What Are These Strange Symptoms I'm Experiencing in the Middle of My Life?
Mrs. Malaprop: a character in Richard Brinsley Sheridan's 1775 play The Rivals. "A...woman of almost fifty [emphasis added] who...is famous for misusing...long words that sound similar to the correct words."
-- Larousse Dictionary of Literary Characters
Malapropisms: the type of verbal errors made by the character Mrs. Malaprop.
There are some topics almost no one talks about till you do first. The stampede for the male impotence drug Viagra unveiled one such topic. This book is about another one: the previously unrecognized cognitive symptoms that are caused by the effects of perimenopause and menopause on the mind.
Sometimes it begins out of the blue with occasional slips of the tongue, meaning to say one word and unexpectedly hearing another pop out. Or when you realize that you, once a champion speller, aren't so sure anymore how to spell "potato" or "forty." Sometimes it begins with uncharacteristically forgetting important appointments or drawing unexpected momentary blanks -- total blanks -- when it comes to remembering your only child's or best friend's name, or how to turn on the computer you've been using for years. Sometimes with feeling mentally "hazy" "foggy," or "spacey" and not being able to clear things up though you need to be "sharp" at that moment. "What's happening to me" you wonder. "Could this be early, early, early Alzheimer's disease or a brain tumor?"
But it is usually not early Alzheimer's disease or a brain tumor. It is something else, a particular set of symptoms -- a syndrome -- that can occur in women beginning in their mid to late thirties or in their forties or fifties that more than likely can be halted and even largely reversed according to the best evidence available today. It is a syndrome associated with estrogen loss that is mainly experienced from within, and that until now, amazingly, no one has recognized as common among women or has linked to the wealth of post-1990s research evidence revealing the many important newly discovered roles estrogen plays in the remembering, naming, and attending parts of the brain. This is research that helps explain why the symptoms occur and why they can often be reversed.
"I'm losing it," women say. "I'm going out of my mind," "I'm falling apart at the seams." "I'm flipping out." "I'm cracking up." "I'm having a nervous breakdown," "I'm just not myself." "I don't know what's wrong with me." "I do the strangest things." "I think I'm getting early Alzheimer's."
These are not the hysterical rantings of women with vague psychosomatic complaints but rather the blanket descriptions frequently used by perimenopausal (women experiencing or undergoing changes associated with the shifting hormonal functioning of the ovaries that precedes the last period. Symptoms can begin four to fifteen years before menopause.) and menopausal (women who have had their last period twelve months ago) women to describe the dislocating experience of confronting an assortment of unpredictable mind, speech, and behavioral "flash" symptoms. These are surprising symptoms no one has ever prepared them for. Physicians hearing these dramatic statements over the years have simply had no basis in training for understanding what they were hearing and as a result have been able to offer no, or minimally constructive, help to women who dared to mention them.
dTHE SYMPTOMS OF PERIMENOPAUSE AND MENOPAUSE CAN BE VERY STRANGE BUT NORMAL
Before describing the specific symptoms I am referring to it makes sense first to agree about certain realities of a perimenopausal/menopausal symptom you already do know something about. Hot flashes. Consider this: If we on earth had never heard of hot flashes as a "normal" midlife symptom associated with ovarian and hormonal changes, and a returning astronaut-discoverer of a twin planet to ours reported drenching, unpredictable, overheating episodes as normal in otherwise healthy midlife-and-older women, we would likely say in quick dismissal, "Go away! You must have gotten something wrong there. The women were probably fooling with you in some way. You couldn't be right. That symptom is just too weird to be true of normal people."
And yet the reality is hot flashes are definitely normal but strange symptoms for healthy women to have. The fact that they are so common makes them seem normal to us. What makes them believable apart from their strangeness is the fact that they are also sometimes observable to others, leaving "tracks" of the internal experience visible to those who don't have them and who might otherwise be inclined to dismiss them as "too crazy" to credit as real.
PERIMENOPAUSAL AND MENOPAUSAL SYMPTOMS CAN OFTEN BE CURED EVEN WHEN NOT FULLY UNDERSTOOD
It's also useful to point out that though science does not yet have a clear consensus on what specific sequence of events produces hot flashes in women -- beyond the bigger picture of changing ovary and estrogen function during perimenopause and menopause -- nevertheless medicine has developed at least one quite effective empirical treatment for hot flashes based on trial-and-error experience, even in the absence of a clear scientific understanding of their basis. Namely, estrogen replacement. (Other remedies that apparently work for some proportion of women have been considerably less tested and proven.) Successful treatment therefore of a symptom associated with ovarian/hormonal changes can precede biological understanding of the full complexity of the symptom.
The broad array of symptoms I have named the WHM Syndrome -- for Warga's Hormonal Misconnection Syndrome -- may at first, I suspect, appear as strange and bizarre as hot flashes do to those unfamiliar with them. But in the years to come, I believe, it will seem one of the great mysteries of our time that such a common, unusual, but apparently typical set of biologically based symptoms could have been overlooked for so long. Cultural and medical historians of the future, I predict, will long ponder the great divide of female patient/doctor non-communication that is implicit in physicians not having "heard" and detected this set of symptoms and its cause in women for so many years.
What WHMS Is Like
The list of possible symptoms I am specifically referring to is presented in Table 1 to help you better understand the cases you will shortly be reading about. (A fuller description of possible WHMS symptoms with examples of how they actually occur in women's lives follows in chapter 7.) In Table 1, however, I list only the mind/speech/attention/ behavioral symptoms to which I have given the name "WHM Syndrome," or "WHMS." This table does not include any of the mood or physical symptoms that are also frequently but not inevitably associated with menopause and the years preceding menopause. (These are more fully described in Appendix I.)
