I’ve written a handful of posts dedicated to women’s health and those posts receive the most traffic and comments from internet searches (and likely from Russian bots). This tells me I’m on to something. The one that receives the most traffic is a post dedicated to “PMDD”: pre-menstrual dysphoric disorder. 

Wondering about that third word, are you? It means the opposite of “euphoria.” Disorders can’t be cured. So this one has to be addressed and managed. I feel as though I am cured from it, but I know that I am not…

My style is glib at times, but my intensity and interest in this subject is real because being a cisgendered female is hard. I won’t go into my sentiments surrounding the appropriation of my gender by cisgendered males because frankly I don’t have the required bandwidth nor the belief system to fully engage. To me, men feeling as though they are missing out on being a woman and who get to forgo the hips and the breasts expanding, and the periods (missed or on time), and the unwanted advances and leers of horny old men are out to lunch. I’ll trade a week and you can go through it all — you can:

• put on a training bra in the dark or in a locker room,
• deal with feminine hygiene (maybe even in a public bathroom or, say, totally unprepared at your violin lesson for your first time as a WOMAN),
• barter your lunch for three tylenol to abate your cramps and risk suspension or expulsion from school because of it,
• birth one of my kids,
• fight off a drunken asshole’s overtures at a keg party… or
• sit on a couch waiting for your ride home when your date cools off because you won’t sleep with him… or worse.

Go for it.

I also would be willing to bet that most men who want to appropriate my gender wouldn’t have the stones to endure a week of perimenopause.

This is becoming political… my apologies, but I feel I had to say something.

This post is about females and the shit we go through in our middle-life stages.

First: get an app on your smartphone or keep meticulous records. I use “PLog”: https://itunes.apple.com/app/period-log-free-menstrual/id494474881?mt=8 

With that said, one year ago, well into the end of my ninth year of perimenopause (which is the purgatory between getting your periods every month or so and all the emotions and physical symptoms that come along) and the time of life when all that shit stops, I was suffering. My moods were all over the place, yet I didn’t really dial in to them… I just sort of noticed them, “that was rude of me to say…” I’d say to myself. Or, “Since when do you do things like that?” I’m still there.

The weird thing about perimenopause to menopause is that it’s not a pause. A pause implies a restart. And your cycles don’t stop like a machine would stop, say if you turn off your car’s engine. Short of an oophorectomy, it’s believed to be a “pause” of your “menses.” Let’s be honest here too: it’s not at all a ‘pause,’ it’s a full-on shut down, so even the nomenclature is screwed up here. I’m guessing a man invented the word:

The answer to this mystery is found in the origin of the word. In 1821 a French physician named de Gardanne first coined the term menopause when he published his book “De la ménopause, ou de l’âge critique des femmes” using the term menopause to describe the phase in a woman’s life.

YES! It was a man! Merci, dude! I don’t speak French, but I’m seeing blah french blah french blah “critique” and “des femmes” which is never a good combination.

For menopause, things shut down like a forest fire which starts out slowly because someone didn’t put out a campfire. Or because of the climate or winds or a cigarette was tossed out a window… Then it smolders a bit and it gets oxygen… and it spreads to dry grasses or pine needles (which are basically small vats of kerosene because there is so much oil in them) and then a few yards in one direction and then an acre and then an entire forest, and then a national park…  But that’s fire.

For women, it’s much more subtle, but the experiences can feel similar. Just like some fires are “controlled burns” or a “small forest fire,” the clinical definition of menopause requires that a woman’s periods must stop for a full year.

For me, last year about this time, I was desperate for help. And based on the condition I’m in today, I’m nowhere near that year of cessation.

First: what the fuck is going on?

Borrowing from my immediately previous post, this graphic explains is what’s going on:

I’m 49 now. I started on this circus clown car ride (the middle graph) 10 years ago. Any day can be like that middle graph for me. Sometimes it is an entire day that feels like that.

The changes in hormonal levels as women age cause the following symptoms (lifted word for word from the Mayo Clinic site which is much more reputable than webmd, so take a breath, my comments in red):

Symptoms

Throughout the menopausal transition, some subtle — and some not-so-subtle — changes in your body may take place. You might experience:

• Irregular periods. As ovulation becomes more unpredictable, the length of time between periods may be longer or shorter, your flow may be light to heavy, and you may skip some periods. Oh? If you have a persistent (what do you mean, ‘persistent’? like a child, “momcanihaveacookie?momcanihaveacookie?” persistent?) change (vague, object!) of seven days or more in the length of your menstrual cycle, you may be in early perimenopause (early?! ARE YOU %)(!@&_%@ kidding me?! EARLY?!). If you have a space of 60 days or more between periods, you’re likely in late perimenopause. <– not me, not yet. I’m still in this hang time. 

