Unlock Your Menopause Type E-Book

Heather Hirsch

• Herausgeber: Allen & Unwin
• Kategorie: Ratgeber
• Sprache: Englisch

Seitenzahl: 514

Veröffentlichungsjahr: 2023

Beschreibung

Given that millions of women have entered menopause each year since the dawn of time, it's bizarre that it still feels like uncharted territory for the women who are going through it. Dr. Heather Hirsch is committed to changing that. Unlock Your Menopause Type helps women cut through the informational noise and learn how to manage their symptoms most effectively by identifying their personal Menopause Type(s). This is not a one-size fits all solution. Unlock Your Menopause Type features a helpful quiz to identify women's individual Menopause Type(s) such as: -Premature -Sudden -Full-Throttle -Mind-Altering -Seemingly Never-ending -Silent Each type gets a full prescription for exercises, diet and strategies to regain mental focus and make menopause a routine part of maturity rather than a rollercoaster ride of unexpected symptoms and discomfort. The book also includes: -The last word on whether to replace declining hormones -What to do if you're a combination of types -How to get on top of (as it were) changes in your sex life -Crowd-sourced tips and tricks from Dr Hirsch's friend group and patients Dr Hirsch addresses the physical and emotional challenges of menopause and provides solutions from her years of practice. With knowledge, priorities and a plan, you can feel great through midlife and beyond.

Leseprobe

First published in Great Britain in 2023 by Allen & Unwin

First published in the United States by St. Martin’s Essentials,an imprint of St. Martin’s Publishing Group

Copyright © Heather Hirsch, 2023

The moral right of Heather Hirsch to be identified as the author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act of 1988.

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without prior permission in writing from the publisher.

Every effort has been made to trace or contact all copyright holders. The publishers will be pleased to make good any omissions or rectify any mistakes brought to their attention at the earliest opportunity.

Neither the publisher nor the author is engaged in rendering professional advice or services to the individual reader. The ideas, procedures and suggestions contained in this book are not intended as a substitute for consulting with your doctor. All matters regarding your health require medical supervision. Neither the author nor the publisher shall be liable or responsible for any loss or damage allegedly arising from any information or suggestion in this book.

Allen & Unwin

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A CIP catalogue record for this book is available from the British Library.

Designed by Steven Seighman

Trade paperback ISBN 978 1 83895 677 6

E-Book ISBN 978 1 83895 678 3

Printed in

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To my daughter DeMille Margaret Hirsch and her generation of women: My hope is that you will experience a greater awareness of women’s unique health needs and receive greater quality health care throughout the female reproductive lifespan.

Well-behaved women seldom make history.

—LAUREL THATCHER ULRICH, Pulitzer Prize–winning historianspecializing in early America and the history of women, and aprofessor emerita at Harvard University

Contents

Introduction

Part I: Hormonal Havoc

1. The Wild, Wild West of Health Experiences

2. Myths and Misconceptions About Menopause

3. The Hormone Conundrum

4. What’s Your Menopause Type?

Part II: Discovering Your Menopausal Road Map

5. The Premature Menopause Type

6. The Sudden Menopause Type

7. The Full-Throttle Menopause Type

8. The Mind-Altering Menopause Type

9. The Seemingly Never-Ending Menopause Type

10. The Silent Menopause Type

Part III: Treatments to Tame the Tumult

11. Prioritizing Relief and Your Safety

12. Personalizing Your Treatment Plan

13. Self-Care Going Forward

Conclusion

Appendix

Resources

Glossary

Selected Bibliography

Acknowledgments

Notes

Index

Introduction

Whether it’s described as puberty in reverse, puberty’s evil older sister, or premenstrual syndrome (PMS) on steroids, the menopausal transition is an extremely challenging time for most women. Intense hormonal changes, irregular periods, and mood swings may sound a lot like puberty or even PMS. But this time around, the ovaries are gearing down and heading toward full-time R and R, rather than cranking up their function toward reproduction. And because this transition, called perimenopause, often lasts from four to ten years, it can be hard to tell where you are in the meandering journey toward menopause, which is officially defined as one full year from your last period. Even after their periods are behind them, many women find that menopausal symptoms—including hot flashes, night sweats, vaginal dryness, and/or brain fog—continue for a surprisingly long time. In fact, it’s impossible to predict how long they’ll last. All of this adds to many women’s frustrations with this topsy-turvy physiological phase of life.