The WHM Syndrome: Warga's Hormonal Misconnection Syndrome
As you examine the following chart keep in mind that the symptoms below typically occur as brief come-and-go episodes within the context of a functional ongoing nondisabled life, not unlike the manner of hot flashes. Women who experience some of the symptoms need not experience all of the symptoms or even many of the symptoms. Some symptoms may appear similar but are experienced by women as different from each other and are thus listed as distinct, pending additional research. Implied in each symptom is the sense that it occurs with a greater frequency than it did in the past. The symptoms most typically do not occur continuously but in erratic on-and-off intermittent episodes, in the pattern of occurrence of "hot flashes," so each symptom should be read preceded by the phrase "Flash episodes of." The headings over the symptoms are provisional pending further research, i.e., whether a specific symptom belongs under a speech, memory, or attention category may ultimately change as more is discovered about the symptom's biological basis.
Symptoms of Warga's Hormonal Misconnection Syndrome
* Losing your train of thought more often than in the past
* Forgetting what you came into a room to get more than in the past
* Not being able to concentrate as well upon demand
* Feeling foggy, hazy, and cotton-headed and not being able to clear it up at will
* Experiencing a thought blockade: an inability to pull ideas out at will
* Fluctuating agility in prioritizing as well as in the past
* Naming difficulties for long-known names: children, best friends, things, places
* Finding yourself at a loss for words in how to express something while speaking
* Experiencing "It's on the tip of my tongue but I can't get it out" sensation
* Making malapropisms: saying wrong words that are related some how to the intended one
* Reversing whole words while speaking
* Reversing the first letters of words while speaking
* Experiencing "echo" words as unintentional intrusions into present speech
* Relying on "filler" words more often: "whatchamacallit," "that thing," "you know what I mean"
* Organizing sentences and ideas less efficiently while speaking
CHANGES IN THE "BEAM" OF ATTENTION
* Blinking social attention when interested and interacting: listening but not always attending
* Blanking-out amnesia for what you just did
* Experiencing increased distractability
MEMORY CHANGES: SHORT- AND LONG-TERM
* Forgetting what you just did, or past occurrences, with no threads of association to getting back to what's missing: missing links
* Changing certainty in how words should be spelled in once good or great spellers
* Fluctuating agility in calculating and in "counting with a quick scanning look"
* Experiencing changes in the speed and accuracy of memory retrieval
* Forgetting the content of a movie right after seeing it but remembering your emotional reaction to it
* Making behavioral "malapropisms": unintended slips in behavior that are related to the intended behavior somehow, such as putting shampoo in the refrigerator
* Forgetting briefly how to do things long known, such as where to turn on the computer
* Feeling that automatic skills such as driving for a few moments are not "automatic" in the same way as usual
* Dropping things more often that require fine finger/hand coordination
* Absentmindedly, leaving out or reversing letters in words while writing
* Forgetting how to write a word in the middle of writing and having to leave blanks
* Experiencing "translating" hesitations in converting what's heard into writing
* Not handling the same amount of stress in the same way
SPATIAL SKILLS CHANGES
* Changing skill in remembering and/or recognizing faces (not well-known faces)
* "Looking at but not seeing" what you are looking for when it's right there ultimately, more than in the past
* Changing reading skill in visually "seeing" and comprehending reading material
* Spending less time reading, without difficulties above (for formerly heavy-duty readers)
* Forgetting briefly how to get to long-known landmarks in your life
* Experiencing familiar locales in one's experience as momentarily unfamiliar
ALTERED SENSE OF TIME
* Forgetting appointments more or not anticipating events of personal importance with the same accuracy as in the past
* Forgetting important events in your personal history timeline, i.e., which breast you had biopsied
* "Living more in the moment" out of necessity: a "spliced-film-frames" sense of personal time
WHY IT'S CALLED THE WHM SYNDROME
I have named this set of symptoms the WHM Syndrome, or WHMS, because women who experience the symptoms often feel subjectively as if they are observing their own "bad show," watching their mind behaving whimsically, unexpectedly taking off on a whim with seeming intentions of its own while violating their intent.
In my mind WHM originally stood for the Women's Hormonal Misconnection Syndrome. I felt the acronym in good measure characterized the subjective experience of women who had the symptoms without stigmatizing them. And the words behind the letters described what I believe is going on at the neurophysiological level -- namely, cognitive/behavioral/speech episodes that are mis-hits. Episodes that are off the mark misconnections, in which the mind's intentions are not producing the right physiological connections that they used to in the preexisting circuitry and/or chemical flow patterns of the brain. The reason for the misconnections? A body/brain retooling or "retuning" brought on by the effects of declining ovarian function and declining estrogen hormone supplies on a thinking, remembering, attention-creating brain that science has recently learned (see chapter 4) depends heavily on estrogen as a brain "transmission" fluid of sorts, as a fortifying performance-enhancing steroid or multivitamin. (Estrogen is after all a steroid hormone even though it isn't the kind typically used by athletes. I'll explain this more later in chapter 4.)
However, as I continued interviewing women and experts and reviewing the research literature in this area over the span of several years, I came to the conclusion that calling this the Women's Hormonal Misconnection Syndrome would not be prudent. (You'll have to read chapter 14 to find out exactly why.) But for the moment suffice it to say that I learned that science had very recently discovered that male thinking/remembering brains and sex organs also depend on estrogen supplies for their normal function. So for reasons of faltering estrogen hormonal levels in their brains I began to suspect that at least some men too may have similar WHM symptoms at possibly similar ages. What to do?
