We haven’t talked about symptoms, says Ada Calhoun . No wonder this hormonal upheaval is so confusing

You are infantilising women!” I heard my mother yell one day when I was a teenager. Alarmed, I went into the kitchen to find her slamming the phone receiver down.

“Have you seen this?” she said, holding up a roll of paper towels printed with colourful images of teddy bears and blocks.

“Mom,” I said. “Did you just call the Bounty paper-towel company to complain about these teddy bears?”

“Yes,” she said, eyes flashing. “They should be ashamed.”

In retrospect, I think that my then middle-aged mother – dealing with a grouchy teenage daughter, dying parents, marriage problems and an acting career ending because she was no longer young – might have been finding a way to express her feelings without bothering anyone except a supervisor at that paper-towel company.

Twenty-five years later, struggling with a career that felt over, facing various physical problems and trying to get my child into a good school, I found myself paying a lot of attention to my son’s pet turtle.

“Jenny looks bored,” I said, gazing into the tank. “When was the last time Jenny had some fun?”

“She’s a turtle,” my husband said. “Turtles don’t have hobbies.”

“Maybe they want more!” I snapped.

And that was the moment I realised that Jenny the turtle had become my very own paper-towel teddy bear.

Menopause, defined as a full year with no period, hits women on average around the age of 51. But the years before that cessation – called perimenopause – can be more emotionally and physically fraught than we anticipate. We change a lot during these years. And, as we may remember from puberty, transitions can be awkward. Our bodies and our moods frequently betray us, but one of the worst parts of perimenopause and menopause is that no one talks about them.

Sometimes my own perimenopausal moods are more rage than anxiety. I woke up the other day and noticed that my husband had placed a couple of champagne corks on top of a picture frame. It made me want to start breaking things. What is this, a goddamned student house? In this state, I noticed things I had missed before: bags spilling out of cupboards, stacks of receipts and change on a table, my son’s stuff everywhere. “It’s like living in Hoarders!” I ranted. If I’d had a pack of matches I could have burned the place down.

When I open the book How to Face the Change of Life with Confidence, published in 1955, I see a question from a woman, 37, who has wild mood swings before she gets her period. The expert male gynaecologist author tells her: “Man reaches physical maturity at 25, and emotional maturity at 35. Unfortunately, you seem to have missed the boat somewhere along the line, and you are still in your childish stage of emotional reactions.”

Decades of that sort of condescension have kept women from asking certain questions twice.

“Almost every woman I know of my age is feeling confused and in a state of transition even as most of us are at the top of our game in our careers, financially stable and pretty comfortable with being parents,” said Yvette, 43, a Californian who is the COO of a video game company. “I spend a lot of time with other friends of my age. We talk about the fact that we are widening and softening where we don’t want to and don’t know if it makes us shallow or not feminists to do something about it; the fear that we don’t know how to monitor our children’s screen time; the fact that we don’t really like or need sex very often; our worry that we are losing time to try our ‘dream’ job.”

Experts in gynaecology maintain that hormone replacement therapy (HRT) remains the most effective scientifically proven treatment for the symptoms of menopause. And yet, fearing the increased risk of cancer, stroke and blood clots that we’ve long heard comes with a hormone therapy regimen, we’ve gone rogue. That, perhaps, is why Gwyneth Paltrow’s online community Goop can get away with selling us expensive jade eggs to stick up our yonis.

Gynaecologists I spoke to said they weren’t surprised that women were casting around for exotic fixes to their perimenopausal woes. Jacqueline Thielen, who works at the Women’s Health Clinic at the Mayo Clinic in Minnesota, said she sees many women in their 40s and 50s who tell her they’re scared of hormone therapy, but made miserable by symptoms and being swamped with responsibilities.

This makes them vulnerable, Dr Thielen said, to controversial things like subcutaneous hormone pellet therapy, inappropriate ovary removal, or pricey “vaginal rejuvenation”, which can cost a fortune and may involve shooting lasers into your vagina – one more thing I guarantee you our mothers did not have on their to-do lists.

