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Posted on Friday February 6, 2026 in Metabolic Health
An article by Dr Edward Leatham, Consultant Cardiologist © 2025 E. Leatham
This article explores menopause, visceral fat (VAT), hormone therapy, and long-term cardiometabolic risk.
Short on time? Listen to the 15-minute VAT-Trap podcast summary of this article while you walk, drive, or train.
For many women, menopause comes with more than just hot flushes, disturbed sleep and mood swings. One of the most frustrating changes women experience is a change in body shape. This isn’t just about weight gain and clothes becoming tighter, the hormonal changes which occur at the menopause are associated with a change in the way that body fat is stored, leading to more belly (abdominal) fat. There is a shift in fat from the hips to the waist.(1)
Women going through midlife, tend to gain on average around 0.5 kg per year. When we look at evidence on why women gain weight around menopause, we can see that the absolute weight gain is caused by non-hormonal factors, not menopause itself.(1)
However, the belly fat increase which occurs after menopause often signals a deeper problem: visceral fat. Declining oestrogen levels drive an increase in visceral fat, rising from about 5-8% of total body weight to 10-15%. At the same time, metabolic rate falls as lean muscle mass reduces. (2)
Visceral fat is a harmful type of fat stored deep within the abdominal cavity, wrapping around vital organs. High levels of visceral fat are associated with major health risks like heart disease and type 2 diabetes, as this fat actively releases chemicals which trigger inflammation.(3)
The good news? With the right tools including lifestyle support and early screening we can detect and reverse unhealthy visceral fat before it causes harm. Contrary to popular opinion, oestrogen therapy (HRT) does not cause women to gain weight and there is good evidence that Hormone replacement therapy (HRT), also known as Menopause Hormone Therapy (MHT) can prevent abdominal fat increasing after menopause.(2)
Visceral adipose tissue (VAT) is biologically active. It triggers inflammation, worsens blood sugar, disrupts hormones, and increases disease risk. After menopause, falling oestrogen levels make it more likely that fat will be stored around your middle, especially if sleep is poor and stress levels are high.
High levels of VAT are linked to:
Critically, you don’t need to be overweight to have high visceral fat. Even women with a “normal” BMI can carry dangerous levels of VAT(4).
A quick and reliable screening tool is the waist-to-height ratio:
Measure your waist (use WHO method for accuracy), divide by your height. If the result is over 0.5, you may have excess VAT(8).
For example, a woman who is 160 cm tall should keep her waist under 80 cm. This ratio is more accurate than BMI for predicting future disease.
If your waist-height ratio is high, we may recommend a low-dose CT scan to measure your Visceral Adipose Tissue (VAT) from which we can calculate VAT Index (VATI) from VAT divided by height in metres, squared. This provides an accurate picture of how much harmful fat you’re carrying inside, not just what’s visible outside.
Research shows that a VAT over 95 cm2 or VATI above 25 cm²/m² in Caucasian women (lower in South Asian women) is linked to:
Our non contrast CT, developed at VCL, is acquired using a very low dose of radiation averages 1mSv or 1/4 of the dose of a mammogram. The scan is aligned to be exactly 3 cm above the lowest margin of L3 vertebral body, so that it can be repeated after microdosed GLP treatment if necessary.
In the scan above of a 70 year old female lady with coronary artery disease, relatively harmless subcutaneous adipose tissue is shown in blue, while harmful visceral adipose tissue is shown in green. Her VAT is very high at 121 cm2 – VATI 53.8 cm2/m2 which indicates high metabolic risk from raised sdLDL and insulin; in contrast the scan below, from a of similar age and waist, the VAT is nearly half at measures 65.2 cm2, (VATI 25 cm2/m2) – which is a metabolically healthy value. For examples of VAT scans in men (who have much more VAT than women), see other example blog.