To preserve the acronym WHM and prevent the syndrome from being called the rather farcical HM(mmm) Syndrome, I have renamed the set of symptoms Warga's Hormonal Misconnection Syndrome. It turns out that naming new medical syndromes and hormonal/behavioral phenomena after their discoverer has a long history, respectively, in both medicine and behavioral neuroendocrinology (the hormones and behavior branch of science), according to the eminent sociobiologist Edward O. Wilson. Describing a series of known behavior-and-hormones effects in the animal kingdom -- i.e., the Bruce Effect, the Lee-Boot Effect, the Ropartz Effect, and the Whitten Effect -- Wilson in his landmark 1975 book Sociobiology, writes: "In the manner of the medical sciences, the different kinds of physiological change are often called after their discoverers."
Why have I called this set of symptoms a syndrome? Because the set of symptoms occur frequently in association with each other, as a constellation, or sets of subconstellations. Certainly not all women who have some of the symptoms have all of the symptoms, but sufficient cumulative experience interviewing women has persuaded me that the symptoms represent a possible set that are part of the same causative agent.
WHMS SYMPTOMS HAVE TYPICALLY BEEN IGNORED OR WALLPAPERED OVER
Till now in the relatively few instances when popular writers have referred to the above symptoms they have usually used seemingly mild, and nonspecific terms such as "concentration problems," or "forgetfulness," or "memory problems" to refer to women's experiences during these years, without an appreciation of the range of possible "glitches" in speech, behavior, and cognition that women in actuality have been experiencing. Broad-spectrum terms such as "forgetfulness" or "concentration problems," in effect, "wallpapered" or plastered over the variety and the bizarreness of the symptoms women have encountered. The casual, familiar terms masked or obscured the specific reasons why otherwise seemingly normal and healthy women might be inclined to say such phrases as "I think I'm losing it" or "I think I'm flipping out" or "I think I'm cracking up."
If you had occasion to go into major bookstores at the time I am writing this to look in the indexes of the many books now on the shelves currently addressing menopause or perimenopause for such terms as "memory" or "concentration" or "forgetfulness," you would find that in the vast majority there is either no mention of even these broad-spectrum terms or at most a one- or two-line reference to their possibility at this time of life but without much in the way of elaboration. There is virtually no reference in most of these books to the unusual behavioral symptoms listed in Table 1.
HOW DO WHMS SYMPTOMS PLAY OUT IN WOMEN'S LIVES
But how do these symptoms actually play out in the lives of real women? Let's look at three very different women:
Case 1: Katherine Kennedy
Katherine Kennedy (alias) is a thirty-eight-year-old professor of English at an Eastern university who also hosts a weekly talk-radio show. She is married to a scholar, has no children yet, but hopes to have them in the future.
Reproductive state: still gets her period regularly appears to be perimenopausal, though she does not yet realize it.
When I was younger I had the most retentive memory for everything, especially names and faces. Friends in college would say, "Your mind is like a Rolodex." When I entered my thirties I started having these strange symptoms. I would meet people and the next day felt as though I had never seen them before. They'd know me but I had no due as to who they were. Their faces were just not registering. It so happens that I had begun to menstruate copiously around that time, more than before but I did nothing about it. Not recognizing faces still happens. I find that slightly scary because my grandmother was demented; and I sometimes wonder if it's hitting me very early.
What drives me mad is that I now forget the precise names of things, objects, and will end up saying "that thing" instead of "diploma" for example. It's the same with verbs. I will use the word "doing" instead of the verb I actually want to use. I also have the sense that sometimes I'm grasping for a word and I can't get to it. It feels like mental clutter, like I'm shuffling around inside not finding what I want. I find it hard to retrieve things. I'll have a sense of what I want -- it's not even the sense of being on the tip of my tongue but rather I can't get it to my tongue. I'll want to say "chair" and will think "something about sitting" but can't fill in what I want. It's like mental miasma. This happens not all the time but intermittently enough so that it concerns me.
I find it [these symptoms] enormously frustrating. One of the ways it affects me is when I'm having a disagreement with my husband. I'll know there's a point I want to make but I can't make my point. Either that or I lose it midstream.
The difficulty in retrieving, to some degree, also overlaps with what I call fog or haziness. My mind sometimes feels foggy, hazy, or cloudy. If it's fog I'm feeling it's more confused, more grasping than when I'm trying to retrieve something. With fog I don't know what I'm looking for -- that's the worst -- being lost in the fog. When this happens I think I'll end up like my grandmother, not knowing the names of my family and having lost decades. Or like my friend who got ECT [electroconvulsive therapy] and lost decades of her life, big chunks of her brain. At times like this I feel like I'm losing it. And I'll think to myself "I didn't even drink or take drugs and I'm losing it."
In the classroom and when I'm on radio I want to be sharp and alert, and it hasn't happened terribly much, these blunders, when I'm working. In fact when I'm in front of a class or microphone I'm somehow sharper. I have to be really alert and thinking and focused. And when I'm working I'm better than in my private life.
I find now that often when I walk into a room and want to get something, I'm apt not to recall what I went to find. I think it's a little early for this to be happening to me. My mom and grandmother do this. I never did this as much as now.
