Girls start having menstrual periods at about age 12, when they begin to ovulate monthly. This is menarche, the beginning of the fertile period of the female human. Women continue to have regular menstrual cycles, interrupted by pregnancies, until about age 50, when they stop ovulating. Fertility declines from the late 30s, and menopause is its end. Women produce less of the female hormone estrogen in their 40s and much less after menopause. Like menarche and pregnancy, menopause happens: it does not require a physician in attendance. Until the 20th century, in fact, most women didn’t live long enough to reach menopause.
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Of course if the only thing estrogen contributed to a woman’s health was the proper hormonal milieu for ovulation, most women would be more than ready to be rid of it at age 50. But the effects of estrogen are not limited to the reproductive system. Estrogen prevents bone thinning, or osteoporosis, which starts promptly as estrogen levels begin waning in the 40s. In the first ten years after menopause the loss of bone mass speeds up; it continues at a much slower rate, more comparable to that of men, as a woman heads into her 60s. Taking estrogen delays this process; not smoking, weight-bearing exercise (i.e., not swimming), and dietary calcium also help maintain strong bones. Many white women, who have thinner bones than black women, are at high risk for osteoporosis heading into menopause, by virtue of heredity, poor diet, or lack of exercise as young adults. The stooped 70-year-old woman whose vertebral column is painfully collapsing under its own weight and her sister with the hip fracture after a minor fall illustrate the end stage of osteoporosis.
Estrogen increases HDL, the “good” cholesterol, and makes blood vessels more elastic, which probably accounts for the fact that a woman’s risk of heart disease is lower than a man’s before menopause and catches up shortly after. Estrogen also plays a role in vaginal and urethral lubrication and sex drive. Many women report a greater sense of well-being when they take estrogen, and it definitely prevents hot flashes, the sudden rise in body temperature with sweating that’s the hallmark of this change. (The postmenopausal woman who has weathered the hormonal fluctuations and reached a constant, low level of estrogen is free of hot flashes.)
Everyone knows a few women who can’t relate to PMS or who never felt better than when they were pregnant. And 15 to 20 percent of women never have a hot flash. But most women find it takes extra effort to cope with these changes. Some women achieve a sense of control by demanding intervention; Sheehy lambasts physicians who wait until periods stop before prescribing estrogen. Other women feel more in control when they reject the medical prescription; Germaine Greer, in her book The Change, lights into doctors for pushing HRT.
The cover of Sheehy’s book claims it’s “the book that broke the silence.” Nonsense. A local bookstore has a two-page list of books about menopause and aging women; an old reliable, published in 1985, is Sadja Greenwood’s Menopause Naturally. Sheehy admits that when she wrote Passages at age 35 she couldn’t imagine herself at 50, and my experience as a doctor suggests she’s not alone. We don’t address health issues until they’re in our face.
I did.
