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Jen Gunter is an obstetrician and gynecologist. Her latest book is The Menopause Manifesto: Own Your Health with Facts and Feminism, from which this essay is adapted.

For many women, menopause feels like a journey to the unexpected, which is of itself disconcerting. But often their symptoms are dismissed with platitudes such as, “This is just part of being a woman,” or they are given misinformation about what is happening to their bodies and which therapies are effective.

It seemed that everywhere I went on tour for my last book The Vagina Bible, women wanted to talk about menopause – they wanted information and they also wanted to be heard. I realized the culture of silence about menopause was so great that many were not only suffering, but they felt alone. Creating a space to talk about the vulva and vagina as one should – openly and without shame or secrecy – also created a space to talk about the greatest taboo of all.

There is no greater shame in a patriarchal society than an aging woman’s body.

Every woman should know as much about menopause as a well-informed gynecologist. And in addition to the medicine, they should know the history behind menopause. That menopause is not a pre-death or the end of a journey; instead, think of menopause as crossing the crimson bridge – a planned biological change that has been a vital contributor to the evolution of humankind.

When most people think of evolution and survival of the fittest, they only consider the individual and their offspring. This can’t apply to menopause, as menopausal women don’t reproduce, so they’re no longer passing their genetics directly to the next generation. But after menopause, women can still protect their genetic legacy by contributing to the survival of their grandchildren.

The evolutionary advantage of menopause is grandmothers. It’s known as the grandmother hypothesis, and there is plenty of science to back it up.

While it’s true that most mammals – female and male – die relatively soon after they lose the ability to reproduce, humans are not most mammals. Pregnancy is much more of a biological investment for humans. Not only does it divert calories and nutrients, but in the world of mammals, humans have extraordinarily difficult deliveries. I know individually many people consider birth beautiful, or their own delivery at least, and this is totally fair, but from a biology perspective, it’s more of a just-good-enough situation that depends on women bearing the physical carnage.

Humans have longer and more difficult labours than most mammals. Intelligence and being able to walk upright, freeing hands for other tasks, have both conferred huge evolutionary advantages. The problem? Fitting the large fetal head needed for intelligence through the small pelvis we require to be bipedal. It’s painful, tissues get damaged, and there can be significant blood loss. There is also the risk of maternal mortality, especially devastating evolutionarily speaking, because if a mother died during pregnancy leaving one or more children motherless, those children were more likely to die.

After delivery there is the toll of raising a child until it can care for itself. Human infants are uniquely vulnerable, compared with other mammals at birth, in part because our brains and nervous systems are far from being fully developed. Breastfeeding and raising children requires additional calories for the family unit, and young children make it harder to find food and shelter.

Who can help with these resource-heavy tasks? A grandmother. But she can only be gathering food and water, sourcing shelter and providing child care if she isn’t burdened with those tasks herself. The most helpful grandmother hasn’t recently finished with her reproduction; she’s enough years from childbearing that she can leave her own offspring unattended.

Ovarian function slows in the mid- to late-40s and then has a hard stop around 50, but not because women are weak or that the ovaries fail. Rather, this slowing and stopping of fertility while there are still many productive years left is a planned biological event that allowed ancestral grandmothers to contribute to their family unit and improve survival.

For much of our history, Western medicine viewed menopause as a disease because being a woman was considered a disease. According to the ancient Greeks, men were in balance with the world, and much of this balance revolved around fluid. Men could manage their fluid balance with perspiration, but women were too feeble and consequently their very flesh was too moist. To compensate, women released fluid once a month from their uterus. Whenever anyone holds out Hippocrates or uses “ancient” as being aspirational in health, I think of how the ancient Greek physicians believed women were walking defective plumbing.

Most illnesses that affected women were blamed on their uterus and lack of menstruation was a serious sign, as dangerous fluids could accumulate and wreak all sorts of medical mayhem. The blood itself was considered toxic, the cause of a vast array of illnesses from miscarriages to cancer to consumption to rabies. Menstrual blood could also kill plants and ruin mirrors. Women’s health worsened as they aged because they became too feeble to expel this toxic substance, so it accumulated in the body.

