Perimenopause, Menopause, WTFopause

I know this much is true: menopause plays out very differently for different people based on so many factors - health, wealth, race, constitution, lifestyle, and genetics to name a few. But that said, there is also a range of common physical symptoms that most of us will encounter to some degree as we make this change, and it is really useful to know whether you are facing a menopause thing, a nervous breakdown, a stressful life, or 8,000 crazy mystery problems. (And these are very much not mutually exclusive.)

Everyone thinks hot flashes and night sweats are the main sign of perimenopause and menopause, and they are major, but you might develop twelve other symptoms before the hot flashes come along. That creates a lot of anxiety. If you don’t have a grasp of the major symptoms of perimenopause and menopause, you might think you have 70 health problems instead of one normal but annoying hormonal situation.

You should definitely take a quick look at this explainer from Mayo clinic. It goes through perimenopause and menopause terminology, timing, common symptoms, and when to see a doctor.

Okay so if you are too wtfopausal/GenXery to click a link, I will give you the rundown.

Our reproductive hormones - estrogen, progesterone, testosterone - start fluctuating as early as our early 30s. Menopause is medically defined as having begun once you hit twelve months with no period. Perimenopause is the decade or so of fluctuating hormone shitstorm leading up to that time, when the shit is going progressively south. And people, it is a lot to deal with. At menopause, our reproductive hormone levels have hit and largely stabilized at their new (LOW!) normal. For the decade or so leading up to that new low, they are fluctuating, sometimes wildly, with a downward trajectory.

Because symptoms start a good decade before we hit menopause, and often continue on beyond the 12-month official mark, I think it is important to consider the transition as a whole, however helpful defining where we are in the transition might be. I call the whole shebang wtfopause. Because what. The actual fuck.

Clinically, I see patients having first symptoms of wtfopause (irritability, sensitivity to wine) by about age 37. By age 40, most of us have increasing sensitivity to caffeine and alcohol, and decreasing quality and quantity of sleep. Irritability, anxiety, and depression increase, both hormonally and because of what our lives are like right now. You might have noticed at this time of life, which for many of us is overwhelming with young kids, demanding careers, aging parents, pandemics, political clown cars, etc. that wine starts feeling particularly euphoric. Like, much more euphoric than it used to. But then sleep is worsening because the same quality that makes wine so nice for our increasing irritability, is now messing with our sleep in a whole new way. Which requires us to drink more caffeine to get through our overwhelming days, which makes wine all the more appealing, which makes sleep worse, which makes us tired in the morning - forever. And this tiredness can be compounded by hormone-induced “crashing fatigue”, an overwhelming, sudden fatigue with muscle weakness, usually in the afternoon, which necessitates the ingestion of medicinal quantities of sugar. We feel that we need it SO BAD, but we tolerate it less, get hyper and agitated more easily, and of course gain weight around the middle very readily. OMG SO FUN. If you are feeling out of control with it, you are not alone. Try to not shame yourself for struggling through this part. There is a reason there are fifty of these.

These changes often occur before we start having noticeable changes in our menstrual cycles, like shorter periods, longer periods, heavier periods, lighter periods, worse PMS, spotting, headaches at ovulation - things going wonky and unpredictable.

Also, if you are on the pill or IUD, you can’t really go by your menstrual cycles. As a result, a lot of us (and our doctors for some reason?) don’t realize these change are likely hormonal and start taking meds for sleep, depression, and anxiety. And that’s okay, man, that’s why they are there. But the problem with this approach is you end up on a pile of meds and keep adding more without realizing what is actually at the heart of the matter. I see a lot of patients developing acid reflux and constipation or other bowel problems at this time. While all this stress, and not pumping the brakes on coffee, alcohol, and sugar are a factor, there is a hormonal component here as well. All the dryness and tissue changes that come with less circulating estrogen can dry out the bowel and make digestion more delicate.  It just keeps coming.

