What Every Woman Should Know About Perimenopause

The period is having a media moment. We’re starting to talk about it, and everything surrounding it, as though it’s normal – because it is. It should not be a source of embarrassment or shame. Maybe, to badly paraphrase Gloria Steinem, we should take a page from men – because if they menstruated, you know they’d brag about it. They’d live-tweet that shit.

As the period is having her moment, let’s also turn the spotlight toward her older, wiser sisters: menopause and perimenopause.

When our periods began, most of us had mothers, grandmothers, or other experienced older women to show us the way. To tell us how to make it easier. But when we greet perimenopause and then menopause, we often do so without guidance; not because our foremothers didn’t want to show us the way, but because they didn’t know.

The year I turned 39, I started having weird, irregular periods. I’d have one every month, but would spot after it was supposed to be over for another ten or twelve days. I had a D&C – dilation and curettage; a scraping of the lining of the uterus, fortunately done under anesthetic. The bleeding returned. An exam showed nothing structurally wrong. (The nurse who examined my uterus memorably told me it was “cute and perfect, like a little golf ball in there.” Who knew a uterus could be cute? I felt weirdly accomplished – I have a cute-erus!) Ultrasound revealed a small cyst on my ovary.

I brought up other symptoms with my OB-GYN. I was having what felt like two weeks of the worst PMS of my life every month, complete with breast pain, bloating, food/carb cravings, and irritable moods. My libido was in the crapper. I was either spotting, on my period, or having PMS – there was no ‘normal’ anymore.  This was seriously affecting my quality of life. My doctor was a woman my own age; I expected her to be, if not sympathetic, at least understanding.

Wrong.

She offered me anti-anxiety drugs for what she referred to as my “mental symptoms,” recommended ibuprofen for the breast pain and suggested we take out the ovary with the cyst on it. Without any explanation (even when asked) of why that might be necessary, or how I would benefit from having the ovary removed.

I went home. Cried. Asked Google a lot of questions. And found another fucking doctor. I have done so much reading and research on perimenopause in the intervening years, and eventually had guidance from a great doctor. We shouldn’t have to work this hard to find out what’s going on at this stage of life. I’m sharing my experience here, in the hope of making the journey to knowledge and help a little shorter for someone else.

What is perimenopause?

My ‘new’ OB-GYN is an absolutely lovely woman. Going to see her is like going to see your mother, if your mother is comforting, encouraging and super supportive and knows everything there is to know about how your lady bits work. We’ll just call her Dr. Mom for short. She explained to me that menopause – the cessation of the menstrual cycle, which usually happens around age 50 – has a really long on-ramp, sometimes ten or fifteen years. This is what we now call perimenopause.

The things that were happening to me were natural and normal and part of the evolutionary plan. They were not “mental symptoms.” In most of our long human history, at 35 or so we became much more likely to die in childbirth, and/or bear a child with serious health problems. So Mother Nature doesn’t want me pregnant after that age – for my own good, and the good of the species. My collection of symptoms were designed to prevent that from happening. But ‘natural’ didn’t mean I had to live with it. There were options:

Hormone therapy: HRT and bioidentical hormones. Hormone Replacement Therapy, or HRT, is the name for something that used to be standard therapy for women entering menopause fifteen or twenty years ago. These are synthetic hormones, medications with names like Premarin or Provera. Subsequent research indicated women on HRT had poor health outcomes, and HRT was dropped as the standard of care. But there was nothing to replace it with.

Enter bioidentical hormones (thank God).

Bioidentical means the same-shaped molecules as the native hormones our bodies make. There is a lot of confusion and it can be really hard to tell which is which (the pharma companies want it that way). Dr. Christiane Northrup, MD and menopause expert, offers straight-up advice on how to tell the difference. If you’re going to try bioidentical hormones, she’s a great place to start.

Dr. Mom explained that for a long time, it was assumed that perimenopause symptoms like mine were due to reductions in estrogen levels. But it turns out that’s a myth – and the opposite is true. Levels of estrogen during perimenopause are high, out of proportion to its balancing hormone, progesterone. Estrogen dominance is the cause of many perimenopause symptoms (especially now, with environmental estrogens everywhere); and they can be addressed by progesterone supplementation.

Bioidentical progesterone cream is available over the counter, and for a bit I experimented with that. I saw mild relief of some symptoms, but it felt clunky and inexact. I wanted more relief, and more precision. Dr. Mom put me on a prescription called Prometrium. This is bioidentical progesterone in pill form, approved by the FDA and paid for by my insurance company. I took it for about ten days every month, during the PMS portion of my cycle.

Oh, sweet relief.

Progesterone is the ‘mother hormone,’ from which all others are made. When we’re young, we’re all swimming in it. It is incredibly calming, and when taken at bedtime, eliminates the insomnia that often comes with perimenopause – and good sleep alone will change your life.

