Why Is Perimenopause Still Such a Mystery?

Over 1 billion women around the world will have experienced perimenopause by 2025. But a culture that has spent years dismissing the process might explain why we don’t know more about it.

Credit...Monica Garwood

Angie McKaig calls it “peri brain” out loud, in meetings. That’s when the 49-year-old has moments of perimenopause-related brain fog so intense that she will forget the point she is trying to make in the middle of a sentence. Sometimes it will happen when she’s presenting to her colleagues in digital marketing at Canada’s largest bank in Toronto. But it can happen anywhere — she has forgotten her own address. Twice.

Ms. McKaig’s symptoms were a rude surprise when she first started experiencing them in 2018, right around when her mother died. She had an irregular period, hot flashes, insomnia and massive hair loss along with memory issues she describes as “like somebody had taken my brain and done the Etch A Sketch thing,” which is to say, shaken it until it was blank.

She thought she might have early-onset Alzheimer’s, or that these changes were a physical response to her grief, until her therapist told her that her symptoms were typical signs of perimenopause, which is defined as the final years of a woman’s reproductive life leading up to the cessation of her period, or menopause. It usually begins in a woman’s 40s, and is marked by fluctuating hormones and a raft of mental and physical symptoms that are “sufficiently bothersome” to send almost 90 percent of women to their doctors for advice about how to cope.

Ms. McKaig is aggressively transparent about her “peri brain” at work, because she “realized how few people actually talk about this, and how little information we are given. So I have tried to normalize it,” she said.

An oft-cited statistic from the North American Menopause Society is that by 2025, more than 1 billion women around the world will be post-menopausal. The scientific study of perimenopause has been going on for decades, and the cultural discussion of this mind and body shift has reached something of a new fever pitch, with several books on the subject coming out this spring and a gaggle of “femtech” companies vowing to disrupt perimenopause.

If the experience of perimenopause is this universal, why did almost every single layperson interviewed for this article say something along the lines of: No one told me it would be like this?

“You’re hearing what I’m hearing, ‘Nobody ever told me this, my mother never told me this,’ and I had the same experiences many years ago with my mother,” said Dr. Lila Nachtigall, a professor of obstetrics and gynecology at N.Y.U. Grossman School of Medicine who has been treating perimenopausal women for 50 years, and is an adviser to Elektra Health, a telemedicine start-up.

Dr. Nachtigall said her mother had the worst hot flashes, and even though they were living in the same house when her mother was experiencing perimenopausal symptoms, they never discussed it. “That was part of the taboo. You were supposed to suffer in silence.”

The shroud of secrecy around women’s intimate bodily functions is among the many reasons experts cite for the lack of public knowledge about women’s health in midlife. But looking at the medical and cultural understanding of perimenopause through history reveals how this rite of passage, sometimes compared to a second puberty, has been overlooked and under discussed.

Though the ancient Greeks and Romans knew a woman’s fertility ended in midlife, there are few references to menopause in their texts, according to Susan Mattern, a professor of history at the University of Georgia, in her book “The Slow Moon Climbs: The Science, History, and Meaning of Menopause.”

The term “menopause” wasn’t used until around 1820, when it was coined by Charles de Gardanne, a French physician. Before then, it was colloquially referred to as “women’s hell,” “green old age” and “death of sex,” Dr. Mattern notes. Dr. de Gardanne cited 50 menopause-related conditions that sound somewhat absurd to modern ears, including “epilepsy, nymphomania, gout, hysterical fits and cancer.”

Physicians in the 19th century believed that receiving bad news could cause early menopause, and that women who worked in “unwomanly” occupations, like fishwives, were most at risk, according to “The Curse: A Cultural History of Menstruation,” by Emily Toth, Janice Delaney and Mary Lupton. These Victorian doctors also believed that menopausal women grew scales on their breasts and experienced a “loss of feminine grace.”

