Not A Dirty Word
“Rule number one: You can’t get undressed at work, no matter how bad the hot flashes are.”
“My mother said menopause was no big deal; that is all I learned about it. She was wrong.”
I gained 40 pounds after menopause started. Look at these arms and this belly. What happened to me?”
“I had a couple of hot flashes and sputtering periods, and menopause was over in a year.”
“Menopause threw my libido out the window and gave me a short fuse. I didn’t realize that estrogen affects every part of my body.”
“I don’t sleep anymore and don’t have energy. I am not who I used to be. Menopause has to end sometime.”
“Mama was crazy as a yard dog when she went through menopause, but nothing like that happened to me.”
Hot flashes and body changes. Insomnia and irritability. The menopause transition happens to every woman as hormones drop and the reproductive system shuts down.
A normal biological event for half of the population, menopause has been dismissed, ridiculed or overlooked for generations. Adding to the confusion are symptoms that vary with each woman. It can be unclear when menopause starts, how long it lasts, or the correct names of treatments to use.
“Women will live 40 percent of their lives in the perimenopausal stages or post-menopausal state and they know almost nothing about it,” said Dr. Connie Dabezies, who recently helped establish the USA Eastern Shore OBGYN office in Spanish Fort to provide an academic approach to women’s health. Dabezies is one of only seven practitioners in Alabama certified by the North American Menopause Society.
“Pregnant women read everything and are educated about their bodies during pregnancy,” Dabezies said. “It’s the opposite with menopause. Women in the transition come in unprepared, overwhelmed, anxious, depressed or trying to get a leave of absence from work. They are often unsupported at home.”
Arlene Easley learned about menopause and hot flashes when she saw her mother stick her head in the freezer and just stand there.
“My older sisters said our mother was going through ‘the change.’ I remember thinking, ‘What changed?’”
Now 59 and still having her own hot flashes, Easley wants her mother’s refrigerator with the freezer on top.
“While I was talking in a meeting, the inside of my head suddenly felt like it was on fire, and the sweating started,” she said. “Why wasn’t anyone else feeling this? My co-workers looked at me like I was insane, but all I could do was fan my face with my notebook. I told them, ‘Give me a minute. This will pass.’”
Easley said she drives her husband crazy with the roller coaster of hot and cold temperatures in their home and the comforters on or off their bed. Her symptoms have peaks and valleys but no signs of stopping.
“Where's my menopause finish line or a calendar for my family to count down?” she asked.
For most of human history, life spans were short, and women didn’t often outlive the menopause finish line. Women and whales are the only mammals who experience menopause and live past their reproductive years.
The term “menopause" was first used in the 1820s by a French physician for a pause in menstruation. Thirty years later, British doctor Edward Tilt published “The Change of Life in Health and Disease” and described “the change of life” as: “distressing headaches, fretfulness, peevishness, and capriciousness, called temper, by a temporary perversion of moral feeling, or by moral insanity. In others, excessive ovarian action is manifested by motiveless high spirits or depression, by delirium, then called hysteria. The brain feels muddled, and memory is faithless.”
Medical advice columns published in newspapers throughout much of the 20th century were often dismissive, treating menopause as a disease, a deficiency or a weakness in women’s minds. Some described menopause as a “day of reckoning” for women when “nature balances the books” and “the chickens come home to roost.” Menopause was payback for “the discrepancies of bad habits of earlier years.”
In 1966, gynecologist Dr. Robert Wilson published the best-selling book, “Feminine Forever.” Defining menopause as a curable and preventable disease, Wilson advised women to take estrogen and stay young forever instead of “being condemned to witness the death of their womanhood during what would be their best years.”
“Estrogen,” he wrote, “allows women to remain fully feminine-physically and emotionally-for as long as they live.”
“No woman can be sure of escaping the horror of this living decay,” Wilson continued. “Menopause destroys womanhood during her prime. At the very moment when she is most able and eager to enjoy her achievements, her femininity - the very basis of her selfhood - crumbles.”
No longer considered the “death of womanhood” or “living decay,” much of menopause still remains a mystery.
