I experienced my first real hot flash six months after my 50th birthday. Until that point, I had associated the term with cartoonish depictions of middle-age women desperately fanning their faces and flapping their blouses to stave off waves of perspiration. I dismissed the cliché as embarrassing and unrelatable—an outdated punch line that I would surely sidestep with exercise, healthy habits and youthful optimism. That would never be me.
How little I knew.
Never had a hot flash? Imagine being strapped into a roller coaster you don’t want to ride. A prickle of discomfort twitches under your skin as you click up the track. At the apex, a rush of heat consumes you from the inside out. The descent into your own personal inferno lasts only a few minutes, but you wonder if anyone is noticing the panic on your glazed-doughnut of a face as you frantically cast about for the nearest exit or walk-in freezer.
The roller coaster then grinds to a halt and you’re kicked off the ride, bewildered at how casually your body has just betrayed you. All you can think about is peeling off those damp clothes. Because guess what? Now you’re freezing.
At its worst, this would happen to me 12 to 15 times a day, including waking me up every two hours at night.
A Laundry List of Symptoms
Hot flashes may be the most common symptom associated with menopause, but they aren’t even the half of it. The litany of complaints can also include mood swings, achy joints, insomnia, weight gain, recurring UTIs, dry skin and a whole lot more.
“Nobody walks into the menopause transition—everyone gets dragged into it,” says Terri Remy, an internist and Menopause Society Certified Practitioner (MSCP) at VHC Health and its new Menopause Center, which opened in May in the Charlotte S. Benjamin Center for Women’s Health.
Typically, Remy says, women start noticing changes in their menstrual cycle during their 40s, when the production of estrogen—an essential hormone in the female reproductive system—decreases, and periods become intermittent and less predictable.
The average age for menopause (the day of a woman’s last menstrual period) is 51, but symptoms can last five to 10 years on either side of that milestone.
“Eventually there’s a skipped period, and the vasomotor symptoms start,” Remy says, referencing the notorious hot flashes and night sweats that leave many women drenched once hormone fluctuations deprive the brain’s estrogen receptors of the signals needed to control the body’s thermostat.
“When my patients tell me they feel like an alien in their own body, that’s often the first clue,” says Jennifer Lanoff, an MSCP and nurse practitioner at Reiter, Hill & Johnson, an OB/GYN practice with offices in Falls Church. Lanoff also serves on the National Menopause Foundation’s medical advisory team.
Rather than focusing on hormone levels, which can fluctuate so dramatically that blood tests aren’t an accurate measure of whether someone is in menopause, Lanoff says she treats the symptoms.
“I have a list of things I ask about,” she says, “including hot flashes and night sweats, brain fog, low libido, weight gain, mood changes, insomnia, hair loss, joint pain, frozen shoulder, heart palpitations, vaginal dryness, pain during sex.”
And those are just the more common menopause maladies. Her checklist of more than 30 possible symptoms also includes things like burning mouth, difficulty concentrating and panic disorder.
“The first thing doctors want to do when you’re over 50 is put you on antidepressants,” Lanoff says. “I say, ‘Let’s try some estrogen. Maybe you’re depressed, sure, but maybe it’s hormones.’ ”
“The first thing doctors want to do when you’re over 50 is put you on antidepressants. I say, ‘Let’s try some estrogen. Maybe you’re depressed, sure, but maybe it’s hormones.’ ”
Plummeting estrogen levels can wreak havoc on a woman’s mental equilibrium, resulting in irritability, moodiness, anxiety and depression.
For patients who undergo a complete hysterectomy (often for excessive bleeding or cancer) and also have their ovaries removed, the side effects of estrogen loss can be almost instantaneous.
“As the brain is yelling louder at the ovaries to release more eggs, we start having these prominent hormone swings that make people think they’re crazy,” says Amanda Rohn, an OB/GYN and certified menopause practitioner at VHC Health’s Center for Women’s Health. “It’s actually pretty common. There are a lot of treatment options we can try, and sometimes just knowing you’re not alone can be helpful.”
