1The Wild, Wild West of Health Experiences
When women come to see me for the first time about their midlife symptoms, they often say things like:
“I don’t recognize myself anymore.”
“I don’t feel like myself.”
“I feel like someone has taken over my body.”
“I’m at the point where I’m just going to wear elastic pants for the rest of my life because I feel so bloated.”
“When will this vaginal dryness, irritability, [fill in the blank] end?!”
“When it comes to sex, I feel dead inside. I miss my libido!”
Sometimes they’ll ask, “Is this too much information for you?” or “Have you ever heard this before?” Of course, every woman should feel special because truly they are, but these feelings and experiences are common (almost universal!)—and yet women often feel blindsided by them. This is partly because when it comes to accessing accurate information about a woman’s symptoms, menopause can feel like an untamed and unpredictable frontier. In our culture, there is almost a cone of silence around what to expect when you’re in the menopausal transition; plus, every woman’s experience is personal and unique to her and could be vastly different from her friends’ or family members’ experiences.
When Lucy, age fifty, first came to see me, the intensity of her hot flashes was off the charts and she was having heart palpitations along with them, which made them feel like panic attacks; naturally she was scared by these symptoms as well as highly uncomfortable. By the time I met Laura, forty-seven, she’d spent months waking up at 2 A.M., drenched in sweat and unable to sleep; as a result, she was muddling through her days in such a heavy brain fog that she was barely able to function and afraid she’d have a car accident. After having chemotherapy for breast cancer, my patient Anna, forty-three, a trial attorney, experienced such severe vaginal dryness that her vulva and labia continuously felt like they were on fire. Lucy, Laura, and Anna’s symptoms were different from each other’s but all related to menopause—and they were all affecting these women’s day-to-day lives in seriously distressing ways and making them absolutely miserable! And these three women are far from alone. Did you know that 75 percent of women have symptoms that disrupt their lives and/or their ability to function during perimenopause and postmenopause—and that these symptoms often last for years? That adds up to millions of women, many of whom feel utterly bewildered, distressed, or pissed off by these life-altering changes and struggle to find safe and sufficient relief from them.
This is especially challenging to handle because there’s a lot of informational noise about this time in a woman’s life. Women are consistently bombarded with messages about what’s normal or not during the menopause transition, and what to do or not do for their symptoms (there’s a lot of menopause shaming going on out there, too, especially online). The problem is, some of this advice lacks scientific evidence to support it or to refute the claims that are made. And frankly there’s a lot of sheer nonsense out there, much of which is passed around through various social media platforms and advertisements for specific products. So, it’s important, though not easy, to cut through the myths, old wives’ tales, half-truths, and snake-oil promises and zero in on what’s really going on with your symptoms and what’s likely to actually help you.
Compounding the challenge, the health-care system isn’t helping in this respect. In most practices, physicians and nurses haven’t adequately prepared women for menopause by giving them even basic information about some of the symptoms and changes they may experience or how long they may last. Currently, there’s no such thing as a perimenopause evaluation, where a doctor does an assessment of a woman and comes up with a what-to-expect game plan for how she can address menopause-related symptoms, as there is with a pre-surgery evaluation, for example. Many women are still reluctant to talk to their primary care physicians about their menopausal symptoms, whether it’s because they feel embarrassed, they feel like they should just toughen up and stick it out, or because their doctors are dismissive when the subject arises. The reasons for this dismissiveness vary, but research has shown that education about menopause and how to manage it is woefully inadequate in medical schools and residency programs. As a result, it’s hardly surprising that when many women who are experiencing serious menopausal discomfort seek help from their physicians, they receive answers like, “There’s nothing we can do” or “You’ll have to wait it out; this will pass eventually” or, unbelievably, “In previous generations, many women didn’t live to see menopause, so we just don’t have a lot of research about it.”
I want you to know that it doesn’t have to be this way. I will help you cultivate a sense of control over the physical and mental chaos you may be experiencing—without falling for bogus treatments, tearing your hair out (or having more fall out), spending a fortune, or hopping from one medical practitioner to another. With this book, we’ll be putting you in the driver’s seat for this experience and guiding you toward a greater sense of well-being. The first step in this journey is to identify your personal menopause type—a unique approach that I have cultivated based on six distinct patterns I have seen in my years of clinical experience. Using these types, it’s easier to pinpoint which of your symptoms are priorities for obtaining relief and develop a treatment plan that will start turning this ship around.