Meanwhile, trying to find relief for menopausal symptoms is like navigating the wild, wild West, a terrain that’s lawless, unregulated, and untamed. There’s no map, and the landscape is rife with myths and misinformation and self-proclaimed gurus (no, I’m not naming names here; you can probably guess who they are), often with no medical training but claiming to have all the answers and/or the best remedies. Women don’t know what to expect or whom to trust for reliable information and advice, nor do they have a realistic sense of what will work and what won’t to ease their bothersome symptoms. Too many women suffer due to inconsistent and inaccurate information from both physicians and the media. Honestly, it’s a chaotic mess.

In 2010, a small study1 in the journal Women’s Health Issues evaluated the needs of midlife women using focus groups and phone interviews with health experts, and found that women in their forties and fifties crave more information about what to expect around menopause and symptom management. Surprising, huh? The researchers concluded that a serious knowledge gap exists when it comes to “information about symptoms and how to cope with/reduce them, how to communicate with providers about their experience, [and] what to expect.” Sadly, more than a decade later, we haven’t made much progress on this front: Recent research2 reveals that 65 percent of women admit they feel unprepared for the symptoms that menopause may bring.

That comes as no surprise to me. As the clinical program director of the Menopause and Midlife Clinic at the Brigham & Women’s Hospital in Boston, I hear this every day. By the time patients come to see me, they’re typically at the end of their ropes: They don’t feel like their usual selves and they’re alarmed because they hardly recognize themselves. They’re aggravated because symptoms like hot flashes, sleep disturbances, or brain fog have started dominating their days and nights. And they’re often unaware that symptoms like vertigo, pain with urination, hair thinning and hair loss, burning mouth and gums, and heart palpitations may be connected to the hormonal changes their bodies are undergoing. They’re frustrated that they haven’t been able to find relief and they don’t understand why their usual doctors are dismissing their concerns. They’re also worried about the future, fearing that the way they’re feeling now is their new normal.

I’m here to tell you: It’s not—or at least it doesn’t have to be. With the right knowledge and interventions, you can reclaim control of your body and mind. You can feel and function well at midlife and beyond. The key is to identify your personal constellation of symptoms, or your “menopause type”—a unique approach that I have cultivated based on the distinct patterns I have seen in my years of clinical experience. Using these types, it’s possible to identify and prioritize your symptoms to obtain relief, and to develop an appropriate treatment plan. Many women’s experiences will match up with one type; others may experience a combination of types—but either way, the typology approach allows you to pinpoint your unique collection of menopausal symptoms in order to develop a treatment plan that’s most likely to work for you.

Just like puberty, menopause is a universal experience for women—at least we hope it is; otherwise, something is wrong with their reproductive systems, or they die prematurely. Given that millions of women enter menopause each year and have since the dawn of time, it’s kind of crazy that menopause continues to feel like uncharted territory or a shock to the system for the women who are going through it. I’m deeply committed to changing that. With this book, my goal is to help women cut through the informational noise about menopause and learn how to manage it by identifying their personal menopause type(s) so they can treat their constellation of symptoms more effectively.

After beginning my career as an ob-gyn delivering babies, it didn’t take long for me to pivot to internal medicine. I started treating menopausal patients during a two-year fellowship in women’s health at the Cleveland Clinic. Women were flying from all over the country to consult with my mentor Holly Thacker, MD, director of the Cleveland Clinic’s Center for Specialized Women’s Health, about menopause because they were frustrated, confused, and distressed by their symptoms and they weren’t getting the care or relief they needed. Many of these women were downright miserable, and some felt as though they were losing their minds. That’s when I discovered—to my great surprise!—that much of what I’d learned about menopause in medical school and in my residency was incorrect.