In my late twenties if I was writing fast I noticed that I started to reverse letters on words. I also used to be a great speller. Now if I see something that's wrong I won't realize what the correct thing should be. Strangely though, I started doing crossword puzzles only recently as a way to reassure myself of my verbal skills, and I can finish The New York Times crossword puzzle pretty easily writing in ink. But at the same time I just feet really stupid. I used to be and probably still am pretty smart. I always did very well in school. Verbal things were very easy for me. Now I'm still strong verbally but I hate any slippage. It might be analogous to being really gorgeous when you're young and now not feeling as radiant.
I don't think others have noticed the verbal changes because I'm still better than most at noticing names. I'm always the first person who knows the name of a writer or actor. At the same time though I will mispronounce words and can't get back to recalling the correct word. Recently, for example, I was trying to say the plural of roof and couldn't recall if it was "roofs" or "rooves." Both sounded wrong. It's this confusion over basics that I find scary. In the past once I learned something I would have remembered it always. I seem to need a lot more reinforcement than I used to, to learn new commands on the computer.
In the last couple of months I've also begun to lose things and I never ever did that before. My wallet, for example. I lost it and I couldn't think at all where I might have lost it. I had absolutely no associations the way I normally would as to where it might have happened. Fortunately a Good Samaritan returned it, I have a special telephone message pad that's been by the phone forever that's got important numbers on it. I just couldn't remember what happened to it in my home office. It's the lack of associative threads that seems so strange.
I'm the treasurer in my family who does all the practical things. My husband is incredibly brilliant but doesn't really live on this planet. He always loses things and people return them. Recently, I thought I had cash in the bank and when I looked I had appreciably less than I recalled. I couldn't think at all where I spent it. Nothing came to mind in the way of any associations. It's as though I had no links to the past when this happens.
I think I tend to compensate for all of this fairly well. I keep lists and write things down and use the mnemonic devices from childhood that I was always great at. But at the same time all these things affect my whole identity. I've always thought of myself as verbally skilled and these episodes affect my sense of self. I met a woman at the radio station a few weeks ago. Then I met her again two nights later and didn't recall her at all.
Another night I asked the same couple twice if I gave them passes to something and they got annoyed with me. I had already given them the passes.
The ironic part is that as a teenager I had unbearable contempt because my mother couldn't recall the names of people. But she could recall other things really well -- what she paid for something.
All this makes me feel diminished. I now feel not as sharp as I used to be. I'm not depressed but feel like I'm getting dim, with the foggy, hazy, cloudy episodes.
At the same time I'm probably happier in my life than I've ever been. I'm in a great marriage that's working well. My husband and I have a wonderful relationship. Over the years I have had depressions on and off but things are going well now both in my private and professional life. I love the work I do.
I don't go to doctors unless I'm dying and I wouldn't know who to go to with these symptoms anyway. I just keep hoping they'll go away on their own.
Katherine Kennedy's case is an example of pure WHM cognitive/speech/behavioral symptoms occurring at a rather early age -- what I think of as a "one-ring circus" of symptoms -- with no body symptoms (i.e., hot flashes or vaginal dryness) or associated mood/emotional symptoms except for her diminished sense of self in reaction to having the symptoms. Her symptoms can't be said to be occurring in reaction to sleeplessness, or hot flash disruptions, or depression because she does not report these. Like many women her age she isn't thinking about hormone changes in relation to these symptoms, but her mention of greater bleeding in her early thirties when her WHM symptoms appeared to her to begin, likely reflects the increased variability of periods (more, less, longer, shorter) that typically characterizes perimenopause. I view her case as being linked to hormone changes because, as you will see with later cases, it echoes in its pattern of specific symptoms so many of the other women whose symptoms did begin in association with hot flashes or vaginal dryness -- indicators of hormonal changes. Like many women Katherine Kennedy has not seen a doctor about these symptoms. She has been coping with them in multiple ways. As with many women the symptoms are occurring within the context of a fully lived functional life. They are mainly invisible to others though very noticeable to her.
Case 2: Sherry Strumph
Sherry Strumph (actual name) is the forty-nine-year-old president of a highly successful major office-services company in New York City that now employs over thirty-five people. She has built this company from a one-person venture over a twenty-year period through great initiative, ability, creativity, and sustained directed effort. She owns another unrelated business as well. Sherry is married and the mother of a grown daughter.
Reproductive state: "I'm perimenopausal now. I'm still regular but my periods come for ten minutes. The last one was over before I knew it."
I remember this beginning about two to three years ago when I caught myself saying something wrong to myself. I said to myself, "You used to have a 'photogenic' memory" and then said, "You fool, you mean 'photographic' and now you can't even remember what your husband told you ten minutes ago." This was in response to my husband reminding me that he would be out that evening and my not remembering it at all. He said we spoke about it several times. For me it was the first time. I laughed it off thinking "OK here comes old age." I thought memory problems began around age seventy-five, not in your forties. Another time a friend asked me something and I said I didn't remember; and she said, "But you always remember everything. I can't accept that you say you can't remember." She was so taken aback because my memory had always been phenomenal -- everybody relied on it. My husband started saying things like "You used to be so reliable and I used to be able to count on you. Now I never know when you'll do whatever you say you'll do." I realized myself that I wasn't the same as before but I said to myself, "It's the way I am now." I was very accepting. Maybe because I had been so responsible all these years. I used to be so driven to be right. It's kind of refreshing for me not to have to do that.
When this began I had been away from the office for two years. I had excellent management there. I was free as a bird so it wasn't job burnout or stress. My memory lapses created havoc for some of the people around me, but not me. I just accepted it. But then too I didn't know what to do about it and it's not my style to complain to people.
Before I started using estrogen cream nine months ago, I'd say that my worst memory issues were one to two years ago [ages forty-seven to forty-eight]. When I'd forget something I would joke with people and say "Mind-like-a-sieve strikes again."