In fact, any bodily system that’s affected by estrogen is fair game. Even your ear canal. “Some people report that the insides of their ear canals are itchy,” Rohn says.
Others have urinary leakage as drops in estrogen affect the strength and resilience of their pelvic tissues.
And here’s a fun one: When I polled my friends about their craziest perimenopause symptoms, one who just turned 47 shared that she’s struggled with cyclical bouts of constipation so severe they nearly sent her to the ER. They turned out to be caused by enlarged hemorrhoids that were “activated” by the prostaglandins released during her period—“apparently more as I get closer to menopause.”
The myriad symptoms of menopause aren’t just annoying, embarrassing and uncomfortable—they often send us to multiple doctors and specialists (in some cases, waiting months for an appointment), not realizing how they are interrelated.
As my friend Ami, who just turned 48, recently observed: “I’ve seen a dermatologist for my adult acne, an ENT for my tinnitus and an internist for my UTIs, but apparently I just needed to find a menopause specialist.”
After centuries of hushed suffering, menopause has stepped into the spotlight. Society has finally begun to talk more openly about this very real physiological and psychological transition that every person born with female reproductive organs will experience if they live long enough. (This article refers to that population as women, but the group also includes trans men and nonbinary people.)
“Nobody talked to me about the wide range of symptoms that came along in my late 40s—exhaustion, brain fog, weight gain, lack of sleep, night sweats,” says my friend Victoria, now 59. “At one point, a physician suggested it was ‘all in my head’ and perhaps I needed therapy. I cried. Nobody suggested hormone therapy at that time.”
Even if you don’t go through menopause yourself, you’re probably living or working with someone who will. So why is it that we remain so ill-informed about the full spectrum of symptoms and treatment options?
“It wasn’t until 1993 that it was mandated that women be included in clinical trials,” observes Claire Gill, founder of the National Menopause Foundation, an Alexandria-based nonprofit formed in 2019 that focuses on menopause research and advocacy. “They used to just do research on men and then apply it to women. If this happened to men more than women, the crisis would be over.”
In November, the Biden administration created the White House Initiative on Women’s Health Research, calling for $12 billion in funding to address gaps in crucial health data.
“About 1.3 million women in the U.S. enter menopause every year, and women will spend approximately a third of their lives postmenopausal,” says Gill. “Yet we have far too little information and too few clinicians to provide adequate care. Medical school education for OB/GYNs focuses mainly on the reproductive years. We need to do a better job educating clinicians and ensuring that there are enough practitioners to support this population.”
The Truth About Hormone Therapy
Given the role that estrogen—or the lack of it—plays in menopause symptoms and treatment, we also need to set the record straight about hormone therapy (sometimes referred to as hormone replacement therapy, or HRT) and cancer risks, says Remy at VHC Health.
In 2002, a nationwide panic ensued after the Women’s Health Initiative (WHI), an ongoing study out of the National Institutes of Health, suggested that HRT increased the risk of breast cancer by 26%. That finding was later determined to be overblown.
The study, which was intended to assess the impact of hormones on cardiovascular health, used synthetic hormones in oral pill form that are no longer commonly prescribed. Moreover, it was conducted primarily on women in their 60s—a far different demographic from those normally seeking hormone therapy for menopause symptoms.
Medical experts now agree that the study misrepresented and overstated the risks of HRT (a May 2024 review in the Journal of the American Medical Association reinforced this conclusion), but the percentage of women choosing HRT plummeted after the study’s initial release. A whole generation of women suffered unnecessarily, Remy says. “The increased risk was actually about nine women in 10,000,” she clarifies. “It’s the same degree of risk as a woman choosing to have a glass of wine every day, or being obese.”
Newer research from NIH’s Women’s Health Initiative suggests that hormone therapy can actually produce positive outcomes for women who start it before or within the first 10 years after menopause and before age 60 (as is currently recommended).
“Estrogen is good for cholesterol, for your bones, for reducing plaques in your arteries,” says nurse practitioner Lanoff. “Brain function is seemingly better protected, and even the odds of developing cancer are reduced.”