Within the field of medicine, we have cardiac experts, kidney specialists, sleep doctors, and other experts—why isn’t there a menopause specialist? Women typically talk to their internists or ob-gyns who should be well versed in the physical, mental (cognitive), and psychological changes that accompany this life transition. But in reality many are not because menopausal matters aren’t sufficiently addressed in medical school or residency programs. In fact, when researchers3 recently surveyed medical residents at programs in internal medicine, family medicine, and gynecology, most revealed that they had had only one or two hours of education about menopause in their program, and 20 percent reported that they’d had no menopause education whatsoever. The biggest shocker: Only 7 percent of these doctors in training said they felt adequately prepared to treat menopausal women!

Armed with the information in this book, you will be in a better position to work more effectively with any doctor to address your menopausal and midlife health concerns; you’ll have the baseline knowledge about what’s happening in your body and the vocabulary to describe it, as well as the options for treating those symptoms, all of which you can bring up with your doctor.

During my fellowship, the more women I treated, the more I realized there are distinct phenotypes to menopause. Based on my clinical experience, I started to see big patterns that couldn’t be found in textbooks. The depth and breadth of patient experiences, backgrounds, and histories was truly eye-opening, and I became convinced that treatment for menopausal symptoms needed to be individualized. There isn’t one effective way to treat women going through menopause and it’s a mistake to pretend there is.

Fast-forward to today: In my work as the clinical program director of the Menopause and Midlife Clinic at the Brigham & Women’s Hospital in Boston, I work closely with my midlife patients, going over their most private and emotional symptoms and patterns in close detail, which helps them feel seen and heard. That’s very empowering and confidence-building for them, so when we do devise a treatment plan, they’re likely to feel invested in it and stick with it, and we can tweak it over time until they feel really good. This approach works wonders, better than anything they’ve tried before, and it enables them to take control of this topsyturvy experience. I love helping women through this challenging time. By and large, my patients are smart, curious, and inquisitive, and they often have a strong connection between their minds and bodies—that’s part of what makes women excited to take control of this journey.

The reality is, there is no one-size-fits-all approach to managing menopause that works for every woman, and that’s because different women have different menopausal experiences. Research has found that the frequency and intensity of menopausal symptoms depend partly on a woman’s age, the presence of underlying health conditions, her menopausal status, and sociodemographic variables. That said, the most frequently reported severe symptoms include depressed mood and irritability, physical and mental exhaustion, muscle and joint aches, hot flashes, headaches, sexual problems, and sleep disturbances. But individual women experience different clusters of symptoms, and it’s impossible to predict who will experience which ones and for how long. In other words, your mother’s, sister’s, or best friend’s menopausal transition may be quite different from yours, which means it’s best to approach your experience in a way that works for you.

When women hear about these types, they often have an “aha” moment and ask, “Why doesn’t anyone know about this?” I’m on a mission to change that.

That’s where Unlock Your Menopause Type: A Personalized Guide to Managing Your Menopausal Symptoms and Enhancing Your Health comes in. By taking matters into your own hands with this book, you’ll be able to find your own path to feeling better and protecting your long-term health more effectively. Trust me, because I help women do this day after day, week after week in my clinic. In my practice, I take a uniquely personalized approach to helping women navigate and manage the array of physical and emotional symptoms they’re experiencing. But let’s face it, I can’t help every woman face-to-face or via telemedicine—though I wish I could.

By allowing you to take a personalized approach to feeling better and thriving again, this book will help you discover how simple interventions and lifestyle changes can restore your physical and emotional equilibrium, based on your unique experience with the culmination of your reproductive years. And because it will enable you to take action on your own, it will help you feel more empowered and resilient, which will immediately relieve some of the “what the #$@&%*! is happening to me” feelings that often accompany the menopausal experience. My hope is that this essential, comprehensive guidebook will provide you with all the tools you’ll need for getting through this time in your life, happily and healthfully.

In part 1, you will discover what’s really happening in your body during the menopausal experience, and you’ll learn about the role of hormones in your overall health and how their decline not only results in symptoms like hot flashes, but also impacts everything from your bone health to your cardiovascular system. I’ll reveal where myths and misconceptions about this time of life come from. You’ll learn about the concept of menopause types and take a quiz to identify which type(s) you have now (spoiler alert—it can evolve over time).