• Hot flashes and sleep problems. Hot flashes are common during perimenopause (I have been spared the recognizable hot flashes, mostly and so far). The intensity, length and frequency vary. Sleep problems are often due to hot flashes or night sweats (DING! now we’re talking: the intensity of my night sweats for 10 years have rivaled those of my immediate postpartum weeks when the hormones females use to create and sustain life inside the uterus and the rest of her own body, which is effing exhausted from the process, but it’s really only just the beginning), but sometimes sleep becomes unpredictable even without them. <–OMAIGAAAD! I would literally trade all of my Cap’n Crunch for just ONE NIGHT of uninterrupted sleep. I realize the flip phrase, “I’m so tired I could take hostages” is no longer in vogue, but my kids get it.  

• Mood changes. Mood swings, irritability or increased risk of depression may happen during perimenopause. The cause of these symptoms may (y’think?!) be sleep disruption associated with hot flashes (fuck yes). Mood changes (muuuuahhhahaahaaaaaa boooohooowoohaaaaaaaa… waah… grrr… what? me? grr… your mother sews socks in hell… ) may also be caused by factors not (NOT?!) related to the hormonal changes of perimenopause (um: no, highly doubtful).

• Vaginal and bladder problems. (Oh what fun it is to ride…) When estrogen levels diminish, your vaginal tissues may lose lubrication and elasticity, making (you feel as though your privates have been replaced by 03-grade sand paper and generic brand tissues – or so I’ve heard intercourse painful. Low estrogen may also leave you more vulnerable to urinary or vaginal infections (thankfully not there yet: word to the wise, ladies from my doctor: PEE IMMEDIATELY after sex, not in the bed, but y’know, within a few minutes as your urethra needs to flush itself) . Loss of tissue tone may contribute to urinary incontinence. Do those kegels and pelvic floor exercises! Yoga! Find your psoas muscle (no, it’s not a sex muscle).

• Decreasing fertility. As ovulation becomes irregular, your ability to conceive decreases. However, as long as you’re having periods, pregnancy is still possible. If you wish to avoid pregnancy, use birth control until you’ve had no periods for 12 months (and even then: watch it. I have friends who’ve welcomed a new member into the family thinking they were good to go).

• Changes in sexual function. During perimenopause, sexual arousal and desire may change (and not just a little… ). But if you had satisfactory sexual intimacy before menopause, this will likely continue through perimenopause and beyond. (Stay in communication with your partner. That’s the important part… so smoke signals from the other wing of the house are always a good idea, that way your man will know when it’s safe to approach.)

• Loss of bone. With declining estrogen levels, you start to lose bone more quickly than you replace it, increasing your risk of osteoporosis — a disease that causes fragile bones. This is JUST as important and really, a serious issue. Watch the caffeine intake, take moderate walks for resistance exercise, use weights (even low weights) to maintain your bone mass health.

• Changing cholesterol levels. Declining estrogen levels may lead to unfavorable changes in your blood cholesterol levels, including an increase in low-density lipoprotein (LDL) cholesterol — the “bad” cholesterol — which contributes to an increased risk of heart disease. My mom’s went through the roof as she aged; mine has always been about 157 so I need to keep an eye on it. That said, Mom ate cheese like you read about (I just read about eating cheese) and indulged in lots of sedentary, unhealthy behaviors and addictions and basically no did not exercise ever / at all / ever / constantly / never. At the same time, high-density lipoprotein (HDL) cholesterol — the “good” cholesterol — decreases in many women as they age, which also increases the risk of heart disease (you can encourage your HDL levels through exercise and diet. My mom died of a massive cardiac arrest — not a heart attack which (broken down by me) is a major incident and spasm of the heart muscles — but the cessation of electricity to flow to her heart causing her heart to no longer function; coming back from a CA, for a woman in her condition [not good at all] would have been a divine miracle).

More from the Mayo Clinic site includes:

When to see a doctor

Some women seek medical attention for their perimenopausal symptoms. But others either tolerate the changes or simply don’t experience symptoms severe enough to need attention. Because symptoms may be subtle and come on gradually (like a thief in the night), you may not realize at first that they’re all connected to the same thing — rising and falling levels of estrogen and progesterone, another key female hormone.

If you have symptoms that interfere with your life or well-being, such as hot flashes, mood swings or changes in sexual function that concern you, see your doctor.

