Real Talk (and Expert Insight) on Menopause
Hot and cold flashes, chronic sleep disturbance, loss of libido, thinning hair—not every woman experiences every symptom but some actually get them all.
Valerie wondered if she’d ever want sex—solo or with another person—ever again. Nikki’s cold flashes left her shivering and soaked in the middle of the night. And Liza’s weight gain took her totally by surprise.
Three women, three different experiences—but the shared truth is none of them were fully prepared for the menopausal ride. And they’re not alone. The relationship women have with this transition is as personal as their symptoms are—some get through it without much disruption, while others literally sweat it out, finding it to be one of the most challenging times in their lives. And you likely won't know which camp you'll fall into until you go through it yourself.
So, what is menopause, exactly? Technically, it means you’ve gone 12 months without having your period. But most women don’t follow that textbook definition, says Heather Hirsch, M.D., clinical program director of the Menopause and Midlife Center at Brigham and Women’s Hospital in Boston. Instead, many go through perimenopause—the phase leading up to when your periods stop—that lasts anywhere from one to (wait for it!) 10 years.
“The average length of symptoms is about five to seven years. That’s just the average,” explains Dr. Hirsch, who is also an instructor in the women’s health division at Harvard Medical School. “There’s definitely this myth that [you’ll experience one] year that’s really bad, and then, whew, you’re back to normal. Well, no, your body’s completely different, and it’s always going to be post-menopausal.” For 10% of women, the symptoms of menopause last the rest of their lives, she adds.
The Body on Less Estrogen
During puberty, your body ramped up its production of estrogen, progesterone, and, to a lesser extent, testosterone, priming you for sex and childbirth. Menopause is the opposite—your ovaries stop producing these hormones, so levels drop dramatically.
“We call them sex hormones, and we think about them for sex. But they have numerous functions, from core body temperature to metabolism, to sexual function, to mood, to memory, to cardiovascular health,” says Dr. Hirsch. For example, estrogen helps the brain regulate your body temperature and metabolism, and it has protective benefits for the heart (and possibly the brain). These benefits may explain why some post-menopausal women have an increased risk of developing both heart disease and Alzheimer’s disease.
But researchers still don’t know why women’s symptoms can be all over the map once estrogen levels plummet. “The message here is that we’re starting to get a picture that this hormone really affects every organ. And, there are not just environmental factors at play, but definitely genetic factors at play,” too, Dr. Hirsch says.
One clue to the importance of your genes: Your menopause experience may mirror you mom’s symptoms. One theory is that your genes influence how estrogen receptors work. Estrogen receptors are the molecules that receive signals from the hormone. You have these receptors in every part of your body—the brain, the vagina (naturally), your heart, and joints—binding with all the estrogen floating around during your child-bearing years.
“When we lose that estrogen, there’s a wide range of scenarios, but on one end of the spectrum, your receptors say, ‘You know what? Estrogen is not coming back, so I’m going to close up shop.’ And those receptors, therefore, go away,” Dr. Hirsch explains. If you fall into this camp, you’ll probably have less intense symptoms.
At the other extreme are women whose bodies are making more receptors to find whatever estrogen may still be around. In this case, your body thinks it’s being helpful by ramping up those receptors—but it may actually be making things worse. “When estrogen’s not there, the signaling can get really haywire,” as if your body was frantically clicking a light switch on and off, Dr. Hirsch explains.
Many women fall somewhere in between these two poles. And, there are still many things researchers don’t have answers for, including how the environment—diet and exercise, exposure to chemicals, and stress—may influence your genes. For instance, there’s some evidence that early trauma (including physical abuse and sexual assualt) may make hot flashes worse during menopause, at least according to one study. But that may not be true for every woman. And while having children and breastfeeding may delay the onset of menopause, according to some studies, it's not clear whether childbirth affects the severity of symptoms.
There are also no standard symptoms, says Dr. Hirsch. Sure, everyone’s heard of hot flashes—80% of menopausal women have them—but vertigo? Not so much. Yet vertigo, brain fog, thinning hair, weight gain, and insomnia all can be tied to the loss of estrogen and its effects on the tissues of all your organs.
Valerie, Nikki, and Liza each experienced a wide range of such symptoms as they navigated their change in life, offering you a glimpse of how menopause could affect you.
Sleepless Nights and Libido Change
Among the most annoying symptoms for Valerie, 53, of Southern California, are the sleepless nights, which happen at least once a week. “That’s a real hard one—waking up every 20 minutes to an hour. Then the insomnia keeps me up, and my brain decides that it’s going to spend that time worrying and projecting, over and over,” Valerie says.