Things did not get much better for women in perimenopause during the latter half of the 19th century. “A woman consulting the American gynecologist Andrew Currier in the 1890s would have been told that leeches were still an effective remedy for congested genitals,” more commonly known as pelvic pain, according to “The Curse.” Other physicians of the era thought that perimenopausal women were more susceptible to mental illnesses, “among them ‘morbid irrationality,’ ‘minor forms of hysteria’, melancholia and the impulses to drink spirits, to steal, and perchance, to murder.”

In the first half of the 20th century, the hormone estrogen was discovered and its role in menopause was clarified somewhat — after a woman’s period ceases, her estrogen levels are lower than they were during her fertile years. Even though doctors no longer thought menopausal women were murderous lizard people, cultural ideas about them did not improve.

It wasn’t until the 1980s that longitudinal studies — which followed the same cohort of women for years — deepened public knowledge about the role of hormones during menopause. Before that, doctors thought perimenopause was a slow draining of estrogen levels until you hit the end of your period. “But what we’ve learned is it is more of a turbulent process — hormones are bouncing around,” said Dr. Stephanie Faubion, the medical director of the North American Menopause Society.

Even now, perimenopause is described in medical research as an “ill-defined time period” primarily marked when the ovarian reserve is depleted and by irregular periods (but if one has a history of irregular periods, as 14 percent to 25 percent of women do, it may be tougher to tell when the transition has begun). This time period is still often referred to as menopause in common parlance, but the medical definition of menopause is just one day — the last day of your final period — though it is only diagnosed when a whole year has gone by without menstruation.

Because hormones fluctuate wildly during perimenopause, it can be difficult to test for. The average age of the beginning of perimenopause is 47, and the average age of menopause is 51, but again, the length of the transitional period may be much longer, and the onset of symptoms can happen earlier or later.

There are four symptoms of perimenopause that are most common: hot flashes, sleep disruption, depression and vaginal dryness, known as “the core four” among menopause experts. But the full panoply of symptoms related to the perimenopause transition “is not yet known with any great degree of certainty,” said Dr. Nanette Santoro, the chair of obstetrics and gynecology at the University of Colorado School of Medicine. At this point, the perimenopausal period is associated with as many as 34 different maladies ranging from hair loss to “burning mouth syndrome,” which is a tingling or numb feeling in your lips, gums and tongue.

There’s also what Dr. Faubion refers to as “the menopause management vacuum.” As she explained to Lisa Selin Davis, a Times contributor, no one medical specialty really “owns” treatment of perimenopausal and menopausal women, because the symptoms affect so many different systems and parts of the body. Furthermore, less than 7 percent of medical residents surveyed said they felt “adequately prepared” to manage women going through menopause.

Though images of midlife women have definitely improved — a popular meme compares Jennifer Lopez, who at 50 was pole dancing at the Super Bowl, to Rue McClanahan, who at 51 in 1985 was on “Golden Girls” drinking coffee on the lanai — there is still much progress to be made. It was only this year that an online Arabic dictionary changed the description of menopause from “age of despair” to “age of renewal.”

With so much negative cultural baggage, so much still unknown around symptoms and timing, and so few doctors confident in the treatment of midlife women, “no wonder people are confused,” Dr. Nachtigall said. And it helps explain why so many companies and writers are jumping into the morass.

What Angie McKaig is trying to do on a micro level by freely sharing her perimenopause travails with colleagues, health care start-ups, beauty companies and writers are trying to do on a macro level: raising awareness about the experience of this period of a woman’s life (and sometimes selling them products and services along the way).

“Femtech” companies such as the telemedicine providers Elektra Health and Gennev are moving into the perimenopause market; Stacy London, the stylist and reality TV star, just started a skin care company called The State of Menopause; and celebrities like Michelle Obama and Gwyneth Paltrow have spoken honestly about their perimenopause symptoms (though Ms. Paltrow did it in the service of promoting a supplement called “Madame Ovary” that she sells on her website, Goop).

