How to Menopause

DHEA is a hormone produced by the adrenal glands that serves as a precursor to both estrogen and testosterone. Levels decline with age, and low DHEA can contribute to fatigue and decreased libido. Fadal includes DHEA among the key hormones worth tracking during menopause and sometimes recommends supplementation under a doctor’s guidance.

Estrogen is a primary female sex hormone involved in regulating the menstrual cycle and supporting reproductive health, but it also affects the brain, heart, bones, skin, and more. There are three types of estrogen: estradiol (the most prevalent during reproductive years), estrone (which becomes dominant after menopause), and estriol (produced during pregnancy). Estrogen levels begin to drop during perimenopause, which leads to a wide range of symptoms including hot flashes, sleep disturbances, and brain fog. Fadal explains that declining estrogen is one of the key drivers of menopausal symptoms, and that hormone therapy (HT) can help replace what the body no longer produces. Fadal emphasizes that estrogen is not just about reproduction—it is a whole-body hormone, and its loss has far-reaching health implications.

FSH is released by the brain to stimulate egg production in the ovaries. During perimenopause, FSH levels spike as the body tries to compensate for declining ovarian function. Ironically, high FSH does not always mean menopause has started, as levels fluctuate. Fadal cautions against relying solely on hormone blood panels like FSH to determine menopausal status, since they can vary wildly day to day.

Hormone therapy (HT) is used for a variety of health conditions, but when it comes to menopause, it is used to manage physical and psychological symptoms, as well as to prevent further health complications down the road. HT can include estrogen (of which there are three subtypes), progesterone, and testosterone. It is administered in a wide variety of forms, from injections, patches, pills, creams, and more. HT has a controversial history of misunderstanding and fear, but Fadal swears by its benefits and attempts to dispel these rumors. She shares her own initial fear of HT and how she refused it for years, which only led to more problems. This fear (and many others’ fear) was shaped by the flawed 2002 Women’s Health Initiative study, which led to widespread panic and misinformation. Fadal explains how that study used unhealthy, elderly women (far past menopause) and presented misleading statistics, fueling stigma around HT. Now, with safer options like low-dose patches, HT is considered safe if a person has no “contraindications.” Fadal urges women to be informed, explore HT’s benefits, such as relief from hot flashes, brain fog, and osteoporosis, and advocate for their right to choose.

Inhibin B helps regulate FSH and is produced by the ovaries. Its decline is another marker of reproductive aging. Though rarely mentioned in everyday clinical settings, Fadal includes Inhibin B to educate readers on the complex hormonal orchestra involved in menopause.

Menopause is the natural biological process and occurs on the 366th day after a woman’s last menstrual cycle. It typically occurs between ages 45 and 55. It’s diagnosed after 12 consecutive months without a period. Caused by declining hormone levels, it may involve symptoms like hot flashes, mood changes, sleep disturbances, and vaginal dryness. Perimenopausal symptoms tend to decline in the years following menopause. Fadal’s book covers perimenopause up to postmenopause, but the colloquial way to refer to all of these is “menopause.” In this sense, Fadal’s book focuses on Managing the Effects of Menopause, making it a journey of empowerment and self-discovery, and reducing the stigma and shame associated with this life transition.

Contrary to popular belief, perimenopause is the stage when symptoms begin, and can start up to ten years before menopause (the last menstrual cycle). Perimenopause includes physical, psychological, and social effects ranging from weight gain to mood fluctuations to stigma against women as they approach middle age. It can begin as early as adolescence, or as late as in a woman’s fifties. Fadal lifts the veil on perimenopause and explores its full range of consequences, how to manage them, and how to feel empowered during this significant life transition.

Postmenopause refers to the rest of a woman’s life following the end of the menstrual cycle. During the first few years after menopause, symptoms usually continue but gradually decrease. Eventually, symptoms disappear for most women, particularly if well-managed throughout perimenopause. Fadal refers to the postmenopausal phase as a “second adulthood”; it is a time of discovery, renewal, and finding one’s next purpose in life.

Primary Ovarian Insufficiency (POI) is one of the lesser-known conditions related to menopause and occurs when ovaries stop functioning normally before age forty. This leads to irregular or absent periods and symptoms similar to menopause. Fadal emphasizes that many women with POI are misdiagnosed or dismissed; they are quite literally told that they cannot be menopausal and must be imagining things. This issue reflects the broader cultural neglect of women’s health, especially when it comes to menopause. Fadal emphasizes the need for greater awareness, proper diagnosis, and support for those affected. She urges women to advocate for themselves and find doctors who truly understand midlife hormonal changes.

Progesterone is another vital hormone that supports reproductive function, calms the nervous system, and helps regulate sleep. It balances the effects of estrogen and is commonly prescribed alongside estrogen in hormone therapy for women who have not had a hysterectomy. A drop in progesterone can lead to anxiety, irritability, and poor sleep, especially during perimenopause. Fadal underscores how the simultaneous decline of estrogen and progesterone contributes to the complexity of symptoms and why both often need to be addressed together in HT.