The breast pain, irregular bleeding, painful breasts and murderous moods were all gone.

Hormones for low libido. Remember that part about how Mother Nature doesn’t want me pregnant after 35? Low libido is a big weapon in her arsenal. Hard to get pregnant if you can’t stand the thought of the male of the species within five feet of you. The good news, doc said, was that my libido fluctuates during my cycle – high right after my period, progressively lower as my period approaches. That means my low libido is related to my hormone fluctuations and not something else, and can be addressed – and also that it will return to normal (and perhaps even be increased) after my menopause is complete.

Dr. Mom prescribed bioidentical testosterone cream. Yep, ladies make testosterone too, and we need it. It’s not only responsible for our libido, but it has a hand in mood, metabolism and energy, and helps us maintain muscle mass and definition as we age. I applied the cream every day about two hours before bedtime, enough to keep my testosterone levels at the high end of normal for a female. I had to get it through a compounding pharmacy, and my insurance did not cover it. It helped; on a scale of one to ten, it took my libido from a zero to a five. Great progress, but not yet where I want it to be.

I recently stopped the testosterone cream to try a less messy and less expensive option called DHEA. It’s the precursor to testosterone, and I take one every morning, in combination with an herb called maca. It’s only been a couple weeks, but I feel it’s delivering a steadier boost, and I’m hopeful about continued progress.

Ovarian cysts. Our ovaries, I learned, are not useless to us once we’re done having children. These things are our lady-balls, and even after their reproductive function is over, they produce hormones that are central to our well-being. Removal should be a last resort – not, as in the case of my original OB-GYN, the very first suggestion. Women who have had their ovaries removed are at risk of a cascade of cardiovascular, cognitive, sexual and quality of life effects.

And making cysts is sort of what they do. If your cysts aren’t cancerous (and a biopsy can tell you this), the major risk is torsion – where the cyst makes the ovary become so heavy it falls over and twists on itself. I elected to live with this risk. It’s painful enough that I’ll know if it happens, and deal with it then.

Surgical options. Endometrial ablation is the destruction, with heat, of the lining of the uterus. It’s an office procedure or outpatient surgery. While it was originally meant for women with uncontrolled bleeding as an alternative to hysterectomy, many women who’ve had one say it helped with their PMS-like perimenopause symptoms as well.

Hysterectomy is still an option, especially for women with very heavy bleeding. Now most surgeons preserve the ovaries (and thus our health) and remove only the uterus unless there’s a definitive reason to take the ovaries too.

It’s all up to you. How we handle this time is very personal and personalized; it impacts us all differently, and there is no wrong way. It also changes over time, the closer we come to menopause. My cyclic progesterone recently stopped controlling my symptoms and I felt like I was back to square one. Dr. Mom changed my progesterone so I am taking it every day. It’s too early to tell if it works.

If it’s possible to be ‘tempted’ by surgery, then I am tempted by endometrial ablation. I know six women who have had it, many of them for symptoms just like mine; they were all turned off by the tinkering involved in working with bioidentical hormones. And they each say the ablation is the best thing to happen to them in years. But I’m freaked out by the thought that I’d be ‘destroying’ a part of myself, a part heavily symbolic of my femininity and wisdom. Which sounds totally woo-woo but there it is.

As always, these are my experiences only, and not medical advice. Let’s surface these issues, talk freely about them and share our knowledge, so when our daughters arrive at this point in their lives they will greet it with confidence, knowing how to care for themselves.

Maybe they’ll even brag about it.

Maybe they’ll live-tweet that shit.

 

A(n) Unfit Mother’s Take on Parenting

The October that Adrienne was ten months old, I pulled into a gas station with her asleep in her car seat. I filled the car…she didn’t wake. Rather than wake her, I locked the car doors and went inside to pay. I was parked at the pump nearest the building – when I was at the checkout counter, I was about ten feet from my car, able to see Adri through the glass door, keys in my hand. I laid my $20 bill on the counter, turned to go, and a woman burst through the door, shoving me aside.

She looked like she’d had a hard life. She had grizzled shoulder-length grey hair, and one of her front teeth was missing. At the top of her voice, she yelled, THERE IS A BABY ALONE IN THE CAR OUT THERE! WHOSE BABY IS THAT!?

Mine, I said, hand on the door.

WHAT THE HELL IS WRONG WITH YOU, LEAVING A BABY ALONE LIKE THAT? YOU ARE A UNFIT MOTHER!

I said something like, “She’s fine. And what you’re actually doing right now is keeping me from her,” and walked out the door.

“YOU ARE A UNFIT MOTHER,” she yelled again, at my retreating back.