Libido, arousal, sexual function, and vaginal tone decrease. Declining testosterone messes with our drive as declining estrogen causes dryness and irritation - but we often don’t realize this as a hormonal symptom because the circumstances of our lives - irritability, depression, weight gain, fatigue, night sweats, overwork, and overwhelm can be their own impediments to a satisfying sex life. The tissue changes like vaginal thinning and atrophy that result from menopause are also at play. These changes can cause sex to be not just less pleasurable but very painful. Vaginal dryness and atrophy make us more prone to urinary incontinence and infections, which many women attribute to damage from childbirth, but also has a hormonal component.

Speaking of tissue changes, loss of collagen and estrogen leads to dry skin, fine lines, crepey skin and general droopiness.

Heart disease, high cholesterol, heart palpitations and reduced cadiovascular stamina scare the bejeezus out of people, and suck too. Yes, it’s part of wtfopause.

Aphasia, brain fog, and memory loss are caused by declining estrogen levels causing dysregulation in the hypothalamus, which has a say in not only temperature control (hot flashes! night sweats! cold flashes!), but ability to feel alert, process information, and fall asleep. Declining estrogen levels in the blood also lead to decreased use of glucose by the brain, and decreases in grey matter in the brain. Good news: verbal memory, learning, and processing speed can return to normal levels post-menopausally!

Joint pain, bone loss, loss of collagen occur as prolonged decrease in estrogen really sinks in at the tissue level. Feeling achy and creaky is commonly ascribed to lack of exercise or sitting all day at work - and that is part of it - but it is really happening physiologically.

Speaking of bone loss, dry mouth, bitter or metallic taste in your mouth, crooked teeth, tooth pain, bite problems, burning mouth, oral thrush, and gum disease from dry bleeding gums to red gums to bone loss, all result from estrogen decline causing bone loss and decreased circulation to gums.  It is called “menopause mouth” which is frankly rude. I have never had a dentist or OB/GYN talk to me about this - have you?

In each of these cases, it is so understandable why you wouldn’t know that the downward spiral of hormones is a core factor in your symptoms, because there is a non-hormonal life-situation that is also factoring in. Also a lot of what we experience is just plain weird and so wide ranging it is difficult to create a comprehensive list.

And last but not least, hot flashes and night sweats and…COLD FLASHES?!? Yes, also a thing.  For many of us, swinging temperature changes finally turn on the lights that hormonal changes are happening, and wtfopause is underway.

Having this information, you can make some choices. This is not a one-size fits all situation. The full western suite of meds is available to you: hormone replacement therapy (HRT), anti-depressants, insomnia meds, whatever you want. Also acupuncture, Chinese herbs, massage, chiropractic. And we all need to come up with a livable, mature approach to nutrition, exercise, and meditation. (If the word meditation bothers you, just think “a regular practice to steady the mind”) I’d love to hear what has been meaningful to you so far.

Being informed, in itself, makes things a little better. This isn’t mystery illness, it is a natural, healthy transition that sucks to go through, like puberty in reverse. You aren’t sick and failing and falling apart. You aren’t alone in it, at all. And it won’t last forever. Nothing does.

Interview With a Master Acupuncturist

Professor and Senior Practitioner of Chinese Medicine Frank Scott discusses how to become masterful in recognizing what your body needs, and how to bring balance, vigor, and calm to your life in times of transition.

Hot, flashy science

This research from the NIH is hard science and without some kind of medical degree might be tough to wade through, but it has some really interesting points to make about wtf is going haywire, exactly, in our bodies during our evening hot flashes. I am going to try to translate it into plain English without removing the science. If you are interested in getting a little nerdy about why we are getting so hot, stay with me. I think it such a power move to understand the physiology of this, and of course understanding what causes an issue leads to possible solutions.

Most (oversimplified) articles will tell you that hot flashes and night sweats are caused by reduced estrogen levels, but there are plenty of people around - children, men - who have low estrogen levels and are blithely going about their sleeping business without sweaty sternums. This article poses a compelling theory: that it is estrogen WITHDRAWAL, partnered with elevated norepinephrine in the brain, that is causing us to go slightly outside our “thermoneutral zone”.