When this began I had no idea this could even be related to hormonal changes. I learned this from the experience of my friends. I thought menopause was about going through hot flashes. I didn't associate hormonal changes with what I was experiencing. I didn't have any mood swings during this time the way some women do. In fact I was the calmest, most unflappable I'd ever been. Things I had feared doing before I could do now, like driving at night. But my memory was a mess. I'd write things down and forget where I'd put the list.
I thought about going to a doctor but I'm not one to go running to them very readily. I thought maybe I was pre-Alzheimer's but then I said to myself, "No one in my family has ever had it." I did stop using my deodorant, however, because I had read that something in deodorant -- aluminum -- caused Alzheimer's. I also stopped using aluminum foil and switched to shrink-wrap for that reason.
My concentration also changed. I would start to read a book and pick it up two weeks later and have absolutely no memory of any of it. As though not a trace had stayed with me. However, when I tested myself, by pulling cards from a deck and reading them to myself, to see how many I could remember, I could do it if I tried. This forgetting happens more when I'm on automatic pilot. I need to really pay attention to "get" some things now, more than I used to. And I can but I need to make a conscious effort to do so.
I finally broke down and bought a date book and I'm pretty religious about writing in it but not at all religious about looking at it.
I started to make the connection that the things happening to me were related to hormones when friends started telling me what they were going through. My friend A. said to me one day that she was much more forgetful than I was. She was diagnosed as needing estrogen for her bones and started being treated with it, and she said it was working for all her symptoms. Then another friend said that she'd been put on estrogen and could think like a young girl, meaning that things came easily again. I was percolating on this information and then my friend A. said she was switching to an estrogen cream. She used to be a chemist. After she went on the hormone cream she said she stopped being hot all the time (the way I am too all day without any hot flashes), her memory got better, and amazingly she was able to successfully lose weight.
I started using the [estrogen] cream in August (nine months ago) and they say to give it three months. I've noticed a difference in some things but not a great difference in everything. But I also haven't used it consistently -- probably about 50 percent of the time. I forget to. But I'm also afraid of hormones because of my family history. I'm the only one in my family who hasn't had cancer. So I've got a love/hate relationship to taking estrogen. Now at least I know I have a choice in whether I want to stay this way if it lasts.
After I went on estrogen my attention got better. I'm more focused. It might also be because I'm back at work full-time. It kind of forces me to be focused. The result is I appear more focused than I am in my personal life. Besides my husband and good friend, I don't think others noticed any difference in me. The changes weren't blatantly observable.
Did I go to a doctor about this? Yes and no. At regular intervals I would go to my internist and when I told her what I was experiencing she said, "Well, welcome to the club honey." She's only a bit older than me. She didn't offer me anything. She knows better. I'm normally unwilling to take even aspirin. I mentioned the heat thing to my gynecologist. He felt that since it was constant it wasn't likely related to menopause. He did take blood level tests and told me I'm perimenopausal.
I'll do these strange things every now and then. The vice president of my company and I take turns picking each other up on alternate days to drive in to work. One day I left the house, got into the passenger seat, and sat there waiting. When I realized what I'd done I started laughing. Even more recently I unpacked groceries. I put canned tomatoes into the fridge and put fresh lettuce and spinach in the pantry closet where I found them a week later. Other times I'll be cooking and go into the pantry and say, "Now why am I here?" and then realize I meant to go to the freezer or spice shelf. This now happens all the time.
Spelling too is strange. I used to be a great speller. I didn't have to think about it. Now I have to think about it. The other day I couldn't remember if the word "comrade" had an e at the end. Working with language has been my business so this is not like me. I'll also now substitute short words for the ones I can't think of. I also have more difficulty prioritizing things than before. I'm still very good at it but I feel there's a change in the directness with which I organized a task before.
I used to be able to compute things mentally and now I have to write them down. I sometimes have someone check it for me. I now blank out on phone numbers and names that I've known forever. I never needed a phone book but I think now I should start writing them down. I've also blanked out on mail I received at home that I acted on. I wouldn't remember having talked to anyone about what was involved but then they would tell me I had already.
I'll also catch myself now half focusing on things. People will be speaking and I'll have no idea what we just spoke of. My friend M. was speaking the other day and I realized I had no idea what the conversation was about. I've also stopped carrying keys. Keys no longer exist in my consciousness. I have given new meaning to the phrase "living in the moment." I own a house and two businesses but I no longer carry any keys. They were gone all the time. I had a garage opener built into my car for that reason. It's funny because my husband always relied on me for locking everything up. Now he does it all. I used to be obsessive about it. Now I'm cavalier about it, nonchalant. I'm also not as suspicious as I used to be. I'm more trusting of people. In the past if I got on a train I used to automatically size people up and think "Do I want to be caught in an alley with this person?" Now I don't look for traits in that way anymore. I'm less mistrusting of the looks of someone.
Would I rather go back to the way I was? I don't seem to feel as much need to control everything. To me I think estrogen is like the fuel that wants me to try to get big bites out of life and my appetite has diminished somewhat with the diminishing of the estrogen.
Sherry is an old friend who was unaware of what I had been doing the last several years. When she read the New York magazine article I had written in the summer of 1997 and my allusions to WHM symptoms in the article, we spoke. She said, "That's me," and proceeded to tell me her story.
