The WHI trial measured the most serious and life-threatening outcomes: breast cancer, heart disease, stroke, and blood clots, among others. But for a woman who is constantly losing hair, has joint pain, suddenly realizes her scent has changed (and not for the better), or is depressed or exhausted, for many of those women, the net benefits of taking hormones, of experiencing a better quality of life day by day, it may be worth facing the incremental risks that hormone therapy entails, even after age 60. Even for women like me, whose symptoms aren’t as drastic but whose risks are low, hormones can make sense. “I’m not saying all women need hormones,” Rubin says, “but I’m a big believer in your body, your choice.”
Conversations about menopause lack, among many other things, the language that helps us make these decisions. Some women navigate happily into motherhood, but there’s a term for the extreme anxiety and depression that other women experience after giving birth: postpartum depression. Some women menstruate every month without major disturbances; others experience mood swings that disrupt their daily functioning, suffering from what we call premenstrual syndrome (PMS), or in more severe cases, premenstrual dysphoric disorder. A significant portion of women do not experience any symptoms as they navigate through menopause. Others suffer near systemic breakdowns, with brain fog, recurring hot flashes, and exhaustion. Others feel different enough to know they don’t like what they feel, but they are hardly incapacitated. Menopause, that loose term, is too big, too overdetermined, creating a confusion that makes it especially difficult to talk about.
no symptom it is more closely associated with menopause than hot flashes, a phenomenon that is often reduced to a comic trope: the middle-aged woman furiously waving a fan in her face and throwing ice cubes under her shirt. Between 70 and 80 percent of women have hot flashes, but they are almost as mysterious to researchers as they are to the women who experience them, a reflection of how much we still have to learn about the biology of menopause. Scientists are now trying to find out if hot flashes are just a symptom or if they trigger other changes in the body.
Strangely, the searing heat a woman feels roaring inside is not reflected in any significant increase in her body’s core temperature. Hot flashes originate in the hypothalamus, an area of the brain rich in estrogen receptors that is crucial in the reproductive cycle and also functions as a thermostat. Deprived of estrogen, with its thermostat now unstable, the hypothalamus is more likely to misinterpret small increases in core body temperature as too hot, triggering a burst of sweat and general dilation of blood vessels in an attempt to cool the body. This also raises the skin temperature. Some women experience these glitches once a day, others 10 or more, each lasting anywhere from seconds to five minutes. On average, women experience them for seven to 10 years.
What hot flashes can mean for a woman’s health is one of the main questions that Rebecca Thurston, director of the Women’s Biobehavioral Health Laboratory at the University of Pittsburgh, has been trying to answer. Thurston helped lead a study that followed a diverse cohort of 3,000 women for 22 years and found that about 25 percent of them were what she called superflashers: Their hot flashes started long before their periods became irregular, and women continued to experience them for so long. up to 14 years, which changes the idea that, for most women, hot flashes are an irritating but short-lived inconvenience. Of the five racial and ethnic groups Thurston studied, black women were found to experience the most hot flashes, experience them the most bothersome, and endure them the longest. In addition to race, low socioeconomic status was associated with the duration of women’s hot flashes, suggesting that living conditions, even years later, can affect the body’s handling of menopause. women who experienced child abuse were 70 percent more likely to report night sweats and hot flashes.
Could those symptoms also indicate harm beyond the impact on a woman’s quality of life? In 2016, Thurston published a study in the journal Stroke showing that women who had more hot flashes, at least four a day, tended to have more signs of cardiovascular disease. The link was even stronger than the association between cardiovascular risk and obesity, or cardiovascular risk and high blood pressure. “We don’t know if it’s causal,” Thurston cautions, “or in what direction. We need more research.” There may even be some women for whom hot flashes accelerate physical damage and others who don’t, Thurston told me. At the very least, she says, reports of frequent, severe hot flashes should prompt doctors to take a closer look at a woman’s heart health.
While Thurston was trying to determine the effects of hot flashes on vascular health, Pauline Maki, a professor of psychiatry at the University of Illinois at Chicago, was drawing associations between hot flashes and mild cognitive changes during menopause. Maki had already found a clear correlation between a woman’s number of hot flashes and her memory performance. Maki and Thurston wondered if they could detect some physical representation of that association in the brain. They embarked on research, published last October, which found a strong correlation between the number of hot flashes that a woman has during sleep and signs of damage to the tiny vessels of the brain. In a lab in Pittsburgh, which has one of the most powerful MRI machines in the world, Thurston showed me an image of a brain with small lesions represented as white dots, ghostly absences on the scan. Both their number and location, she said, were different in women with a lot of hot flashes. But whether the hot flashes were causing the damage or whether changes in the brain vessels were causing the hot flashes, she couldn’t say.
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