Let’s unpack that. The body has a pretty small window of temperatures it is able to fully function at - you know 98.6 as the ideal norm - and even a few degrees too warm takes us into a sweating response, while a few degrees too cool triggers a shivering response - the upper and lower ends of our thermoneutral zone. The thermoneutral zone is where the body is happy and can safely and fully function, without sweating or shivering.

Norepinephrine is a hormone secreted by the adrenal glands in times of stress. Like adrenaline, it switches the body from its normal happy “rest and digest” (parasympathetic) state into its emergency - “fight or flight” (sympathetic) response. It sends blood and energy away from our internal organs and to our muscles so we can run or fight or defend ourselves. This is super helpful during a bear attack. It is less helpful in the middle of the night. Here are a few of the symptoms of increased norepinephrine in the brain oh gosh let’s see if any feel familiar: anxiety, rapid heart beat, agitation, and sweating. Over time, sleeplessness and loss of libido.

Norepinephrine is thought to narrow what our body considers to be a safe and reasonable thermoneutral zone, causing us to trigger into sweating more readily. We have all experienced this - someone snaps at you, you get nervous and start sweating. It looks like this.

HILARIOUSLY, estrogen serves to mellow the action of norepinephrine in the brain. If we have any. When estrogen drops in the middle of the night, and norepinephrine rises, we overheat, get anxious, wake up, and sweat.

Why is norepinephrine elevated all of a sudden in the middle of the night? It isn’t! We are living in stress response too much of the time in our day. This causes increased norepinephrine all the time. Which is decreasing our thermoneutral range, triggering us to overheat more easily day and night, and now with ever less estrogen to balance us out.

Is this not so interesting?! I am an endocrine nerd, so I like knowing this. But aside from sheer glandular fun, this info suggests a strategy: lower your norepinephrine load! How do we do that? Spend more time in rest and digest (parasympathetic) mode and less time in fight or flight (sympathetic) stress mode.

And how do we do that?

It is all the annoying shit you already know, just now with science! We can do a few things to lower the number of times we get stressed during the day:

1. Put your phone on silent and turn off as many notifications as you can. Those beeps and pings and little red circles give us virtual pellets of excitement, which stimulate fight or flight response, switching us to sympathetic mode. Turn them off.

2. Don’t watch a lot of zombie shows and murder things. Like duh but also seriously. You have no idea how much murder podcast related insomnia I treat.

3. Don’t play video games. (except tetris!) They are adrenaline machines. I’m so sorry. I know some people like to unwind playing games but it might be counterproductive. I am always bad news Jane on this stuff. Get a load of number 4.

4. Don’t drink coffee. Or just the less the better. It is made to rattle your teeth in your skull. Our tolerance for that sort of shit really plummets around age 45. And have you noticed your teeth rattle in your skull now more anyway? #boneloss Also, sugar. And cocaine. Again, very sorry and also you know this.

But we can absolutely not avoid getting triggered into sympathetic nervous system mode a jillion times a day because 2023 am I right?? So, let’s look at how to get back to parasympathetic nervous system once you’ve gotten startled.

1. Laugh in the face of peril. We need to let our bodies know that the danger has passed. It isn’t enough to think to ourselves, “okay that meeting is over, and it hasn’t killed me”. We actually need to make physical sounds of relief like laughing and great big sighs to signal to our adrenals that the emergency has ended, and it hasn’t killed us.

2. Shake it like a polaroid picture. Once your body has, in a panic, sent all your blood and energy to your muscles to escape the bear attack, the best way to burn through that literal nervous energy is by moving it. Brisk walking, running, tree climbing, shimmying, and dance parties all work. Ideally, you would sprint three blocks, climb a tree, and loudly proclaim “hahaha I have outrun the bear!” So, something like that. Shake it off. Shake it up. You will know it worked when suddenly you have a sense of relief and pleasure coursing through your veins instead of panic and overwhelm. Yoga helps enormously.

