Why we don’t talk about perimenopause, HRT, or women’s pain

Can sharing our stories help women at the doctor's office?

By Anne Holub

I turned 46 about six months ago, and at that point, it turned out I’d already had a taste of perimenopause for six months. From night sweats to mood swings and yes, that unpleasant weight gain around my middle, I was miserable most of the time. But this spring, I decided to do something about it. 

This is how I realized I had symptoms of perimenopause – I started talking about it.

Over Christmas, I made plans with a group of 40-something lady friends and we decided to have a mocktail night – mostly because we all confessed that alcohol, even just one or two beers, would lead to night sweats without fail. The conversation turned to the discovery we’d all had that perimenopause was definitely a part of our lives now. Our group included moms and not-moms in our group, women who live “super healthy” lifestyles and those of us just getting by, but we were all pretty much in the same boat: the beginning of what our moms called “the Change.”

Then we started talking about what we were going to do about it. Sharing our stories helped.

What the Heck is Perimenopause, Anyway?

Perimenopause means “around menopause” (not “before menopause,” as you might assume). During perimenopause, you might have sporadic periods, with heavier or lighter flows, but you’re still able to get pregnant. Perimenopause begins typically in your 40s, but can start as early as your 30s, too! Menopause is officially marked when you naturally don’t have a menstrual period for 12 consecutive months.

Your body’s fluctuating estrogen levels make perimenopause so wacky. This creates a range of symptoms, which can (but don’t always) include the following: 

• Menstruation fluctuations

• Hot flashes

• Night sweats

• Mood swings

• Insomnia

• Vaginal dryness and other skin issues

• Lowered sex drive

• Bone loss

• Change in cholesterol levels

• Trouble concentrating

• Bladder leaks

• Joint and muscle aches

• PMS-like symptoms

Reading over this list of super fun symptoms that can attack at any moment makes the desire for relief very natural! Now if only getting that help was simple. Not only are these symptoms similar to a host of other problems women face as they grow older, they also might come and go on a whim, no apparent cause or correlation. And depending on your healthcare provider and their training, your doctor might not know much about, or even recognize, perimenopause as a specific or significant problem.

And that’s exactly what happened to me. Right before my 46th birthday a year ago, I had a high cholesterol ding in my annual blood work, but I also had terrible depression, anxiety, and insomnia due to (what I thought was) just work and life stress. I had night sweats, but I’d also gained weight; I thought I was just a “hot sleeper” and just grumbled through it all. My doctor saw my labs and didn’t really blink. I’d been getting full panels for a few years, ever since I had asked for an A1C test. I also had blood sugar readings in the prediabetes range after gaining weight, so we monitored that yearly. But high cholesterol? Not a thing for my medical history. 

My doctor was also so overwhelmed with her own workload that I didn’t get much beyond a letter saying that this or that number was high, but she knew I could bring it down. It takes me three months to get in to see her normally, so a quick follow-up wasn’t really feasible. 

Why we don’t talk about perimenopause treatments

Our medical system is frequently overwhelmed, and looking for an answer to every single symptom is next to impossible. It’s tempting to follow our “Doctor Google” searches to discover what’s maybe going on with our bodies, and just add broccoli and oatmeal to the grocery list. I was also dealing with life chaos, depression, and a host of other things at the time, so, like many women do, I pushed my issues aside.

In fact, women’s distress doesn’t seem to faze doctors much at all, and our medical system as a whole doesn’t seem to give a lot of thought to relieving women’s pain. There are tons of examples of doctors not listening to female patients, even as they report massive physical pain, only to find out something has ruptured or broken inside after they’re sent home. And since aging women are even more often swept to the side of our public attention, women well past the age of “not young enough to date Leonardo DiCaprio” are seriously put out to pasture. 

Compared to medical and pharmaceutical research, medical treatments for peri- or menopausal women get much less attention than men’s health research. Nicola Swanson, noting the UK’s gender gap in research, asked this rhetorical question in The Guardian in 2019:  “Women have been woefully neglected': does medical science have a gender problem?”

To which women around the world shouted, “Duh!” 

Swanson wrote: “Less than 2.5% of publicly-funded research is dedicated solely to reproductive health, despite the fact that one in three women in the UK will suffer from a reproductive or gynecological health problem. There is five times more research into erectile dysfunction, which affects 19% of men, than into premenstrual syndrome, which affects 90% of women.”

And that’s just in the United Kingdom, with its publicly-funded health system. United States private (for-profit) pharmaceutical companies would really rather not solve the problems that could affect nearly every menstruating woman when they reach a certain age. 

