Introduction: The Manifesto

If menopause were on Yelp it would have one star.

This establishment has temperature control issues. Drenching heat followed by terrible chills. Defies the laws of thermodynamics. Would not recommend.
Awful, awful, awful! Bleeding was scheduled, but was rebooked without notification so arrived 3 weeks later than expected while I was in an Uber and I flooded the car. The driver gave me a terrible review!
The sex was dry.

And it’s no surprise. Most women have no idea what to expect when they are no longer expecting a period, and it’s uniquely awful and disempowering to not understand what is happening to your body and why. Menopause is like being sent on a canoe trip with no guide book and only a vague idea where you are headed—although the expectation is it’s awful. There will be no advice on how to get there or how to manage any of the obstacles, such as rapids. That is if any exist. Who knows? Have fun figuring it out! Good times. Oh, and don’t write. No one wants to hear about your journey or what it is like when you arrive.

Fear? Check. Uncertainty? Check. Medical ramifications? Check. Unpleasant symptoms? Check. Societal irrelevance? Check.

No wonder menopause receives such awful reviews.

The culture of silence about menopause in our patriarchal society is something to behold. Menopause doesn’t even rate the shame that society gives to the vulva and vagina. Apparently there is nothing of lower value than an aging woman’s body, and many in our society treat menopause not as a phase of life, but rather as a phase of death. Sort of a predeath.

What little that is spoken about menopause is often viewed through the lens of ovarian failure—the assertion that menopause is a disease that exists because women and their ovaries are weak. The only grounds for this claim are that men don’t experience menopause. But comparing women and men in this way is the same as comparing the liver with the heart. The liver isn’t weak or diseased because it doesn’t beat like the heart, and women aren’t diseased because the ovaries stop making estrogen.

The absence of menopause from our discourse leaves women uninformed, which can be disempowering, frightening, and makes it difficult to self-advocate. Consequently, many suffer with symptoms or don’t receive important health screenings or therapies because they have been dismissed with platitudes like “This is just part of being a woman” or “It’s not that bad.” But the issues with menopause even go beyond these knowledge gaps and the medical neglect. Women tell me that menopause is lonely; that there are no stories or culture. And so there is no whisper network to take up the slack from medicine. Nothing to offer comfort.

But many women are desperate to know more about menopause so they can understand how and why their body is changing, and they want information so they can make decisions that work for them. They also want to talk about what is happening to their body.

I contrast these experiences with my own. Having started medical school when I was twenty years old and my OB/GYN training when I was twenty-four, I can’t remember back to a time when I didn’t have a detailed understanding of the hormonal changes of both the menstrual cycle and menopause. And not just the biology, but how to apply it practically to my own body. I never once thought, “Wow, that is unexpected,” or “Why am I sweating so much at the age of forty-five?” or “WHAT IS GOING ON—WHY AM I BLEEDING EVERYWHERE!?”

My medical knowledge didn’t prevent me from having menopause acne, hot flushes, or those “special” heavy periods that are all typical of the menopause transition. But because I knew exactly what was happening and when to seek care, it made the whole process feel routine. Because I knew the tests that were indicated and those that were not, and because I understood the medicine, it was much easier for me to navigate the treatment options and choose the safest most effective therapy and avoid the snake oil. By the time I entered my own menopause transition, I had spent over twenty years speaking with women about their menopause and helping them manage their symptoms and any health concerns, so I had heard many stories and had knowledge of the range of experiences as well as the treatment options. It was fortunate that my view of the subject wasn’t confined to what I saw at home. My mother’s menopause was volcanic, and if that was all I had to go on, I would have been quite frightened.

