After having worked in women’s health all over the world for more than two decades, I thought I knew it all.  But looking back, I now realize that menopause was never brought up.  Not even once. Can you believe it? Now I know that by focusing almost exclusively on female reproductive years as most women’s health experts do, I was missing health issues that affect a third of all women – those over 50. And the changes that occur in this stage of life are significant and aren’t just limited to hot sweats and mood swings – they can be serious. On this episode of Sex, Body, and Soul, I talk to Dr. Heather Hirsch, an internal medicine physician who specializes in women’s health and menopause care, and particularly treating the many (and often odd and unexpected) symptoms of perimenopause and menopause.  You’ll want to listen to this! I wish I had learned all this when I was starting my perimenopause journey, but better late than never.

For many women – including me – menopause was a stage I knew vaguely about. I’d heard jokes about hot flashes and mood swings, with jokey warnings not to cross a woman’s path during what I thought was probably a few months to a year-long phase (wrong again). What I didn’t know until recently is that women can get many other symptoms when they start to enter perimenopause that can be unpleasant (periods so bloody they look like a murder scene) to downright nutty (the sensation that bugs are crawling on your skin). But even for the lucky 10% of women who have no symptoms entering menopause, it’s important to recognize the risk of serious conditions like osteoporosis and heart disease increases, along with the likelihood of depression, anxiety, and a ton of changes associated with estrogen loss you would never expect (hello, more urinary tract infections? What?).

Why don’t women know more about something they will live with for a third of their lives or more? The onset of periods, issues around fertility and sexuality and childbearing for those who choose are all huge issues for women for decades, but when we approach the end of our fertile years, nobody talks about the new health issues we face. And that includes the medical establishment, which often treats women like men who happen to have boobs and uteruses, ignoring the effect that menopause can have on our brains and bodies. Not good! Dr. Hirsch and The Body Agency are working to change this.

Let’s get down to basics first: In the U.S., most women probably start perimenopause around 45 or earlier, and the average age at which they enter menopause is 51.5 (recall that a woman is officially in menopause after she has not had a period for a full year).  But there’s a wide age range. It can be hard to tell because most women won’t recognize when they start having perimenopausal symptoms - partly because most women don’t know what perimenopause is!

Early symptoms of perimenopause often include a change in periods – heavier, lighter, full of clots. Some women start to have migraines or PMS for the first time. Others may have tingling legs, insomnia, night sweats, or anxiety. And yes, many women experience hot flashes and mood changes. Brain fog is a big one. This happens to me. So does breast tenderness and the feeling that I’m going to get my period…and then I don’t. The phantom. Blame volatile hormones. Truly, during perimenopause they are all over the place. Then along comes menopause, and for many women, this is accompanied by a drop in libido. Of course, this is not true for everyone.  In fact, Dr. Hirsch’s forthcoming book is all about the different experiences women have in menopause and perimenopause. Look for Unlocking Your Menopause Type on the shelves in 2023!

To figure out what can help women who experience low libido, Dr. Hirsch generally begins by asking them if sex is painful or pleasurable, because this gating question can help her figure out which direction treatment could take.  If sex is painful, that’s the place to start. After all, she points out, if you burned yourself on a stove once, you’re not likely to want to do that again! Same thing with pain during sex.  It’s hard to get horny if you know you’re going to be in pain when things heat up. That’s a totally natural human response. The good news is there are now a host of options for women who have pain with sex, so it’s really a question of finding the one that works.  But the first step needs to come from the woman, raising something that can feel embarrassing or very personal with her health care provider and not take the standard “just use lube” as a response. As I always say, if you can’t get real with your doctor, get another doctor.

Often pain, like many other uncomfortable or unpleasant menopausal symptoms, can be resolved with hormone therapy, either systemic or local (both available by prescription). Some women use both systemic and local simultaneously to great effect. It bears repeating that these hormones are extraordinarily safe and in fact protective against major causes of morbidity for older women like osteoporosis and heart disease.  I’m largely talking about estrogen here (which pairs with progesterone in hormone therapy for women who still have a uterus), but Dr. Hirsch tells us it may sometimes be appropriate for female libido loss to use testosterone, although there isn’t a ton of research on this yet. I did learn from Dr. Hirsch that testosterone is not just a male hormone – women have it too in lower amounts (obviously), so when it drops, some women feel that loss. Dr. Hirsch also told me there are also several non-hormonal options to improve libido. So, if you are missing your mojo, let your fingers do the walking (for once I’m not talking about masturbation – I’m talking about calling your doctor).

By the way, hormone therapy is not just for pain - women who want to protect themselves against other hormone-related symptoms, like hot flashes and their nocturnal partner night sweats, poor sleep, or mood disturbances, are also good candidates.  I agree with Dr. Hirsch on this point, but unlike her, I am not a medical doctor, so please be sure to talk to your health care provider about what is right for you. What I can tell you though is that if your provider makes blanket statements about the harm of hormones, find one who is more up to date!

Oh, and if you are starting to notice bothersome symptoms like brain fog, take your partner to your appointment so they can learn that your symptoms are real. The only thing worse than suffering in silence is having everyone around you think you are either losing it or faking it. Not ok!

The bottom line here is that whether or not you have menopausal symptoms – and the vast majority of us do – menopause ushers in a new phase for women’s health and it’s important to be prepared for those changes. But despite the fact that women have been going through “the change” since the beginning of time, the message is still not getting through. We need to mobilize to make sure women know they are not crazy. They are not alone. There are things that can help. The Body Agency has a Happy Hormone kit with some of the essentials that I like to call our menopause powerhouse– but more is needed.

The Body Agency has you covered! Check out our page for educational resources for the girls and women in your life of all ages and stages. I make it a point to learn something new every day, and here you can too.

Be well!

All my love,