That’s surprising for someone who was a kids’ empowerment entertainer—teaching kids about positive energy—until the pandemic shut down her job. But menopause has made her moodier. “I’m more down in the dumps … My focus is bad. My attitude’s bad. I say bad words,” Valerie admits. Even her friends notice she’s more prone to snapping.
Before menopause, her go-to to go to sleep aide was masturbating. “It was great. But now I have no desire. It’s hard to reach climax. That’s probably one of the hardest parts too, because I really enjoyed that part of my life. But the libido thing is gone for a while and I hope it comes back,” she adds.
Sleep disturbances, loss of sex drive, and depressed moods are something many women experience, researchers from Temple University School of Medicine found after sifting through data collected from women going through menopause. Roughly 37% have sleep issues, 42% go through sexual problems (like vaginal dryness or loss of drive), and nearly 17% feel depressed. Five percent have all three at once.
But your drive can go the opposite way, too, as your hormones fluctuate. Nikki, 47, who lives suburban Orlando, FL, has found that her interest in sex peaks right before she gets a period—which is how she knows she’s about to get one, since her cycle has been stop-and-go for a couple of years now.
Hot and, Yep, Cold Flashes, Too
In her early 50s, Liza, 58, of New York City, started having hot flashes that woke her up at night, though she didn’t really realize what they were. That soon changed when she began having them during the day.
“They were full-blown drenchers, where the sweat would pour down my face, for 10 minutes. And they’d occur every half-hour or so,” she says. She carried a fan with her on the subway so she could cool down after a particularly bad flash. She always had tissues to sop up the sweat, and she stopped using facial moisturizer because “just putting it on made me sweat."
So, what’s the deal with hot flashes? Deep inside your brain is the cone-shaped hypothalmus, which, among other things, controls body temperature and hormone production. When estrogen levels drop, the hypothalamus has a harder time keeping your core temperature stable. If the brain senses your body is getting hotter (even if it isn’t, really), the hypothalmus will trigger the blood vessels to dilate to get rid of the extra heat.
Those hellish hot flashes made Liza miserable, so she asked her gynecologist about hormone therapy (HT). HT are pills or patches that pump female hormones back into your body. Not everyone is a good candidate for hormone therapy. Women who have a history of breast cancer or blood clots are considered at higher risk for strokes or breast cancer because estrogen plays a role in both. But for most women, these risks are minimized if you’re put on a low dose and you start before age 60 (or within 10 years after your last period).
Liza’s gynecologist was reluctant to put Liza on it because she had a family history of breast cancer. “She asked me to make some lifestyle changes—cut out alcohol before bed, exercise more—and come back in six months. I went back in six months after nothing had changed. She put me on a low dose of HT right away,” says Liza.
There’s a reason why lifestyle changes may not have been enough to improve Liza’s symptoms. “Certainly, if you sleep better, if you just overall have a healthier diet, if your mental health is in check, if you have a good support system, those things can help,” says Dr. Hirsch. “But I really always tell my patients, ‘There’s a huge chunk of this that is out of your control.’”
That’s why Dr. Hirsch also talks about HT with her patients. “For the majority of women who are finding that their symptoms are affecting their quality of life, or they’re having more bad days than good days, almost always hormone therapy does help, once we find the right regimen or route for the patient,” she explains.
For Liza, HT helped lessen the intensity of the flashes but didn’t end them. (“Which made me sad,” she admits). Even now, she still gets hot flashes five or six times a day. “They’re not full-blown, sweat-pouring-down-my-face episodes, but they’re annoying enough, and worse during the summer,” Liza notes.
Meanwhile, two or three times a month, Nikki gets cold flashes at night. Like hot flashes, cold flashes are another sign that your brain is struggling to properly control your body’s temperature. Sometimes they occur after a hot flash (one that simply didn't wake you up). “A lot of people get cold after a hot flash, because their body is trying to evaporate all the sweat,” Dr. Hirsch explains.
“Nine times out of 10, I can just get changed and go back to sleep, but there have been a couple of occasions where I've had to full on get up and change the bedding,” Nikki says.
Extra Weight Around the Middle
“The weight gain took me by surprise,” says Liza, who carried those extra pounds around her belly and waist. “I’m tall, so I get away with it, but tunics became my friends, and I’ve gone up a size in some clothes.”