By treating and tracking more than a thousand women in my clinical practice, I’ve identified the following six menopause types:
The Premature Menopause Type, which occurs before age forty, tends to bring a surprising and often abrupt wave of symptoms such as hot flashes, night sweats, mood swings, mental fogginess, vaginal dryness, and decreased sex drive.
The Sudden Menopause Type, which often results from surgery or chemotherapy (but can occur for other reasons, as you’ll see), is often a shock to a woman’s system with its arrival and intensity.
The Full-Throttle Menopause Type, which is marked by diverse and often fierce symptoms from pretty much every direction, can be absolutely overwhelming and sometimes downright debilitating.
The Mind-Altering Menopause Type primarily involves mood and cognitive changes—such as anxiety, depression, dramatic mood swings, brain fog, difficulty with concentration, and memory challenges.
The Seemingly Never-Ending Menopause Type is marked by one or two symptoms (such as the occasional hot flash, persistent vaginal dryness, or low libido, or less common ones like dizziness or olfactory changes) that go on and on and … on.
The Silent Menopause Type, where you’re largely symptom-free but need to pay attention to new health challenges and risks that emerge postmenopause because whether or not menopausal symptoms are present, your body is changing from the drop in hormones.
In the chapters that follow, you’ll learn much more about each of these different menopause types. Many women’s experiences will match up with one particular type; other women may experience a combination of types—a hybrid type, so to speak. Either way, my unique typology approach allows you to pinpoint your personal collection of menopausal symptoms in order to develop a treatment plan that’s most likely to help you feel better ASAP. In my clinical experience, when women discover they have a certain menopause type or a hybrid, it makes them feel seen, heard, and understood—and not alone!—and it gives them a name for what they’re experiencing; this in turn lends a sense of order to the seemingly unwieldy experience, which comes as a tremendous relief. Perhaps most important, once you know what you’re dealing with, you can develop a plan that caters to your personal symptoms and is likely to work for you. Let’s face it: Your mother’s, sister’s, neighbor’s, or best friend’s experience with menopause is likely to be quite different from yours, so interventions that helped them may not help you. This really is all about you—and that’s a very good thing, as you’ll see in the chapters to come.
Personalized medicine (a.k.a. precision medicine) is the wave of the future, and my approach to helping women navigate menopause works within this framework. Only in this case, we’re not using an individual woman’s genetic profile or specific biomarkers to guide decisions for her care (though some day we may be able to do that, which would be amazing!). At this point, we’re using her personal cluster of symptoms and their severity, her health history and current health status, and her personal preferences and goals to inform her treatment plan. The menopause type approach is both reactive and proactive because it addresses a woman’s current symptoms and also takes into account her future health risks with preventive measures. Best of all, it involves a unique combination of medical interventions and lifestyle modifications.
THE PHYSIOLOGY OF MENOPAUSE
Before we dive into the details about the different menopause types and their recommended treatment regimens, let me give you a brief refresher about what’s happening in your body that triggers the changes you’re experiencing. As you approach menopause, your ovaries—which make the vast majority of your estrogen—are downshifting and heading toward retirement. When you’re in the phase of life where you still have your period, your estrogen levels fluctuate between 50 and 500 pg/mL every single month. At menopause, which is defined as a full year since a woman’s last period, those levels are effectively zero, though some women have a little extra estrogen because adipose (fat) tissue makes some estrogen. Yes, you read that correctly: A woman’s fat cells produce some estrogen (we used to think of body fat as an inert substance but now we know that’s not true). Throughout the menopausal transition, progesterone levels also decrease—in fact, we now think that progesterone may decline at a faster rate than estrogen throughout perimenopause, which may lead to a lot of the mood and anxiety changes that occur then. Levels of testosterone, which is the sex-drive hormone for women as well as men, also decrease. The majority of symptoms of menopause—such as hot flashes, night sweats, mood changes, and vaginal dryness—stem from the loss of estrogen, while a drop in libido can result from the loss of testosterone.