3. Meditate. Okay I know I know. But here is the trick: don’t try to meditate when you are freaking out. Meditate every day for 15-60 minutes as part of a regular practice. It is too late once you’re freaking out. You can’t think your way out of a norepinephrine-induced panic attack. But you can lower your threshold for tipping INTO a norepinephrine-induced panic attack by meditating regularly at a quiet point in your day. The old joke goes if you don’t have 20 quiet minutes to meditate in your day, meditate for 40 minutes. If your life really genuinely doesn’t have 20 quiet minutes in it, and you can’t see any place to carve 20 minutes from, it isn’t hard to imagine why you are feeling so jangled.

4. Carve out some quiet times throughout the day. If your eyes pop open in the morning and you grab your phone and immediately go into 17 hours of panicked overstimulation, don’t think there is anything in this world that will allow you a peaceful and restorative night’s sleep. You will never find the time. You must insist upon the time. Carve it with a knife. This leads naturally into a whole rant about late stage capitalism and the oppressive, racist, colonialist, misogynistic, misogynoir norms that keep us running when we should be resting and I am frankly out of steam from writing this post. Just literally too tired of typing to rant. But I have one ready to go at some later date, believe that. Let’s just say I am going to go rest and you should too. I spend an amount of time lying on the couch under a pile of cats every day that has to be seen to be believed.

5. Get freaky. Any physical thing in you life - sex with yourself or others, swimming, a walk, yoga, qi gong - that is some intense burst of physicality followed by some feelings of relief and relaxation will help the cause.

6. Breathe. Deep belly breaths, making your exhales last a little longer than your inhales, making noises and sighing as you exhale all release tension from the body. Equal breathing is an ancient yogic practice that will absolutely restore you to parasympathetic rest.

What does a hot flash feel like for you? How long does it last? How does it come on and how does it end? Are you cold after? Is there emotional or body sensation? Describe it! Tell me everything!

I was on a podcast!

People, I said it as well as I can say it on this interview with the fantastic Alka Bromiley of Changing Platforms on Spotify. She asked THE QUESTIONS and we had such a good talk. Just 30 minutes of what is up. Enjoy, and tell me what you think! Ask your own questions below:

HADOY

Ha-absolute doy. Stop the presses. And also here is some helpful information about what perimenopause can do to your cycle.

Advice?

I didn’t create this to give advice, but to share information. For me, acupuncture, herbs, nutrition, yoga, and moderating sugar and alcohol and coffee have been really useful so far. What has worked for you? Get specific! If you have found a great pair of no-sweat jammies, or lube you are passionate about, please spill the tea. Practices, products, mindsets…what have you got?

WTFopause STORIES

Everyone has their own unique experience of menopause, AND menopause as a process has a lot of innate qualities. My favorite thing about hearing menopause stories is finding the flickers of commonality - what we share in the experience, amid the private individual details of how we go through the experience. Same storm, different boats. Over at Stories, I am amassing a series of interviews from a diverse group of people on what their experience has been so far - perimenopause, hysterectomy-induced menopause, testosterone as HRT, chemo-induced menopause, how things are ten years after menopause - and many more to come. Each person tells their own individual story and in doing so describes our shared human experience. I am so honored by what depth and heart they have entrusted to this project. If you ever want to feel less alone, head over there and hang out with some brave, amazing souls.

Worry club* is called to order

What are we worrying about when we wake up in the middle of the night? A lot of us are up at 3am being irrationally freaked. What’s on your mind? Bonus points for actually posting at 3am.

*this may be your only chance to be in a club with Erika, the superhot genius who made it up, so I advise you take it

What even is a hormone? And what is their DAMAGE

When you hear the word “hormone”, you probably think of estrogen, testosterone, and maybe progesterone, but there are so many others. Insulin is a hormone, and so are adrenaline, norepinephrine, and cortisol. You probably have heard about or tested your thyroid levels, but maybe don’t know those tests are measuring thyroid hormones like TSH, T3 and T4. There are a veritable buttload of other hormones and they are all enormously fascinating if you are a gigantic nerd.

