17 Oct 2025 12 min read no fucks left to give

October 18 Is World Menopause Day!

By Kate Felmet

Kate is an OG member of the Croning Collective. She’s also a doctor, and she wrote this piece for the first issue of Croning, the zine. It was a bit too long for print, but I’m happy to be able to offer it in its entirety now. Wishing you a blessed World Menopause Day!—JJ

What Is Menopause?

At its simplest, menopause happens when we run out of ovarian follicles with the potential to mature. In our reproductive years, follicle stimulating hormone (FSH) spurs the maturation of a few hundred follicles each month to support the release of one dominant follicle as a fully matured egg. The growing dominant follicle releases estrogen and suppresses FSH. Leutenizing hormone supports the release of the egg, and the ruptured follicle produces progesterone to support a pregnancy in case of fertilization. These hormones are the major players in the menstrual cycle, but not thinly ones. We begin puberty with about 300,000 follicles. When the follicular mass is exhausted, menses cease. Menopause is defined as 12 months of amenorrhea not due to other causes. Age at final menstrual period varies widely, with a median at 52.5 in the United States.

During the denouement of fertility, it takes more and more FSH to create one mature ovulation, and sometimes final maturation fails, producing anovulatory cycles of variable length that are associated with decreased estrogen release. We produce less progesterone beginning in our 30’s, and the deficit is more severe in anovulatory cycles. It is a complex interplay of these hormonal changes together with the process of aging and the culturally determined life changes that happen in midlife create the phenomenon we know as menopause.

The experience of each woman’s menopause is unique; the type of symptoms and their intensity vary widely. Many women report no symptoms at all. Some of the symptoms of the menopausal transition, like hot flashes, sleep and mood disturbance, will ameliorate in the months to years after with the cessation of menses, once the transition to the post-menopausal state is complete. Others, like genitourinary symptoms, vaginal atrophy and dryness, are progressive throughout post-menopausal life. Other persistent changes, like sleep disturbance, are difficult to tease out from the impact of aging.

Menopause is not a discrete event; changes are happening long before we recognize them. Fertility begins to decline in our 30s and fizzles to nothing over a period of nearly 2 decades despite regular ovulation and menses. Many women expect menopausal changes to start at 50 or assume that they will miss a period before they occur. In fact, menopausal symptoms start when we are still having your periods, potentially years before we skip a period. Since both the age and the duration of premenopausal is variable, women may not recognize the symptoms until they are nearing their final period. Sometimes menopause is only recognized in retrospect. It doesn’t help that the term “menopause” is used confusingly in the literature, to refer to the entire period lasting 10 years or more, to the final menstrual period, to the post-menopausal phase of life.

There are times when embodiment as a woman feels like you are at the whim of a body that’s governed by hormones. Menopause can be seen that way, if this image serves you, however, menopause is not just a hormonal event. Although it’s clear that research is lacking, it’s equally clear that we can’t account for all the changes in menopause based on hormonal changes alone. Aging occurs alongside menopause and may account for some of the changes we experience during these years. Menopause is not even a completely biological event. It occurs in the context of changes in our families, in our roles as spouse, mother, or daughter, of changes at work, changes in the way we view our potential futures and a myriad of life stressors.

There is enormous variation in the ways that women experience menopause, and some of this variation is culturally determined. Culture affects what symptoms are reported and how these symptoms are viewed. Around the world, muscle and joint pain, temperature instability or hot flashes and qualitative changes in short term memory are most consistently reported symptoms of menopause, but there are regional differences in reported symptoms which may not be accounted for by genetics. For instance, Japanese women report “chilliness” associated with menopause, and there is no word for “hot flash” in Japanese. North African women are more likely to report psychological symptoms. Economic vulnerability and marginalized status are associated with more severe symptoms. In the Untied States, the menopause transition is medicalized so the focus is often on the treatment of physical symptoms rather than psychosocial experiences.

It may be that in cultures where menstruating women are seen as impure and dangerous to men, women tend to ignore bothersome menopausal symptoms or tolerate them silently, giving more value to the freedom attained from the end of menses.

Transitory Symptoms

Irregular periods with occasional heavy bleeding: In perimenopause menstrual irregularity is common, with both anovulatory cycles, with sparse bleeding and long intervals between menses, and ovulatory cycles with heavy bleeding and shortened interval. Cycle tracking can be helpful in identifying perimenopause. Menopause occurs in stages: an early stage characterized by changes in menstrual cycle length of 7 days or more and a late stage characterized by the occurrence of amenorrhea for 60 days or more.