The first formal dissertation on what we now call menopause was written in 1710 – the Latin title translates to “Final Menstruation, Beginnings of Disease,” which is an accurate summary of the thinking of the time. It may as well have been called “Being a Woman, from Bad to Worse.” Medical illness increased with age – this was known – but when men had an ailment there was a reason, not one we might think of now, but an explanation that fit the understanding of the human body of the day. For women it was the uterus. If you see women as inferior or weak or dirty or damaged, it’s easy to make the medical knowledge, such as it was, fit your world order. It is a very important lesson that we in medicine should never forget.

Shortly after the first dissertation on menopause, writings on the subject – for both physicians and the general public – began to appear in Europe and England. The Ladies Physical Directory, first published in 1716 by the anonymous A Physician, had multiple printings. By 1727 it was in the sixth edition, and included information on how to treat many conditions that would have been common for women in their late 40s and beyond: heavy periods, missed periods and uterine prolapse. So clearly there was interest. Most of the therapies of the day involved bloodletting, leeches and purgatives (laxatives) – methods for removing “toxins” and/or fluid that had accumulated due to a lack of menstruation.

Looking at the recipes, they could not possibly have been effective medically, although many likely triggered diarrhea and possibly uterine contractions, possibly leading to some bleeding for women in the menopause transition (not normal menstruation, rather a sign that a bad thing has happened to the body!). These effects were courtesy of the dangerous ingredients, such as oil of savin, arum root and iron filings. Other recipes were likely benign and ineffective, possibly producing results via a placebo effect or more likely the wine chaser and long walk that was often recommended as part of the therapy. There was also a range of vaginal potpourri that would make Gwyneth Paltrow jade with jealousy.

A variety of terms to describe symptoms of menopause can be found in these texts; many are similar to what we use today and some are even better. What we now call the menopause transition was known in England during the 18th and 19th centuries (and possibly earlier) as the dodge or dodging, as women were dodging between irregular periods. During the dodge women might experience headaches, back pain, vasomotor symptoms (what we now call hot flushes or hot flashes and night sweats), wandering pains and general unease. The terms for hot flushes were feverish heats, flushing heats and hot blooms.

The dodge is so perfectly descriptive it’s delightful. I now use it in the office when I explain the menopause transition, and almost universally I get a smile. A “hot bloom” is wonderfully apt because the heat feels as if it starts internally and blooms upward and outward to my head, face, neck and arms. Even today we see the language of menopause continue to evolve. Some women like to call their hot flushes power surges, and whatever term works for you is just fine. After all, it is your experience.

A hot flush isn’t just a feeling of heat; the body is warm to the touch. Hot flushes may be accompanied by sweating, redness in the face, nausea, agitation and anxiety. The hot flush experience can vary woman to woman, but there’s one constant – heat. Night sweats are hot flushes during the night that result in excessive sweating, and they’re a source of sleep disturbance. They are also unpleasant, as waking up in soaked bedsheets is gross.

A hot flush happens when a wonky inner thermostat informs your brain that you’re hot when you are not. Thermoregulation – the control of body temperature – happens deep in the brain in a region called the hypothalamus. Various hormones and neurotransmitters work together – receiving signals from the body and the environment – to keep body temperature in a relatively narrow zone.

Reproduction and temperature control are closely related. For example, body temperature is highest midway between ovulation and menstruation due to elevated levels of progesterone. The theory is the slightly higher temperature during this time is favorable to implantation. Consequently there are neurons (nerve cells) involved in regulating both temperature and the menstrual cycle. A good analogy is that thermoregulation and reproduction share the same motherboard.

