Today, Explained - The perimenopause moment

Episode Date: July 26, 2026

Women’s health and hormones have been misunderstood by the medical establishment for decades. That’s changing. This episode was produced by Ariana Aspuru, edited by Jenny Lawton, fact-checked by Melissa Hirsch, engineered by Brandon McFarland, and hosted by Jonquilyn Hill. Photo by Edwin Tan for Getty Images. If you have a question, give us a call at 1-800-618-8545 or email [e-mail] to Explain It to Me ad-free by becoming a Vox Member: vox.com/members. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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They might be closed. Performance Auto Group is open to serve you. Join Performance Auto Group this Saturday or Civic Holiday Monday 9 to 5 for the best time to shop this summer. Oh my gosh, perimenopause, holy jamoli. And I'm a little bit in denial about it. I'm not going to lie. I'm at a point that I'm starting to think, maybe this is the beginning, but then I just don't know. So my name is Amy Sybil.

I live in Oregon. One day Amy looked in the first. mirror and noticed something was different. I started getting curly hair. I had always had long, straight hair. I know. But then some very not fun things started happening. Night sweats were the most disruptive and horrible.

Cramps, heavy bleeding, like, oh my gosh, what is wrong with me? And then also emotional impacts, like it was clearly feeling more anxiety and dread, none of which were fun at all. She had her suspicions, but she was 40, on the young side for menopause. Besides, she was still getting her period. But the symptoms kept coming. Acid reflux, really bad.

And went through a whole year of like endoscopy and changing diet and not eating after 5pm. No red wine, no chocolate, sleeping on a slanted bed. And that was happening kind of on this side path at the same time that I was speaking with my physician, and she eventually, after about a year, put me on oral birth control. Within days, my acid reflux went away, just gone. Turns out, Amy had begun the change before the change, a nebulous period that doctors now call paraminopause. It can last for years. It impacts a ton of people, and it has a wide range of symptoms.

I had random, what I thought was random, panic attacks. It was like being run over by a truck. Brain fog, frozen shoulder, depilitating exhaustion. Kind of feeling like I was getting the flu every month, really, around my cycle. And yet, when it comes to women's health, there's a ton that modern medicine just hasn't figured out yet. Why is that?

I'm John Gwyn Hill, and this week on Explain It to Me from Vox, we're going to talk about it. Okay, to start, we got to do. define some terms. Menopause is technically when it's been one year where a woman hasn't had periods, and perimenopause is all the time leading up to that, which can be a decade for many women. Heather Hirsch is an internist that specializes in treating women in midlife. I think it is the biggest transition a woman will go through, and we think about puberty, and this is actually puberty in reverse. The biggest physiologic change is happening, which is that, that our sex hormones are declining.

And so we know that there is a lot of changes in the brain at this time. The brain is changing in terms of both the sex hormones and then also the neurotransmitters. And so that can change your mood. It can change your ability to process at fast speeds to remember multiple things. These are things that definitely frighten women when they cannot remember their neighbor's first name. But it's common because all of these changes in the brain. We know the skin's changing. the heart and the bone. So we know a lot of the physiology, i.e. the anatomy and things in what's changing

and how that's experienced clinically what women will say and feel. You know, there is a lot of things that happen to women that seem totally unrelated. So for example, you could get the worst headache of your life all of a sudden in your 40s. This is a migraine and it's sometimes triggered by the rapid loss of estrogen. Paltitation. So all of the first, of a sudden you feel like your heart skipping a beat, this is really anxiety provoking. The first time you feel your heart, you almost wish you never knew you felt it. Women will talk about a new onset of ratches, itchy ears, dry skin. You may end up in the dermatologist's office, right?

Join aches and pains? Here's a funny one. If you notice before your period, like your hips are really stiff or maybe even your fingers or your knees, and then it seems to get better once you get your period. And in the first part of your cycle, perimenopause. Okay, a lot of these things, though, could be other things. How do you know if it's paraminopause versus any other thing that makes your body do these things? There's two things you can think about.