Why aren’t these newer findings widely known? Lanoff shrugs. “There hasn’t been a press campaign to correct the misinformation. You know what they say: The lie gets halfway around the world before the truth even gets its shoes on.”
“Hormone therapy carries the same degree of cancer risk as a woman choosing to have a glass of wine every day.”
Kamili Wilson had no idea what was going on when she first started experiencing perimenopause symptoms at age 43—earlier than the average, but not unheard of for a Black woman. (Black and Native American women are more likely to hit menopause earlier.) At first, her symptoms were bothersome but typical: night sweats, adult-onset acne and an unpredictable menstrual cycle. But when her emotions got pulled into the mix, things took a dark turn.
“I was having these really intense bouts of rage, particularly at work,” recalls Wilson, a senior VP at AARP with a background in strategic communications. “They were violent, disproportionate to the situation, and very scary for me. I didn’t feel normal. I’d spent years managing the ‘angry Black woman’ trope, and then here I was, experiencing the kind of rage that made me afraid that if I went in to the office, I would lose my job.”
Wilson discussed her symptoms with the OB/GYN she’d been seeing for years. He dismissed them as “just part of the aging process.” She decided to take her health care into her own hands.
“I’m a true Gen Xer, so I started Googling everything,” says Wilson, who has lived in Arlington since childhood. “All the images were of older, White, white-haired ladies. If you start experiencing menopausal symptoms in your 30s and 40s, that’s not you. I remember feeling so alone.”
Though the severity and duration of menopause symptoms can be genetic, factors such as race and environment also come into play. “African American women tend to have worse vasomotor symptoms, are more likely to have a hard time getting access to care and are less likely to feel like they’re heard and understood by health care providers,” says Rohn at VHC Health.
Having undergone two surgeries to remove uterine fibroids, Wilson was reluctant to try estrogen therapy while she was still getting her period (“estrogen can fuel the growth of fibroids,” she explains). At first, she attempted to manage her symptoms through diet and lifestyle choices.
“The changes I made didn’t cure my symptoms,” she says, “but I learned about things like my triggers for hot flashes—sugar and alcohol.”
In 2021, Wilson launched Menopause Made Modern, an online community and resource for women of color going through perimenopause.
“I decided I was going to put the stuff out there that I was looking for—the information that would have helped me,” she says, “so that if someone goes looking for culturally competent care, they can find it. I want to have representation and inclusion not be an afterthought.”
Now 50, Wilson ended up leaving her previous gynecologist for Waldorf Women’s Care, an all-Black, women-led practice with offices in Arlington and two locations near Waldorf, Maryland. She’s recently found relief in nonhormonal medications, including the anticonvulsant medication gabapentin, which is often prescribed to help perimenopausal patients with sleep problems and hot flashes. She also uses testosterone, which alleviates joint pain and inflammation and offers the ancillary benefit of helping build muscle.
“Navigating this stage of my life, I’ve realized that I have to be my own advocate,” she says. “I write down questions when I go to the doctor… so that I won’t feel overwhelmed or rushed and forget to ask. I take notes during the visit.”
New and Expanding Treatments
The treatment options for menopause symptoms are expanding. In 2023, the first FDA-approved nonhormonal drug to combat vasomotor symptoms hit the shelves, sold under the brand name Veozah. A second hot flash drug, elinzanetant, was recently submitted to the FDA for approval.
But this new frontier in medicine also has its snake oils. We ladies of a certain age have all heard celebrities and Instagram influencers touting various gadgets and supplements (I’m looking at you, jade egg). “Anyone who’s making money off of menopause makes me uncomfortable,” Lanoff says.
Rohn concurs: “Homeopathic and herbal treatments are very poorly studied and not well-regulated,” she says, “but things like mindfulness, meditation, healthy eating and exercise are all helpful. They reduce stress, diminish cardiovascular risk, strengthen bones, and help you feel better in your body—even if they don’t necessarily cure everything.”
