Excerpt. © Reprinted by permission. All rights reserved.
CHAPTER 1
What to Expect When You’re No Longer Expecting
Menopause is a condition shared by half the population –
so why isn’t anyone sharing any information about it?
"In my adult life, I don’t recall one serious conversation
with another woman about what to expect."
—Oprah Winfrey[i]
"I’m hot, because I have a very rare medical condition called menopause. It’s only about one in one woman who experience it, so it’s a little bit under the radar at the moment. Nobody really knows anything about it, because it’s not something that happens to men, so there’s no data or research."
—English comedian Bridget Christie[ii]
In the summer of my 45th year, I suddenly found myself lurching awake at 3 a.m. with the sort of instant alertness that meant hours of sleeplessness lay ahead. Staring into the darkness during what author Samantha Irby has called "menopause o’clock,"[iii] I would attempt all the soothing, borderline-monotonous mind tricks I’d recommended as a longtime health writer: progressive stretching exercises, reciting state capitals, planning weekly meals. None of these worked. In the daytime, I stumbled around, fuzzy and fatigued, trying to keep pace with my toddler.
One supposedly effective trick to bring on slumber is to take a mental tour of your childhood home. And so, on one sleepless night, I visited my former house in Pittsburgh, last seen in 1975. Here was the avocado-colored fridge in the kitchen, there was the brown plaid couch that sagged in the middle. By the couch sat a fake-wood side table, which contained an embedded metal ashtray. When my parents finished huffing a Kool, they could push a button on top of the ashtray, which spun the ashes and butts into a mottled collection bin below, where the smoky mulch remained for months.
Why didn’t my parents empty the reeking table ashtray? I wondered one night. Maybe they were comforted by the smell of old cigarette butts? The ashtrays in our Buick LeSabre were always filled to overflowing, too. When did cars start phasing out ashtrays and cigarette lighters?
My meandering thoughts were narcotizing enough, yet I still couldn’t drop off. What the hell was wrong with me? I had never had sleep problems in my life. I turned over, careful not wake my husband, or jostle my boobs, which had been sore lately.
I froze. My boobs, which had been sore lately.
Hold up. When was my last period? I calculated backwards. Two months. I had gone off the pill, but we practiced the horribly named "rhythm method," in which we avoided sex during my supposedly fertile times.
My blood chilled further as I realized I was bloated, too. "Tom," I whispered. It was nearly dawn, anyway, and our two-year-old daughter would be awake soon. He opened his eyes blearily; as I told him my suspicions, he abruptly sat up. We had always wanted one child, and we were happy with our choice. We had never even considered another. Nor was I young: I’d had Sylvie the week before my 43rd birthday, after a so-called "geriatric pregnancy." I did not envision myself as a 45 (soon to be 46) year old parent to another newborn. I had already developed lower back problems from lifting our kid.
Tom and I sat quietly on the bed, our heads whirling with the emotional, financial, and logistical complications of having another child.
Finally, he reached over and squeezed my hand. "If this turns out to be a pregnancy, well, then…" He broke off, then gathered himself. "Well, then, we’ll make it work."
I covered his hand with mine. "I was thinking the same thing," I said in a high, choked voice.
***
I wasn’t pregnant.
I had skipped my periods because I was perimenopausal.
I know this now, but I didn’t then. In my mid-40s, the idea of perimenopause — the term for the transition into menopause, "peri" meaning "around"—simply hadn’t occurred to me. I was taking my toddler to Elmo-themed birthday parties. Acne congregated on my chin. I still bought my pajamas from teen websites because they were cheaper (I just avoided the crop tops). I had a vague idea that menopause awaited, hazily, in the future—but that was still far off, when I’d start wearing visor hats and orthopedic food-service clogs. Wasn’t menopause for older ladies? It had always been an easy subject to stash away.
Soon after, my periods grew more erratic: a drought one month, the Rio Grande the next. Perimenopause lasts, on average, for four years but can stretch to eight, and symptoms can sneak up on you —and before you’re fully aware, they become your new normal.[iv] [v] My nails took on a flaky, baklava-like texture. My mouth became so dry that I began hacking like my hairball-prone cat.
One night, I woke up drenched from head to toe. Immediately, I assumed I had peed the bed—as a former bedwetter, you never quite outgrow that feeling of Oh Lord, I did it again. My last incident had been in high school, when I’d received a coveted invitation to a sleepover at Kim Kelly’s house. Every moment of that night is etched in my brain. First, we watched a Love Boat episode starring Sherman Hemsley and Jaclyn Smith while guzzling can after can of grape Shasta.[vi] When it was time for bed, Kim’s older brother Raymond commandeered their one bathroom for what seemed like hours. (What could he be doing in there? I remember thinking, naively.) Eventually, as I nervously waited in one of Kim’s twin beds for Raymond to leave, I fell asleep.
