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.