A Nature editorial published in May, 2023 noted that “Despite its importance for the health of half the world’s population, menopause is under-studied. And, at least in the United States, it is difficult to track funding for menopause research, because the NIH hasn’t assigned menopause a unique identification code like the ones other conditions (such as anorexia or prostate cancer) have. Someone wanting to find out must read every grant that mentions ‘menopause’ and add up the numbers manually.” 

That’s an incredible burden on someone just trying to find out how many women are left out of the equation, right?

Susan Dominus wrote in the New York Times in February about menopause treatments that most women know nothing about – instead suffering through awful, often debilitating symptoms for years, if not decades. Women are trained from an early age to please, not to make a fuss about ourselves, so we suffer through it all, from monthly periods to painful cramps and all the emotions, bloating, and distress. 

Evolving past this in our 40s — and seeking out much-needed help — is not easy, but at least more of us are talking about it, and speaking up to access better care. 

Dominus wrote that she was hearing about the same roadblocks at doctor’s offices as her middle-aged friends. They either had doctors who didn’t want to address their perimenopausal symptoms as “serious” or “treatable”, or were unwilling to prescribe HRT. It made these women feel like they couldn’t or shouldn’t speak up for themselves to advocate for living a life without pain or distress. (Leading, ironically, to more distress.)

Anne’s debut poetry chapbook, 27 Threats to Everyday Life, was published by Finishing Line Press in 2023 and was a runner-up in the press' New Womens Voices Competition.

The resurgence of HRT, despite bad press

And that’s the thing. If you’re in your 40s now, you likely had a mother or relative go through “The Change” in the 1980s and ‘90s and who sought out HRT at its peak popularity. That’s also when it all fell apart. 

Dominus wrote that menopausal hormone therapy was once the most commonly prescribed treatment in the United States, until a now-shown imperfect study was published in 2002. In it, the authors claimed to have found links between hormone therapy and elevated health risks for women of all ages. 

“Panic set in; in one year, the number of prescriptions plummeted,” Dominus wrote. “Hormone therapy carries risks, to be sure, as do many medications that people take to relieve serious discomfort, but dozens of studies since 2002 have provided reassurance that for healthy women under 60 whose hot flashes are troubling them, the benefits of taking hormones outweigh the risks. The treatment’s reputation, however, has never fully recovered, and the consequences have been wide-reaching.”

And indeed, this one imperfect study led doctors to also shy away from the practice of prescribing HRT to patients. Meanwhile, women don’t ask for HRT because of the vague baked-in memory we have of there being “something wrong” with it, like those red m&m’s (which are also OK now). 

An analysis of the flawed study published in the medical journal Obstetrics and Gynecology in 2019 by Angelo Cagnacci and Martina Venier noted that the publicity for the study’s negative results created a panic for women and doctors.

“The clear message from the media was that HRT had more risks than benefits for all women,” they wrote, despite a WH1 trial reanalysis and new studies showing HRT’s cardiovascular benefits for younger and early postmenopausal women. The public opinion on HRT hadn’t changed enough yet, “leading to important negative consequences for women’s health and quality of life.”

New HRT studies show that the therapy is helpful for women in perimenopause to relieve symptoms, and it can also have benefits in the long term, including: 

• a lowered risk of cervical cancer

• a lowered risk of Alzheimer’s disease

• a lowered risk of diabetes

• a lowered risk of bone fracture

• a lowered risk of bowel cancer

For women taking a combination of estrogen and progesterone HRT (what you likely receive if you still have a uterus) there was a slight increase in the chance for serious medical complications, including thromboembolism, stroke, and breast cancer after long-term HRT use. Women who only took estrogen replacement also showed an increased risk for breast cancer and heart attacks. However, these complications are similar to the risks we take for many other common medications, including birth control pills. Smoking or high blood pressure, along with other conditions, can increase risks. 

The best way to know is to talk to your doctor about your risk factors and if HRT is right for you. Next time, I’ll share my personal experience with HRT, because it’s so important to talk about it. 

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Anne Holub is a writer and poet whose last name means “pigeon” in Slovak. Her poetry has been featured on Chicago Public Radio, Yellowstone Public Radio, and a whole slew of publications both online and in print, including the anthology Bright Bones: Contemporary Montana Writing (Open Country Press 2018). Her debut poetry chapbook, 27 Threats to Everyday Life was published by Finishing Line Press in 2023 and was a runner-up in the press' New Womens Voices Competition. Originally from Charlottesville, Virginia, and after more than a decade in Chicago, she now lives, writes and grows things in the dirt in Montana with her husband Dan, their two dogs Merle and Rosie, and a sourdough starter named Rhonda. Catch up with her writing at aholub.com. Follow her on Instagram: @izatchu or where she types poems on vintage postcards @poetrypostcard.