Later that night, I was horrified to discover that I had duly peed Kim’s bed. This would be all over the school Monday morning unless I acted quickly. While Kim slept, I stealthily removed the fitted sheet, fanned it up and down for an hour until it was dry, then, slowly and quietly, turned the mattress over and replaced the sheet.
Kim never knew.
I had the same feeling of dread as I lay, stuck to my sheets. Why did I guzzle so much lemonade last night? Did the pee reach my sleeping husband?
Tom heard me stirring, turned over, and stared, confused, at my wet hair, which was plastered to my head.
"Did you just work out?" he said, squinting at me. No, I told him. Nor, I eventually figured out, had I peed myself. It was night sweats.
Peeing myself was still ahead.
***
At my annual physical a few months later, I mentioned the night sweats to my doctor, who ran a battery of fruitless tests and concluded that it was probably “stress.” This conveniently vague quasi diagnosis was not exactly wrong—who doesn’t have stress?—but is used, research shows, more often on female patients As the months rolled on and my symptoms piled up, I saw a dentist for my bleeding gums, a dermatologist for my crawlingly itchy skin, a cardiologist for my irregular heartbeat. After spending countless hours in doctors’ waiting rooms, I had caught up on all the latest issues of Reader’s Digest but was no closer to any sort of prognosis. Not one connected my symptoms to menopause.
My experience was not exactly novel: perimenopausal women can spend several years trying to get the right diagnosis and treatment. Medicine, of course, has a long history of telling women that their symptoms are all in their heads; it’s even more common, studies have found, for women of color and those of larger size.[vii] [viii]
When I finally figured out what was happening to my body and brain, I was floored. How could I have been so clueless? I’m a health writer, for God’s sake. For more than two decades, I’ve been reporting on mental and physical health for publications such as The New York Times, Vogue, and O, The Oprah Magazine. I had a longtime sex column in GQ. I’ve written countless articles about women’s health, and I have interviewed hundreds of physicians and scientists over the years. As a patient, I diligently schedule all my annual "well visits" in January. I am what doctors would call a "well-informed active self-manager of my medical care." How is it that I never had a single conversation, with anybody, about a life transition that lasts for years, sometimes a decade-plus?
And if I was unprepared, what about all women who don’t write about health for a living? I tell Makeba Williams, M.D., Certified Menopause Practitioner and Associate Professor of Obstetrics and Gynecology at Washington University, how mortified I am that I didn’t pick up on this.
"Oh, you can’t believe the bewilderment that I encounter on a daily basis," she says. "Menopause is so little talked about as a transition in our lives that it really catches people off guard. So they come in blindsided, having no understanding that many of these changes that they’re experiencing are related to a normal, natural physiologic event. Or they’re been grossly misinformed, and I sort of have to bring them back and reset." She sighs. "We haven’t done the anticipatory guidance to prepare women. We have to create expectations around menopause and normalize it, just like we do for puberty."
"Hey, I’m in D.C. where you’re got the smartest, wealthiest people on the planet," chimes in urologist and Sexual Medicine specialist Rachel S. Rubin, MD, Assistant Clinical Professor in Urology at Georgetown University Hospital, "and they are fucking clueless."
Certainly, my mother, who gritted through The Change in silence, never said a word to me about it. We have coming-of-age ceremonies for girls who are becoming women, such as the Jewish bat mitzvah, and celebratory rituals such as wedding and baby showers where vital information is exchanged to help prepare the person to enter the next realm of life. There’s no Menopause Shower, where a woman can receive gifts like retinol-infused neck cream and vaginal lube. While girls often receive The Talk before their first period, no one gives you a Menopause Talk before your final one.
That includes many doctors. A 2013 survey found that less than one in five ob/gyn residents received any formal menopause training at all.[ix] Not until 1993 were “women and minorities” federally mandated to be included in clinical trials.[x]
And don’t think that physicians who specialize in women’s health get any more insight into this phenomenon. A 2019 survey of internal medicine and ob/gyn residents found that only 6.8 percent of felt "adequately prepared" to manage women experiencing menopause. Menopause used to be the domain of gynecologists, but as the 2013 survey coauthor Wen Shen, MD, assistant professor in the Johns Hopkins Medicine department of Gynecology and Obstetrics in Baltimore, tells me, the field has splintered into more procedural-based areas like infertility, which can be more lucrative.
"It comes down to the business of medicine," she says. "When you treat patients in menopause, you’re not doing any procedures, so you’re not getting any reimbursement." (To put this in perspective, according to the nonprofit FAIR Health, the national average cost for an obstetrician to deliver a baby vaginally in 2018 was $12,290.[xi]) "It’s also a very time-consuming consultation with a provider – that’s a big part of it, too," adds Shen. "and at the very top, medicine is still a very paternalistic establishment."
