.

Why Cravings Intensify in Perimenopause

Several hormonal mechanisms converge during perimenopause to make cravings more intense and harder to resist:

Oestrogen and serotonin. Oestrogen is thought to influence serotonin regulation — the neurotransmitter most associated with mood, contentment, and satiety. As oestrogen fluctuates and declines, serotonin activity may be affected in some women. The brain, seeking to restore a sense of wellbeing, can turn to the fastest available route: carbohydrates and sugar, which trigger a rapid (if short-lived) serotonin release. This is why cravings are so often specifically for sweet or starchy foods, and why they are frequently worse in the late afternoon or evening.

Blood sugar instability. Reduced insulin sensitivity means blood glucose levels fluctuate more dramatically than they did in your thirties. A sharp drop in blood sugar — which can happen more easily during perimenopause — triggers a powerful, urgent craving for fast-release carbohydrates. This is the body’s emergency response to perceived low fuel, and it is extremely difficult to override with willpower alone.

Ghrelin and leptin dysregulation. Ghrelin is the hunger hormone; leptin is the satiety hormone. Both are disrupted during perimenopause. Poor sleep — itself a hallmark of the transition — raises ghrelin and lowers leptin, meaning you feel hungrier and less satisfied after eating. This creates a physiological state that is almost designed to produce overeating.

Cortisol and dopamine. Chronic stress elevates cortisol, which in turn drives cravings for calorie-dense, rewarding foods. High-sugar, high-fat foods activate the brain’s dopamine reward pathway — the same system involved in habit and addiction. Under chronic stress, the brain increasingly seeks these dopamine hits as a coping mechanism.

Practical Strategies That Actually Help

Understanding the mechanism is the first step. The second is choosing strategies that work with your biology rather than demanding you override it:

Stabilise blood sugar first. The single most effective craving-reduction strategy is preventing the blood sugar crash that triggers them. Eating protein and fibre at every meal, not skipping meals, and having a protein-rich snack in the mid-afternoon (when cravings typically peak) significantly reduces the frequency and intensity of sugar cravings.

Do not try to white-knuckle cravings. Restriction tends to amplify cravings over time. A more effective approach is to ensure you are genuinely well-nourished — adequate protein, adequate fat, adequate fibre — so the craving signal is less urgent. A small amount of dark chocolate (70% or above) or a piece of fruit with nut butter satisfies the sweet signal without the blood sugar spike of ultra-processed alternatives.

Address the serotonin deficit directly. Regular exercise — particularly resistance training and outdoor walking — raises serotonin naturally. Adequate sleep is essential for serotonin regulation. If low mood and cravings are occurring together, this is worth discussing with your GP, as it may point to a need for additional support beyond lifestyle changes.

Identify your craving triggers. Cravings are rarely random. Common triggers include: skipping meals, poor sleep the night before, high-stress days, boredom, and specific times of day. Keeping a brief food and mood diary for two weeks can reveal patterns that make cravings much easier to anticipate and manage.

Eat mindfully, not reactively. Slowing down at meals — chewing thoroughly, eating without screens, pausing between bites — gives the gut-brain satiety signals time to reach the brain (which takes approximately 20 minutes). Many perimenopausal women find they eat significantly less when they eat slowly, not because they are restricting, but because they can actually feel when they are full.

A note on ultra-processed foods: Research increasingly shows that ultra-processed foods — those engineered for maximum palatability — are disproportionately craving-inducing. They are designed to override satiety signals. Reducing them is not about willpower; it is about removing a biological trigger from your environment where possible.

“Once I understood why I was craving sugar at 4pm every day, I stopped fighting it and started eating a protein snack at 3:30pm instead. The craving just… stopped.” — Patient, aged 51

MYTH: Cravings in perimenopause are a sign of poor self-control.

FACT: Cravings are driven by hormonal shifts in serotonin, blood sugar instability, and disrupted hunger hormones — all of which are biological, not behavioural.

Blood Tests and Red Flags: What to Ask Your GP For

Perimenopause is a critical window for metabolic health. The hormonal changes occurring during this transition can silently alter blood sugar regulation, cholesterol profiles, thyroid function, and cardiovascular risk — often before any symptoms appear. Knowing which tests to ask for, and what the results mean, puts you in a far stronger position.

The Core Metabolic Screen

If you are in perimenopause and have not had a recent metabolic screen, the following tests are worth requesting at your next GP appointment. Many are available as part of an NHS Health Check (offered to adults aged 40–74 every five years), but you can request them individually if you have specific concerns:

The Thyroid Point Deserves Special Mention

Hypothyroidism — an underactive thyroid — is significantly more common in women and increases in prevalence during midlife. Its symptoms overlap almost perfectly with perimenopause: fatigue, weight gain, low mood, brain fog, constipation, and feeling cold. It is not uncommon for women to be told their symptoms are perimenopause when an underactive thyroid is contributing or even primarily responsible. Always ask for a TSH test if you have not had one recently, particularly if weight gain has been rapid or unexplained.

Red Flags That Warrant Prompt GP Review

Beyond routine screening, certain symptoms alongside weight changes should prompt an earlier, more urgent conversation with your GP:

A word on “normal” results: A blood test result that falls within the standard reference range does not always mean optimal. A fasting glucose of 5.5 mmol/L is technically “normal” but sits close to the impaired fasting glucose threshold. A TSH of 3.8 mIU/L is within range but may be suboptimal for some women. If your results are in the upper or lower end of normal and your symptoms are significant, it is worth a conversation with your GP about whether they warrant monitoring or further investigation.