This is when I knew that mom-shaming is really a thing. It was funny, but it also left me shaken. It was suddenly clear that just about anyone would feel free to judge my choices, and that as a mother, I was going to be held to a standard different than Anthony. (I doubt the same woman would have yelled at him this way.)

There are many similar experiences (don’t get me started on the time I forgot it was picture night at dance), but they all point to the same thing: parenting in the current culture means knowing that every decision can open you up to judgment.

Why? Why are we so into judgment and shame right now?

Because we’re scared. People who are comfortable with their own choices don’t need to judge the choices of others. In 1979, the mom next door didn’t give a shit what you were doing with your kids; she’d just made hers go outside and was about to light up a Virginia Slim and watch General Hospital.

But now none of us can be truly at ease with our choices – the world feels different, like the stakes are so high we can’t afford to be wrong. These high stakes, along with cultural pressure and the constant threat of judgment, drive us toward overparenting. We know this new intensive, competitive parenting isn’t good for us, and robs our kids of self-reliance and resilience. Still we can’t seem to stop.

This impacts every aspect of our kids’ lives, in school and out. It’s no secret that many of our kids are overscheduled. But in addition to doing more, the doing feels different. A generation or two ago, a kid who spent twenty hours a week at a single non-school activity was a rare bird – a musical prodigy, an ice skater with Olympic dreams. That’s not so unusual now; every activity seems to come with pressure attached to achieve, perform. Now you have to be an elite dancer, you have to be a gymnast or a martial artist or first chair – you can’t just be a kid who takes dance or tumbling or karate or noodles around on the oboe.

Don’t get me wrong, I think extracurriculars have great value. Setting and going after goals, working as a team, developing resilience in the face of failure, are all skills critical to adulthood that kids can develop through athletics and the arts. But once they became tied to the college application, some of these lessons were lost in service to achievement and performance. Activities ceased being ‘extras’ – and too often ceased being fun. Now we stack up our kids’ activities like gold bars, bring them out for those college applications as proof that a child excels in all areas, is ‘well-rounded.’ When in fact, the relentless pressure to achieve is creating kids that are the opposite of that.

Competitive parenting shows up in our bank accounts, too. This recent article in The Atlantic explores why so many people who have middle-class incomes are secretly in financial distress, to the point of being unable to come up with $400 in an emergency: because we spend to the brink for the kids’ education (most often paid for by where we buy our homes). It’s our kids’ shot at life. We judge, we overparent, we overschedule, all for the same reason we overspend: because “in a deeply unequal society, the gains to be made by being among the elite are enormous, and the consequences of not being among them are dire.”

Frankly, I was glad to know we’re not all just spendthrift assholes. I mean, aren’t you relieved? High five! Thanks, Atlantic!

But this is still the environment we have to parent in. How do we gain perspective, walk it back to something just a little more sensible in the short time we have to parent our children?

This pressure to be the perfect parent, to overextend yourself in every way possible in service to your children, is so pervasive that it’s hard to see outside it, hard to get any distance – like a fish can’t see the water. But over time, I’m learning to recognize signs of overparenting in myself, and sometimes, to catch them in time to change course:

Resentment. If I feel resentful, angry, or taken for granted, it’s a sure sign I’m either not communicating with my parenting partner, or I’m overdoing it on Adri’s behalf (usually on stuff she never even asked for). Most likely both. And that’s the point at which I need to back off what I’m driving myself to do for others, ask myself what I need, and try to give it. Martyrdom only serves the martyr; it doesn’t serve our kids. Nobody wants to be the person their parent “sacrificed everything” for. Don’t ask me how I know.

Invisibility. Our positions on the sidelines, as permanent cheerleaders, maids and chauffeurs for our kids, do a double disservice. First to our own lives, as we give up many of the things that make us whole. And also for our children. Everything I do models for my daughter how it is to be an adult woman – and not just the stuff I want her to see. I hope to show her that, while it means being there for your people, it sometimes also means they are there for you – that you too are seen, recognized and appreciated, and sometimes even take center stage.

Here’s what I know for sure. The things Anthony and I do, the limits we set that save our sanity and make everyday life worth living, are also the things most likely to make Adri a balanced, functioning human that others can stand to be around. That was true in early childhood (yes you must go to bed; no you do not get a present when it’s someone else’s birthday), it’s true now (sometimes mom and dad do stuff that doesn’t include you; it’s what grownups do), and I expect it to hold true in the future (our retirement account takes precedence over your college fund; you can thank us later). That knowledge is my life-ring in the sea of pressure and judgment – even if I sometimes lose my grip.

Distress

At lunch yesterday, one of my coworkers was sharing her grief over a friend’s teenage son, who was being treated for depression and died by suicide over the weekend. His parents, recognizing a mental health crisis, took him to the emergency room where a resident evaluated him, found him calm and harmless, and released him. The boy killed himself within 48 hours of the release.

