Susan R.
HRT fixed her symptoms. One integrated protocol finally fixed her weight — 32 lbs in 8 months after 8 months of zero progress.
She was already on HRT. Hot flashes gone, sleep restored, mood stable. But the 35 lbs hadn't moved in 18 months of tracking, walking, and cutting carbs. The missing pieces were insulin resistance, an unaddressed thyroid pattern, and a testosterone no previous provider had touched.
Already on HRT — Still Stuck
Susan is a 51-year-old healthcare administrator at a regional hospital network — post-menopausal for 18 months, married, with two college-age kids. She had been on HRT for 8 months with a previous provider, and it had genuinely helped. Hot flashes resolved. Sleep improved. Mood stable. By those measures, her HRT was working.
But the 35 lbs she had gained over four years — concentrated almost entirely in her midsection — hadn't moved. She had been tracking calories for 18 months, walking five times a week, and experimenting with low-carb eating. Her OB-GYN's response: "Weight is just menopause — nothing to do." When she asked about GLP-1, she was refused. A separate weight loss clinic pushed phentermine, which she declined. She was being managed by two non-communicating providers and getting nowhere.
What brought her to FLOA wasn't dissatisfaction with her existing HRT — it was a specific ask: find one provider who could manage her hormones and her metabolic health together, look at the full picture, and actually do something about the weight.
What Her Previous Providers Had Missed
- 35 lbs of midsection weight gain — diet and exercise-resistant for 18+ months
- Moderate insulin resistance: HOMA-IR 3.2, fasting insulin 14 µIU/mL, HbA1c 5.8% (prediabetic)
- Testosterone never addressed: total T 12 ng/dL, free T 0.6 pg/mL — contributing to fatigue, lean mass loss, and libido decline
- DHEA-S low at 78 µg/dL — not flagged by previous provider
- Reverse T3 elevated at 22 — T4-to-T3 conversion impaired, thyroid functionally suboptimal despite "normal" TSH
- Elevated leptin — signaling leptin resistance contributing to weight loss resistance
- Systemic inflammation: hs-CRP 2.4 mg/L
- Dyslipidemia: triglycerides 168, HDL 48
- Significant lean mass loss during menopause transition — had been doing cardio only, no resistance training
- Low afternoon energy and mild brain fog persisting despite HRT
- Reduced libido — entirely ignored by her previous hormone provider
- Fragmented care: two non-communicating providers, no integrated strategy
What FLOA Built on — and What They Added
Comprehensive metabolic deep-dive layered onto her existing hormone labs: fasting insulin, HOMA-IR, full lipid panel, HbA1c, leptin, reverse T3, inflammatory and liver markers. All four metabolic locks identified: insulin resistance (HOMA-IR 3.2), inflammation (hs-CRP 2.4), cortisol (flat afternoon curve, AM 17 high-normal), and thyroid dysfunction (reverse T3 22 — impaired T4-to-T3 conversion). Coaching team nutrition audit, exercise history, and stress review completed.
Estradiol patch 0.05mg twice weekly and oral progesterone 100mg nightly continued with minor dose adjustment — what was working was kept. The addition: low-dose compounded testosterone cream at 2mg/day, addressing the libido loss and lean mass decline her previous provider had never touched. DHEA 15mg daily added to restore depleted adrenal precursor levels.
Started at 0.25mg — the dose her OB-GYN had refused to prescribe. Escalated only as needed; held at 0.5mg by month 5 with full results achieved. Goal: eliminate food noise, address insulin dysregulation, and create the metabolic opening that 18 months of calorie tracking had failed to produce because the underlying IR had never been treated.
Reverse T3 of 22 indicated impaired conversion of T4 to active T3 — a pattern consistent with chronic metabolic stress. T3 trial initiated and evaluated at 6 weeks. Reverse T3 normalized by month 3, restoring afternoon energy and metabolic rate that thyroid dysfunction had been suppressing despite technically "normal" TSH readings.
Susan had been doing cardio exclusively — the wrong tool for menopausal body composition. Resistance training program introduced as the primary training modality for lean mass preservation and metabolic rate support. Protein-first nutrition targeting 140g/day. FLOA fasting protocol introduced at month 3 (16:8 → 24-hour weekly fasts). Stress regulation practices added given flat cortisol curve.
Phase by Phase
Food Noise Gone — First Movement in 18 Months
GLP-1 eliminated the food noise that calorie tracking had never addressed — the constant background appetite that had made every diet attempt exhausting and unsustainable. Down 6 lbs — the first meaningful weight movement in 18 months. Energy improving as testosterone and DHEA came online. Libido beginning to stir for the first time in over a year.
→ Down 6 lbs; first weight loss in 18 months; libido stirring
Strength Gains Visible — Brain Fog Clearing
Down 12 lbs. Resistance training producing measurable strength gains — the body composition response that years of walking had never triggered. Brain fog clearing as testosterone, DHEA, and improving metabolic function combined. HOMA-IR improved from 3.2 to 2.4 — insulin sensitivity beginning to restore.
→ Down 12 lbs; HOMA-IR 2.4; strength gains emerging
Thyroid Normalized — Fasting Introduced — Afternoon Energy Restored
Down 18 lbs. Reverse T3 normalized on T3 trial — the afternoon energy crash that HRT had never resolved finally lifted. FLOA fasting protocol introduced (24-hour weekly fasts), made manageable by the GLP-1 eliminating hunger spikes. Midsection reduction becoming visible.