In part 2, I’ll help you identify your menopause type(s) and address what’s driving the changes in how you’re feeling and functioning; then, I’ll assist you in picking and choosing the evidence-based treatments that make the most sense for your symptoms, your health history, your needs and preferences, and your priorities. In some instances, hormone therapy may be recommended. I’ll walk you through the pros and cons of hormone therapy, as well as what we’ve learned in the past decade about how women can use hormones effectively—whether orally, vaginally, transdermally, topically, or in long-acting or short-acting formulations—depending on their menopause types, their symptoms, and their long-term goals. But if hormone therapy isn’t an option for you, rest assured: There are many other medical and lifestyle-based approaches that can relieve your symptoms and improve your sense of well-being. Each menopause type has its own baseline treatment plan, as well as additional recommendations for dietary, lifestyle, and psychological strategies to help you feel at the top of your game again.

In part 3, I will show you how to personalize your menopause survival plan by adding remedies that address your specific or remaining symptoms. You’ll find things you can do without any help from your doctor to mitigate typical challenges like hot flashes and night sweats, less well-known ones like breast tenderness and skin rashes, and the ones you may be embarrassed to talk about like pain during sex or loss of libido. I’ll also help you formulate a long-term game plan for taking care of your physical, emotional, and mental (cognitive) health into the future, even as things shift with the different seasons of your life.

What we’re going to do is create a customized road map through this often tumultuous transition and put you in the driver’s seat: Besides helping you make your way onto steady terrain, this approach will arm you with knowledge about smart detours and troubleshooting measures if unexpected potholes or obstacles arise along the way. One way or another, I promise you, you can get to where you want to go—to a new, healthy, feel-good chapter of your life. These days women spend more than a third of their lives in the postmenopausal zone, given the increasing human life expectancy. Why not feel amazing during those years?!

Using my custom-tailored approach, the majority of my patients feel significantly better and reclaim their health and their ability to lead fulfilling lives throughout the menopausal transition. I’m confident that I can help you do the same because I see these transformations every day in my clinic. With this approach, you’ll gain a sense of empowerment as you take ownership of the experience and develop confidence that you can start living your best life from this moment forward. Every woman deserves to feel and function at her best during menopause and after, setting the stage for better health into her sixties, seventies, and eighties. Let’s get started!

Part I |

HORMONALHAVOC

1 |

The 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 symptomfree 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 hypothalamicpituitary-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 pretransition 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 folliclestimulating 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.

What’s in a Name?

People are often confused by the terms that are used to describe this reproductive transition in a woman’s life. This is partly because they’re sometimes used interchangeably when they’re actually distinct entities or have specific definitions. Here’s what they really mean:

1. Perimenopause: the period of time leading up to menopause, a transition that can last four to ten years.

2. Menopause: the celebratory milestone where a woman has gone a full year without getting a menstrual period. It’s a retrospective event, given that a woman won’t know when her final period occurred until she has gone twelve months without another one. Some women can’t rely on their periods as an indicator—if they’ve had a hysterectomy or endometrial ablation or have a progesterone-releasing IUD in place, for example—so they should use blood tests showing a persistently elevated FSH level of greater than 35 mIU/mL and an estradiol level of lower than 20 pg/mL as a gauge for when they’re postmenopausal.

3. Menopause transition: the time span from perimenopause to your last menstrual period, which can take up to a decade for some women. Think of this as a broad way to describe the beginning of the maelstrom that will continue until your final period.

4. Premature menopause: menopause that occurs before age forty for one reason or another, including genetic disorders (such as Turner syndrome).6

5. Early menopause: menopause that occurs between the ages of forty and forty-five. Research has found that women who’ve never been pregnant or given birth are considerably more likely to have premature or early menopause; the same is true of those who got their first period at a young age (before eleven). Also, women who have autoimmune diseases7—such as rheumatoid arthritis, lupus, or certain thyroid disorders—may have an earlier menopause.

6. Premature ovarian insufficiency (POI): a disorder in which a woman’s ovaries stop producing eggs before age forty, which also means they no longer produce sufficient estrogen.

7. Diminished ovarian reserve (DOR): This phrase refers to a condition in which the ovaries lose their normal reproductive potential, thus compromising fertility. This can be a result of the normal aging process but it can also occur due to a medical condition or injury. Women who find out they have DOR often make the discovery when they’re trying to get pregnant.