Menopause occurs naturally, medically or surgically, and misunderstandings begin with the stages and names to use. The average age of menopause is 52 and it begins a year after the final menstrual cycle. But physical changes from fluctuating hormones start years before in the stage called “perimenopause” that can last up to 10 years. Some women in their 30s go through premature menopause. The full menopause experience could last 20 years or longer.
The symptoms of menopause are also misunderstood. The decrease in estrogen leads to vaginal dryness, mood changes, night sweats, hot flashes, aching joints, brain fog, and painful sex.
Entering the perimenopause age range is the time to start the conversation with a GYN about symptoms and changes, Dabezies said.
“Women come in embarrassed, but all they have to say is, ‘Tell me about menopause,’ and we will start from there,” she said.
Since every woman is different, Dabezies begins with a physical exam, asking about a family history of cancer and heart disease, and giving each patient a sheet with the eight significant menopause symptoms to circle and rank in order.
“Many symptoms are connected, so I look at the whole picture for treatment,” she said. “Menopause is becoming its own field of medicine, and there is a lot more we can do to improve quality of life. Women don’t have to tough it out.”
Hot flashes are at the top of most lists, and Dabezies defined hot flashes as temperature instability.
“It’s not just hot flashes: You are either really hot or cold,” she said. “Hot flashes are controlled by the hypothalamus in the brain. The good news is that a non-hormonal medication that blocks the effect of the loss of estrogen on the hypothalamus is going through FDA approval and may be out next year.”
Improving temperature regulation can also help sleep disorders, Dabezies said. Better sleep reduces fatigue and brain fog, improving mood and focus.
The North American Menopause Society reported that Hormone Replacement Therapy (HRT) is one of the most effective therapeutic options for treating hot flashes and other menopause symptoms. The benefits and risks of hormone therapy vary, depending on age and health history. In general, healthy women in their 50s get more benefits from hormone therapy than postmenopausal women in their 60s.
“By the time women are 60, we have missed the opportune time to begin hormone treatment,” said Dabezies.
Hormone Replacement Therapy is a combination of estrogen and progesterone (referred to as EPT) for women with a uterus, or just estrogen (referred to as ET) for women who have had a hysterectomy. Hormones are taken as a patch, pill, gel, vaginal ring, cream, or a mist with formulations that fit a woman's lifestyle.
“I carefully go over the risks and benefits of hormones,” Dabezies said. “If hormone therapy is appropriate, we test it for three months and keep tweaking for the best results. We also have a plan for weaning women off when the risks outweigh the benefits. We no longer tell women to take hormones for the rest of their lives.”
HRT was once one of the most commonly prescribed treatments in the US, but in 2002, a single study by the Women’s Health Initiative linked hormone therapy with elevated risks of breast cancer, stroke and heart disease for women of all ages. Prescriptions for HRT plummeted, leaving women with few options for treatment for 20 years.
“The study ended abruptly — doctors panicked and pulled women off hormones,” Dabezies said. “Looking back, that was probably the worst thing we could have done. Years later, we started seeing earlier mortality due to heart disease and significant morbidity due to osteoporosis.”
Since then, additional research showed that the benefits of HRT outweigh the risks and that hormone therapy is safe for most women, Dabezies said.
With hormone receptors located in every part of a woman’s body, the drop in estrogen also plays a role in regulating skeletal, cardiovascular and central nervous systems. That includes cholesterol and blood sugar levels, bone and muscle mass, circulation and blood flow, collagen production and moisture in the skin. Lower levels of estrogen also increases the risk of depressive symptoms while accelerating bone loss and weight gain.
Hormone therapy offers protection against cardiovascular disease and bone loss, according to the Cleveland Clinic. After menopause, women are at a higher risk of cardiovascular disease, which is the leading cause of death of women in the US. As estrogen drops, women also lose an average of 25 percent of their bone density from menopause through age 60.