While hormone therapy remains the gold standard for treating menopause symptoms, all estrogen therapies are not the same. Physicians interviewed for this story caution patients against using compounds marketed as “bio-identical” that are not FDA approved. (See glossary at the bottom of this article.)
The Menopause Society (formerly the North American Menopause Society, or NAMS) now recommends transdermal estrogen—administered via a skin patch—in lieu of oral medication, which is processed through the liver and has an associated risk of clotting.
For patients experiencing vaginal dryness and pain during sex, vaginal estrogen in the form of a cream or insert is another option. Given its low systemic-absorption levels, this remedy is often considered safe even for women with a history of breast cancer.
“Low sex drive is a whole thing in and of itself,” Rohn says. “It’s so complicated. Does sex hurt? Is it good? Do you have body image issues? Are you too busy and you can’t turn off your brain and you’re in your head the whole time? Are there relationship problems? If you have discomfort, we need to fix that because you’re never going to want to have sex if it hurts. Vaginal estrogen can be life-changing.”
Also, she adds, “I hate hearing people say things like, ‘I can’t jump on a trampoline with my kids, but that’s the price you pay for childbirth’ and think there’s nothing they can do about it. This is where vaginal estrogen and pelvic floor therapy can be incredibly helpful.”
The bottom line: Every patient comes into the exam room with a different combination of symptoms, complaints, lifestyle choices and mitigating health factors. Treatments have to be customized. “Any medication comes with risk,” says Lindsay Spudic, a nurse practitioner with The Menopause Center in Tysons. But forgoing hormone therapy also carries its own risks.
“The loss of estrogen production can compromise bone density, increase risk of dementia and cardiovascular issues, and contribute to brain fog,” she says. “The longer you can have a stable influx of estrogen, the longer you protect yourself. You’re deferring the risk. We don’t have a hard-and-fast rule for when to stop using hormones as long as you’re healthy and keeping up with [regular health screenings].”
Unless they’ve had a hysterectomy, patients who take supplemental estrogen must also take the hormone progesterone, Remy says, to prevent an overgrowth of the uterine lining, which can lead to complications like uterine cancer. Bonus: Progesterone has the added benefit of working as a sleep aid.
“The loss of estrogen production can compromise bone density, increase risk of dementia and cardiovascular issues, and contribute to brain fog.”
Not everyone is a candidate for hormone therapy. Though every patient is different, it may not be an option for women with a history of blood clots, chronic liver disease, previous heart attacks or active breast cancer.
Connie (not her real name) fell into the latter category. “I was 46 when I was diagnosed with estrogen receptor (ER) positive breast cancer the first time. I had a lumpectomy, took tamoxifen, and soon after went into menopause,” says the Arlington mom, now 55. “Then, less than five years later, I had a mammogram and was diagnosed with a new, different type of breast cancer.”
She was prescribed tamoxifen—the estrogen-suppressing drug given to many breast cancer patients post-surgery—for five years between her two diagnoses. Hormone therapy to treat menopause symptoms was off the table.
“I didn’t realize at the time that my quality of life would be awful,” she says. “The tamoxifen was harder to endure than the cancer. It aged me overnight. Estrogen is a fabulous way to stay young, and when you don’t have it, you wrinkle up like a cornflake. I was going through [menopause] younger than all my friends. None of them understood. After you have cancer, no one really asks, How’s your menopause? That’s not the follow-up question you get at the cocktail party. All people want to know is, How’s your cancer?”
Despite her discomfort, Connie was initially reluctant to try even nonhormonal medications. “I’m nervous about taking anything because I don’t want to become dependent,” she says, “but recently I started taking the lowest dose of gabapentin to help me with hot flashes and with sleep. Now I wake up and my joints don’t hurt. Why suffer?”
Some women take a while to arrive at that conclusion. Even medical professionals like Teresa Mason, a health care attorney and former ER nurse.
“It was 2020 when I first started having symptoms,” says the Donaldson Run resident and mother of three. “I was losing sleep, having hot flashes. I thought it was symptoms of pandemic stress. My husband and I were dealing with aging parents, kids who needed us and full-time jobs.”