Books on the topic from Heather Corinna, a sexual health expert, and Dr. Jen Gunter, a Times contributor and OB/GYN, will be published this spring; newsletters and online communities like TueNight and The Black Girl’s Guide to Surviving Menopause are gaining traction with tens of thousands of readers.

One community aimed at connecting women during their perimenopausal transition is called The Woolfer — named for the writer Virginia Woolf. The website and social platform started as a Facebook group called What Would Virginia Woolf Do? The name was meant to be a “dark joke,” said Nina Lorez Collins, 51, the founder and chief executive of The Woolfer — as in, “Should we just throw in the towel and wander into a river,” as Woolf did?

The answer, of course, is a resounding no. Ms. Collins said her group has helped women normalize the more shocking symptoms of the menopause transition. (More than one woman interviewed for this piece used the phrase “crime scene periods.”) And they have also reframed the journey into menopause as one of triumph, not irrelevance.

Though perimenopause presents as so many different symptoms, there are treatments available. However, there “is not one single solution,” Dr. Faubion said. The treatment is symptom dependent: If heavy or irregular bleeding is the issue, an intrauterine device, or a birth control pill could help. A low-dose birth control pill may also relieve hot flashes. “Birth control pills are made up of so many different permutations and combinations of hormones,” it’s important to discuss which one is right based on your medical history and individual needs, Dr. Nachtigall said. If mood issues are the biggest complaint, an antidepressant might be appropriate. (Hormone therapy may be an option for some women to help ease symptoms, but it is more frequently prescribed after menopause).

Ongoing longitudinal studies are finding associations between women with intense perimenopause symptoms in midlife, and risks of heart disease and osteoporosis in later years. Currently, there is not evidence to support the use of vitamins or supplements like black cohosh or magnesium, contrary to claims that these products help with hot flashes.

Despite expanded and continuing research, finding a knowledgeable physician who won’t dismiss your symptoms or tell you there’s nothing they can do to help is a struggle for many women. Ms. McKaig said that though her therapist diagnosed her as perimenopausal, her family doctor keeps telling her that her symptoms can’t be perimenopause because she’s still having her period sometimes. She said she’s “given up trying to educate her.”

For Black women, there is an added layer of difficulty in finding a sympathetic doctor, with ample research showing racial bias in physicians’ consideration of symptoms. As The Washington Post noted earlier this year, Black women “have a higher risk of experiencing hot flashes but are less likely to be offered effective hormone replacement therapy.” Jennifer White, 46, a journalist who recently relocated to the Washington, D.C., area, has been experiencing perimenopause-related insomnia and painful, irregular periods for a year. “Finding the right clinician to take seriously my concerns as a Black woman, and not tell me to walk it off, is top of mind,” she said.

The North American Menopause Society’s website lists qualified physicians throughout the country and abroad, but if you live outside major metropolitan areas, the pickings may be slim (for example, there are only two NAMS-certified menopause practitioners listed for the entire state of Wyoming). Telemedicine is aiming to fill the void, but even in the Covid era, there are limitations and complications to practicing medicine across state lines.

Though finding a qualified and sympathetic doctor may be a challenge, shifting the cultural narrative may be just as vital.

“I actually think it’s extraordinarily important to change the conversation. Because so much of what you hear about perimenopause is spoken about in an anti-feminist and ageist way,” said Dr. Lucy Hutner, a reproductive psychiatrist in New York. Dr. Hutner said that many of her patients who are navigating these midlife shifts find them deeply empowering. They feel more resilient, and are following their “inner compass.”

While part of it is just the wisdom that comes with age, many women feel that once they are through the menopause transition, they don’t have to make themselves appealing to the world. As Dr. Hutner put it: “I feel liberated because I’m not trying to take care of everyone else or correspond to anyone’s societal view. I have been able to shake off the shackles.”