My friend Mira, who realized she had gone a year without her period, booked an appointment with her ob/gyn to craft a menopause action plan. After a few desultory questions, her ob/gyn handed her a pamphlet on menopause, suggested she take up yoga, and hustled her out the door. “She wasn’t being dismissive,” says Mira. "I just think she didn’t know what to tell me."
Even if women know what symptoms to look for and actually seek treatment, a Yale School of Medicine study found that they aren’t likely to get it. Researchers looked at insurance claims from 500,000 women and found that three quarters of the women who sought medical attention for their menopause symptoms got no treatment at all.[xii] A 2021 AARP survey of women age 35 and up found that only 18 percent said they felt "very informed" about what to expect in menopause and perimenopause.[xiii]
In other words, 82 percent of us are walking around largely oblivious about the most significant change in our physical lives since puberty.
Chapter 1 Footnotes
[i] In my adult life…: Oprah Winfrey, “How Heart Palpitations Led Oprah to Discover She Was Approaching Menopause,” Oprah.com, September 24, 2019, https://www.oprah.com/health_wellness/oprah-reveals-how-she-realized-she-was-approaching-menopause.
[ii] I have a very rare condition called menopause: Bridget Christie (Guilty Feminist), “Fighting for Hope with Bridget Christie,” YouTube channel, October 11, 2021. https://www.youtube.com/watch?v=llrD5GZXNvo
[iii] menopause o’clock: Samantha Irby (@bitchesgottaeat), “…deliriously awake at menopause o’clock,” January 20, 2021, https://www.instagram.com/p/CKQd0Kgg2Zf/?hl=en.
[iv] perimenopause lasts, on average, for four years: “Perimenopause,” Cleveland Clinic, last modified October 15, 2021, https://my.clevelandclinic.org/health/diseases/21608-perimenopause#:~:text=The%20average%20length%20of%20perimenopause,are%20no%20longer%20in%20perimenopause.
[v] perimenopause can stretch to eight [years]: Menopause 101: “A Primer for the Perimenopausal,” The North American Menopause Society, accessed July 8, 2022, https://www.menopause.org/for-women/menopauseflashes/menopause-symptoms-and-treatments/menopause-101-a-primer-for-the-perimenopausal.
[vi] First, we watched a Love Boat episode starring Sherman Helmsley and Jaclyn Smith: Mandi Bierly, “The Love Boat on DVD: Heaven of Hell?” Entertainment Weekly, last modified October 27, 2008, https://ew.com/article/2008/10/27/the-love-boat-j/.
[vii] it’s even more common, studies have shown, for women of color: “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” National Library of Medicine, accessed July 8, 2022, https://pubmed.ncbi.nlm.nih.gov/25032386/.
[viii] and those of larger size…: Jennifer A. Lee and Cat J Pausé, “Stigma in Practice: Barriers to Health for Fat Women,” Frontiers in Pyscology 7, no. 2063, (2016), doi: 10.3389/fpsyg.2016.02063.
[ix] A 2013 survey found that just 20 percent of ob/gyn residents received any sort of formal menopause training at all: Mindy S. Christianson et al., “Menopause Education: Needs Assessment of American Obstetrics and Gynecology Resident,” November 2013, https://pubmed.ncbi.nlm.nih.gov/23632655/#affiliation-1.
[x] Not until 1993 were “women and minorities” federally mandated in clinical trials:
Institute of Medicine, “NIH Revitalization Act of 1993 Public Law 103-43” in Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies, eds. AC Mastroianni, R, Faden, and D. Federman (National Academies Press, 1994), https://www.ncbi.nlm.nih.gov/books/NBK236531/.
[xi] To put this in perspective, according to the nonprofit FAIR Health, the national average cost for an obstetrician to deliver a baby: “Royal Birth Spotlights US Childbirth Costs, Fair Health, June 28, 2018, https://www.fairhealth.org/article/royal-birth-spotlights-us-childbirth-costs.
[xii] Researchers looked at insurance claims from 500,000 women and found that three quarters of the women who sought medical attention for their menopause symptoms: Karen N. Peart,“The High Cost of Hot Flashes in Menopause,” Yale School of Medicine, August 27, 2014, https://medicine.yale.edu/news-article/the-high-cost-of-hot-flashes-in-menopause/.
[xiii] A 2021 AARP survey of women age 35 and up found that only 18 percent said they felt “very informed”: Cheryl Lampkin and Colette Thayer, “Perimenopause Is More than Hot Flashes: What Women Need to Know,” AARP, May 2021, https://www.aarp.org/research/topics/health/info-2021/perimenopause-hormonal-changes-impact.html.