The first is it's really helpful to track them. If it's perimenopause specifically, and we're talking about perimenopause, which is when women are experiencing symptoms, but they're still menstruating or they're still ovulating, they might have a cyclic pattern. So if you notice hot flashes or night sweats or mood symptoms that seem to go on a cyclic pattern, this is one very strong indication that it could be hormonal because your hormones do have this cyclic pattern of about every four to five weeks. Although, again, that will change as you get into perimenopause. The other thing is that sometimes you know it's perimenopause when we actually start

Menopuzzle hormone therapy. Because if we are to start menopuzzle hormone therapy in sort of a diagnostic way, sometimes that really helps women say, oh, wow, it was hormonal. So let me give you the example of palpitations or the joint aches and pains. If we start menopuzzle hormone therapy and my patients say, wow, Dr. Hirsch, they're gone. That's also how we know it is hormonal. I think for a lot of people, this can be really isolating. you know, you feel like something's off, you feel like maybe something's wrong, but you can't get a clear answer. Why is that? You know, I think it has so much to do with still the taboo and the shame on the topic, whether it's, you know, aging or it's just changing how culturally you're perceived. You're no longer

someone who can reproduce. You're no longer getting your periods. Maybe you're no longer youthful. and your body is changing so much. So for many women, when they start to experience these symptoms, they start to feel socially isolated because maybe you are exhausted. You get home from work. It took all of your energy to get through work. Now you just want to take your clothes off. Maybe you've gained weight.

You want to sit on the couch. You want to go to bed and you just want to veg out. I talk with women all the time. They still say often in their friend groups or among their siblings. It's still not a topic that's easily talked about. Now, these are changing, but still slowly. We feel like we've made such a big change. And a lot of that I do believe has to do with social media.

But there's a difference between talking to avoid and actually talking to one of your best friends or your partners. It can feel more vulnerable when it's someone that's very, very close to you. There is still this idea that we have to suffer through this. There's this idea that that's what our grandmothers did and our great-grandmothers. And so we should just suffer through it. And I am here to say to anyone listening that suffering not only is unnecessary, there's no metal at the end, but it will derail your health. And so what's been exciting in the last couple years is there's more and more and more acceptance of how to treat symptoms through perimenopause, that they're safe, they're effective, and they can be life-changing for the vast majority of women who start them. Up next, we get into that life-changing treatment.

And we bust some myths about it, too. Support for Explain It to Me comes from Fetch Pet Insurance. Here's something that might surprise you. Every six seconds, a pet owner in the U.S. gets hit with a vet bill over $1,000. That's according to a study from a pet insurance company. Be prepared with Fetch Pet Insurance. Fetch is the most complete coverage for dogs and cats, according to Consumer Advocate.org. Fetch covers accidents, illnesses, diagnostics, and more.

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Code explained at Imadehealth.com slash explain. These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose tree cure or prevent any disease. I'm JQ, back with more Explate it to me. And we're talking with Dr. Heather Hirsch about the pause before the pause, paraminopause. So, Heather, to deal with their symptoms, a lot of people turn to hormone therapy, how does it work? Well, you know, essentially what you're doing is you are replacing what you're missing. So there's lots of examples of where we do this.

Diabetics, specifically even type 1 diabetics, they don't have insulin, a hormone that helps them take, you know, carbohydrates, glucose, and utilize it well. And so we're kind of doing the same thing with menopause, perimenopause. Because your hormones are starting to low, get lower, and drop, we're replacing them. Now, we're replacing them in actually very low, low doses. And it can be extremely helpful for the places that the body is missing it. We've already talked about the brain, the heart, the bones, the pelvic floor, the skin. It can make a huge difference when we replace them. I love a breakdown. Which hormones are we talking about and what are doctors looking for? There's sort of three big ones if we think about the trifecta. And I always explain this as sort of an ice cream cone analogy.

When we think about estrogen, this is kind of if you're craving a Sunday, let's say, okay? It's a hot summer day. This is like the ice cream. This is the main ingredient. This is what you want to go down to the ice cream shop for. estrogen when it drops can make us feel hot and dry. So that can be the hot flashes, the night sweats, the dry skin. It can make us feel like we have low mood or anhydonia or depression because estrogen actually keeps serotonin in the brain longer. It's a natural antidepressant. Oh, okay. And it also plays a role in keeping our heart and our bones healthy.

