Books editor Catherine Woulfe reviews game-changing menopause books This Changes Everything, by Niki Bezzant and Don’t Sweat It, by Nicky Pellegrino.
Here’s what I thought I knew about menopause before reading these books: Actual menopause is when periods stop. Before that there’s a long shitty stage called perimenopause. Might start at any point from mid to late 30s. High chance it’ll be hell on earth. I might get desperate enough to try hormone replacement therapy (HRT) but that’ll be a fraught decision because it causes breast cancer and probably lots of other awful diseases. Whoo! Lady-medicine!
Staggeringly, according to two superb new books about menopause, a lack of training means that’s basically where many New Zealand GPs are at, too.
In her book, Niki Bezzant emphasises that she doesn’t want to bag GPs, that it’s “a bloody difficult job”, that it’s only gotten more difficult since Covid-19. And there are good ones, of course.
But, she writes: “We can see the legacy of … hundreds of years of medical and general misogyny in the fact, highlighted by dozens of women I’ve talked to for this book, that primary medical care for menopause is – let’s say – patchy.
“For some, it’s that when they first reported their symptoms to their GP, they weren’t recognised as being related to perimenopause at all. For others, it’s that they were dismissed when they asked the question: Could this be perimenopause? And for others, it’s that the treatments offered to them were not appropriate, up-to-date or best practice. At worst, I’ve spoken to women who’ve been refused HRT by their doctors when they’re clearly in need of some form of treatment, for reasons that bear no relationship to the current state of the evidence.”
It turns out most of what I knew about menopause is accurate, unfortunately. But – and this is crucial – not the bit about HRT (also known as MHT, or menopausal hormone therapy). Of all the extremely useful information in these books the major takeaway for me is that HRT is safe and, for many women, as close to a panacea as it gets.
Bezzant again: “We now know that HRT is not as scary as we once thought it was; in fact it’s a potentially life-changing treatment for many women who are suffering from symptoms of menopause that are wrecking their quality of life.” She writes that HRT is the most effective treatment for hot flushes and sweats, as well as for dryness and itching of the vagina, vulva and urethra. “It’s also very likely to improve other menopause-related complaints, such as joint and muscle pain, mood swings, sleep disturbances and sexual dysfunction (including reduced libido).” Importantly, it can also be protective for the heart, bones and possibly the brain, which are left vulnerable as oestrogen levels drop.
There are caveats, of course, which both books are very clear on. It’s best to start HRT before the age of 60, within 10 years of the last period. Only women whose quality of life is suffering should take it. And women with certain medical conditions, such as acute liver disease and particular cancers, should avoid it.
I couldn’t have told you why I was so twitchy about HRT. Turns out it’s a similar story to the disastrous Andrew Wakefield work on vaccines and autism. Briefly: in 2002 a major study was abruptly halted over a finding that women on HRT had a 26% greater risk of developing invasive breast cancer than those on placebo. Alarming, but as Bezzant explains, 26% was the relative risk, not the absolute risk, which remained very small: about 1 in 1200 women. Further, the study involved only older women – average age 63 – who would not usually need or want to be on HRT. They were on an old-fashioned form of the drug, not what we use now. And hidden behind that ta-da breast cancer number were a bunch of positive findings.
Even as the academic paper and press release went out, some of the researchers involved were frantically trying to edit the misinterpretations and pull back the language.
No joy. As Nicky Pellegrino writes: “People freaked out. Women flushed their hormone supplements down the toilet, lawsuits started flying around; basically it was one big drama and HRT’s reputation was shot. The mantra from then on became ‘the lowest dose for the shortest period’, and a lot of doctors were very nervous about prescribing HRT at all.”
The pendulum’s been stuck at that point ever since, she writes. (To be clear, it has been stuck for 20 years.) Overseas it seems perspectives are changing, but as an indicator of where we’re at in 2022 in Aotearoa, here’s Pellegrino’s advice to women seeking an HRT prescription from a GP:
Most doctors will prescribe hormones to treat severe hot flushes but not any other disease or symptoms.
So if you are set on HRT, don’t bother mentioning your interest in the benefit to your bones or your hopes of staving off diabetes or dementia. If you’re struggling with mood swings and sleeplessness, it’s best not to bring them up either or else you’ll be offered other options – like anti-depressants.
In your precious fifteen minutes of GP face-time it pays to stay on message. Have a diary of your flushes, with information about frequency and severity. Make it clear how much this is affecting your life and overall health. Also show an understanding of the risk factors. But mainly talk about being hot, hot, hot. This is the thing most likely to score you the hormones you’re asking for, from your pressured, short-on-time and possibly over-cautious GP.
(Worth noting: one in five women don’t get hot flushes. They could well be suffering from other symptoms, though.)
Women should go and get a second, third and fourth opinion if they need to, urges Auckland endocrinologist Megan Ogilvie, in Bezzant’s book. “Until they find somebody who has kept up to date in this area and is prepared to listen and to provide some of these options as viable treatments.”
