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What if I told you that something major was going to happen to your body, but instead of accurate information you’ll receive a barrage of negative messaging and be slapped with depressing stereotypes?
That’s menopause for many women.
Menopause is simply puberty in reverse. But while puberty is celebrated, menopause is ignored. Menopausal women are expected to choose their player—witch, lady detective, snarky matriarch, or woman with an ever increasing number of cats—and cope in silence, as their value to a patriarchal society vanishes along with their estrogen.
Consequently, many women don’t know what to expect when they’re no longer expecting a period, and that lack of information can be frightening and disempowering. It can negatively impact quality of life and even lead to serious health consequences. Take hot flushes (also known as hot flashes or vasomotor symptoms), for example. Many women are told by their medical providers that they are something to simply endure or that they aren’t bad enough to need treatment.
Imagine if we had that same attitude with age-related vision changes? Sorry, ma’am, it’s normal to become shortsighted with age. Maybe you need longer arms?
As a gynecologist I had a unique advantage entering menopause. I was aware of how my body would be changing. I knew hot flushes might start years before my final period, so when they did, I wasn’t thrilled, but I knew it was typical. When my periods became irregular, I knew what was expected and could distinguish the bothersome from the medically concerning. I also knew about the range of therapies, as well as their benefits and risks—I could tell what was just hype or fabricated social media “wisdom.” By the time I started my own menopause transition, I’d had the privilege of speaking with women about menopause for over 20 years, so I was exposed to a breadth of experiences as opposed to the mostly negative public perceptions.
When we exclude menopause from our discourse, we say it doesn’t matter. But I’m here to change that. It shouldn’t take an act of feminism to understand what’s happening to your body or to find the therapies that you need to improve your health, longevity, and happiness.
What to expect when you’re no longer expecting a period
Menopause technically starts a full year after your last period; the menopause transition is a phase of variable length that precedes the final menstrual period, and postmenopause is everything afterward. However, many people—myself included—often use the term “menopause” to describe this entire continuum.
The menopause transition is marked by hormonal chaos, and so some women experience their most bothersome symptoms during this phase. The universal symptom of the menopause transition is an irregular menstrual period, but a heavier flow is also common. Many women develop other symptoms, such as hot flushes, night sweats, difficulty sleeping, mood changes, and memory concerns. Symptoms such as vaginal dryness and pain with sex typically start after the final menstrual period, but every woman is different. In the postmenopause phase hormone levels are stable, the hallmark being low levels of estrogen.
Before we get into what these symptoms can look like, know this: Symptoms are worthy of treatment if they’re bothersome. Just because it’s normal to experience hot flushes doesn’t mean you have to suffer through them.
A hot flush is a wave of heat that feels as if a furnace is cranked up, but on the inside. Biologically speaking it’s caused by a narrowing of the thermoregulatory zone. Basically the brain’s thermometer goes wonky and believes the body is overheated when your temperature hasn’t actually changed. To fix this nonexistent temperature problem, the body diverts blood to the skin surface to dump heat and also triggers sweating. And yes, your body gets hot to the touch in the process. (I’m lucky that my hot flushes don’t typically wake me from sleep, but my partner is less of a sound sleeper and he tells me the heat radiating from my body is incredible.)
Hot flushes are often accompanied by palpitations and nausea. They can feel like an anxiety attack, only adding to the discomfort. For me, hot flushes feel like that moment when I’ve had too much to drink and I’m sweatily thinking about hugging the toilet. Except hotter.
As you might expect, getting rid of heat unnecessarily leaves a person cold, and so many women shiver once their hot flush has passed. For some women this cycle of intense heat and shivering can happen 30 or more times a day. This is also no sprint—the average course of hot flashes is seven years, but some women can suffer for 10 years or even longer. For me the wave of heat was as intolerable as the unpredictability.
When we dismiss hot flushes, even when no treatment is desired, we also lose the opportunity to inform women that those with hot flushes have a greater risk of heart disease. It’s not that hot flushes cause heart disease, but there is likely a shared vulnerability, meaning the wiring that results in severe hot flushes could be the same wiring that leads to heart disease. So it’s important to talk to your doctor and not write hot flushes off as something you simply have to suffer through like a character in a Nancy Meyers movie.
The menopause continuum doesn’t just expose women to symptoms; it opens the door for many other medical conditions. Most notably cardiovascular disease (heart attack and stroke), osteoporosis (fragile bones), and dementia. So, when navigating therapies, women should consider their risks for these conditions and others and how they may be impacted by treatment.
The truth about hormone therapy
Messaging about therapies for menopause-related concerns often feels overly patriarchal and geared to frighten women—as opposed to actually explaining the benefits and risks and then letting women decide what serves them best.
Take, for example, menopausal hormone therapy (MHT), which is estrogen (and the addition of a progestogen for women with a uterus to prevent the estrogen from causing endometrial cancer). This is one of the most needlessly controversial treatments in women’s health. The Women’s Health Initiative (WHI), a large study on MHT, was halted prematurely in 2002 in part due to data that indicated a 26% increased risk of breast cancer. The headlines were dramatic and scary, and the use of MHT plummeted.
