This week, Naomi Campbell made headlines for having a hot flash and declaring herself pre-menopausal during a taping of her new show, “The Super Models.” She was hailed for her candor.
But even mere middle-aged mortals privately grapple with heavy periods, insomnia, hot flashes, night sweats, a low libido, hair loss, bladder and bowel woes — the list goes on. And while many women assume that these symptoms start in menopause, they can actually take hold years before, when we’re in our prime parenting years. There’s nothing quite like sleeping for three fitful hours on sweaty sheets and then rolling out of bed for an 8 a.m. soccer game. So let’s talk about it.
Menopause marks the end of ovarian function and menstruation. Perimenopause is the rocky, twisting road leading up to that milestone, as estrogen in particular starts to dwindle. Dr. Heather Hirsch hopes to normalize this phase. Hirsch directed the Menopause and Midlife Clinic in the Division of Women’s Health at Brigham and Women’s Hospital until 2022. Her new book, “Unlock Your Menopause Type,” came out in June 2023.
Now, she runs a private practice, has a (very relatable!) Instagram presence, and hosts a podcast on midlife women’s health, where she demystifies these gray areas and amorphous symptoms. She’s especially well-versed in hormone-replacement therapy. We chatted about all of it on the brink of Menopause Awareness Month — yes, it has its own month! — coming up in October.
These symptoms aren’t new. Our moms went through them. Our grandmothers dealt with them. But this is the first generation that’s finally normalizing it and talking about it. It feels good to be seen and to feel understood. I think there’s a lot to be said just for talking about this stuff more, so thanks for being part of that.
I’m so happy to. I think that it’s really mind-blowing that we have this big hormonal shift, and we call these hormones our ‘sex hormones’ — but they really have impacts on our entire body, multiple organ systems, and this has just never been factored into our health in any meaningful way. It’s really quite exciting to watch, in real time, as women are starting to become curious and ask more questions, and doctors are starting to even question what they were taught and seek out more information.
Let’s talk about perimenopause specifically. What happens?
This is a great question. The average age of perimenopause per the CDC is 47, but I don’t think that’s right. Really, that would have to mean that all clinicians are recognizing perimenopause and charting it, and I don’t think that’s happening at all. I actually don’t even know that the age of menopause is necessarily correct, which the CDC says is 51-and-a-half. I think there are very subtle changes that start to happen in our bodies closer to our early 40s. The average age of my patients is probably 45.
What’s that turning point in our bodies? What do people complain about?
Changing periods is the first thing. Actually, you know what it is? All of a sudden, women start seeing the doctor more. It’s this utilization of healthcare: ‘Wait a second, I’m going to my doctor: I’m telling her I’m really fatigued. I’m going to my OBGYN: My periods are really heavy. … Now I’m having headaches. Now I need to go back on birth control. I don’t want to get pregnant.’
The first clue is this utilization of healthcare where the majority of women, not all, start to see doctors all of a sudden. They’re like: ‘What is wrong with me? What is going on?’
I bet the same thing is true with perimenopause, and we have documentation that women with symptoms of menopause are going to doctors all the time. They’re leaving work, they’re missing work, they’re going to their internist and their gynecologist. Then they get referred to an endocrinologist, and then a sleep specialist, then the weight clinic, then a psychiatrist, and then cognitive behavioral therapy. All of a sudden, they have all these doctors. Now, things are multifactorial, but I would actually say the key is that all of a sudden you start to go to the doctor more and no one gives you answers. That’s how you know you’re in perimenopause.
I do wonder: How do you know you’re in it? There’s not really a test for it, and it’s easy to put things under this hormonal umbrella. What would you say to a woman who is going from doctor to doctor?
Perimenopause makes this a little bit more difficult than menopause, but I’ll give you the example of menopause. With menopause, it’s a little bit easier because you just don’t make any hormones anymore.
People ask me all the time, ‘Heather, how do I know if this is long COVID or menopause? How do I know if this is my fibromyalgia or menopause?’
And I say, ‘Well, we start HRT [hormone-replacement therapy] — and if [the symptom] goes away, it’s menopause.’
The same thing applies for perimenopause. Perimenopause is just a little bit more difficult because you’re still making hormones, and they’re kind of volatile. It takes a good doctor to help you sort through and figure out. But the answer could still be the same.
Common things happen commonly. Instead of getting the Botox for the bladder or spending three hours in a sleep study, and then sleeping in a separate room from your partner, try the hormones first. There’s a really good chance that your symptoms are going to improve.
I think [women are] pretty in tune with their bodies and they can say, ‘This got better. It didn’t get perfect, maybe, but I can see an improvement here. So I’m starting to wonder, do I really need the Botox, or do I really need to fly to Mayo Clinic to see this vestibular doctor?’