Alternative treatments are available for those who can’t take hormones, Dabezies said. For example, antidepressants can safely be used to help hot flashes and mood swings. Vaginal therapy to prevent atrophy include: vaginal lubricants, vaginal moisturizers, hormonal rings and creams for the vagina or a dilator used at home that expands the vagina. Exercise, diet, cognitive behavioral therapy and lifestyle changes also make a difference.
Dabezies also recommend books such as “The Menopause Manifesto” and “The Galveston Diet.”
“Every woman’s body and menopause story is different,” she said. “The more women know about our bodies and what actions to take, the less we feel that we are going crazy.”
Ashley Rains and her husband, Stephen, tried to start a family in their mid-30s, but it wasn’t easy. Going through a variety of doctors, medical procedures and hormone testing, Rains thought she had learned everything about her body. Both of her pregnancies ended with medical procedures for miscarriages.
“My body wouldn't even miscarry correctly, and I never had a baby,” Rains said. “Making bad things worse, I soon went into hot flashes and mood swings.”
Blood tests showed she was in menopause at 37 years old.
“I had no idea about this stage of life,” she said. “Nobody prepares women for the ups and downs at the end of estrogen. My mother had a hysterectomy in her late thirties, and I couldn’t learn from her.”
Rains said the conversation about changes in hormones is different for men.
“I am into sports, and there are plenty of commercials about low testosterone or hormone replacement for men,” Rains said. “Men say the quiet parts out loud and make it normal. Why is talking about menopause still taboo for women?”
Working with her doctor, Rains found the right hormone therapy.
“I finally feel better, and I am now in a safe place for other women in similar situations who need someone to talk to,” she said. “Menopause can be physically and mentally painful, but we must open up and stop suffering in silence. There are better ways through this.”
Menopause isn’t a disease or a dirty word, but it is the elephant in the room for most women over 40 and they don’t know how to talk about it, said Fatiha Johnson, a women’s health nurse practitioner at the University of Alabama in Birmingham.
“Health care providers and the older generations of women in families should be educating and passing down information about menopause,” she said. “Instead, menopause is brand new and misunderstood by many women when the symptoms begin. They wonder if this is normal or if they are going crazy.”
For women born in the 1970s, many of their mothers or aunts had a hysterectomy, Johnson said.
“At that time, the management of issues with the uterus was a surgical hysterectomy leaving little information about medical history for mothers or aunts to pass down,” she said.
Bridging the gap in women’s health is a reason Johnson entered healthcare, and she encourages patients to bring in their husbands or partners to talk about changes in libido or painful sex so they can understand menopause together.
“Sometimes a woman can’t have a conversation with her husband or partner to explain the changes in her body or sex drive,” Johnson said. “Low libido is more than always being too tired or not in the mood, and it can cause marital problems if a couple doesn’t understand what is happening or the remedies.”
A nurse practitioner since 2018, Johnson said women's health and treatment of menopause symptoms have changed drastically over the last five years with safe options for all women.
Johnson and Dabezies agree that the more doctors know about the family health history of a patient, the better they can help. That history includes osteoporosis or fractures, the reason for hysterectomies, early onset heart disease, breast, uterine, or endometrial cancer, and menopausal symptoms of the mother, maternal aunts and grandmother.
“Humans are genetically determined and with improved genetic screening techniques, we can offer risk-reduction surgeries and better screening for cancers,” said Dabezies.
Dabezies also warns her patients of misinformation about treatments or promises of staying young from those who aren’t trained in gynecology or menopause.
“There is so much out there telling women what they have to look like or how to find the secret to the fountain of youth,” Dabezies said. “The fountain of youth is from the inside — taking care of yourself mentally, physically and spiritually.”
Dabezies is 55 and understands menopause from both sides. She experienced the symptoms of menopause, including hot flashes and brain fog, while sending her kids off to college and adjusting to an empty nest.
“Big life changes happen at once, but women are also realizing this is when we finally have more time to care for ourselves,” she said.
“The conversations about menopause in my office and with my friends are amazing,” Dabezies said. “Women are learning from each other how to navigate through menopause and normalize this third stage of our lives. We will make this a happy, fulfilling, productive time.”