In practical, what-does-this-mean-for-me terms, the 26% risk from MHT translated into slightly less than 0.1% of women per year on MHT developing breast cancer. Let’s contrast that with another risk factor for breast cancer: age of pregnancy. Giving birth after the age of 35 is associated with a 40% increased risk of breast cancer compared with giving birth before the age of 20. If preventing breast cancer is the goal, why target only women after menopause with terrifying headlines?
The most effective medical therapies for hot flushes are estrogen, some antidepressants, and some antiseizure medications. As a doctor, I knew—despite all the claims on social media and various wellness sites—that diet, acupuncture, wearable magnets, and supplements were either ineffective or unproven. And on top of that, some of these so-called alternative therapies have risks. Especially supplements, which are unregulated and can sometimes contain hormones or antidepressants—medications that shouldn’t be taken without appropriate supervision.
I also practiced cognitive behavioral therapy (CBT) for hot flushes. There is good evidence to support its use here given the connection between hot flushes and anxiety; there are some shared connections in the nervous system that explain the overlap in symptoms, which may be why some medications that can treat anxiety can also improve hot flushes. Some might call that complementary or alternative medicine, but if it’s proven to be effective—which CBT is—then, for me, it’s just medicine.
For many women—women like me—menopause isn’t just about the bothersome symptoms. I knew my family history put me at high risk for osteoporosis. My mother began developing fractures in her 50s. She was likely in menopause by her early 40s, but such was the cloak of shame at the time that I can only approximate her age based on what I remember about her seemingly constant yelling at my father for shutting the windows.
Like many women, my mother’s osteoporosis was ignored. When I suggested she get screened for osteoporosis, she was told she didn’t need it. When I suggested she start hormone therapy treatment, she was told she “didn’t want that”—and that was even before the public concern surrounding estrogen. As women age their health concerns are often ignored as women themselves are expected to fade away into oblivion. After a miserable final 10 years with fracture after fracture, she died at age 86 from osteoporosis, having spent much of those final years in pain and in hospitals.
Estrogen prevents the accelerated loss of bone mass characteristic of menopause, so I knew it was the right choice for me to treat my hot flushes and protect my bones. I opted for estradiol, which is the main type of estrogen made by the ovary before menopause. While all pharmaceutical grade MHT is low-risk, transdermal estradiol is the safest option as it’s not associated with an increased risk of blood clots, so that’s what I chose. To protect my uterus, I chose an oral form of progesterone, as it is associated with the lowest risk of breast cancer (and even then, research shows the low risk seems to only start after several years of therapy).
Also popular are “bioidentical,” or compounded, hormones, but I would never recommend that approach or choose it for myself. “Bioidentical” is a quasi-medical term of varying definitions. These products aren’t one step away from ground-up yams; they are synthesized in a multistep process in a lab, as are most hormones in MHT. In other words, these terms are not medical—they are marketing and are misleading.
There are serious safety concerns with compounded hormones. They may contain more or less hormone than advertised and their absorption may be erratic, leading to increased risks of complications such as endometrial cancer. With an FDA-approved prescription, I know exactly what I’m getting and how much is absorbed. There is a wide range of dosing and formulations available, so pharmaceutical MHT can be customized to suit each woman's need. And no, I don’t take money from the pharmaceutical industry—I just demand precision in my medications as all women should. We deserve to know exactly what we’re putting into our bodies.
Navigating—and destigmatizing—menopause treatments
A woman’s decision to start hormones should be based on her symptoms and her risk of osteoporosis, but also her personal medical history. It’s important to consider a variety of risk factors and conditions that may be positively or negatively affected by MHT, such as breast cancer, heart attack, stroke, type 2 diabetes, elevated triglycerides, blood clots, and dementia.
The North American Menopause Society has a fantastic app (MenPro) and excellent information on its website to get started, but ultimately, women need a conversation with their provider, a blood pressure check, cholesterol screening, test for diabetes, up-to-date breast cancer screening, and possibly a physical exam to make fully informed decisions about therapies for menopause. What isn’t needed are hormone tests. They only provide the illusion of customization and safety and are impossible to interpret, as values can fluctuate day to day.
It’s important to remember that MHT or other prescriptions are just one piece of the menopause puzzle. The three healthiest things a woman can do for her menopause transition (and her life postmenopause) are to quit smoking if she’s a smoker, get the recommended amount of exercise (at least 150 minutes a week of moderate physical activity), and eat a healthy balanced diet.
It’s a lot, I know. There is a fantastic wealth of quality medical information on menopause, but there’s a major gap in getting that information to women in an unbiased fashion. That’s why I’m writing a book on the subject and striving to help women navigate the complicated terrain of menopause symptoms and treatments.
Menopause shouldn’t be a mystery. After all, if you include the menopause transition, many women can expect to live half of their life in the menopause continuum. Menopause matters. This isn’t a peripheral concern that needs some kind of separate curriculum—it’s simply women’s health care.
Jennifer Gunter, M.D., is an ob-gyn and the author of The Vagina Bible and The Menopause Manifesto (May 2021).
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