Online, on book tour for The Vagina Bible, and during many interviews with reporters I often heard (and still hear today) “What do I do?” and “Where do I turn?” from women about menopause. I remember one interview in particular that had nothing to do with menopause or even menstruation and when for some reason I tangentially mentioned I was using an estrogen patch the conversation derailed and all the reporter wanted to discuss was menopause. Hearing over and over again from women from many countries about this need for knowledge made me obsessed with the idea that every woman should know about menopause like a well-informed gynecologist and so that is what I have set out to do in these pages.

For women to navigate menopause, they need facts because empowerment requires accurate information—but they also need feminism because our bodies, our medical care, and even our thoughts have been colonized by the patriarchy. The cultural absence of menopause from our discussions isn’t because that’s what women want. The often pejorative language about menopause and the medical neglect also aren’t up there on the meno wish list.

Women often only hear the awful stories about menopause, but the truth is the menopause experience is a vast diaspora. Many women have mild symptoms, some moderate, and others severe. Often these symptoms are temporary, but occasionally they’re long lasting. Menopause does start a series of biological events that increase a woman’s risk of several medical conditions, such as cardiovascular disease and osteoporosis. But menopause isn’t the only paint on a woman’s canvas. Age, other medical conditions, diet, exercise, and even adverse childhood events are also adding color to her portrait. So when a woman wants to consider what she should do, it’s important to step back and look at the whole picture. Managing menopause is the ultimate exercise in whole body or holistic medicine.

Menopause is not a disease. It is an evolutionary adaptation that is part of the survival of the species, like menstrual periods or the ability to suppress the immune system during pregnancy so the body doesn’t attack the fetus. Like these other biological phenomena, menopause is associated with downsides—in this case its bothersome symptoms for some women and an increased risk of several medical conditions. But menopause also occurs while a woman is aging, so it’s equally important not to brush off every symptom as hormone related. It’s vital that women know about menopause, but also everything that is menopause adjacent, so they can understand what is happening to their own bodies, put that in perspective, and advocate for care when indicated.

A manifesto is a public declaration or proclamation and we are well past due for a manifesto on menopause as 2021 is the 200th anniversary of the introduction of the word. My manifesto is for every woman to have the knowledge that I had to help them with their own menopause. I demand that the era of silence and shame about menopause yield to facts and feminism. I proclaim that we must stop viewing menopause as a disease, because that means being a woman is a disease and I reject that shoddily constructed hypothesis. I also declare that what the patriarchy thinks of menopause is irrelevant. Men do not get to define the value of women at any age.

If you are years from menopause, this book will hopefully help you understand the road ahead. My hope is that it allows you to view menopause as a phase of life, as well as inform you of the preventative care that can be taken to lessen any impact of menopause on your health. In addition, may this book provide the knowledge to best manage your menopause with a view to your unique concerns.

If you are already on Team Menopause, I hope this book helps you understand how you got here—biologically speaking—and informs you of important health considerations that may still lie ahead. It’s never too late for preventative health care and many symptoms and medical conditions may still need managing.

And if you are in your menopause transition and experiencing that hormonal chaos, know for many women this is the rockiest phase. Often just that acknowledgment can help. I hope the information here helps you reframe what is happening to your body, and if you are suffering I hope you take comfort knowing there are many explanations for how and what you are feeling, as well as therapies—and these rapids won’t last forever. My hope is that this book helps to hold your canoe steady so you can catch your breath.

Facts can bring order to the chaos and uncertainty of menopause, because knowledge can dispel fears and open up treatment options. Even if the option is to take no action, it is still a position of power because it is an act of self-determination. Feminism can help women see the biases that may have informed previous beliefs and reframe their menopause not as a terminal event, but as another phase of life.

Women want more information about menopause and that knowledge can reduce suffering. Knowing what’s happening to your body and that you’re not alone in your experiences is powerful medicine. Facts empower women to make the health decisions that work for them—you can’t be an informed patient with inaccurate information.

It shouldn’t require an act of feminism to know how your body works, but it does. And it seems there is no greater act of feminism than speaking up about a menopausal body in a patriarchal society.

So let’s make some noise.