Like many women Sherry did not connect the symptoms she was experiencing with hormonal factors, but instead attributed them vaguely to aging or the possibility of developing early Alzheimer's disease and went so far as to make changes in her life. Like many women with WHMS she did not run to a doctor after experiencing the symptoms or get much specific help from doctors in response to describing some of them. What stands out about her case to me is the atypical equanimity with which she accepted the cognitive/behavioral symptoms she watched herself exhibit, the attributions she ascribes speculatively to her reproductive hormones, the motivational drives she suspects they impelled her to, and the diminished vigilance around safety she describes in herself, i.e., less suspiciousness, diminished fears around driving at night, less compulsiveness around keys, locking up, etc. Are these new traits unique to her? Is there something here to follow up? I'm not sure. Sherry was experiencing what I think of as a "two-ring circus" of symptoms associated with hormonal changes. She experienced the cognitive/speech/behavioral changes -- the mind changes, and one physical change -- she was hot all the time.
Like many perimenopausal or menopausal women with erratic memory who take hormones, Sherry's symptoms lead her to sometimes forget to take medications consistently (although in her case, ambivalence due to fears of cancer related to her family history may partially account as well for her forgetting). Product manufacturers need be mindful of memory as a basis for noncompliance with prescribed and nonprescribed treatments.
Case 3: Quiana Mortier
Quiana Mortier (an alias) was referred to me by one of the menopause experts I had come across in my research. He had recently started to treat her at the time of our interview. Ms. Mortier is widowed, the mother of a daughter now twenty-one, and supports herself in a position she has long held, working in the billing department of a physician.
Reproductive state: now fifty-two and in menopause.
I'm now fifty-two but my symptoms started when I was forty. I was perimenopausal then. I went to the doctor because I wasn't feeling right. Weird words were popping out of my mouth that I hadn't intended to say, and I'd cry constantly. I thought I was cracking up. This had been going on for a couple of months and my husband and I went to our internist. I told him about the wrong words that would come out. And I told him it felt like I was seeing things. I'd go to take something that I was sure was there before. And then it wasn't there when I went to look for it again. He diagnosed me as having paranoid schizophrenia. He told my husband that in private and my husband was very upset. He told me that night what the doctor had said. I was very upset and called the doctor and said, "Did you really say that?" He denied he told my husband that. But I believe my husband more than I believe him.
I was so upset with what he said that I went to another doctor, a psychiatrist, to check it out. After telling him the same things, he said it wasn't schizophrenia or paranoia. He didn't know what it was.
Then I started getting hot flashes. My body started to change. My periods came real heavy. Then they didn't come. I never knew what was going to happen from month to month. When I was forty-three or forty-four my memory started to get even worse. I thought it might be due to stress. Frustrating things would happen. I was going into the bank to pay my bank mortgage one day and parked my car and saw the meter maid behind me. I had the coin in my hand and intended to put it in the meter, but I forgot in a second what I was going to do and went into the bank holding it. When I came out the meter maid was writing the ticket. I was so mad. Things that frustrated me like that kept on happening. In a second I'd forget what I was going to do. I'd misplace things I'd kept in the same place forever. This happens with keys, money, earrings. I'll look in the refrigerator and think "Who ate this?" You know you brought it in and you can't find the food. At one point there was a reason for this happening -- my daughter had a girlfriend living here, and she was hiding her. But this happened before and after that too.
But you become paranoid. You suspect people because you are missing things, misplacing things. At times I'd say to myself, "This must be Alzheimer's."
I did speak to another doctor about this. He said it was probably related to stress and never related it to menopause.
This has gotten better though -- the misplacing things. I just take Rejuvex and I think it's helped me. It relaxes me. But even now I still come into a room and don't remember what for. I have trouble with speaking. It's as if you don't remember any words in a sentence. If the sentence I wanted to say was "The cow jumped over the moon," I couldn't remember the word for cow. Even now, I have difficulty repeating a sentence back. It's like the recall button takes longer to bring things to the mental screen. Names escape me the minute I hear them. I still have difficulty with my memory. If I don't write things down, forget it -- which is usually what I do. But I forget to write things down. I have only short-term memory now. I thought it was just aging.
I didn't know this could possibly be related to menopause until Dr. D. told me that it could. Before him I went to an Italian gynecologist about all of this, and he just didn't believe in taking hormones. The speech difficulties he said were due to stress! He said to relax, which didn't help much.
For the last seven to ten years I've felt like I was in a bubble. I've only recently come out of that bubble. I felt like I was in a vacuum and certain things weren't important to me, like the silver candelabra my mother left me when she died. My family thought I was crazy. "Leave her alone," they would say. My daughter would say this too. My sister even tried to take advantage of my memory problems. She thought I had forgotten that she had the candelabra and acted surprised when I asked about it a year later.
But other times if something wasn't directly in front of me it was out of my mind, as if I had amnesia or something. At different times I've forgotten my ATM code, my social security number, my family's birthdays, which I've had in my mind forever. They just flew out and later just flew back in. That's what it feels like. It feels like you are going crazy. You don't know what's going to happen next.
How did I manage at work? My husband is dead now and I work in a doctor's office on billing. The computer has a format for what I do so I can handle it. I have to focus in on it but I do OK. I've been at it a long time. At home I studied to become a travel agent a couple of years ago when it was really bad and things would just go out of my head, I have to read something over and over and over to retain it and within a week it's gone. I'll forget it like I never read it before. It all feels brand new if I read it again.
Now it's a lot easier. Whatever was going on with me the last ten or so years has leveled off. It was a really bad time. I just recently went to Dr. D. He wants me to take estrogen. He's for it but I went to two other gynecologists who were against my taking estrogen. They still don't relate any of this to menopause. Dr. D. knew what I was talking about and said it's related to menopause, but nobody else ever said that. I'm still not sure of taking it [estrogen-progesterone hormone replacement therapy (HRT)], even though nobody in my family ever had breast cancer. The other doctors said not to. So I'm not sure yet what I'll do.