The mechanisms behind vasomotor symptoms are very complex and not completely understood. It’s not the estrogen levels that matter, otherwise girls would have hot flushes before puberty. A hot flush depends on a brain that had estrogen and then that estrogen is taken away. The faster the drop, the more profound the effect, which is why removing the ovaries before menopause leads to more hot flushes and more severe symptoms than the more meandering drop in hormones typical of menopause.

Estrogen has an interesting role in temperature regulation: it appears to suppress messages from a group of neurons that communicate about heat. With menopause, these neurons no longer have estrogen as a gatekeeper, so the area of the brain with these heat-promoting neurons gets larger. Some research suggests a hormone released by the brain that rises during menopause, follicle stimulating hormone (FSH), may also have a role in hot flushes.

Without the influence of estrogen, the thermoregulatory system becomes extremely sensitive to minor increases in temperature and responds in an exaggerated manner – so one flight of stairs feels like a long run in heavy clothes on a hot day. Think of it as part of your brain randomly yelling “Fire in the hole” when all systems are operating just fine and there isn’t estrogen around to say, “Don’t be so shouty and honestly, let’s gather all the facts first.”

In an effort to cool off, blood vessels dilate and blood is shunted to the skin where it loses some of its heat. This is the wave of heat (and often redness) in the face, neck, upper chest and arms. Sweat glands are also triggered to perspire. The heart rate goes up (this can contribute to a feeling of anxiety for some women) and there is reduced blood flow to the brain. This heat episode lasts an average of two to four minutes, stopping when the body temperature eventually drops from the cooling efforts. Because you were never hot to begin with, the body temperature may now be lower than needed so there may be accompanying chills and some women are more bothered by the chills than the heat. Shivering may even occur to bring the now lowered body temperature back to normal.

Were you exhausted just reading about it? For some women these episodes happen 20 or 30 times a day. The intensity of vasomotor symptoms vary from woman to woman and are associated with difficulties sleeping and depression, and they negatively affect the quality of life. Some women are very bothered, and others not so much. It can be draining and stressful, and hot flushes make many women feel awful. Hot flushes are also unpredictable, meaning one day an activity triggers what seems like an endless wave of heat throughout the day and on another day that same activity may have no effect. The unpredictability just makes it worse because it can feel as if your body is out of control and that’s unsettling.

While hot flushes may be the symptom most often associated with menopause, many women experience vaginal dryness and pain with sex; others may develop depression, and sleep difficulties and brain fog are also common experiences. For some, these symptoms may start during the menopause transition, which is often referred to as premenopause (this is the time, typically several years, leading up to the final menstrual period). Or they may happen after the final menstrual period, in the phase known as postmenopause when ovulation is no longer possible. During the menopause transition menstrual irregularities such as heavy periods, skipped periods and irregular bleeding are common. In addition to symptoms, there is an increased risk of osteoporosis, urinary tract infections and type 2 diabetes – to name a few of the medical conditions linked with menopause.

There are many options for managing symptoms and minimizing the medical consequences of menopause, and for some that will include menopausal hormonal therapy or MHT. But it’s important to remember that the three healthiest things a woman can do for her menopause have nothing to do with hormones. They are quitting smoking, getting the recommended amount of exercise and eating a diet that meets nutritional needs. While MHT can help many women with quality of life and sometimes longevity, greater gains can be made with these other changes. This doesn’t mean women shouldn’t use MHT; rather, it’s important to put the benefits of MHT into perspective as it’s only one piece of the menopause puzzle.

Knowing what is happening to your body and that there are options is itself powerful medicine. Menopause has only been about frailty and weakness because that was the messaging from a patriarchal society. The story I want people to know is about value, agency and voice, and the knowledge to keep yourself in the best of health while demanding an equal seat at the table.

That is my manifesto.

Excerpted from The Menopause Manifesto: Own Your Health with Facts and Feminism by Dr. Jen Gunter. Copyright © 2021 Dr. Jen Gunter. Published by Random House Canada, a division of Penguin Random House Canada Limited. Reproduced by arrangement with the Publisher. All rights reserved.

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