Then her periods stopped and her symptoms started to ramp up: “I’d wake up twice a night completely soaked or break out in a sweat on Zoom calls. Thank God I wasn’t in the office. I started gaining weight and thinking, Is this Covid?”
Mason made appointments to get her thyroid checked and assess her estrogen levels (“I had none left”), but she still didn’t feel like she had any solutions. She was 46.
“I showed up for my annual OB/GYN appointment and started crying,” she says. “I thought maybe I was stressed beyond the max. My doctor closed the door and sat down and said, ‘Oh honey, let’s make this a menopause consultation.’ It was the best doctor’s appointment I’ve ever had in my life.”
Her doctor, Amy Porter of Healthcare for Women, talked her through the constellation of symptoms and urged her to consider hormone therapy.
“I finally felt like I wasn’t crazy. Someone understood what I was going through and was able to explain that my joint pain, weight gain and emotional instability were all connected.”
Last year, Porter and her colleague, OB/GYN Ingrid Winterling, helped launch the Hormone and Menopause Resource Center at their Falls Church practice. With this specialty, they’ve dedicated longer appointment slots that allow them to spend more time with patients beyond the limited annual visit check-in.
“We talk about family history and genetic testing, check hormone levels, do basic bloodwork to assess liver and thyroid function and check cholesterol and diabetes—because all of that plays into what we do going forward,” Winterling says. “For women who are not candidates for hormones, SSRIs and SNRIs [two classes of antidepressant medications] are good options. We’re not saying that this is made up and people are crazy, but we know that these drugs work.”
They also discuss heart disease and the importance of diet and exercise. “We should all be eating a Mediterranean diet,” Winterling says, echoing a common refrain among the doctors interviewed for this story.
So is the recommendation to think about exercise differently. What worked for us in our 30s isn’t necessarily what our bodies need once the menopause transition begins.
“Lifting weights three to four times a week should be the foundation of your exercise regimen,” says Heather Fannon, a cardiology nurse who previously taught strength training classes at 24 Hour Fitness in Falls Church. “Reduce the crazy cardio—keep your workouts at a conversational level.”
As we age, she says, weight-bearing, strength training and balance exercises are crucial, not only for weight management but to ensure our bodies continue to function as they should.
When Fannon hit perimenopause, she put on 20 pounds. “I love interval training, but apparently the menopausal body doesn’t like that,” she says. “It can stimulate cortisol, which tells your body to store fat.”
She now walks 30 minutes every day to help lower her cortisol, but “unfortunately, I’m doing all of those things and I’m still gaining weight.”
Mason, the attorney and former ER nurse, can relate. Though she says HRT made a huge difference in her quality of life, the longtime athlete was frustrated to see her weight continuing to creep up, even with supplemental estrogen. Her changing body felt foreign to her 5-foot-4-inch frame.
“I would eat nothing—a hard-boiled egg for breakfast, salads without dressing for lunch—and I still managed to gain 30 pounds,” she says. “I had a terrible relationship with food and my kids were witnessing it.”
Last year Mason started taking semaglutide, the ingredient in weight-loss drugs like Ozempic. She says she was careful to shed pounds slowly until she was back to her premenopausal weight, then she decreased the dose. “People think it’s easy to get the weight off, but there was no way out,” she says. “My goal is to not be on this forever, but I’d be happy to stay on a maintenance-level dose to keep my weight in check.”
The long-term effects of semaglutide are still somewhat unknown (and a topic for another story), but Mason says her decision wasn’t driven by vanity. She’s over the shame of finding a medical treatment for the long list of other health problems that come with carrying excess pounds.
“Listen—menopause sucks, and I found a solution. It’s different for every woman, and there’s not a one-size-fits-all answer,” she says. “Before, I was miserable, always hungry, and felt sad and out of control. Now my closet is mine again. My mental health is better, and I have a better relationship with food. I’m just trying to feel good again, and that’s all that matters to me.”
Adrienne Wichard-Edds is a writer based in Arlington.