Hormones are secreted by glands and coordinate vital life functions throughout your body, mostly via the bloodstream. There are also hormone-counting glands throughout your body that detect tiny changes in circulating hormone levels, and produce hormones in response that tell other glands to produce more or less of those hormones. Think of a guy at the door of a bakery counting people coming into the bakery. When a lot of people are coming in he yells to the kitchen “Luigi! More donuts!’ and when customers taper off, he says “Luigi! Smoke break!” That is EXACTLY how your hormone (endocrine) system works. You are basically an endocrinologist now.

And not to play favorites or anything, but to really understand what is happening in wtfopause, there are a handful of hormones that are really crucial to understand, and a much bigger handful that we can skip (better luck next time, glucagon-like peptide 1).

Estrogen, whew. You don’t know what you’ve got ‘til its gone. Estrogen is present and plays a role in reproductive function in people across genders and sexes. It is mainly produced by the ovaries, but also by the adrenal glands and fat cells.

There are three types of estrogen - estrone, estradiol, and estriol. Estrone is the dominant form after menopause. Everyone of reproductive age produces estradiol. Too much estradiol can cause acne, loss of sex drive, osteoporosis, weight gain, irregular periods, PMS, PMDD, and depression. Very high levels can increase the risk of uterine and breast cancer. Low levels can result in weight gain and cardiovascular disease. That’s where the guy yelling at Luigi comes in - really keeping those levels in the exact right range, in a dynamic way and in the face of all the rapid metabolic pressures on a body on any given day (how many people are going in and out of the bakery). Estriol is the dominant type in pregnancy, peaking just before birth and helping the uterus prepare for birth.

The reality is, we don’t know everything estrogen does in the body, and much of its purported actions are extrapolated from how we feel as we run out of it. Generally, estrogen is a nest builder. It stimulates egg growth and ovulation in the ovaries, thickness and lubrication of the vaginal wall, enhances, maintains and regulates uterine mucus secretions, and builds breast tissue. During puberty, increasing estrogen levels increase waist to hip ratio and other body composition changes. Estrogen affects sex drive and ability to maintain an erection. It also has body wide actions involved in regulating cholesterol levels, blood sugar levels, bone and muscle mass maintenance, circulation and blood flow, collagen production, skin moisture, brain function, and ability to focus. You can see why we experience what we experience - as we stop producing so much estrogen, we have declines in all these tissues and actions estrogen is responsible for maintaining. Does that make you want to take estrogen? I get it.

Testosterone is present and plays a role in reproductive function in people across genders and sexes. Believed to be responsible for fetal testicular development and descent, sperm production, and enlargement of the penis and testes. Testosterone is also involved in hair patterns on the head and body, vocal changes, voice deepening, growth spurts in puberty, and skeletal muscle growth. Testosterone stimulates red blood cell production. Testosterone levels tend to drop with increasing age, causing a decrease in testicular size, a drop in libido, lower bone density, muscle mass decline, increased fat production, decreased red blood cell production, and anemia.

Progesterone is secreted after ovulation to try to get you pregnant and keep you pregnant. It thickens the uterine lining (making it stickier for a fertilized egg), prohibits uterine contractions that might reject a fertilized egg. Low levels of progesterone can be responsible for irregular menstruation and frequent miscarriage. Often, progesterone and estrogen are used together in hormone replacement therapy.

Adrenaline and norepinephrine are secreted by the adrenals in times of stress to help us respond with quickness and stamina to threats. Cortisol is secreted by the adrenal cortex to keep adrenaline circulating. Prolonged excessive cortisol levels caused by excessive stress and inadequate exercise lead to belly fat buildup and heart disease. Estrogen is also secreted, in part, in the adrenal glands. Insulin is secreted by the pancreas in response to consumption of sugars and carbs and even things that taste sweet like fake sweeteners (and that creates problems!) and regulates blood sugar levels and fat storage. Insulin resistance has been linked to estrogen levels but the connection isn’t well understood. Thyroid hormone is secreted by the thyroid gland and coordinates tons of actions throughout the body including but not only our pep and stamina, temperature, immune system, and metabolism.