This is where it gets fun for me. Because I went to my doctor. She put me on a low-dose birth control pill, “Lo-Estrin 1/20” because of my complaints:

Wanting to punch people, exhaustion, brain fog, emotional projection, confusion, inability to take a joke, complete viper-like mood swings, appetite disruption, back aches, headaches (which I simply never get), sleep disruption, fantasies of running off to Cabo (still never found a cure for that).  

I took the pill. For the first cycle, it’s 21 days of the drug. Within two days, I felt like I was 26 again: super able, focused, interested in sex, I had an appetite for food, I was sleeping like a dog (that’s a good thing because we all know babies don’t sleep) and other stuff. I felt great. As is the case in a standard birth control pack, on the first Sunday of the fourth week, you take a sugar pill (or just skip a week and start back up on Sunday with the new pack) and that starts a period. 

I did that. 

Halfway through my second cycle on the pill, when I was supposed to be “ovulating” I started to spot. I made a note. It lasted five days. On the first Sunday of the fourth week, I took my sugar pill to begin the standard pill-induced menses.

On Tuesday, I began to have thoughts that can be best described as sympathetic to suicidal ideation. I’m not kidding. 

I practice mindfulness (it’s how I’ve avoided becoming an alcoholic or other addict). I have spent years on a therapists’ couch so I understand emotions, and I get how powerful they are. Being a writer I was able to back out of this “sympathetic interest” and write a script, in my head, or a narrative about a woman who resembled me (but was taller, natch, and blonde) and my station in life who woke up and decided she didn’t want to live anymore. 

The depths of this transient depression were unlike anything I’ve ever experienced before, maybe I can equate it to the loss and ineffable grief I felt after I was dumped by a boyfriend, with whom I thought I would spend the rest of my life, when I was in college. Maybe. It was deeper than the grief I felt after my mother died — but maybe it was just faster and more intense. My grief surrounding my mother’s death lasted months and wavered in intensity. This moment hit me hard and fast. Out of nowhere. One minute I was pouring my coffee and the next minute I thought of suicide. 

I knew what was up. I did the math: this is a new deep and ugly feeling. I’m taking this pill, this is supposed to be my period, and I have PMDD but it’s under control…

So I grabbed my dogs and we took a very brisk walk for an hour. Charlie was all about it, but poor Murphy, who was 8 at the time, was frequently looking up at me and saying, “Can we take a break now? Please?” I was so grateful for their company. They kept me present. I have said twice to myself that my dogs are keeping me alive and this was the second of those times. The first time was when Murphy vocally persuaded a man, whose intensity and energy was palpable from 50 yards, to turn and cross the street away from us. Murphy is a golden retriever, he doesn’t bark warnings to humans; it’s not part of his breeding.  

Halfway through the walk, I started to feel better. I worked out the scene and projected it on to a false character. I put her through her paces from ideation to the moments of and the grief of her surviving loved ones and the days, weeks, holidays and life’s milestone moments which would undoubtedly follow because LGO: life goes on.

After I worked all that out, I did take a break in my walk and I called my doctor. I told her assistant what was up and she asked me if I needed emergency assistance and I told her I was ok. That I was outside. That I had no weapons or agents of harm with me. That the sun was on my face and my dogs were by my side and I was ok, really. Because I was and I thanked her for her concern, but I was calling to let her know what was going on because it was really scary when it first started. I asked, “Should I take the real pills now instead? Should I continue with the sugar pills?” (I felt like the patients who took L.Dopa in Awakenings; I didn’t want to stop the pill!) 

She relayed my message to my physician who said back to the assistant, “Tell her to stop the Lo-Estrin and call us after her periods stop for a year…” That doctor, is Joanne Herrmann, MD, and I don’t think I’ll be crossing her threshold any time soon. I understand it was a game of “Operator” going on, and you can call me weird and codependent, maybe, but if I had a patient who told me what I told her assistant, I’d be calling back that patient myself. She certainly practiced Primum non nocere. I guess.     

Later that day, I had lunch with a friend and I told her everything that happened. She listened intently; but I think I scare people because I’m so vivid and in-tune with how I’m doing. That was the last time I saw her.

Since that last pill, I’ve gained a new respect for estrogen and progesterone. I’ve learned that any time I’m feeling shitty and allowing it and noting it is a good thing because it means the process is still happening. It means I’m here.

I had a very high-level understanding of the phrase “mood swings” until that day. The take-away: investigate your options. Lo-Estrin 1/20 might work for you… just be ready for those sugar pill days.  