She’s right, of course she is, but ugh. I’m too busy for this. Too tired. Kids, work, lockdowns, a sick parent, a to-do list that just never gets done. I’ve started putting things on there like “cut my nails” and “breakfast” because otherwise they get squeezed out, forgotten. As one woman told Bezzant: “This period of time feels very dense. It’s just absolutely thick with stuff.”
“It’s worth womaning up,” writes Bezzant, and she’s right, too, but could the medical system not do the womaning up, for once?
I read Don’t Sweat It and This Changes Everything in the first days of 2022, as all of Tāmaki Makaurau broiled in a hot flush.
I kept thinking about how much it must have sucked for Pellegrino and Bezzant, both journalists, to realise they were writing neck-and-neck for rival publishers on essentially the same brief. (“Science, but make it relatable.”) For readers, though, there is richness in the double-up. When you’re grappling with new and important information, repetition is no bad thing. Nor are different – albeit middle-class Pākehā – perspectives. Before, we had no current New Zealand books about menopause. Now we have two.
On one level these books are pragmatic primers. You could definitely go through with a highlighter and Post-Its then march off to your doctor (then the next doctor, and the next one). But just as importantly, they’re also an acknowledgement of what many women go through as they enter menopause. We see you, they say, to the woman awake all night and raging all day, coping with spectacular bleeds and sweats, itching, digestive problems, brain fog and memory loss, plummeting libido and an abrupt loss of confidence. To be clear, it’s not always like that – Pellegrino and Bezzant both talked to women who breezed through these years, but they also talked to many who felt like they were falling apart, that they had early-onset dementia. We see you, their books say, to these women too.
I suspect both authors had to edit their own rage, at times, in the service of succinctness and generally not coming across as madwomen. But they allow themselves the occasional satisfying flash of frustration and anger. Also, they are both very funny. Pellegrino: “Eventually my whole body is going to be pleated like an Issey Miyake dress, so I may as well get used to it.” Bezzant: “I know I definitely feel more svelte when I’ve had a decent poo.” These are easy reads, fascinating reads. It was like having brilliant, illuminating conversations with two very different friends.
Pellegrino has a background in women’s mags. She now writes health features for the Listener and glorious novels involving food and romance and Italy. Here she has a light touch, naturally dropping in pop-culture references and celebrity pull quotes. Alongside the science she covers topics like appearance medicine, clothing and the importance of mindset. I started with her book and was glad I did. But I was equally glad to push a bit deeper into the science with Bezzant, who founded the Healthy Food Guide and takes a similarly robust, data-driven stance here.
When I was seven I learned about the mechanics of sex via the mummy and daddy robots in the Usborne classic How Your Body Works. Just like when I was seven, I’ve emerged from these books spluttering, evangelical. Did you know, I keep saying to my friends. Here, read this book. But this time, I’m also angry.
There’s anger at this big, tumultuous thing that’s coming for me. There’s anger at how much my body’s already had to cope with, at how much all women have to cope with. But mostly, I’m angry that when I talked to my friends, it turned out all of us smart, privileged, middle-aged, nerd-inclined women were absolutely clueless about menopause.
All of us know, of course, exactly why we’ve been allowed to be so poorly informed: because menopause doesn’t happen to men.
There’s so much important information in these books that I don’t have space to go over. It’s by no means all HRT; other treatments for various symptoms are covered, as well as lots of solid advice about diet and exercise as we age, and large sections of the internet that Pellegrino and Bezzant would cheerfully carpet-bomb. (Google “menopause” and you’ll trigger an algorithmic feeding frenzy.)
But here’s the other standout for me: There is no test to determine whether a woman’s in perimenopause. That’s because if you are, your hormones will be bouncing around all over the place, sometimes in the space of one day. Any test snapshots just a moment in time, making it useless, a crapshoot. So all we can do, really – and all a doctor can do – is take stock of our symptoms. And it’s important to know that the possibilities here go way beyond hot flushes and period stuff.
Bezzant lists 42 symptoms of perimenopause. I’d never seen them laid out like this; I ticked 23. These are symptoms that have been debilitating and exhausting, and have mostly hit in the last year or so (I’m 39). Loads of them are to do with mood and mental health, but I also have migraines, insomnia, wicked PMS, hearing problems, skin problems, erratic periods, weird abrupt weight gain.
I’d been seeing all of these as a constellation, a scattering of discrete bad times. That’s because whenever I’ve floated the idea of perimenopause with various GPs, I’ve been referred for blood tests that come back “normal”. I clenched my teeth as I read the following, from endocrinologist Anna Fenton, in Bezzant’s book: “Women are actually very good at telling you what they think’s going on, and I’ve learned over the years that if you ignore women, you do so at your peril. They’re usually right.”
So I’m going back to my GP, books in hand. I’m still angry. But I’m also deeply grateful to the women who saw the need for information in this vast empty space, and filled it.
This Changes Everything: The honest guide to menopause and perimenopause, by Niki Bezzant (Penguin, $37) is available now from Unity Books Auckland and Wellington. You can also pre-order Don’t Sweat It: How to make ‘the change’ a good one, by Nicky Pellegrino (Allen & Unwin, $36.99), which is available from 17 January.