WHEN I WAS 48, I JOINED a new book club. At my first meeting, talk turned to an ex-member who’d been having a hard time with hot flashes. One evening, the women said, things got especially bad for her. She shifted uncomfortably all through the book talk, until finally she had to peel off her sweater for relief. When that wasn’t enough, she tore off her blouse. When that wasn’t enough, off came her tank top, too—until there she sat, red-faced and dripping, in just her bra.
Back then, the prospect of hot flashes terrified me; my mother’s had been ferocious. If you haven’t yet reached menopause, you might be terrified, too— and not just by the idea of turning into the incredible flaming woman, stripped to her skivvies in someone else’s living room. There are the hot flashes, the night sweats, the brain fog, the mood swings, the free-range rage, the bloating, the weight gain.
And on top of those miseries is the loss they’re supposed to portend: of sexiness, of fertility, of the best and juiciest part of your life, of femininity, of—if you take it far enough—your very womanness. You will become shrivelled and uninteresting, the story goes, a dried-up, barren husk of your former self, an old hag that no one lusts after anymore. And then you’ll die.
Here’s the truth: You probably will sweat the physical stuff. And possibly the mood stuff. Maybe a lot. Perhaps a ton. You will likely—sometimes astonishingly—encounter bodily changes no one ever told you about. You might be frustrated and, yes, enraged by modern medicine’s incomplete understanding of what is happening to you and by the cultural sexism that underlies that failure.
But. You may also make a significant discovery— something grand and important. You might even call it the discovery of a lifetime: that menopause, far from being the tragic end of the best part of a woman’s existence, can actually be a threshold, a gateway, the passage to the you you’ve been waiting your whole life to become.
BEGINNING WITH THE FIRST period, at hormonally about age 12, to be female is to experience a decades-long cycle in which two powerful sex hormones, estrogen and progesterone, rise and fall, triggering the rhythms of menstruation. Estrogen, secreted by the ovaries as an egg matures, reaches its highest level during week 2 of a typical four-week cycle. Progesterone, secreted after the egg follicle ruptures during ovulation, peaks between weeks 3 and 4. These two hormones are primarily responsible for getting a woman’s body ready, month after month, to achieve and maintain a pregnancy.
As the ovaries age in the four-to-ten year lead-up to menopause known as perimenopause, which usually begins in the mid- to late 40s (see “Get Firm on the Terms,” below), they don’t reliably release an egg every month. And whenever a cycle takes place without ovulation, there’s no empty egg follicle and no progesterone is produced. So that month there’s an imbalance—too much estrogen, too little progesterone—and maybe the same is true two months later when again there’s no ovulation, and a month or two after that. It can all lead to roiling hormonal swings that are a lot like puberty. Except worse. Because these inner storms happen while you’re up to your eyeballs in the trappings of responsible adulthood.
“My perimenopausal patients are in the middle of very busy lives,” says JoAnn Pinkerton, MD, a professor of obstetrics and gynecology at the University of Virginia and executive director emeritus of the North American Menopause Society (NAMS). They’re juggling their jobs (and might be at the height of their careers, or trying to reboot after being downsized, or stressing over ageism in the workplace), their kids (who might be hormonally charged teens themselves), their aging parents (with their increasing care needs), their other health issues (which could include chronic conditions like hypertension, arthritis, and diabetes), and their love lives (which could be affected by all manner of factors, from divorce to romantic malaise to partners facing health issues of their own). “All of these make the process of perimenopause much more difficult even than puberty was,” Pinkerton says.
Yet when it comes to navigating that process, women are, to a stunning degree, left to their own devices. “Every girl gets the period talk, but almost no woman gets a talk about what’s happening on the other end,” says Stephanie S. Faubion, MD, medical director of NAMS and director of the Mayo Clinic Center for Women’s Health. “That’s really a shame. And as a result, we have women coming to the clinic in a panic. They can’t sleep, they’re having heart palpitations, they’re forgetting things, their hair is thinning, they’re anxious— and they literally think they’re dying when, in fact, they’re just in perimenopause.”
If there were such a thing as the menopause talk, it would make sense for doctors to initiate it. But by and large, medical training doesn’t equip them to do so. In a 2019 study in which researchers surveyed 177 residents in family medicine, internal medicine, and ob/gyn, 20 percent received zero menopause lectures during their residency; less than 7 percent said they felt prepared to manage the care of women in the various stages of menopause. The knowledge gap reflected in those numbers may explain why, in another survey, only 7 percent of midlife women with urogenital changes (like vaginal dryness, pain during sex, urinary incontinence) said they had doctors who broached the subject of such changes with them. Instead, many women complain of doctors who minimize their concerns with, essentially, a pat on the head and a shrug of the shoulders and a reminder that menopause is just part of life.
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