For some women, it’s not a big deal. For others, it can be crushing. In a survey by the American Association of Retired Persons, 84% of participating women said that menopausal symptoms interfered with their lives.

“You know,” said JoAnn Pinkerton, executive director of the North American Menopause Society (Nams), “we tell people who are grieving not to make major changes for a year. I don’t think anybody’s ever said: ‘Don’t make a major decision when you’re perimenopausal.’”

Good idea, I think. We can just take it easy until perimenopause ends. “How long is that, anyway?” I asked.

“Anywhere from a few months to 10 to 13 years.”

“Oh my goodness,” I said.

Facebook Twitter Pinterest ‘So as not to call attention to ourselves as women, we pretend it’s not happening.’ Illustration: Hanna Barczyk/The Observer

“On average, they call it four years,” she said. But she added that menopause “is actually a lot easier than the perimenopausal transition… which is unpredictable. It’s based on ovarian fluctuations. You might have six months of severe hot flashes, skipping periods and then your cycles come back for three to five years before it happens again.

“Women need to recognise that it’s a time of vulnerability, and there are some things that they can do to help.”

Dr Pinkerton gave me an example: “A woman came into my office and said, ‘I hate my husband. I hate my marriage. I need to get out of this.’ The husband had called me earlier and said, ‘I’ve noticed that my wife is really having exaggerated responses to things around the time of her periods.’

“We ended up getting her into counselling as well as on to oral contraceptives. The contraceptives calmed the hormones down and then doing some counselling let her start to see some of the stressors that were hidden.

“I saw her recently,” Dr Pinkerton continued, “and she said her marriage could not be better. She recognised that the perimenopausal hormonal fluctuations were making the problems seem incapable of being solved. I guess what I would just say is if you’re in perimenopause, recognise that hormonal fluctuations may make the problems at work or at home seem larger.”

Women also benefit exponentially from sleeping more, Dr Pinkerton added. “It’s often the first thing to go, but it’s absolutely one of the things that can help you navigate this time. Then, stress reduction.”

But here’s what I want to know: why are Generation X women arriving in their 40s knowing something is going to happen, but without a clear idea of exactly what that is?

One answer is: denial. We have had incentives for a long time to pretend we are the same as men in every way. For decades, women have had to argue that they could still work and function through those messy period, pregnancy and menopause-related symptoms, and as a result we’ve minimised them, both to others and to ourselves. So as not to call attention to ourselves as women, we pretend it’s not happening. Boomer women arguably started this, entering the work world in shoulder-pad armour. It makes sense that they felt they had to hide the inconvenient fact of their womanhood, particularly in middle age.

After taking our children to see the latest Star Wars, a friend and I sat at her dining table while the kids ran around. “It’s just too hard,” she said. “This has ruined my life! Two years without sleeping through the night! Two years with hot flashes! Two years with no energy.”

I’d had no idea. I asked why she hadn’t told me before.

“I hate talking about menopause,” she said. “It’s like saying you’ve closed up shop as a sexual being. It’s embarrassing.”

Aside from the embarrassment, we are getting less help than we should from our doctors. A 2013 Johns Hopkins survey found that only one in five American obstetrics and gynaecology residents had received formal training in menopause medicine. That’s 20% of gynaecologists. Forget about general practitioners.

As it turns out, the reason Gen X women have grown up believing that hormone replacement therapy – again, one of the only proven treatments for menopausal symptoms – is dangerous is something that happened in the medical community in 2002.

It’s like saying that you’ve closed up shop as a sexual being

In 1993, as the menopause was becoming a hot topic, the Women’s Health Initiative (WHI), a national, long-term study on the possible benefits of hormone treatment for postmenopausal women, was launched in the US. But, in July 2002, the premature termination of the oestrogen-progesterone part of the study was announced. The reason given was an apparent rise in the risk of coronary heart disease, stroke, blood clots and breast cancer.

There was a hitch in this: WHI had been looking at what the hormones did in women aged 50 to 79. The aim was to figure out if this type of hormone treatment could help protect these women from heart disease and other illnesses. It was not about short-term hormone therapy for treatment of symptoms in women in their 40s and 50s. But many midlife women heard only “cancer” and went off HRT immediately.