I’m very careful to not say, ‘All women need HRT, and that’s the only answer. You’re doomed without it.’ No, no, no. But we know that, for menopause — and this is peri, but they’re probably very connected — 75 percent of women have symptoms that last seven years. That’s not a little thing. It’s not like, ‘Oh, you got a cold.’ And as women we’re so tough! We’ll just acclimate. We’ll just adjust. We’ll just be miserable and just do all the things that we still have to do.
When we talk about hormones, what are we talking about? And what do they do?
I use an ice cream cone metaphor. Estrogen’s the main character. It’s the ice cream. When you go to the ice cream store, you want ice cream. That’s estrogen. It’s the biggest player here.
In menopause, you just don’t make estrogen anymore. A lot of symptoms start to develop in perimenopause because of the volatility of estrogen. Estrogen controls our core body temperature. It controls our hair, skin, nails, mood, digestion, pelvic floor, hearts, vascularity.
The main role of progesterone is to protect your uterus. That’s like the cone. It’s protecting the ice cream from dripping everywhere. But for women in perimenopause, progesterone is also a sort of natural relaxant. It can help with sleep, and it can help with anxiety, because progesterone is kind of the body’s natural chill-out hormone.
Testosterone is the cherry on top. Its main role — and it has others, so I don’t mean to oversimplify here — is probably libido. So, without testosterone, we probably wouldn’t have sex, and therefore carry on the species.
Many women worry about cancer risk and estrogen. Can you address that?
Studies show that when we use bioidentical, FDA-approved — this is crucial — Estradiol [estrogen] and Prometrium [progesterone], there is really no statistically significant increased risk of breast cancer from baseline. None.
Is that oral, or patch, vaginal cream, or in all forms?
All forms. What we do know is that, for women who take hormone therapy, they actually have reduction in all cancer mortality. They live longer, they die less from all causes, and there’s a statistically significant reduction in colon cancer and really no increased risks in other cancers.
Once you hit middle age, things get weird. Sometimes symptoms are actual warning signs of bigger problems. Not to say that hormone imbalances and perimenopause aren’t big issues. But what are red flags?
I hate to say it, because it means you have to work harder, but if you’re tracking on an app or you’re journaling, this is actually going to be very calming. You can start to see when something really does become out of your normal.
Heavy bleeding is a characteristic of perimenopause, but when does it become abnormal? That really depends on you. For example, if a woman’s periods are three days, four days, and all of a sudden, they have a period that lasts for 14 days. Or any type of bleeding that has an odor or is associated with fevers of unknown origin, or severe pain where you can’t work or the color is just totally different. But that’s contextual. A lot of people will say: ‘It’s gunky, it’s brown, it’s chalky.’ And that’s just normal — for them. Tracking at least will give you some ownership: ‘I know this is not normal for my body in perimenopause.’
And, even if it’s fatigue, joint aches and pains, or hot flashes, again, I would say with a good doctor, you can trial HRT to actually use it as a [perimenopause] diagnostic tool. I had a patient see me, and she had tinnitus, ringing in her ears, still having periods, but spacing out. She said, ‘This really started when my period started getting crazy. I’m going to see this neurologist in UCLA,’ and she lived in Maine. She said: ‘But I just can’t get over the fact that I think it might be hormonal.’
We started her on a little bit of estrogen, and it went away. I said, ‘Well, push your appointment back six months. If it’s still gone, you can feel pretty confident that it was hormonal the entire time.’
How long does it usually take for replacement hormones to work? I’m guessing that you don’t slap on a patch and feel like a new person the next day.
This is a great question. Interestingly, some people really do feel like they’re better the next day. But usually, for perimenopause, it takes longer to see because these are really subtle sometimes. And for example, if they’re cyclic, you only get to see if it’s working every couple of weeks. It can take a long time: six weeks, eight weeks, 12 weeks.
What tracking apps do you like?
I like the Balance app. This is by a doctor in the UK named Louise Newson. It’s really geared for perimenopause and menopause. Or just straight up pen and paper. But that way you really can, instead of spiraling, when you get that period that’s really, really heavy, or you’re soaking through pads or you have crushing fatigue, you can at least go back to your own stats for context. And then, when you talk to your doctor, feel a little bit more empowered: ‘Well, for the last six months, my periods were ‘X,’ and now this is happening.’
Scary things don’t actually happen to us all that commonly in our forties. Some things, but not a lot. But it is the preparation, or the beginning, of this big change to menopause. And so, the more in tune you are with your body and the sooner you recognize these could be or are symptoms of the hormonal flux and change, the better you’re going to be prepared. Awareness in general about perimenopause is so, so important.