→ Down 18 lbs; thyroid normalized; afternoon energy restored; fasting established
Body Composition Shift Visible — GLP-1 Held at Starting Dose
Down 26 lbs. Resistance training producing visible body composition change — lean mass building while fat mass dropped. Semaglutide held at 0.5mg — no escalation required. Midsection reduction that 18 months of diet and cardio had never produced now clearly visible.
→ Down 26 lbs; visible recomp; semaglutide at 0.5mg only
Target Hit — Prediabetes Reversed — Libido Fully Restored
Down 32 lbs — target achieved. HbA1c 5.3% — prediabetes reversed. HOMA-IR 1.4. Libido fully restored. Lean mass significantly improved versus menopausal baseline. Long-term plan confirmed: integrated hormone + metabolic protocol with one provider, microdose semaglutide maintenance, and FLOA monthly fasting.
→ Down 32 lbs; HbA1c 5.3%; HOMA-IR 1.4; libido restored; target achieved
"HRT treats hormonal symptoms — hot flashes, sleep, mood. It does not treat insulin resistance. Susan's weight was completely unresponsive to diet and exercise because moderate IR was the wall she was running into every time. Until you address the metabolic lock, no amount of calorie tracking produces sustainable fat loss. Her previous providers were managing half the problem and wondering why nothing was working."
What Changed at 8 Months
Weight & Body Composition
32 lbs lost in 8 months — after zero progress in the prior 8 months on HRT alone. Significant midsection reduction and visible lean mass gain from resistance training.
Metabolic Reversal
HbA1c from 5.8 → 5.3% — prediabetes reversed. HOMA-IR from 3.2 → 1.4. Fasting insulin normalized. No metformin required at any point.
Cardiovascular Markers
Triglycerides from 168 → 110. HDL from 48 → 56. hs-CRP from 2.4 → 0.9 mg/L — systemic inflammation resolved as metabolic function normalized.
Hormone Optimization
Free testosterone optimized on compounded cream. DHEA-S restored. Thyroid pattern normalized on T3 trial — reverse T3 cleared. Every hormonal gap her previous provider had missed, addressed.
Strength & Lean Mass
Resistance training replacing cardio-only approach — strength gains visible by month 2, lean mass significantly improved by month 8. The tool that menopause-related lean mass loss actually requires.
Integrated Care
One provider managing hormones and metabolic health together — the strategic outcome Susan named as her primary reason for coming to FLOA. No more fragmented, non-communicating care teams.
| Category | What Changed |
|---|---|
| Weight | First meaningful loss after 18 months of tracked dieting and walking producing nothing |
| Food Noise | Chronic background appetite eliminated — making calorie moderation effortless for the first time |
| Afternoon Energy | Energy crash resolved at month 3 as reverse T3 normalized — HRT alone had never fixed this |
| Brain Fog | Cleared by month 2 as testosterone, DHEA, and metabolic function combined |
| Libido | Reduced → fully restored; her previous provider had never addressed testosterone |
| Strength | Measurable gains by month 2 after switching from cardio-only to resistance training |
| Midsection | Visible reduction by month 3 — the specific outcome 18 months of diet and walking had failed to produce |
| Prediabetes | HbA1c 5.8 → 5.3% — reversed without metformin |
| Care Integration | One provider, one coordinated strategy — ended the fragmented two-clinic approach |
| Confidence | Described as significantly improved — "I finally feel like the system is working with me, not against me" |
"I was doing everything I was supposed to do — HRT, calorie tracking, walking every day, cutting carbs. Nothing was moving. My OB-GYN told me the weight was just menopause and refused to discuss anything else. FLOA looked at labs no one had run, added testosterone I never knew I needed, addressed insulin resistance that had been blocking everything, and finally treated me as one system. Thirty-two pounds in eight months after eighteen months of nothing. I finally feel like the system is working with me."
Clinical Takeaways
Susan's case makes a critical distinction that every post-menopausal woman on HRT needs to understand: hormonal symptom relief and metabolic optimization are not the same thing. Her HRT was working — it had resolved her hot flashes, sleep, and mood. But it had done nothing for her weight because weight loss resistance in menopause is not a hormone symptom. It is a metabolic problem, driven by insulin resistance, cortisol dysregulation, thyroid dysfunction, and leptin resistance — all of which her previous providers had never evaluated.
The testosterone gap was particularly consequential. Low testosterone in post-menopausal women contributes directly to lean mass loss, fat accumulation, energy decline, and libido suppression — yet her previous hormone provider had never run or addressed it. Adding 2mg/day of compounded testosterone cream was not a cosmetic choice. It was a foundational correction that changed her body composition trajectory and restored a quality-of-life outcome her previous protocol had completely ignored.
The exercise prescription also mattered. Susan had been walking five times a week for 18 months — a cardiovascular tool applied to a body composition problem. Resistance training is the primary intervention for menopausal lean mass preservation and metabolic rate support. Switching her to a resistance-first program produced measurable strength gains by month 2 and visible body composition change by month 5. The calories were never the problem. The strategy was.
If Your HRT Is Working But Your Weight Isn't — This Is Why
HRT treats hormonal symptoms. Insulin resistance, thyroid dysfunction, and untreated testosterone deficiency require a different layer of intervention entirely. If you're on HRT and still stuck, the answer isn't more discipline — it's a complete metabolic picture.
Individual results vary. This case study is for educational purposes only. © Dr. Jones DC — FLOA Protocol.