Table to show the ranges we use to allocate our patients into different VATI groups, by gender and ethnicity. We use the same values to define a VATI target, which can then be used to estimate a waist measurement required for a metabolically healthy VAT. For patients taking GLP medications, defining a target waist is extremely helpful.
HRT has been used for decades to treat menopause symptoms like hot flushes, disturbed sleep and mood swings. But there’s now strong evidence that HRT also helps reduce VAT and improve long-term health when used appropriately.
And despite outdated fears, HRT does not increase overall mortality in women who start near menopause⁸. In many cases, it improves both quality and quantity of life.
However it is important to note that there is no evidence to initiate HRT to lower VAT, see editorial quote from 2022 “The balance of benefits and risks, however, does not support use of HRT for primary or secondary prevention of disease, and international guidance recommends against use of HRT without a clear indication (12).”
This is an important concern. Here’s what the data show:
For many women, the small increased risk from HRT is outweighed by its benefits, especially when combined with lifestyle measures that reduce VAT.
If your VATI is elevated or waist-to-height ratio is high, we offer a tailored programme to lower VAT and improve long-term health. It includes:
Shown to reduce VAT more effectively than moderate activity(14).
To see what this entails see our 10 min strength training blog
Protein supports muscle while reducing central fat. We use CGM (continuous glucose monitoring) and Dr Shape, a food analysis app to personalise food plans and reduce post-meal sugar spikes(15).
Used when lifestyle alone isn’t enough. These medications reduce visceral fat and support sustainable appetite control, especially in insulin-resistant women(16).
This isn’t a quick-fix diet—it’s a long-term health reset. Many women experience better sleep, more energy, less joint pain, improved blood pressure, and stronger muscles.
The latest UK guidance supports longer-term HRT use when symptoms persist and benefits outweigh risks. We believe that in some women it’s not only reasonable—but may be beneficial—to continue HRT to:
It’s time to move past one-size-fits-all advice. If you feel better on HRT and you’re reducing VAT, that’s meaningful.
You don’t need to wait until disease strikes to take action. The build-up of harmful visceral fat starts silently—but it can be measured, tracked and reversed.
We recommend:
✅ Early screening with waist-height ratio and low dose VATI if Height-to-Waist> 0.5
✅ High-intensity training and smart nutrition to reduce VAT
✅ Low-dose GLP-1 therapy, where appropriate, to accelerate VAT loss
✅ Monitoring and support from our expert clinical team
You deserve proactive, personalised care. Let us help you take control. Get in touch if you are interested in seeing our faculty for HRT advice or advice about a low dose VAT CT, Cardiac CT with FAI, or metabolic health assessment
In cardiometabolic medicine, muscle is not a cosmetic tissue but a metabolic organ. Evidence consistently shows that strength, not muscle mass, predicts insulin resistance, cardiovascular risk, and survival. Many older adults are not losing muscle tissue — they are losing muscle function, and that is the pathology that matters.
The most effective path to reducing visceral fat without medication is not just to “eat less.” It’s to build more muscle, eat smarter, and track your progress. In this blog, which also forms one of the chapters of an ebook, I outline the programme and tools our patients use in our cardiometabolic clinic.
Is is increasingly obvious that not everyone with raised coronary inflammation and elevated risk of heart attack simply has a raised LDL Cholesterol- in fact there appears to be a mixed bag of risk factors associated with high coronary artery inflammation, including raised LDL, raised LP (a), raised Homocysteine, hypertension and dysregulated glucose. Our metabolic health assessment is therefore designed to offer a comprehensive dive into known contributory causes, the latest and most controversial of which is 'glucose dysregulation', the principle topic of this article.
For much of modern cardiology, in its battle against coronary artery disease—one of mankind’s greatest threats—the “enemy” seemed clear. When I trained, the diagnostic armoury was focused on accurately identifying flow-limiting narrowing of one or more coronary arteries. Yet in the last decade, a profound paradigm shift has unsettled these foundations—and in some respects, turned them on their head.