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Experts weigh in on the significance of obesity in the menopausal woman

ORLANDO, Fla. — Previous studies have established that obesity can change the metabolic profile. However, researchers here have turned their attention to obesity’s link to hormones and health at midlife, in addition to new and emerging weight management strategies.

Endocrine Today interviewed Nanette Santoro, MD, professor and E. Stewart Taylor chair of obstetrics and gynecology at the University of Colorado at Denver, and Steven R. Smith, MD, scientific director at the Florida Hospital, Sanford - Burnham Translational Research Institute, regarding their presentations at the North American Menopause Society 23rd Annual Meeting.

Hormones and health

“Not only [have we learned that] fat is metabolically active — we used to think it was just a passive storage depot in the body — but we’ve also learned that it’s inflammatory and also seems to affect the reproductive hormones that are circulating,” Santoro told Endocrine Today.

Nanette Santoro, MD 

Nanette Santoro

Citing the Study of Women’s Health Across the Nation (SWAN), Santoro said she and other researchers found that obesity had a weight-dependent effect on lowering all of the reproductive hormone levels.

“This was something new because when endocrinologists think about obesity, typically they think of polycystic ovary syndrome if it’s a woman; it’s not all about that. Far more women are obese than have PCOS,” Santoro said. “When we looked at the SWAN study with regard to women going through menopause, we found that if a patient is obese, they have relatively lower follicle-stimulating hormone (FSH), and changes in estrogen are gentler.”

After menopause, Santoro said estrogens are higher. Additionally, Santoro said there is often the question, “Are the hormones obese women have a consequence of the fat tissue that they’re laying down, or do the hormones lead to the accumulation of fat?”

Santoro and colleagues discovered waist circumference as the best predictor but that mid-body waist fat led to an increase in androgens and decreased some of the hormones. However, Santoro said there was not a strong correlation with estrogen.

“Sometimes it looked like it was the fat causing the increase in estrogen, and other times it didn’t. That was a little less clear. But with testosterone, the sex hormone binding globulin and with FSH, fat accumulation seemed to predict the changes in those hormones,” Santoro said.

Santoro said her patients often say they do not sleep well and gain weight that becomes harder to lose.

“There’s something about the process of the menopause transition that may stress women out to the point that it’s going to lead to this weight gain, and until we can get a grip on it, it’s not going to get better. Many of the same women will be able to lose weight once they’re through the worst of their symptoms,” Santoro said.

Emerging treatments

“Weight management is not just important for primary care providers, but for specialists like endocrinologists as well,” Smith told Endocrine Today.

Steven R. Smith, MD 

Steven R. Smith

In his presentation, Smith reported a large gap in treatment options for obesity despite the high prevalence and its associated costs.

“We have an increasing understanding of the health risks associated with obesity. For many of us in the obesity field, we’re getting beyond the use of BMI and waist circumference (WC) as a gauge of who and when to advance and accelerate treatments for obesity,” Smith said during his presentation.

He reported on a recent tool developed by Canadian researchers Sharma and Kushner called the Edmonton Obesity Staging System (EOSS).

“It’s a multifactorial view of whom and when to treat based upon a staging system that includes not only BMI and cardiometabolic risk, but also physical symptoms and obesity-related psychological symptoms,” Smith said during his presentation. “This is actually beginning to gain traction so that we are certain to focus our attention on patients who absolutely need treatment and it helps us understand how to gauge who and when to treat.”

Obesity drugs

“I think we’re at a turning point in the medical practice regarding obesity therapy. We now have on the market two new anti-obesity drugs, and there are several others in the pipeline today,” Smith told Endocrine Today.

Smith said when lifestyle intervention and behavioral counseling don’t produce results and a patient is not eligible for surgery, newly approved lorcaserin (Belviq, Arena) and extended-release phentermine plus topiramate (Qsymia, Vivus) could be options.

“Now we have tools in the tool kit other than being encouraging and using lifestyle management techniques in the office,” Smith said. – by Samantha Costa

For more information:

Santoro N. Plenary Symposium #6: Obesity, Hormones & Health at Midlife.

Smith S. Plenary Symposium #6: New & Emerging Weight Management Strategies: What Does It Mean for Your Practice?

Both presented at: the North American Menopause Society 23rd Annual Meeting; October 3-6, 2012; Orlando, Fla.

Sharma AM. Int J Obes. 2009; 33:289-295.

Disclosures: Santoro has stock options in MenoGeniX, and has received a research grant from Bayer. Smith is an advisor, board member, consultant, and has equity stake in or receives research support from: Amylin, Arena, Boehringer Ingelheim, Bristol Myer Squibb, Jenrin, Eli Lilly and Company, Nimbus, Novo Nordisk, NGM Pharma, Orexigen, Pfizer, Vivus, and Zafgen.

ORLANDO, Fla. — Previous studies have established that obesity can change the metabolic profile. However, researchers here have turned their attention to obesity’s link to hormones and health at midlife, in addition to new and emerging weight management strategies.

Endocrine Today interviewed Nanette Santoro, MD, professor and E. Stewart Taylor chair of obstetrics and gynecology at the University of Colorado at Denver, and Steven R. Smith, MD, scientific director at the Florida Hospital, Sanford - Burnham Translational Research Institute, regarding their presentations at the North American Menopause Society 23rd Annual Meeting.