8. Surgical menopause: menopause that’s caused by the surgical removal of both ovaries (if only one was removed, it’s not surgical menopause because the other ovary may keep working).

9. Natural menopause: menopause that occurs spontaneously or without any intervention after age forty-six. This is due to the loss of active follicles in the ovarian tissue and the natural decline in estrogen production.

10. Medication-induced menopause: menopause that’s caused by a medically induced cessation of ovarian function, often from chemotherapy, which is known to kill rapidly dividing cells in the ovarian tissue or alkylating agents (also used in cancer treatment). Other medications that can cause menopause to come early include methotrexate (which is often used to treat rheumatoid arthritis) and long-term use of methylprednisolone (used to treat lupus, multiple sclerosis,8 and other inflammatory conditions) or GnRH therapy (used to treat endometriosis or fibroids); also, radiation to the pelvic area can alter the timing of menopause.

11. Postmenopause: the span of time that follows the day of your official one-year anniversary without menstrual periods and continues into the future; in other words, every day after menopause.

I must confess: I tend to cringe inside when women say they are “done with menopause” or they “already had menopause” because those statements don’t make sense. Similarly, saying that you’ve “reached menopause” isn’t accurate because there isn’t an endpoint or a destination; technically, menopause is a one-day milestone because it marks one year after your final period. The important thing to recognize is that once you are postmenopausal your body will always be different than it was premenopausally, and that’s true regardless of the menopause type(s) you have. It’s true even if you never experience menopause-related symptoms (meaning, you have the Silent Menopause Type). So fasten your seatbelt because you’re in for a long and possibly bumpy ride!

Whatever stage your symptoms seem to fall in, having a road map, even if it’s a somewhat sketchy one, can help you identify what’s happening now and what to expect going forward, which can help you make more informed decisions about interventions. The reality is: Every woman’s road map is a little bit different. And while the STRAW+10 model presents a useful framework for the progression of menopause-related changes, women’s experiences in real life can vary considerably. Rather than follow a linear progression in an orderly fashion, research has found that some women skip a particular stage (or several). Others get stuck in a particular stage for a surprisingly long time, while still others swing back and forth between specific stages. And some women have regular periods until they suddenly and mysteriously stop, almost as if a faucet were turned off for good one day. Simply put, the trajectory from the reproductive years to menopause is not necessarily uniform or predictable.

And there’s no one-size-fits-all approach to managing menopause that works for every woman, and that’s because women have different menopausal experiences, health goals, and personal priorities for symptom relief. Individual women experience different combinations of symptoms, and it’s impossible to foresee who will experience which ones. On a near-daily basis, I see lots of women with vastly different menopausal symptom patterns. Here are snapshots of two patients I recently treated who had contrasting experiences and turned out to have two totally different menopause types.

When Nancy, fifty-four, a history professor, came to me complaining of confusion, brain fog, and depression, she was having trouble staying organized at work and sometimes even misplaced her students’ papers; simply put, she felt like she was losing it. During our appointment, it became clear that she had the Mind-Altering Menopause Type. To promote alertness, I recommended she reduce her consumption of starchy carbs and increase her protein intake and do aerobic exercise every day, even if it was just a twenty-minute brisk walk; I also started her on Wellbutrin (an antidepressant with stimulant properties). Within two months, her ability to concentrate and be productive was back on track and her mood had improved.

By contrast, Erin, forty-nine, a physician’s assistant in orthopedic surgery, was experiencing up to thirty severe hot flashes per day and drenching night sweats, which disturbed her sleep. Her Full-Throttle Menopause Type was so intense that during surgery, hot flashes were causing her goggles to fog, impairing her ability to assist safely. (I know—yikes!) With the help of hormone therapy, a reduction in her intake of caffeine and other stimulants, and relaxation exercises in the evening, her symptoms improved considerably.

As you’re probably starting to realize, the onset and length of the menopausal transition also can vary significantly from one woman to another. A woman is born with all the follicles (egg sacs) she’s ever going to have and the rate at which they deteriorate during her life plays a role in the timing of her menopause. Because ovarian follicles are rapidly dividing cells, they are easily susceptible to damage from both environmental factors and medical stressors. So, while a woman’s body mass index (BMI), ethnicity, and genetic factors can affect the timing of the menopausal transition, lifestyle factors can also influence when she’s likely to experience “the change.”

