- Food is complex
- Weight is complex
- Women are complex
- Menopause is complex.
If you’re using, or considering using, 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) are medications that are similar to a natural hormone 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, glucose-dependent insulinotropic polypeptide (GIP).
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. GPs in England are starting to prescribe on the NHS for patients with the highest clinical need.
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. 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.
Are there side effects?
The most common side effects are gastrointestinal, 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. The impact on mood and overall emotional wellbeing seems to be mixed, with some people reporting positive effects and others suicidal thoughts. 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.
“Many people using the medications are buying them online, and may not realise the medications interact with contraception and HRT, or can affect us if we have an operation.”
What about for women specifically?
Pre-menopause, the medications are just as effective for women as they are for men. Post-menopause, 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, 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.
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.
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.
Identifying the evidence
Most women in mid-life will gain weight despite the same nutrition and movement patterns, and how that impacts us is very tied up with how society views both women and weight. The cost of the injections is not insignificant, at up to £300 a month, and they do stop working for most people when discontinued.
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.
Our You Rock contributor, Christine, shares her experience of GLP-1s.