So estrogen is kind of like the main ingredient. Now, progesterone is like the ice cream cone. It keeps the estrogen safe, or really, it's also protecting a woman if she has her uterus still. Progesterone in the brain converts to alopregnolone, which binds to gab receptors, and it makes you feel calm and sleepy. So many women, if they've ever had a pregnancy, will remember in their first trimester, they can feel really tired. That is the effects of progesterone. It's really, really increasing in that first trimester. And then I think about testosterone as sort of the toppings of your Sunday.

So maybe a little sprinkles, maybe a little cherry on top. Kind of really cinches things together. Not necessary. You could absolutely have an ice cream Sunday. You don't need any toppings, right? The ice cream is good enough. But some women like to have toppings. Testosterone helps with libido for sure.

And it can also help with reducing brain fog. Sometimes can help with reducing joint aches and pains in helping mood. More research needs to be done on testosterone. The vast majority of research in terms of these three hormones is actually on estrogen, then progesterone and then testosterone, which actually isn't technically FDA approved for women. I would love to know more about hormone panels. I feel like I've seen more and more people bring that up online.

What does it take to get a full hormone panel? Flat out say, I want a blood test. on a full panel. Ask specifically for a full hormone panel. We are becoming data junkies. We love our loop. We love our Apple Watch. We love our aura ring. And all of those are okay. They just need to be taken in context. The most important thing for women to do is really that journaling and tracking. If you can track what symptoms you're having in correlation with either when you're bleeding or maybe when you're ovulating, this is the most helpful thing because perimenopause, believe it or not, is a clinical diagnosis. And all that means is the clinician decides,

which can be frustrating, right? So women are trying to sort of get support and they're looking for a diagnosis. But if their clinician doesn't know what to do, they're thinking maybe lab work will help me. But there is no lab that tells you you are in or not in perimenopause. It's all about how you're feeling over, you know, a period of time. Why are we so, I don't know, prickly when we hear the word hormones? Because I've seen it when people talk about paraminopause and menopause and hormone replacement therapy. I've seen it with discussions online about birth control, just like no hormones. Hormones bad.

Why do we have this kind of contentious relationship with hormones? I think the word itself is very broad, right? When I hear the word hormones, I think of like, and this is, sort of silly and personal. So this probably applies to no one else. But I think of like agriculture where they're injecting hormones into animals, right? They're doing it unethically and they're kind of disrupting our food supply or so they tell us. And so when we think about the word hormones, it sort of has a negative connotation to it. It just does. And I think that's part of the patriarchal and sexist society that we live in, not that we need to go deep onto that. But again,

the idea that the word hormone has become negative or has become tainted or is something bad, is something that should make us sort of think like, why do I even think that right? Interestingly, for perimenopause, we're actually very often using plant-based estrogen or plant-based progesterone in very, very, very low doses. And so when we think about it as estradiol or transfermal estrogen or prometrium or progesterone that mimics our natural progesterone, it feels different, right? A little bit than just the word hormones in general.

Hormones has this idea that we're like, you know, artificially injecting things into our bodies, but we make a lot of hormones every single day. And so, you know, I think that maybe why. I think it's just that our perception, the media, has shaped what this word means to us. And it's not just perception that shifted. Even the way we study women's health has changed.

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Quince.com slash explain it. Support for this show comes from whatnot. It's hard to follow your business streams and not enough people talk about the time. and effort you have to put in to make your dreams a reality. What Not is the largest dedicated live shopping platform, whether it's beauty, collectibles, electronics, luxury fashion, even cookies. Sellers are building real, thriving businesses. Instead of uploading a listing and crossing your fingers, sellers can go live, showcase products directly to viewers,

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able to chat with the salesperson, you're able to chat with people bidding around you. It was great. Search What Not, W-H-A-T-N-O-T-O-T. in the app store. Download and you can start selling right away. The estrogen patch made the world of difference. I wish I would have had that two years ago. So why are primary care providers not being trained on that of a 40-year-old woman's body? Thanks. Bye. This is explained to me. I'm JQ. Modern medicine has made so many strides when it comes to health care,

things that felt inevitably unpleasant don't have to be. But why does it sometimes feel like doctors are still playing catch up on some pretty basic aspects of women's health? Because it's true. It takes a long time for medical science to catch up with the glaring gaps in our health care system. And the gaps are not just about the obvious women's health issues. That's Elizabeth Komen. She's an oncologist and a professor at NYU. And she focuses on the gap between women and modern medicine. We focus a lot on breast cancer.