Hot flashes: Hot flashes come on rapidly and last only a few minutes. Women’s experience of the severity and frequency of hot flashes varies widely. A major hot flash can cause facial and upper-body flushing, sweating, chills, and even confusion. Some women have no hot flashes, some have 10 a day and wake with night sweats. Hot flashes are a relatively late sign of menopause and are usually experienced first three years after cessation of menses. Women who experience them earlier or more severely are more likely to have a prolonged experience with hot flashes—even a decade or more.

Disrupted sleep: Sleep disturbance is one of the most common and bothersome symptoms of menopause, and also one with the most impact on our health. About one third of premenopausal women report sleep problems, but more than half of perimenopausal women do. Sleep disturbance is worse in the 3 years before and after final period. Hot flashes may interrupt sleep, but increased difficulty falling asleep and subjectively poor quality of sleep are also common. Menopause is also associated with sleep-disordered breathing (sleep apnea) independent of weight. Sleep disturbances are also associated with aging, and although post-menopausal women continue to consistently report sleep disturbances, the quality of sleep judged by studies of sleep architecture may be improved after the transition is complete. Poor sleep quality and shorter sleep duration have been tied to increased atherosclerosis and greater weight gain in women at midlife and to increased cellular aging.

Mood disturbances: Associated with menopause, many women report an overall decreased sense of well-being that is hard to put into words. Women are most likely to report mood related symptoms before menses cease, beginning with an increase in severity of premenstrual mood symptoms. As fertility begins to decline. the associated hormone fluctuations may be responsible for mood symptoms such as irritability, decreased memory and concentration, fatigue, sadness and depressive symptoms, depressive, and anxiety symptoms. Up to 70% of perimenopausal women endorse symptoms of depression and/or anxiety (compared to 30% of premenopausal women.) It should be noted that depression and mood disturbance in midlife are complex phenomena. In addition to the hormonal transition of menopause, we may be dealing with our own aging, transitions of our role as mother, wife, or daughter, changes in our roles at work, and other stressful life events.

Weight gain and increased waist circumference: Hormonal changes are responsible for a change in the location of fat tissue in our bodies of fat from the fertile pattern of deposition hips and thighs to a pattern of deposition around the waist. The ratio of fat to muscle also changes beginning in perimenopause with is a rapid increase in fat mass and a slower decrease in the mass of lean muscle. This change in body composition is also associated with aging and may be multifactorial. After the menopause transition, the rate of increase in fat mass slows to a rate that more closely tracks the loss of lean muscle and the body composition associated with aging. Weight gain and increased waist circumference correlates to some extent with the severity of hot flashes.

Progressive Symptoms

Genitourinary symptoms: Chronically low estrogen can cause uncomfortable changes in changes in urinary, genital, and sexual function. These include vaginal dryness and decreased sexual lubrication, pain with urination and recurrent urinary tract infections, atrophy and shortening of the vaginal canal and resulting pain with intercourse. The symptoms are progressive across and beyond the menopause transition and are reported by at least 50% of women but the time menopause is complete. Topical and systemic estrogen therapy are effective treatments for these symptoms.

Decreased sex drive: There is an age-related (not menopause related) drop in testosterone levels in women that, together with genitourinary symptoms and other life changes may result in a noticeably decreased sex drive in some women. Lack of sexual desire and difficulty with arousal and sexual lubrication are common.

Muscle and joint aches: Estrogen plays a role introducing inflammation and protecting joints and cartilage, and chronic lack of estrogen is probably responsible for the muscle and joint aches and stiffness experienced by 40% of women in menopause. Menopausal joint pain and stiffness is typically worse in the morning and tends to lighten up as the day progresses and movement increases. Joint pains may indicate increased risk for osteoporosis and osteoarthritis over time.

Menopause and chronologic aging: Sleep disturbances, changes in the ratio of body fat to lean mass, decreased testosterone levels, joint pain, and arthritis are all part of aging independent of female reproductive hormone levels. Disentangling the relative contributions of chronologic and reproductive aging to women's health is a complex task. Recent studies suggest that menopause speeds up cellular aging by an average of 6% that later menopause is associated with longer life.

Healthcare Interactions

Women are routinely dissatisfied with healthcare interactions surrounding menopause—for good reason.