Estrogen receptors are everywhere in a woman’s body, though we have the most estrogen receptors in the vagina and the second largest concentration in our brains. So when estrogen is no longer present after menopause, those estrogen receptors continue to look for their old friend estrogen. When they don’t find the hormone, the receptors freak out in a way that’s like flicking a thermostat off and on, off and on; this is what we currently think triggers hot flashes, as well as some downstream effects such as mood shifts and cognitive changes. In other words, this flicking effect is what can make you feel like your body and mind aren’t quite your own. It’s true that eventually your body will adjust to these lower hormone levels and these symptoms will quiet down, but this period of flicking off and on can last for several years.
Researchers and menopause experts aren’t sure why menopausal symptoms are more severe in some women than others. The current hypothesis is that it has a lot to do with genetic factors, as well as environmental factors that may turn specific genes “on” or “off”—not just influences that come from your mom but also those that could stem from Dad’s side of the family or even second- or third-degree relatives. During this time of life, some women are programmed to have receptors that are more persistent in “looking” for that missing estrogen, which results in more severe or longer-lasting symptoms like hot flashes. By contrast, other women have a genetic predisposition for their estrogen receptors to give up the search, and hence they experience fewer symptoms. The fact that genetics seems to play a significant role should take the feeling of what am I doing wrong? off your shoulders—because your symptoms probably aren’t being caused by anything you are or aren’t doing. But that doesn’t mean you can’t take steps to ease them, as you’ll discover in later chapters.
Let’s back up a few steps and consider the in-between time—perimenopause and later stages of the menopausal transition. Perimenopause, which is like a long suspension bridge with an uneven surface, carries a woman from her reproductive years into menopause. The symptoms the transition brings often sneak up on women, catching them by surprise. Some women in their forties haven’t even heard the word “perimenopause,” so when these disruptive symptoms come on suddenly and make women feel like they’re having an out-of-body experience, they’re like, WTH?! And because these women are typically still menstruating, most don’t connect the dots between hormonal changes and the physiologic changes (such as irregular periods, hot flashes, night sweats, and vaginal dryness) and emotional changes they’re experiencing.
I can’t even tell you how many women have come to me saying things like, “When I had my first hot flash, I thought I was spiking a fever and getting sick.” (In 2020 and early 2021, so many women went and got tested for COVID-19 and quarantined until they got their results.) I heard this from women in high-powered professional jobs as well as women who worked at retail stores and fast-food joints.
Not long ago, I read an article in which celebrities shared their experiences with the menopausal transition,1 and I found actress Kim Cattrall’s experience particularly interesting. In her role as Samantha Jones on Sex and the City,2 the actress had to pretend she was experiencing hot flashes on screen before she ever had them in real life. Ironically, she thought the acting experience had prepared her for the real thing—but that just wasn’t the case. Two years later, her own experience was significantly more dramatic, as she experienced hot flashes that felt “earth shaking … like being put in a vat of boiling water.”
Believe it or not, symptoms of perimenopause can start as early as ten years before your final menstrual period. Most women experience menopause between the ages of forty and fifty-eight, with the average age being fifty-one, according to the North American Menopause Society (NAMS).3 During perimenopause, a woman’s hormones really are on a roller-coaster ride. In particular, major swings in estrogen levels—from high to low and back again—can irritate your brain. Simply put, the female brain seems to prefer a steady state of hormones, which is why some women experience premenstrual syndrome (PMS) or even premenstrual dysphoric disorder (PMDD) as their reproductive hormones fluctuate each month with their menstrual cycles. While a woman is still menstruating, estrogen and progesterone levels go up and down in a fairly predictable pattern that resembles rolling hills. During perimenopause, these hormonal fluctuations turn into sharper and more sporadic peaks and troughs. The brain can really struggle with these dramatic swings, which is why many women experience anxiety, irritability, insomnia, and other mood-related changes during this time.
Complicating matters, because the perimenopause transition can last from four to ten years, it can be hard to tell where you are in the meandering journey to menopause. Before we dive into what’s really going on behind the scenes, it’s important to understand the key players in the menopausal transition. You’ve probably heard about the hypothalamic-pituitary-adrenal (HPA) axis, which is the body’s central stress response system; it’s what leads to the release of the stress hormone cortisol when something stressful happens. But you may not be familiar with the hypothalamic-pituitary-ovarian (HPO) axis, a tightly regulated system that secretes hormones involved in female reproduction. (Keep in mind: Both the hypothalamus and the pituitary gland are in the brain stem.)