We focus a lot on reproductive function or our gynecological needs. But really, the gaps also exist head to toe from our neurologic care, our gastroenterology care, how our hearts function, how our immune system functions, how our joint functions. And so the gaps are real and the experiences are real. Can you walk me through some of the history? Like, what did it look like to study women's health? before the 20th century. What were we dealing with? For much of history of medicine, at least in the Western world, the idea was that at best, we were small men. And at worst, there were many ridiculous

diagnoses like hysteria and a long legacy of dismissing women's medical needs because we were largely not taken care of by women. And those women that were caregivers in the history of medicine, whether it was the midwives or other types of healers, were largely pushed up. out of medicine as it became codified and the idea of medical science really came to rise in the late 19th century. So I'm guessing they weren't really talking about menopause at the time, let alone paraminopause. Well, parimenopause wasn't anything that was even discussed. With respect to menopause, I mean, one of the famous physicians wrote a book Feminine Forever and referred to women going through menopause as vapid cows. and he was the one that advocated in the 60s and 70s for women to be on hormone replacement therapy.

I have seen untreated women who had shriveled into caricatures of their former selves. She is incapable of rationally perceiving her own situation. That's just such a wild way to refer to a group of people. I mean, just about half the population will go through this at some point. And you're just dismissing all of them as vapid cows? Pretty much, pretty much, crazy at best. How were these hormones marketed to people when HRT first became a thing? Well, that this would help you be less crazy, that you would have more vigor.

I mean, it depends on which advertisements that you look at. Husbands, too, like Premarin. The physician who puts a woman on Premarin when she is suffering in the menopause usually makes her pleasant to live with once again. But if you look at advertisements of women, in the 1950s, 60s, and 70s. A lot of women were being just prescribed anti-anxiety medicine. You know, can't manage your household at home,

don't want to take care of your kids. Here's what will sedate you and at least make you able to prepare breakfast for your husband. Formerly nervous and tense, a librium-treated patient is better able to enjoy her family. Now she can cope. Thanks to Butesol, the daytime sedative for everyday situational stress.

It's really shocking and yet not that surprising. If you look at Instagram today, are we really that far off from what gets marketed to women? Women sink billions of dollars probably into sham supplements and sham treatments because they don't feel care for when they go to the doctor. And what fills that space, a lot of people trying to market things that have no proven evidence. You know, I think it's really interesting how at one point hormone replacement therapy was like this big thing. Because I feel like growing up in the 90s and 2000s, hearing women who are older than me speak, they were very kind of anti-hormone. How did the pendulum swing that way? Well, the pendulum has swung in wildly different directions. So at first it was every woman needs to be on it and there were wildly successful sales. and then there was the women's health study that over-exaggerated the risk of breast cancer. The announcement yesterday that a hormone replacement regimen taken by six million American women did more harm than good

was met with puzzlement and disbelief by women and their doctors across the country. A rigorous study found that the drugs, a combination of estrogen and progestin, caused small increases in breast cancer, heart attacks, strokes, and blood clots. The New York Times, July 2002. Certainly during my training, and up until very recently, the thought was that these risks were, as we were taught, over-exaggerated, meaning we were taught that all these women that were getting breast cancer that I was seeing in clinic, it was secondary to their hormone replacement therapy, and that simply we don't have the evidence for. And now we've become much more granular about what we know and what we don't know, but I still think we're far behind on the science.