Dr Wulf Utian, founder of the Nams, wrote an editorial calling the manner in which the study was ended “poorly planned, abrupt and inhumane”. In 2017, Professor Robert D Langer, one of the original WHI investigators, said that errors in the 2002 report led to a lot of unnecessary suffering for women.

However, this has done little to calm the fears of hormone therapy among women, and even doctors. “9 July 2002 was the day the music died for menopausal women,” said Dr Mary Jane Minkin of Yale, one of the nation’s leading experts on gynaecological health. “One of the things that was very bad about it was that no one was given advance notice this report was coming out. There was also a journalistic cock-up. A WHI investigator gave the story to the Detroit Free Press on the grounds that it was an embargoed study due to appear the following week in the Journal of the American Medical Association. The Detroit Free Press broke the embargo.

“That’s how Good Morning America got the story. Everybody went insane,” she continued. “In that week, every American woman went to her cabinet and took out her hormone prescription and flushed it down the toilet. Which, of course, was ridiculous, because the WHI Part One was the only study that was stopped at that point. That was the oestrogen plus progesterone. The oestrogen-only went on for another two years. It eventually showed a decreased risk of breast cancer, not an increased risk of breast cancer.

“People of Generation X tend to be demanding, and they’re having all these things happen to them. Why?” asked Dr Minkin. “What’s going on? They’re being told: ‘Just ignore it; it’s going to get better,’ or ‘You can take an SSRI [antidepressant], which will help your hot flashes – though, yeah, it’s going to make you love sex less and get fat.’ Your options are not too fabulous, but they don’t know how to handle hormonal therapy, because they think it’s going to give you breast cancer. The other part of the problem is that you have such authoritative spokespeople as Dr Kim Kardashian, Dr Suzanne Somers, Dr Oprah Winfrey, Dr Gwyneth Paltrow…”

Dr Minkin does not believe women should grin and bear it. Here is some of her advice for us: get daily exercise, especially weight-bearing exercise; a good diet; plenty of sleep. For hot flashes, she advises layering clothes and keeping a dry set of nightclothes next to the bed so you can change quickly if you wake up in the night. She recommends keeping the bedroom cool and getting your partner an electric blanket if he or she complains.

Other non-pill things can make life easier, too, like absorbent “period-proof underwear” and period tracker apps. She advises many women to consider oestrogen and progesterone hormone therapy (or just oestrogen, if you’ve had a hysterectomy), in the form of pills, patches, gels, or sprays, though it’s important to do so only under the direction of a doctor, because there are risks.

Low doses of an SSRI or SNRI antidepressant can combat hot flashes, as can gabapentin (Neurontin). For heavy or irregular periods, Dr Minkin says you can take a birth control pill or get a progesterone IUD called Mirena. When it comes to herbs and supplements like evening primrose oil or bee pollen, there’s no proven benefit, though some women say that those things make them feel better.

Sifting through all the advice is hard, especially because it can seem to change with every new headline. In her history of hormones, Aroused, Randi Hutter Epstein writes: “Those of us old enough to be in menopause can’t help but wonder if the experts are going to change their minds again.”

In her 2019 memoir, Deep Creek, Pam Houston gives a younger woman this advice: “I’m just saying, I guess, there’s another version, after this version, to look forward to. Because of wisdom or hormones or just enough years going by. If you live long enough you quit chasing the things that hurt you; you eventually learn to hear the sound of your own voice.”

Perimenopause may last months or years; it may be more or less drastic; but one day it will be over. On the other side, we’ll be different – perhaps more focused on what’s most important to us and almost certainly calmer. Psychotherapist Amy Jordan Jones told me: “This is the time of life when we learn we don’t have to be pleasing; the work now is just to become more ourselves.”

This is an extract from Why We Can’t Sleep: Women’s New Midlife Crisis by Ada Calhoun, published by Grove Press UK on 5 March. Order it for £12.59 at guardianbookshop.com