Causes

As you go through the menopausal transition, your body’s production of estrogen and progesterone rises and falls. Many of the changes you experience during perimenopause are a result of decreasing estrogen.

Risk factors

Menopause is a normal phase in life. But it may occur earlier in some women than in others. Although not always conclusive, some evidence suggests that certain factors may make it more likely that you start perimenopause at an earlier age, including:

• Smoking. The onset of menopause occurs one to two years earlier in women who smoke than in women who don’t smoke.
• Family history. Women with a family history of early menopause may experience early menopause themselves.
• Cancer treatment. Treatment for cancer with chemotherapy or pelvic radiation therapy has been linked to early menopause.
• Hysterectomy. A hysterectomy that removes your uterus, but not your ovaries, usually doesn’t cause menopause. Although you no longer have periods, your ovaries still produce estrogen. But such surgery may cause menopause to occur earlier than average. Also, if you have one ovary removed, the remaining ovary might stop working sooner than expected.

Complications

Irregular periods are a hallmark of perimenopause. Most of the time this is normal and nothing to be concerned about. However, see your doctor if:

• Bleeding is extremely heavy — you’re changing tampons or pads every hour or two for two or more hours
• Bleeding lasts longer than seven days
• Bleeding occurs between periods
• Periods regularly occur less than 21 days apart <– that’s one I will now begin to keep an eye on

Signs such as these may mean there’s a problem with your reproductive system that requires diagnosis and treatment.

So this is all good, and I’m thankful for it. But the bottom line for all of us in this situation is symptoms and how we manage them.

About three years ago, Dr. Herrmann suggested I take something called “Brisdelle” which is a subclinical / super low-dose (7mg) of Prozac. The idea is that it will calm you down enough to sleep at night and abate next-day anxiety which is increased because of night sweats which happens because you’re anxious…? I’m still a little fuzzy on that. So I tried it for four days. It made me feel like I was a narcoleptic game show host. I stopped after a week. Some people have doubted my claim, that the drug needs to be in my system for six weeks before it takes full metabolic effect.

Mmmmmkay. Survey says….?! Znnngngzzzgngn! Where are you from, little lady….? Znnnngngngnnnznzzng.

I take herbal supplements: Estroven AM and Estroven PM; they help. Maybe they’re doing an insanely bang-up job and I have no idea because I’ve been taking them for about a year. Before that I took something called “Herbal Equilibrium” but Dr. Herrmann told me to stop taking it because she doesn’t believe in supplements… well, she believed in that Lo-Estrin 1/20 enough to prescribe it and it made me very sad, so maybe she’s wrong.

But we address problems by understanding what they’re made of. In this situation we need to dial in: WHAT does estrogen do??? Since we all know how we got here, thanks estrogen, we need to know what is going on and what estrogen regulates because it’s super subtle stuff.

A year ago, I did not know that estrogen played a major role in digestion. Did you?

I did not know that estrogen is involved in the sleep process and the release of other hormones which help us get a good rest. Did you?

So I went back to the web, and I blew off Webmd again and went straight the alma mater of one of my besties’: Northwestern University, for help. This page and its title, “How Hormone Depletion Affects You” was exactly what I was looking for. It will have all the information about WHAT estrogen and progesterone mean to you and why this crazy circus clown car is in your life.

Here we are ladies:

That feels about right…? Doesn’t it?

Oddly, I am comforted by that image.

It tells me, “Sigh. Finally. Someone out there understands. I’ll have that Nescafé International Coffee now… Vienna Font Brick Caramel please… yes, I’ll wait… ”

The paragraph accompanying that DaVinci -esque image does a great job of introducing content that I simply can’t improve upon (for many reasons, the foremost of which is because I’m not a doctor), and it will behoove you to read it and learn about what is going on because all I can do is commiserate with you:

Hormones are the messengers in the body that travel through the blood stream to start, stop, speed up or slow down your physical and chemical functions and processes across all body systems. Your ovaries are the source of estrogen and progesterone, the two key hormones that control the reproductive system, including the menstrual cycle and fertility in women. You are born with all the eggs you will ever have. The eggs are in the follicles, which are found in the ovaries. During menopause, the number of ovarian follicles declines and the ovaries become less responsive to the two other hormones involved in reproduction—Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH). As your ovaries age and release fewer hormones, FSH and LH can no longer perform their usual functions to regulate your estrogen, progesterone and testosterone. These inevitable changes in your hormones and natural decline of estrogen levels during menopause can significantly affect your health for years to come. Click on the bars next to diagram to discover how estrogen depletion can affect each part of your body.

We’ve got this, sisters. Keep the conversation going.

Thank you.