Hormones and health

“Not only [have we learned that] fat is metabolically active — we used to think it was just a passive storage depot in the body — but we’ve also learned that it’s inflammatory and also seems to affect the reproductive hormones that are circulating,” Santoro told Endocrine Today.

Nanette Santoro, MD 

Nanette Santoro

Citing the Study of Women’s Health Across the Nation (SWAN), Santoro said she and other researchers found that obesity had a weight-dependent effect on lowering all of the reproductive hormone levels.

“This was something new because when endocrinologists think about obesity, typically they think of polycystic ovary syndrome if it’s a woman; it’s not all about that. Far more women are obese than have PCOS,” Santoro said. “When we looked at the SWAN study with regard to women going through menopause, we found that if a patient is obese, they have relatively lower follicle-stimulating hormone (FSH), and changes in estrogen are gentler.”

After menopause, Santoro said estrogens are higher. Additionally, Santoro said there is often the question, “Are the hormones obese women have a consequence of the fat tissue that they’re laying down, or do the hormones lead to the accumulation of fat?”

Santoro and colleagues discovered waist circumference as the best predictor but that mid-body waist fat led to an increase in androgens and decreased some of the hormones. However, Santoro said there was not a strong correlation with estrogen.

“Sometimes it looked like it was the fat causing the increase in estrogen, and other times it didn’t. That was a little less clear. But with testosterone, the sex hormone binding globulin and with FSH, fat accumulation seemed to predict the changes in those hormones,” Santoro said.

Santoro said her patients often say they do not sleep well and gain weight that becomes harder to lose.

“There’s something about the process of the menopause transition that may stress women out to the point that it’s going to lead to this weight gain, and until we can get a grip on it, it’s not going to get better. Many of the same women will be able to lose weight once they’re through the worst of their symptoms,” Santoro said.

Emerging treatments

“Weight management is not just important for primary care providers, but for specialists like endocrinologists as well,” Smith told Endocrine Today.

Steven R. Smith, MD 

Steven R. Smith

In his presentation, Smith reported a large gap in treatment options for obesity despite the high prevalence and its associated costs.

“We have an increasing understanding of the health risks associated with obesity. For many of us in the obesity field, we’re getting beyond the use of BMI and waist circumference (WC) as a gauge of who and when to advance and accelerate treatments for obesity,” Smith said during his presentation.

He reported on a recent tool developed by Canadian researchers Sharma and Kushner called the Edmonton Obesity Staging System (EOSS).

“It’s a multifactorial view of whom and when to treat based upon a staging system that includes not only BMI and cardiometabolic risk, but also physical symptoms and obesity-related psychological symptoms,” Smith said during his presentation. “This is actually beginning to gain traction so that we are certain to focus our attention on patients who absolutely need treatment and it helps us understand how to gauge who and when to treat.”

Obesity drugs

“I think we’re at a turning point in the medical practice regarding obesity therapy. We now have on the market two new anti-obesity drugs, and there are several others in the pipeline today,” Smith told Endocrine Today.

Smith said when lifestyle intervention and behavioral counseling don’t produce results and a patient is not eligible for surgery, newly approved lorcaserin (Belviq, Arena) and extended-release phentermine plus topiramate (Qsymia, Vivus) could be options.

“Now we have tools in the tool kit other than being encouraging and using lifestyle management techniques in the office,” Smith said. – by Samantha Costa

For more information:

Santoro N. Plenary Symposium #6: Obesity, Hormones & Health at Midlife.

Smith S. Plenary Symposium #6: New & Emerging Weight Management Strategies: What Does It Mean for Your Practice?

Both presented at: the North American Menopause Society 23rd Annual Meeting; October 3-6, 2012; Orlando, Fla.

Sharma AM. Int J Obes. 2009; 33:289-295.

Disclosures: Santoro has stock options in MenoGeniX, and has received a research grant from Bayer. Smith is an advisor, board member, consultant, and has equity stake in or receives research support from: Amylin, Arena, Boehringer Ingelheim, Bristol Myer Squibb, Jenrin, Eli Lilly and Company, Nimbus, Novo Nordisk, NGM Pharma, Orexigen, Pfizer, Vivus, and Zafgen.

    Perspective
    Michelle P. Warren

    Michelle P. Warren

    There is some evidence that as you get older you lose lean body mass and that’s really the predictor of resting metabolic rate. Mid-life is a time of great vulnerability for considerable weight gain.

    There’s a gap in terms of treatment in the women who have a BMI of 30 to 35, and we don’t really have good treatment strategies for those women who are not eligible for bariatric surgery. The insurance won’t pay for a woman with a BMI of less than 35. That’s the largest group of women who are at risk for obesity.

    The new drugs are interesting. However, as I listened to Smith, I wondered how women at risk for other modalities are going to react to those drugs. There’s also going to be a learning curve with learning to give the medications safely. I think there’s promise but there’s no golden way of doing this. Overall, I think that the session tantalized us with possibly new drugs and possibly some new science.

    • Michelle P. Warren, MD, NCMP
    • Endocrine Today Editorial Board member NAMS Board of Trustees 2011-2012 Professor of medicine and obstetrics & gynecology and Medical Director of the Center for Menopause, Hormonal Disorders, and Women’s Health at Columbia University Medical Center, New York, NY

    Disclosures: Warren is on the advisory board or review panel and has received consultancy fees from: Agile Therapeutics, Ferring Pharmaceuticals, Pfizer and Yoplait.

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