There's lots that we don't understand, such as how we can improve testosterone replacement therapy in women, how we can give potentially hormone replacement therapy to women who are very far out from their breast cancer and may have had what we call triple negative breast cancer, breast cancers that are not driven by the estrogen receptor. There's just still a lot that we need to learn. But fortunately, an understanding of the prior studies and what their limitations are has come to light. You mentioned the Women's Health Initiative study from 2002. Why was that such a game changer? Well, it was a game changer because it included a lot of women. There was a lot of hype around it. There was a lot of fear. Obviously, breast cancer is something that is terrifying for so many

women and the landscape for how we treat it has improved. But understandably, women were terrified. I mean, they were told by the media by reputable scientists that these risks were significantly high and that they could not be on it. And then we didn't leave them with any alternatives. And I'll give you an example also where we know that intrabaginal estrogen, where it is not, where it's inserted into the vagina and it's not systemically absorbed, meaning it's not traveling throughout your whole body. and hitting other tissues in the body is relatively safe for even breast cancer patients. And this is something that we have not been giving breast cancer patients. And yet for years, we've been telling women, oh, sex is uncomfortable.

Oh, your vagina feels so dry under many circumstances, or you're at increased risk for urinary tract infections, but we don't really have anything for you. And fortunately, that has changed in recent years. What do you think it will take for people to trust their doctors again? Like, instead of turning to treatments, they're being sold online, that might be dangerous, feeling good about the interactions they're having at the doctor's office. I think it's going to be really challenging. First of all, we can't blame patients because we've done them into service. And certainly medicine has fragmented the care of many patients, not just women, but men as well.

We have to build a health care system that allows for time to be with patients and really hold space for them. I think that's where the trust is really going to be built. is at the end of the day, despite all the technology that's available, medicine is about human to human care. And that is what everybody wants to be treated as a human to be seen and heard in the ways that you can't just reduce a body to biology. Remember Amy who we heard at the beginning of this episode? She started paramedopause in her early 40s. Now she's 55 and still there. I have been in paramedopause for nearly 15 years, and I have still not had a year.

without a period, so I'm still in the technical definition for perimenopause. It's been a journey, for sure. Amy's been able to manage her symptoms with hormone replacement therapy prescribed by her doctor and by talking with other women in the same stage of life. Not everyone has the same symptoms, not everyone has the same path, it doesn't happen at the same time, but finding other women in this same age group and actually being open and honest, finding room to discuss these things, not only complain and be curious about, but also kind of like

celebrate some of the new things we find out about ourselves. If you could give advice to, I don't know, maybe even like your 30-year-old self or your 25-year-old self about this time in life and navigating it or preparing, what would you say to her? Yeah. Well, I love that you used a 25-year-old self example because my older daughter is 25. If I could go back and tell my own self at 25, I would say to make the assumption when you're in your 40s and early 50s that any weird new thing that comes up might be hormonally related and explore that and bring that up with your caregivers and doctors. And then also know that some really good things happen with aging too. You know, that you shaped life happiness curve for me has been really true. I'm still in perimenopause, and yet I feel like I have a more clarified sense of purpose.

I have a much stronger sense of self-acceptance. I feel even more connectivity to just being a human and a woman and connecting with people that are in these same stages of life. And those have been really enriching and freeing at the same time. So be well-informed, pay attention to your body, talk about it with people and then welcome the changes. Just leap in, keep leaping in. Don't become fearful of change in new things. It's hard, but it's been really fun.

That's it for this week. Thanks to everyone who called in and shared their story. Next up, we're working on an episode about vacations, which, given the state of the world, may look a little different for you this year. Has money influenced your recent vacation plans? Do you have a great stay occasion to recommend? Tell us about it. Call 1-800-618-45 or email AskVox at Vox.com. If you want to support this work, consider becoming a Vox member. You get to listen

to the show ad-free. You can find out more by heading over to Vox.com slash members. This episode was produced by Ariana Spur. It was edited by Jenny Lawton, fact-checked by Melissa Hirsch, engineered by Brandon McFarland. Our executive producer is Miranda Kennedy. And I'm your host, John Glenn Hill. Thank you so much for listening. I'll talk to you soon. Bye.

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