In particular, smoking can push a woman into earlier perimenopause or menopause than she was genetically programmed to have. Both current and former smokers are at risk for earlier menopause, and the intensity, duration, cumulative dose, and earlier initiation of smoking all matter on this front. Research9 has found that current smokers who have smoked for fifteen or more years have a fifteen-fold increased risk of premature menopause and a six-fold increased risk of having menopause arrive one to two years earlier than it does for non-smokers. Ongoing exposure to secondhand smoke is also associated with an earlier arrival of menopause, even among women who are non-smokers.

Meanwhile, exposure to other chemicals—especially endocrine-disrupting chemicals (EDCs)—which can mimic, block, or interfere with hormones in the body, including estrogen—have been linked with an earlier age of menopause.10 The chemical culprits that fall into this problematic category of EDCs include dioxins (persistent organic pollutants, meaning they stay in the environment), polychlorinated biphenyls (PCBs, which are no longer produced in the US but also remain in the environment), pesticides, phthalates (which are used to soften plastic and personal care products), and perfluorooctanoic acid (PFOA, which is used in nonstick cookware and stain-repellant applications). These chemicals are ubiquitous in the modern world—but that doesn’t mean you can’t take steps to minimize or mitigate your exposure to them, as you’ll see in later chapters.

The reason the issue of timing matters is because women who enter menopause at a later age have lower risks of cardiovascular disease, osteoporosis, and premature death, which is great news for them. On the other hand, women who enter menopause at an earlier age have increased risks for developing heart disease and osteoporosis and dying young—but we can take steps (thanks to hormone therapy, for example) to reduce those risks and help these women lead long, healthy, vibrant lives.

Of course, various genetic factors also may influence when a woman is likely to become menopausal, though there isn’t a clear consensus on them. Research has, however, found some differences in symptom severity during the menopausal transitions in women of various ethnic groups. For example, perimenopausal African American women are twice as likely to report hot flashes and severe hot flashes as Caucasian women, while Hispanic women are more likely to report menopausal mood changes, decreased energy, heart palpitations, and breast tenderness than Caucasian women.11 The reasons for these variations aren’t completely understood—and here’s why: Not only is menopause under-researched in general, but the majority of research is focused on Caucasian women—and this is not okay. It’s so important to understand how menopause affects women of all races and ethnicities and more dedicated research needs to be done in these areas.

Meanwhile, other factors can influence the intensity of a woman’s symptoms during the menopausal transition. For example, women who take chemopreventive drugs—such as tamoxifen, raloxifene, or aromatase inhibitors—to lower their cancer risk (because they’re at high risk) or prevent a recurrence (if they’ve already had cancer) may have an increased intensity of menopausal symptoms, especially hot flashes. Also, long-term use of steroids—for a connective tissue disorder, an autoimmune disorder, asthma, or another medical condition—may worsen symptoms, especially hot flashes, for some women as they navigate the transition.

The way I see it, women are on a need-to-know basis when it comes to information about the menopausal transition and what to expect. There shouldn’t be a gap between what healthcare providers know (or should know) about the final chapters in a woman’s reproductive life and the information that’s accessible to the women who are going through them. But often there is. That’s entirely unacceptable because it’s your body and you should be armed with the knowledge and the tools you need to take care of it in an optimal fashion. Rather than feeling like you’re on a runaway train, my goal is to put you in the driver’s seat for this journey. Rather than feeling distressed or debilitated by your symptoms, I want you to feel empowered to take charge of your health as you navigate this stage of indeterminable length and erratic hormone levels. This really matters because how you treat your body during the menopausal transition can affect your health for decades to come—for better or worse.

(Note: Wherever you are in the menopausal transition, keeping a journal and using it to track your daily symptoms, along with their fluctuations, can help you get a forecast of what your menopause type is and/or a leg up on developing greater body awareness to help you through the transition. If you don’t already keep one, I encourage you to start one now—see the appendix for a sample.)