Research and our understanding of the physiology of menopausal symptoms is still limited, and studies are limited to western cultures and samples of mostly white women. In some cases generalist physician’s education about menopause is limited, and recommendations about hormone replacement therapy (HRT) are shifting and confusing. The duration of a regular visit is inadequate to discuss and validate a woman’s experience. There is no test for menopause. FSH testing is not routinely recommended to identify menopausal stage because it varies from cycle to cycle and from day to day, although single high value may be useful in identification of approaching menopause. The normal range for final menstrual period spans almost 2 decades, and sometimes, menopause and the final menstrual period is only recognizable in retrospect. Many women are told by their physicians that they are “too young for menopause,” leading to misattribution of symptoms and the need to rule out other causes.

Outside of the physician’s office, it’s hard to get access to reliable information that is not conflated with commercial motivations around selling a product or a program.

Life stage versus medical problem: Many women view the medicalization of menopause as the transformation of a normal life stage into medical disorder and pharmaceutical moneymaker. However, dichotomizing menopause as either a disease to be treated or a natural process to be left alone may be devaluing the lived experience of people who have really troublesome transitory symptoms as well as dismissing the need to treat progressive symptoms when they are bothersome.

Symptom management and risk avoidance: In 2000, when hormone replacement theory (HRT) was universally recommended for prevention of osteoporosis, cardiovascular disease, and other aspects of aging, roughly 40% of women in their 50s used HRT. In 2002, a Women’s Health Initiative study was terminated early due to trends in the data showing that HRT was associated with increasing and breast cancer in postmenopausal women and at best failed to prevent cardiovascular disease. By 2010 only 7% of women in their 50s used HRT.

Since that time, new data has emerged suggesting new benefits to HRT and identifying populations for whom HRT is higher risk. The most current data as of 2023 suggests that HRT is good for bone health and decreases the risk of Alzheimer’s disease. Late initiation of menopausal hormone therapy (MHT) in the range of 10 years after final menstrual period is associated with increased risk of stroke. And we now know that women with high risk of hormone-sensitive cancers and stroke usually should not take HRT.

HRT is without question an effective treatment for hot flashes, other symptoms of the menopausal transition, and for the vaginal atrophy and other genitourinary symptoms that are progressive during and after menopause. Selective serotonin reuptake inhibitors (SSRIs) can be useful in treating hot flashes and mood symptoms in women who have hormone dependent cancers or otherwise can't take hormones. There are other lifestyle changes, like gentle exercise and weight loss, that may ameliorate hot flashes, joint symptoms, sleep disturbances, and mood symptoms.

Over-the-counter preparations and botanicals for the treatment of menopausal symptoms abound, and misleading information about the benefits of these treatments is the norm. remedies have been clinically proven to be effective, and they may prevent women from seeking diagnosis and treatment for a real medical need. Topical estrogen creams are an exception. Many women do find them helpful in reducing vaginal dryness and restoring elasticity and these products seem to be safe (anyone with an estrogen-sensitive breast tumor should talk to their doctor before using these.) It’s worth noting that although there is biologic plausibility for an impact of soy on menopausal symptoms, it would depend on an ability to metabolize soy isoflavones into an estrogen receptor agonist S-equol. Ability to metabolize S-equol varies with populations and appears to be dependent on diets that support the necessary gut microbiome. Typically, women in Asia metabolize S-equol more readily than women in Europe or North America.

The Grandmother Hypothesis

Very few animals have many years of post-reproductive lifespan. (Orcas do!) There is a theory based in the relative age of fossils that, about 30,000 years ago, longevity increased substantially, such that the upper limit of lifespan pushed past 30 years. This would have led to the first period in which three generations coexisted, and it coincided with tremendous cultural development among humans.

Because humans have an extended time from weaning to reproductive maturity, a non-reproducing and relatively young and vibrant grandmother provides extended survival benefit to her kin by while the reproductive daughter or daughter- in-law continues to give birth. Women who begin childbearing while their mother is still alive raise more children to adulthood. Post-reproductive females have many vital years and contribute to childcare, food production, and leadership.

Menopause is a profound interplay between fluctuating hormones, the aging process, and social and cultural contexts that are different for each woman. The experience of menopause varies widely, encompassing a spectrum of transitory and progressive symptoms that are often misunderstood or inadequately addressed by the medical community. While the medicalization of menopause has created confusion around treatments and risk, viewing it solely as a biological problem ignores the significant psychological and life changes that accompany it. The holistic vision presented in the Grandmother Hypothesis helps us reframe this stage not merely as an end to fertility, but also as the beginning of a new, vital, and evolutionarily significant phase of life.