When the HPO axis works properly, a woman’s body has monthly menstrual cycles that include ovulation and priming of the uterine tissue for possible implantation of a fertilized egg; if conception doesn’t occur in a given cycle, the lining of the uterus is shed and a woman gets her period. When the HPO axis doesn’t work properly, ovulation doesn’t occur on a regular basis. Here’s where the menopausal transition comes into the picture: During perimenopause, the HPO axis starts to malfunction and eventually its activity comes to a screeching halt once a woman experiences menopause. At that point, the brain recognizes that the HPO axis isn’t providing the hormones it wants—namely, estrogen—so it often turns to the HPA axis and activates the adrenal glands. But, because the adrenal glands don’t have estrogen, instead they may release cortisol, which can unfortunately contribute to or worsen menopause-related symptoms such as acne, irritability, low libido, and a slowing of metabolism.
It’s against this backdrop that the “stages of menopause” come into play.4 Did you even know there are stages of menopause? They’ve been around for a while and have been refined over time. In 2011, an international panel of experts revised the criteria for the different stages of perimenopause and menopause that had been established ten years earlier in the Stages of Reproductive Aging Workshop (STRAW). In modifying the staging system, the 2011 group, which came to be known as STRAW+10,5 reviewed advances in understanding the key changes in hypothalamic-pituitary-ovarian function that occur before and after a woman’s final menstrual period. This is important because there are actually several phases in the run-up to menstruation’s not-so-grand finale (it’s more of a petering out, really), with a great deal of individual variation in terms of when the phases hit, how long they last, and how sensitive women are to the hormonal changes that occur.
Here’s a look at how the different stages compare:
Late reproductive stage (Stages-3b and-3a): A sort of pre-transition before perimenopause, this is the final stage of the baby-making years, a time when fertility begins to decline and a woman’s ability to have a baby drops significantly. She may start to see subtle changes in the volume and frequency of her menstrual bleeding, often experiencing shorter cycles in Stage-3a.
Early menopausal transition (Stage-2): During this phase, the length of a woman’s menstrual cycle becomes erratic and begins to vary by seven or more days from one cycle to the next. Her body is making estrogen but less progesterone. During this stage, which can last an unpredictable amount of time, you may experience an increase in irritability due to declining progesterone levels, and PMS-like symptoms and bleeding patterns can vary.
Late menopausal transition (Stage-1): During this stage, you may begin to skip periods, going for sixty or more days without one. In addition to variability in menstrual cycle length, you may experience extreme fluctuations in hormonal levels (including estrogen and progesterone), and you may frequently have cycles in which you don’t ovulate. (These are called anovulatory cycles.) Overall, you’ll experience a decline in estrogen but simultaneously there can also be dramatic fluctuations in hormonal levels, including estrogen, progesterone, and testosterone. Vasomotor symptoms like hot flashes are common during this stage, which is estimated to last one to three years on average.
Early postmenopause (Stages +1a, +1b, +1c): These stages occur at least one year after a woman’s last period—thus, it corresponds to the end of perimenopause. During this stage, estrogen and progesterone levels decline to very low levels, while follicle-stimulating hormone (FSH) levels—FSH is what tells the ovaries to release an egg (a.k.a. ovulate) each month during a woman’s reproductive years—continue to increase for approximately another two years. Stage +1a marks the end of the twelve-month span since a woman’s final period; Stage +1b also lasts a year, at the end of which levels of FSH stabilize. During these stages, vasomotor symptoms like hot flashes and night sweats are most likely to occur or worsen. During Stage +1c, which can last three to six years, hormone levels tend to stabilize even more to ultra-low levels.
Late postmenopause (Stage +2): During this phase, hormonal shifts and changes in reproductive endocrine function are more limited but some of the processes related to reproductive aging become a greater concern. Symptoms of vaginal dryness (including itching and irritation) and urogenital atrophy (a scary term for changes that occur in tissues in the vulva, vagina, bladder, and urethra due to declining estrogen levels) become more prevalent; these changes can lead to pain with intercourse, recurrent urinary tract infections, urinary frequency and urgency, and other anatomical changes, such as pelvic organ prolapse. Changes that occur to the pelvic floor are now collectively called genitourinary syndrome of menopause (or GSM, for short), a mouthful of a term that inclusively describes all the changes that are occurring to the vulva, vagina, perineum, bladder, and urethra.
Copyright © 2023 by Heather Hirsch