Remember: The menopausal experience is a natural part of a woman’s reproductive life, just as puberty was. For many women, as human lifespans increase, over half their lives will be spent in a postmenopausal state—meaning they have a lot of living still to do. They deserve to have their troublesome menopause symptoms alleviated, so that they can not only feel the best they possibly can, but lead their best lives during these years. You do, too! And it can be done.

Trust me, because I help women do this day after day, week after week in my clinic, where I take a uniquely personalized approach to helping women navigate and manage the array of physical and emotional symptoms they’re experiencing. Now it’s your turn. By reading and using this book, you’ll be able to forge your own path to feeling better and protecting your long-term health more effectively into the postmenopausal years. I may not be with you in person but I will be with you in spirit and guiding you with my words, every step of the way.

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Myths and Misconceptions About Menopause

You know the old adage that you shouldn’t believe everything you hear? Well, that definitely applies to the menopausal experience. There’s a lot of misinformation about menopause in the media, as well as passed down from one generation to another or from one girlfriend to another. This is part of the informational noise I mentioned previously. The effects can be misleading, if not downright harmful or dangerous, which is why it’s important to separate fact from fiction about this natural life transition.

When it comes to the menopausal experience, women are on a need-to-know basis, whether they’re in the midst of the transition or anticipating it. It’s your body and you have a need and a right to understand what’s happening during this final act of your reproductive years. You shouldn’t be led astray by the myriad mistruths about menopause that are running rampant in our world. Not only will getting the unvarnished truth help you allay your worries, it can also help you ease into the transition as smoothly as possible with the help of the trustworthy advice you’ll find in the chapters that follow.

Here are common myths about menopause that not only deserve to but need to be busted—now!

MYTH: BECOMING MENOPAUSAL MEANS YOU’RE OLD

In our culture, menopause has lots of negative connotations but it really shouldn’t. For one thing, “old” reflects a state of mind or poor health but it doesn’t have anything to do with your actual age or reproductive status. For another, menopause can be a time of life that can bring new opportunities for growth and flexibility. It can bring a chance to reinvent your relationship with your body or refocus on yourself, especially if you have kids that have grown up and are becoming more independent. By this point in your life, you also probably have a strong sense of your values and what you like or don’t like, which can be inspiring and liberating.

Plus, women in general are aging in ways that are different from the way their mothers or grandmothers did. There really is some truth to the notion that fifty or sixty is the new forty. It all depends on how you work with the changes that are happening for you physically, emotionally, socially, and spiritually. It’s a mind-set shift, really, and this is a transition that should be embraced and celebrated.

MYTH: MENOPAUSE SYMPTOMS LAST FOR ONE YEAR

This is a misconception more than anything else. Menopause is defined as one year with no periods; after that, a woman is considered postmenopausal but she can still have symptoms. I hate to be the bearer of bad news but the average length of menopausal symptoms is five to seven years. A woman can have hot flashes and night sweats during perimenopause, even when she’s still getting her period, and women with the lingering type of menopause can have symptoms for longer. Sadly, there’s just no way to predict how long they’ll last because the menopausal transition operates on its own schedule or timetable for every woman. But that doesn’t mean there aren’t steps you can take to tame your bothersome symptoms—for however long they do go on.

MYTH: YOU NEED TO HAVE A BLOOD TEST TO DIAGNOSE MENOPAUSE

For many women, the diagnosis of menopause comes clearly and naturally—going a full year without a period tells you what you need to know. This is one of many reasons I recommend that women track their symptoms and periods—your clinical history is much more relevant than any test I could order for you. But it may not be that simple for some women, including those who don’t get regular periods, those who have an IUD in place, those who had an endometrial ablation (a procedure to remove the endometrial lining of the uterus), or those who had a hysterectomy (removal of the uterus). In these instances, the diagnosis can be aided by a blood test to measure FSH and estradiol levels—having an elevated FSH (above 35 mIU/mL) along with low estradiol (under 20 pg/mL) on two separate occasions, six to twelve weeks apart, will deliver the news.

