Before You Start a GLP-1 in Midlife: 4 Things Your Doctor Should Be Asking

A physician-led telemedicine approach to GLP-1 prescribing for women over 40

Weight loss medications like Wegovy (semaglutide) and Zepbound (tirzepatide) can be powerful tools for women in midlife, especially those navigating weight gain, inflammation, and hormonal shifts during perimenopause. As a physician specializing in midlife metabolic health for women, I prescribe these medications with a focus on long-term health and body composition, not just the number on the scale. My goal is simple: help women feel and look their best today while building a stronger, healthier foundation for the second half of life. Here's the four-point framework I use before prescribing a GLP-1 to any woman in midlife.

1. Do you actually need to lose fat?

GLP-1 meds are powerful drugs with significant potential side effects. As a licensed physician, my job is to first, do no harm. Giving someone a medication when they don't actually have a health problem is not helping them. Everyone has a right to do what they want with their bodies, but I personally don't choose to participate in prescribing drugs for people who don't actually need to lose weight.

2. Is your metabolism already suppressed?

Many of my overweight clients are actually not eating very much. Their metabolism has adapted to eating fewer calories, and they might be sedentary, further decreasing how many calories they burn. If someone is already eating very few calories, that is a yellow flag for adding a GLP-1 medication. The added appetite suppressant effect of a GLP-1 medication may put them at risk for under-nourishment and insufficient vitamin/mineral intake unless approached very cautiously.

I try to focus on adding more activity and gradually increasing their metabolism, through a process called reverse dieting, before we would consider adding a GLP-1 medication.

3. Do you have enough muscle mass?

Again, this is a yellow flag, but should always be considered in the context of health, especially for women in perimenopause. GLP-1 medications cause not just fat loss, but also muscle loss, if you don't follow very targeted nutritional and exercise strategies. In midlife women especially, the tendency towards loss of strength and muscle is something we want to counteract as best we can. If I do prescribe a GLP-1 medication, I use the lowest effective dose and to do extensive counseling about the nutritional and exercise interventions that should accompany medication use. Important for everyone, but doubly important for women who don't have a baseline high amount of muscle mass.

4. What is your digestion like?

Do you have a history of IBS, colitis, heartburn, constipation, or bloating?

GLP-1 medications notoriously disrupt digestion. In severe cases, they can cause repeated vomiting and severe abdominal pain. This is NOT common (so don't be scared!) but if people already have digestive issues, I do tend to be more cautious about starting a GLP-1 medication. These meds slow down gastric emptying and thus can aggravate heartburn, bloating, and acid reflux.

SIDE NOTE: Perimenopause by itself can cause problems with digestion/heartburn/bloating due to hormonal changes, and the bloating can be miserable. So it's important to counsel patients about the potential for worsening during the first couple months of GLP-1 treatment.

When to See a GLP-1 Specialist for Perimenopause Weight Gain

If you're a woman in your 40s or 50s noticing unexplained weight gain, changes in body composition, low energy, or digestive issues that seem to have come out of nowhere: you're not imagining it, and it's not just about eating less and moving more. Perimenopause creates a unique metabolic environment that requires a different approach. A GLP-1 medication may be one piece of the puzzle, but only when it's prescribed thoughtfully alongside the right nutritional, hormonal, and exercise strategies. If you decide to take one, this is a conversation that should include a discussion of lifestyle and how best to optimize long-term health as you age.

Dr. Nicole Rowe is a board-certified physician specializing in women's metabolic health, body composition, insulin resistance, and healthy aging. She combines evidence-based, comprehensive medicine with a practical, sustainable approach focused on improving strength, energy, long-term health, and quality of life.

Her practice emphasizes thoughtful, individualized care for women navigating perimenopause, menopause, midlife weight gain, fatigue, and other metabolic changes that occur after 40. To schedule a consult, book here.