Impact of Menopausal Status and Female Reproductive Aging on the Outcomes of Bariatric Surgery: A Narrative Review

Women comprise the majority of patients undergoing metabolic and bariatric surgeries, yet the influence of menopausal status and female reproductive aging on postoperative outcomes remains poorly understood. The menopausal transition is associated with profound hormonal, metabolic, and skeletal changes that may modify the efficacy and risk profile of bariatric surgery. This narrative review aims to synthesize current evidence on how menopausal status influences bariatric surgery outcomes, including weight loss, metabolic outcomes, body composition, and skeletal health. A literature search was conducted using PubMed/MEDLINE, Embase, and Web of Science to identify peer-reviewed studies evaluating bariatric surgery outcomes in adult women stratified by menopausal status, reproductive aging stage, or age-based proxies for menopause. Available evidence suggests that postmenopausal women experience less weight loss after bariatric surgery than premenopausal women but achieve comparable reductions in visceral adiposity and improved lipid profiles. Body composition analyses indicate that bariatric surgery does not uniformly exacerbate sarcopenia in postmenopausal women; however, disproportionate loss of fat-free mass relative to total weight loss in middle-aged and older patients is associated with adverse cardiometabolic outcomes. Skeletal health is the most negatively affected outcome, with postmenopausal women demonstrating accelerated declines in bone mineral density (BMD), deterioration of bone microarchitecture, and persistent elevations in bone turnover markers following both laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB). This review shows that menopausal status is an important yet underrecognized modifier of bariatric surgery outcomes in women. While bariatric surgery confers metabolic benefits in postmenopausal patients, it amplifies skeletal vulnerability in this hormonally susceptible population. These findings highlight the need for menopause-informed preoperative counseling, postoperative monitoring, and targeted strategies to mitigate bone loss. Future studies should prioritize large, longitudinal, menopause-stratified cohorts incorporating hormonal, metabolic, body composition, and skeletal assessments to better inform clinical decision-making.