MYTH: WEIGHT GAIN IS UNAVOIDABLE WITH MENOPAUSE

Menopause doesn’t necessarily cause a woman to gain weight but it can increase belly fat (hence, the dreaded “menopot”). In this case, whether or not the number on the scale actually changes, adipose (fat) tissue can shift to the abdomen and breasts thanks to a drop in estrogen levels, which is why your clothes may fit differently. Meanwhile, the natural aging process can cause your metabolic rate to slow down as you lose muscle mass; it’s true for men and women. But you don’t have to take any of these changes sitting or lying down—or be destined to gain weight in your forties, fifties, or sixties. To prevent menopausal weight gain, the keys are to trim your calorie intake by about two hundred calories per day, up your protein consumption, and/or increase your physical activity by aiming for at least 150 minutes of moderate-intensity aerobic activity per week, plus strength training twice a week. Building or preserving lean muscle mass will help keep your metabolic rate humming faster.

MYTH: MENOPAUSE RUINS YOUR SEX LIFE

Some women actually feel sexually liberated after menopause, knowing their days of worrying about getting pregnant are in the rearview mirror. While it’s true that vaginal dryness can become a challenge during and after the menopausal transition, that doesn’t have to be a deal breaker in the bedroom (or anywhere else). Applying a prescription low-dose estrogen cream or using an estrogen ring or suppository in the vagina can counteract the thinning and dryness of vaginal tissues; similarly, using over-the-counter waterbased lubricants during sex can help make the experience more comfortable, while a daily moisturizer can help keep the tissues hydrated in general. And here’s the great news: When sex isn’t painful, the more often you have it, the healthier and moister your vaginal tissues may become.

As for changes in libido, that can be more of a psychological issue at this stage of life, which means you should consider: Has something changed in your mood or in your relationship? Did you have issues with desire before menopause? Taking into consideration the answers to these questions, there are lots of things you can do to get your sexual groove back and improve your sexual mind—even after menopause. (Spoiler alert: Regular exercise helps improve desire and orgasm potential; so can engaging in self-stimulation with a vibrator.)

MYTH: IF YOU GOT YOUR PERIOD AT AN EARLY AGE, YOU’LL DEFINITELY GO THROUGH MENOPAUSE EARLY

Not necessarily. In the past, some research had reported that women who got their first menstrual period early (a.k.a. early menarche) also had earlier menopause, but other, more recent studies found that women who started getting their periods at younger ages had later menopause.

A major study in a 2018 issue of the journal Human Reproduction1 investigated this issue among 336,788 women in Norway and found that (drumroll, please!) . . . women who started getting their periods at age nine or younger actually had a nine-yearlonger reproductive lifespan than those who started menstruating at age seventeen or older.

The take-home message: There isn’t a consistent correlation between the age at which a woman starts getting her period and when she’s likely to go through menopause. The patterns vary widely, depending on the study (and real life), so it’s a mistake to guesstimate when you’re likely to become menopausal based on when you got your first period. You’ll just have to wait and see how this plays out for you.

MYTH: IF YOU’RE FIT AND STRONG, MENOPAUSE WILL BE A BREEZE FOR YOU

There are no guarantees on this. While there’s no question that being fit and strong is beneficial for your overall health and functionality, as far as the menopausal experience goes, there isn’t a clear association between fitness levels and the severity of symptoms. In fact, research has yielded some conflicting and often counterintuitive results on this subject. For example, a recent study2 that examined the physical activity patterns and intensity of hot flashes among pre-, peri-, and postmenopausal women found that sedentary behavior predicted nighttime hot flashes. By contrast, a 2009 study3 found that higher levels of physical activity among midlife women were significantly linked with a greater likelihood of having moderate to severe hot flashes. Meanwhile, a study published in a November 2021 issue of the journal Menopause4 found that menopausal women with greater muscle mass have more vasomotor symptoms, including hot flashes, than women with sarcopenia (loss of muscle mass). That said, many women5 find that regular physical activity improves their ability to cope with hot flashes and night sweats. (As you’ll see in the chapters that follow, I strongly recommend exercise for a variety of reasons.)

MYTH: YOUR ATTITUDE TOWARD MENOPAUSE WILL AFFECT YOUR EXPERIENCE

Maybe it will and maybe it won’t. To be honest, I have seen this go both ways among women in my clinical practice. Some women have a lousy attitude toward menopause, often based on their mother’s or sisters’ negative experiences, and have frustration with their own menopausal transition—but others do just fine. In a 2010 review6