What is revealing about Quiana Mortier's case is the many years that this syndrome can apparently persist and that it can become better with time; also, that verbal and perceptual (cognitive) errors together with reduced control over her emotions were Ms. Mortier's earliest symptoms, preceding hot flashes and menstrual irregularity. What stands out too is the misdiagnosis of her symptoms as "paranoid schizophrenia" by an internist, and complete unawareness of the basis for her symptoms by other physicians, except for Dr. D., a male ob/gyn who specializes in treating perimenopausal and menopausal women and has been correctly sensing what women have been trying to communicate to him about their experiences over the years.
WOMEN, WHMS, AND DOCTORS: WHAT HAPPENS NOW WHEN WOMEN REPORT THEIR SYMPTOMS TO DOCTORS
The bigger picture at present is that most physicians know very little if anything about the specific mind/speech/behavioral symptoms I have named the WHM Syndrome. They haven't been taught of their possibility during medical training. They may have learned something about these symptoms if they have been carefully listening to some of their patients over the years. However, some women, as we've seen, don't go to physicians about these symptoms for multiple reasons, but some women do speak up about their symptoms.
At present when women go to their ob/gyns or other physicians with their symptoms here is what may happen:
1. Women are told to relax more, or to take a vacation, that the symptoms are probably stress-related. The cost of following this seemingly innocuous advice, however, can sometimes be high. A woman with multiple WHM symptoms, for example, was led by her doctor to believe her symptoms were due to stress. She quit an exciting, demanding job she loved, only to discover her symptoms did not improve at all with a less stressful job, but got worse. They did improve significantly after she was put on a three-month diagnostic test-trial of estrogen alone to see if estrogen decline was the basis for them. When she had determined that her symptoms were related to estrogen loss, wary of estrogen for family history reasons, she then went off the pharmaceutical estrogen her doctor had prescribed and turned instead to weaker plant-based estrogens, phytoestrogens. And it worked in her case. The three months of estrogen was used as a diagnostic tool, to identify the cause of her symptoms. (See chapter 10 on treatments.)
2. Women are told the symptoms are the result of aging and to "accept it" as inevitable.
3. Doctors, like many other human beings, tend to deny or dismiss what they don't understand. And their training to date hasn't included any grounded scientific rationale that would logically explain the basis for the symptoms. So women are given "It's probably nothing" admonitions, or quizzical looks that imply they don't know what they're talking about. The tone of these encounters is "if the doctor hasn't heard about it, it is probably nothing too important, or it doesn't exist."
4. Women who show up in doctors' offices with WHMS can be misdiagnosed as having a psychotic condition. You saw that this is what happened to Quiana Mortier. Describing her WHM symptoms as best she could, "strange words popping out" and "things being there and then not being there," Mrs. Mortier's internist attributed her strange unfamiliar symptoms to a psychotic condition, paranoid schizophrenia, and gave this diagnosis to her husband but not to her directly. But what if her job had depended on this diagnosis? What if this diagnosis unbeknownst to her became part of a permanent HMO medical record made available to others? Mrs. Mortier's prudent decision to see a psychiatrist for a second opinion paid off in her case, when the psychiatrist was forthright enough to say he didn't know what disorder she had. But do all psychiatrists exercise this option? How often can they say "I don't know" to those who refer patients to them for a diagnosis? I don't know.
5. Sometimes women with WHMS symptoms are diagnosed as having Attention Deficit Disorder (ADD). Two women with WHMS symptoms I interviewed were given this diagnosis, one by a psychologist, the other by a psychopharmacologist she was referred to. Both were advised to take Ritalin, the stimulant drug used to help focus attention in youngsters with ADD. Taking Ritalin helped one of the two women with WHMS symptoms. (Might this be a potential form of treatment for some women with WHMS attention changes?) Both women had no prior history of attention, reading, or word-reversal difficulties.
After interviewing these women I decided to interview several experts on ADD. I asked if ADD ever manifested with adult onset -- if the disorder could show up initially in adulthood without a prior history in childhood. I was told that in instances where ADD is first detected in adulthood, the assumption commonly made is that it was likely present in childhood but not detected or diagnosed at that time! It is my suspicion that in some women with WHMS an intermittent ADD-like disorder can show up in adulthood for the first time as one possible subset of WHMS symptoms in association with estrogen loss. It's important to be aware, however, that not all women with WHMS symptoms have ADD-like symptoms.
6. Sometimes women with WHMS who insistently pursue their quests for diagnosis at memory or Alzheimer's disease research centers within major medical centers are suspected of having early Alzheimer's disease and given this tentative diagnosis. Though they test normal on the battery of cognitive tests they are given, the symptoms these women describe lead clinicians to suspect a diagnosis of Alzheimer's disease, since the symptoms outwardly can sometimes appear to overlap. The women are then asked to return at regular intervals for follow-up testing and evaluations, to see what happens to their symptoms -- if they progress with time, stay stable, or disappear. What happens over time helps the experts clarify the diagnosis. Imagine, however, being told by experts that your WHMS symptoms might indeed be Alzheimer's disease! You might very well redirect the whole course of your life or live in a bubble of suspended anxiety if you thought your remaining cogent time on earth was likely very limited.