A Special Note for South Asian and Afro-Caribbean Women

If you are a South Asian or Afro-Caribbean woman reading this, I want to speak to you directly — because your biology carries additional layers that mainstream perimenopause conversations almost never address. The risks are real, they are well-documented in the research, and they are not your fault. But they do require a more tailored conversation.

South Asian Women: The Thin-Fat Phenotype

South Asian women are disproportionately prone to storing visceral fat — the deep, dangerous fat that accumulates around the abdominal organs — and this risk is amplified during the hormonal shifts of perimenopause. Research consistently shows that South Asian women accumulate more visceral fat than white European women at the same BMI, and crucially, this can happen even when your weight appears entirely normal on a standard scale. This is known as the “thin-fat phenotype”: a body that looks lean on the outside but carries a higher proportion of metabolically dangerous fat on the inside.

Why does this happen? One proposed explanation is the “thrifty gene hypothesis” — the idea that populations who endured repeated cycles of famine, as South Asian communities did across centuries of food scarcity and colonial-era famines, may have gradually developed genes that are extraordinarily efficient at storing energy as fat during times of abundance. In an era of food insecurity, this would have been a survival advantage. In the modern world, with calorie-dense food readily available, those same genes may continue to drive rapid fat storage — preferentially depositing it as visceral fat around the abdomen and organs.

The consequences are significant. South Asian women have a higher risk of type 2 diabetes, insulin resistance, and cardiovascular disease — and these risks begin at lower body weight thresholds than standard charts suggest. The BMI chart was not designed with South Asian bodies in mind. Major health bodies including the WHO recommend that for South Asian women, the threshold for increased metabolic risk begins at a BMI of 23 (not 25), and waist circumference risk begins at 80 cm (31.5 inches) rather than the standard 88 cm (35 inches). These are risk thresholds, not diagnostic cut-offs — but they are important signals to act on.

If you have a South Asian background, it is worth asking your GP for a full metabolic screen — fasting glucose, HbA1c, fasting lipids, and waist circumference — rather than relying on BMI alone. And do not dismiss abdominal weight gain as simply “getting older” or “it runs in the family.” It does run in the family — but it is not inevitable.

Afro-Caribbean Women: A Different Pattern, An Equally Important Risk

The story for Afro-Caribbean and Black women is distinct — and it is one that is frequently misunderstood, even within healthcare.

Unlike South Asian women, Afro-Caribbean women tend to carry less visceral fat than white European women at the same BMI. On the surface, this sounds reassuring. But the picture is more complex. Black women tend to carry more subcutaneous fat — the fat stored beneath the skin, particularly around the hips and thighs. Research from the Study of Women’s Health Across the Nation (SWAN) — one of the largest longitudinal studies of women’s midlife health — has suggested that subcutaneous abdominal fat in Black women may be associated with insulin resistance in a way that differs from patterns seen in white women, though the evidence in this area continues to develop. The fat may be in a different location, but the metabolic risk is still elevated.

There is another important biological factor: leptin resistance. Leptin is the hormone that signals fullness and satiety to the brain. Several studies have suggested that Black women have higher circulating leptin levels but also greater resistance to its effects — meaning the brain may not receive the “I am full” signal as efficiently. This can make appetite regulation harder, independent of willpower or dietary choices.

Afro-Caribbean women also carry a significantly elevated risk of hypertension — one of the most dangerous consequences of excess weight and visceral fat. In the UK, Black Caribbean and Black African women have among the highest rates of overweight and obesity, and the cardiovascular consequences are serious. Some studies suggest that Black women may experience menopause earlier on average than white women, meaning the window of oestrogen protection may be shorter — and the metabolic risks of perimenopause may arrive sooner.

Added to this is the well-documented role of chronic stress. The lived experience of racism — both structural and interpersonal — is a physiological stressor that elevates cortisol, drives insulin resistance, and promotes abdominal fat storage. This is not merely a social observation; it is a biological mechanism. The body does not distinguish between the stress of a difficult workplace and the stress of navigating a healthcare system that does not always see you clearly.

What the Evidence Says Works

For both South Asian and Afro-Caribbean women, the core strategies in this article — resistance training, prioritising protein, managing blood sugar, protecting sleep, and considering HRT where appropriate — are directly relevant and evidence-supported. The table below highlights the key differences between the two groups:

For Afro-Caribbean women specifically, research has found that community-based, group-oriented, and culturally tailored approaches to weight management are significantly more effective than standard NHS Tier 2 services, which many Black women report feeling disconnected from. Programmes that incorporate culturally familiar foods, group support, and verbal and visual learning — rather than clinical handouts — show better engagement and outcomes. If standard services have not worked for you in the past, that is not a personal failing. It may be a service design problem.

For both groups, the message is the same: do not rely on BMI alone. Ask for a full metabolic screen. Know your waist circumference. And advocate for yourself in a healthcare system that has historically used population averages that were not built with your body in mind.

Start Here: Eight Things to Do This Week

You do not need to overhaul your entire life overnight. Start with these actions:

A Note on Grace

I know how hard it is to look in the mirror and not recognise the shape looking back at you. Especially for women of colour, where cultural expectations around body size and weight can carry intense, complicated pressure — and where the pressure to appear slim can coexist, painfully, with a body that is storing fat in ways that are genuinely difficult to shift.

But please, offer yourself some grace. Your body is working incredibly hard right now. It is navigating a profound transition.

Your body is not betraying you. It is adapting.

The more you understand those changes, the better you can work with them rather than against them. You do not have to become the woman you were at 25. You can become a stronger, healthier version of yourself at 50.

The Soulful GP | Mind · Body · Soul

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