Since she’d never gained weight that quickly, she even went to her doctor because she thought she might have diabetes. She didn’t, but there are reasons why menopause can do a number on a woman’s weight.
For one thing, your metabolism becomes more sluggish with the decline of estrogen, says Dr. Hirsch. And those extra pounds now gravitate toward your abdomen instead of your hips. There’s also a link between low estrogen and insulin resistance, one reason why post-menopausal women are at higher risk for developing type 2 diabetes than women in their child-bearing years.
Aching Shoulders and Heart Palpitations
Among Nikki’s weirder symptoms is a nagging, intermittent pain in her upper right shoulder that a steroid shot hasn’t fixed (her provider thinks she’s torn a muscle). But that could also be menopause-related, notes Dr. Hirsch. “What we do know is that typically the loss of estrogen can cause arthralgias, the medical term for achy joints. But there are estrogen receptors in our joints, so the same thing happens—they're looking for estrogen, and estrogen is no longer there, so the physiologic screaming can play out as arthralgias,” she explains.
Valerie hasn’t noticed any pain in her joints, but she does have heart palpitations two or three times a week. Her heart does what she describes as “this whole funky, fancy dance beat” for a few minutes at a time that leave her weak and dizzy. Researchers from the University of Indiana School of Nursing found that they affected roughly one in four women, and the odds increased if you were sleeping badly or were stressed.
Heart palpitations are also common during perimenopause when estrogen is fluctuating, says Dr. Hirsch. Estrogen affects the rhythm of your heart, and when it drops, it can cause your heart to beat irregularly (the condition is known as premature ventricular contractions, or PVC).
Thinning Hair and Hair Loss
For Liza, one of the “worst” symptoms has been the most recent: thinning hair. “About a year ago I saw a picture of myself in a pool, and you could see my scalp through my wet hair! I was mortified,” she says. “I’d gladly deal with the other symptoms if I could just get my hair back!”
The culprit behind thinning hair? You guessed it—declining estrogen (and progesterone, another sex hormone). When you have a normal amount of these two hormones, they keep your hair in its growth stage for longer, which means it grows quickly and stays on your head longer (remember pregnancy?). Once they start to plummet, hair grows in more slowly—so the amount you lose becomes more noticeable. And even though Liza’s tried Rogaine and is on HT, so far, nothing has worked.
By now, you may be thinking there’s not much to look forward to when you go through menopause, except an end to your periods—which is “pretty great,” Liza admits. But here is one message to take away: No matter how strange or embarrassing your symptoms are, speak to your provider.
“I want to encourage women to advocate for themselves and to feel knowledgeable about what’s going on in their body,” Dr. Hirsch says. If they feel their doctor is being dismissive, then she advises women to go to menopause.org and search for a NAMS provider, which is a doctor who’s had extra training in menopause-related topics. “In all honesty, that makes a huge, huge difference,” says Dr. Hirsch in the kind of information and care you ultimately receive.
Last names have been omitted for privacy.
Trauma and Menopause Symptoms: JAMA Internal Medicine. (2019.) “Associations of Intimate Partner Violence, Sexual Assault, and Posttraumatic Stress Disorder With Menopause Symptoms Among Midlife and Older Women.” pubmed.ncbi.nlm.nih.gov/30453319/
Childbirth and Menopause: JAMA Network Open. (2020.) “Association of Parity and Breastfeeding With Risk of Early Natural Menopause.” pubmed.ncbi.nlm.nih.gov/31968114/
Hot Flashes and Menopause: Journal of Midlife Health. (2019.) “Menopausal Hot Flashes: A Concise Review.” ncbi.nlm.nih.gov/pmc/articles/PMC6459071/
Sex, Sleep, and Mood in Menopause: Journal of Women’s Health. (2015.) “Symptoms of depressed mood, disturbed sleep, and sexual problems in midlife women: cross-sectional data from the Study of Women's Health Across the Nation.” pubmed.ncbi.nlm.nih.gov/25621768/
Estrogen’s Role in Insulin Resistance: Pathology Oncology Research. (2012.) “Interplay between insulin resistance and estrogen deficiency as co- activators in carcinogenesis.” pubmed.ncbi.nlm.nih.gov/21984197/
Heart Palpitations During Menopause: Journal of Women’s Health. (2020.) “A Menopause Strategies–Finding Lasting Answers for Symptoms and Health (MsFLASH) Investigation of Self-Reported Menopausal Palpitation Distress.” liebertpub.com/doi/10.1089/jwh.2020.8586