The biggies answered. 

By Sarah Miller
Illustration by Julie Houts

First, when we were young, it was wall-to-wall Are You There God? It’s Me, Margaret period talk. Then that progressed to: “Are you on the Pill? Should I go on the Pill? I really don’t want to get pregnant.” Eventually that progressed to, “I want to be pregnant” (and maybe a few months of “Why can’t I get pregnant?”). 

Then fast-forward a bunch of years and it’s talking about when your daughter might get her period (and hoping she doesn’t get pregnant). The part you’ve skipped, of course—the part that no one and her mother seems to want to talk about—is menopause (technically, the point at which you haven’t gotten a period in a year) or perimenopause (your estrogen’s going-out-of-business sale that can last anywhere from two years to—sweet Lord in heaven—a decade). I’d like to end that now. A whole bunch of my friends and I are in perimenopause, and we want answers to the questions that I’m assuming you have too. In fact, I’d bet my last box of tampons on it.

I have hot flashes. I’ve heard drinking can make them worse. But I’ve also heard from a very reputable source—myself!—that wine is the only thing that makes me feel better. What’s a (middle-aged) girl to do?

  “How did the universe do this to women?” asks Leah Millheiser, MD, director of the Female Sexual Medicine Program at Stanford Medical Center, laughing. Then she offers this sad, not terribly fun advice: “If you drink wine, you may have to limit the amount to what you know won’t have an impact on you—or just decide that the occasional night of poor sleep is worth it.” Surely, there must be something else I could drink more of? Nope—any alcohol can disrupt the body’s ability to control temperature. Ergo, hot flashes and disrupted sleep. “Do I want to have a lot of fun from six to eight and feel bad from nine to eleven?” my friend Kelly says, sighing. “It’s a dilemma I face daily.” Fortunately, symptoms won’t last forever. “As estrogen production lowers, the nervous system takes some time to adjust,” Millheiser says. “But eventually, for most women, it does.” That’s when you can drink two glasses of wine and toast yourself for getting through it.

My friend went on the Pill in her early 30s when she was done having kids. Now she’s 50 and wondering if she gets her period for real, or if the Pill is calling the shots. Should she go off it? And what’s the deal with hormone replacement therapy? Some friends swear by it; some friends swear it’s going to give me cancer.

  Go off the Pill for one to two months just to see where your body is naturally, says Mache Seibel, MD, with Harvard Medical School and author of The Estrogen Fix: “The Pill has higher hormone levels than hormone replacement therapy, so if you’re actually in menopause, you’ll want to switch dosages.” If you’re still in perimenopause, however, the Pill may be an affordable way to regulate your cycle. As for the raging hormone therapy debate, Siebel votes yes, you should take estrogen and other hormones to alleviate symptoms of menopause, especially hot flashes. He says that the studies from the early 2000s that correlated HRT with cancer were flawed. Granted, breast cancer survivors and women at risk of other diseases should forgo HRT, and you should talk to your own doctor about what’s right. “For most women, the benefits of hormone therapy outweigh the risks,” Siebel says. He adds that it’s always a good idea—HRT or not—to try to regulate your symptoms by exercising, eating better and getting enough sleep. “Been there, done that,” my friend Katherine says. “Now I take estrogen and am a functioning human being—what a concept!”

I’m 50, get my period like half the time, and have more interest in dusting the knick-knacks on the mantel than in having sex. I’ve heard testosterone might help. Is that true? Where do I get some, ideally by this evening, because my relationship is suffering!

  Testosterone is not just for men; women naturally produce it in their ovaries. Levels start declining in our 20s—otherwise known as that time in the distant past when you were red-hot and raring to go 24/7—though symptoms might not appear until much later. That said, applying a little topical testosterone cream every day (usually to your forearm, back or thigh) may help you get back some of your mojo. “There is research demonstrating that testosterone therapy can be effective in helping with postmenopausal sex drive, and that it’s relatively safe at low doses,” Millheiser says. (If you aren’t yet in menopause, use serious contraception if you use testosterone, as it can cause abnormalities in female children.) Siebel, for his part, cautions that you need your doctor to carefully monitor testosterone levels in your blood to pre­vent side effects like acne, male-pattern hair growth or a deepened voice. For all the caveats, my friend Margaret swears by “the T” for bringing back her sex drive, and jokes that “my voice only deepens when I say, ‘Coffee, tea, or me?’ ”

 I’m depressed. When I’m not depressed, I’m irritable. Also, I can’t remember anything. Is this just my life, or is it perimenopause?

   Yes, the low estrogen associated with perimenopause and menopause can lead to low energy, as well as low remembering why you walked into a room, low recall of people’s names—and yet very high levels of finding any and all of those people/symptoms/everything extremely annoying. And if you’re a Lady in Your 40s, or thereabouts, that’s probably what’s going on. For instance, when I describe the two straight weeks I recently experienced of feeling terrible, like a very prolonged PMS, Millheiser simply says, “There’s a good chance your symptoms may be due to peri­menopause.” The good news is that it did eventually pass. But if these feelings are a super every-ding-dang-day thing, it’s possible something else is going on. “It could be depression or anxiety,” Millheiser says. “If there’s a cyclic occurrence to the symptoms, then it’s quite possible that they’re related to perimenopause.” Not fun by any stretch of the imagination, but not abnormal.

I gained 10 pounds in a month! Is my metabolism dead? Also, I know I should be doing weight-bearing exercise, but ugh.

  If you’ve gained a lot of weight in a way that seems truly bizarre—like it’s suddenly all in your stomach—“look for other causes,” Siebel says. “There may be a build-up of fluids. You may also want to get your thyroid checked.” If that all checks out, then it’s time to go back to basics. Exercise might seem impossible right now, but it’s necessary to nudge along a slowing metabolism (thanks, low estrogen). Plus, it helps preserve youthful posture and flexibility. “Weight-bearing exercise actually stimulates new bone cell production,” Millheiser says, so even if you are like “ugh”—and girl, I feel you—find something you semi-enjoy and just do it. “Something as simple as skipping can be great for your bones,” Millheiser says. She also says that women in perimenopause and after menopause actually can lose weight, though it’s no cakewalk: “Carbohydrate metabolism changes. A diet lower in calories, carbs and fat and higher in protein can help.” Siebel adds, “Women over 51 should have 200 fewer calories a day than those 21 to 50.” I’m not exactly cheering, but at least I know.