Another colleague – ordinarily a kind, sensitive and well-informed soul – let loose a stream of tone-deaf remarks that took my breath away.

Oh, they should have taken him to Hospital X instead.

Didn’t the therapist give the family a plan so they’d know what to do in case this happened?

I guess if you don’t understand the system or know how to advocate for yourself…

I had to excuse myself. And it wasn’t even my friend.

I was saddened that with all the recent awareness around mental health, all the progress, a well-meaning and educated person would say things like this. I’m sure she’d never dream of suggesting to a family whose son died of a sudden cardiac arrest that his death could have been prevented if they had taken him to a different hospital. Or had a foolproof, ‘What To Do In Case of Unexpected Heart Attack’ plan stuck to their fridge. Or known exactly the right words to say so that The System would not let their child die.

We don’t expect the parents of a child in cardiac distress to be able to diagnose him on the spot, pull out a scalpel and perform open-heart surgery in the living room. But we expect the parents of a child in mental distress to be able to do the psychiatric equivalent.

These parents did what they should have done, all they could have done – they got him to the professionals when they saw he was in trouble. Given the current state of mental healthcare, I can only imagine the effort and insight required to even get him that far. There is no ‘system’ for people trying to get help for a loved one with a mental illness, no solid support. Instead there is a tightrope over the abyss – and the winds are high.

The professionals could not save their boy either. Whether something was missed by those professionals can change nothing now, and is for nobody but the parents to decide and act on.

One of my favorite authors, Michael Neill, candidly talks about his experience with clinical depression as a teen. He describes a brush with suicide in college as an overpowering feeling that he was being sucked out his dorm room window by an enormous vacuum. No ‘attempt,’ no note; all he would have had to do…is let go.

It is doubly heartbreaking that this young man lost his grip, just as so many people were reaching for him.

Fog Warning

 

I’ve never said I have depression.

I’ve been taking an antidepressant, true. And amino acids. For years. I can feel the grey fog start to swirl around my ankles when I haven’t been taking care of myself. When I don’t sleep. When I eat poorly. When I have a run-in with my past. The fog obscures everyone and everything good in my life, until I just can’t see any of it, and I feel alone. Marooned. I sit on the edge of my bed, drawing on all my reserves just to get up. To speak. To shower.

I’ve never said I have depression.

Why?

Maybe it’s the stigma that still surrounds anything that touches our mental health. But that doesn’t feel true to me; it feels too easy, too simple by half. Why don’t I feel like I have depression?

Part of it is because it feels like my moods are physiological; but depending on your perspective, that could be said of nearly everyone diagnosed with clinical depression. But mostly I cannot say it, because people with clinical depression have fought (and won, and lost) desperate, bloody battles. I have only toured the battlefield. The difference is vast.

Diabetes is often used as an analogy to depression, when it comes to the importance of self-care and trying to bring an end to the stigma surrounding a mental health diagnosis. If you had diabetes instead of depression, would you still feel you should get along without medication?

 The medical world can now identify people who have pre-diabetes, metabolic syndrome, insulin resistance – collections of symptoms and risk factors that mean that, while you don’t have an official diagnosis of diabetes right now, you’re damn sure on the way if you don’t do anything to stop it. I feel like there is a depression version of that. What should we call it? A spiritual syndrome? Serotonin resistance? A fog warning?

I am just coming to terms with the fact that fog-prevention is in my hands. Many times self-care or taking any kind of time to acknowledge and give space to the fog has seemed like a luxury to me. Or like weakness. I can gut this out – I need to get up and get my ass to work.

Last week, I did something different. I took some time.

Over the weekend, I’d had one of those run-ins with my past. I think the world of mental health calls it a trigger. It felt more like a detonation. By Monday, I was leveled. With the alarm clock came the feeling of constriction, of a weight on my chest so heavy I could not draw a deep breath.

I pushed myself into the shower. Couldn’t quite meet my own eyes in the mirror. Dragged on my clothes. This isn’t a reason to stay home from work. Is it?

And then Anthony asked me, “Is there anything at your office today that’s truly pressing?

No.

“Then maybe you should get back into bed.”

I did. I slept for three hours, read, cried, watched Netflix, and generally did not expect anything of myself until I got dressed about 30 minutes before Adri came home from school. By that time, I was steady enough to be a mom. And as the week passed, I felt better. Not immediately, not in a linear fashion, but faster, I think, than if I had tried to just push through.

And I learned something.

Even as I decline to claim something I don’t feel belongs to me (I have depression), I can acknowledge what does. I can listen to the fog warning, and alter my course accordingly. I can care for myself as tenderly as I would one of my loved ones.

I can steer around that iceberg. And so can you.