Bed is on fire: thermometer leg?

I was talking to Meg a few years ago (everyone needs a Meg, that super-wise, superhot friend who is ten years older and can give you the all important heads-ups on what is to come) about getting warm at night and whether it was the beginnings of menopause or life in bed with a husband and three cats under a down quilt and she said “oh yeah? Do you get thermometer leg?”

The…what is it now? Thermometer leg? “Yeah,” she continued, “it’s when you start overheating at night and you kick one leg out of the covers to bring your temperature down. It’s totally hormonal and it gets worse.”

This is wtf I am talking about, people. Thermometer leg is such a known thing that it has a name and apparently we are all doing it. And isn’t it kind of nice to know we are all doing it? Like the biggest, shittiest slumber party of overheatedness. But also very cute to think of all of us snuggled in, except for our thermometer legs.

From a mild sensation of too warmness leading to the amazing thermometer leg strategy, many of us will progress to hot flashes, and then night sweats, wherein our bodies cope with feeling way too hot using the time honored strategy of sweating. So yes, thermometer leg is the beginning of the end.

Wondering - do you overheat? And when you do have you coped with flinging a thermometer leg out of the bed clothes? And along those lines, have you tried allegedly cooling bamboo sheets? Linen PJs? One genius patient of mine going through this started wearing her sweat-wicking running clothes to bed! What has worked for you and what should we all be trying?

Turn and face the strange

Our visions for tomorrow are most vital when they emerge from the concrete circumstances of change we are experiencing right now.

- bell hooks

We went into puberty as children. During puberty, we were rebellious, our skin and hair got weird, our bodies grew in disproportionate fits and starts, we loved Jake Ryan so much, and we hated everything else. Coming out of puberty, we were something new we had never been, and we engaged with the world in a new way. Wtfopause is like that - we are going through changes, and we will be something else on the other side. But what?

Some people treasure the Crone archetype, a wise one who “embodies instinctive ways of channeling wisdom, inner knowing, and intuition, guiding us through the transition of life, and going inward to bring forth the light for transformation.” But crone isn’t the only choice, and there is more than one way to be a crone.

Many feminine archetypes - mother, maiden, queen, huntress, sage, mystic, and lover are available to us for inspiration. So are the masculine archetypes - king, warrior, magician, lover. Our culture and our kids are asking us to move past the gender binary, so why don’t we? What better time than wtfopause to say we are no longer defined by our reproductive capacities and their hormones?

There are symptoms that come along with wtfopause, but there is also a shedding. I am interested in this transformation because as a health care provider, healing always involves transformation.

So far, I am really, really enjoying not getting my period anymore. It hurt so much, it was so bloody, my whole body swelled, I ruined pants, dresses, sheets, futons. I snapped at people, I was too hot. I may always be irritable but I understand how to work with myself better now.

I like that my fibroids are shrinking. Like me, they are being deprived of estrogen. Good.

I like having sex without worrying about pregnancy. I like scheduling a vacation without worrying about whether my period will ruin it. I like buying expensive white sheets.

I feel a sense of impending freedom. All that reproductive baggage - gone. Just me and my empty uterus. I am pregnant with a version of myself, and this process is gestating her and laboring to bring her forth. At times, I am feeling more adult, more centered, more powerful, kinder, and more relaxed than I ever have. Age can bring some profound rewards and wisdom, if we choose to go in that direction.  Like everything, we have a choice in how this goes. Many, many choices.

And I am curious and excited to see who I will become on the other side of this.

Who are some of your wtfopausal heroes? What are some qualities you’d love to bring in? And should we add Riot Grrl to the list of archetypes? Let’s just assume we get to decide, through our words and actions, who we are becoming - who do you have in mind?