The reality is that Alzheimer's disease researchers know very little as yet about how true instances of Alzheimer's disease begin in very specific detail -- how they play out in everyday life. As a former Alzheimer's disease researcher, I know. I would often ask the relatives of patients I was evaluating what were the earliest signs they saw. Typically the first signs were only recognized in retrospect, after the full-blown picture of Alzheimer's had later emerged. "So that's why he acted so funny back then two years ago," they would say.
Alzheimer's disease researchers aren't yet aware of WHMS as a distinct set of symptoms among perimenopausal and menopausal women, even though they may be aware overall of the neuroscience research showing a connection between estrogen loss and changes in the structure and chemistry of the brain, and recent research on Alzheimer's disease and estrogen (see chapter 7). Alzheimer's disease experts are reading about the existence and details of the WHM Syndrome at the same time you are reading this. They aren't yet prepared to diagnose WHMS. They can't diagnose what they don't yet know. But they might mistakenly diagnose WHMS symptoms in relation to what they are familiar with and unintentionally derail the course of a life. I have nothing against the clinicians who diagnose memory disorders or Alzheimer's disease. I am merely cautioning women with WHMS symptoms about what could theoretically happen. Hopefully WHMS will be given the attention it deserves in research efforts so that memory and Alzheimer's diagnostic centers will be aware of it soon. Without intending to add to the fears of women with WHMS, I feel it would be negligent of me not to add that some true cases of Alzheimer's disease can occur within the age range of the forties and fifties. The youngest presumed Alzheimer's patient I ever tested was a forty-two-year-old male. It is my belief, however, that the preponderance of cases of WHMS in women are not manifestations of early Alzheimer's disease cases. As anchoring points for this view, I use as evidence the absence of droves of sixty-year-old Alzheimer's-like women wandering the streets of major cities. (If WHM symptoms are present to one degree or another in a significant proportion of fifty-year-old women, then if it truly represented the beginning of Alzheimer's disease, ten years should be sufficient time for the condition to "bloom" into Alzheimer's disease.) Also in my experiences as a health psychologist treating patients with chronic disease sometimes in rehabilitation and nursing home settings, I found few sixty-year-old women or men with Alzheimer's disease. For very specific reasons that will become clearer in a later chapter, I believe that WHMS in most women represents a "normal," though until now undetected, series of changes.
More Encounters with Doctors
Here are two more experiences of women with self-described WHMS symptoms and encounters with their doctors. They are letters to the editor that arrived in response to publication of my August 1997 article on "Estrogen and the Brain" in New York magazine.
Thank you for validating the absolute nightmare I lived for at least four years. I make a living as a salesperson on the wholesale level. I have always thought on my feet and counted on doing several things at one time. Words cannot express the sheer terror I lived through, losing my quick thinking and my memory, being depressed, and going to doctor after doctor who had no idea what was wrong -- and I was already taking estrogen.
Fortunately, I found a new gynecologist and she picked up my symptoms. My body was not absorbing enough [estrogen] to get me back on track mentally. [Women can differ biologically in their reaction to the same drugs.] Everything is now pretty much back to the way it was -- except that I lost a job that I loved and was working at for fourteen years.
(Name listed in the article, Manhattan)
Here is another:
How good to read [my article]. In my early thirties, I went into premature menopause. With it came what I call "teflon brain" and aberrant bouts of halting speech. Pieces of simple information would fly through my brain, skipping over a slick surface....No small problem for a television-news producer. Of course, when I would tell this to my doctors -- and then add that it had to be because my brain was malnourished from lack of estrogen -- they determined that lack of estrogen had rendered me daft, not forgetful. Now, it seems medicine is wiser....
THE WHM SYNDROME PARALLELS HYPOTHYROIDISM
In many ways the WHM Syndrome parallels, in its effects on thinking and behavior, an established hormone-deficiency syndrome that is also known for having cognitive/behavioral consequences -- hypothyroidism.
In those with hypothyroidism, the very basic hormonal "fuel" that "drives" the body's metabolism efficiently -- thyroid hormone -- becomes deficient for one of several reasons. People with insufficient supplies of the hormone can experience not just mood and physical symptoms such as bone-wearying fatigue and a persistent cloud of depression (as do some women with WHMS), but also well-established cognitive-deficit symptoms ranging from subtle to very serious, in memory, attention, and the fine-tuning of thinking and speaking. The precedent thus exists for a known hormone-deficiency state producing cognitive symptoms in the manner of WHMS. It is even possible that hypothyroidism and WHMS may be related, i.e., that estrogen loss may trigger changes in thyroid function. While little is known about the relationship of estrogen changes on thyroid changes, it is known that changes in thyroid functioning often increase significantly in frequency among women during intervals of rapid hormonal shifts -- e.g., following the birth of a child and around perimenopause and menopause. Some clinicians who treat menopausal women have observed that in association with menopausal symptoms often thyroid disregulation of one kind or another is not an uncommon finding. Moreover it has been discovered in recent years that the respective receptors that bind thyroid hormones and estrogens are part of the same superfamily of steroid receptors and may have evolved in tandem and work in tandem. Both are hormonal systems in charge of major, basic life-sustaining functions -- thyroid hormones for driving the metabolism of cells for daily living and estrogen for underwriting and "fueling" the survival of the species and directly or indirectly affecting many brain, bone, heart, and other body-system functions. Just as the symptoms of hypothyroidism are now known to be readily correctable with thyroid hormone replacement therapy, in the years to come, the cognitive and behavioral symptoms of the WHM Syndrome, I believe, will be formally recognized as a comparably correctable hormone-deficiency state reversible with estrogen hormone replacement or custom-designed drugs or products mimicking estrogen's effects in the brain.
WE DON'T CREDIT HOW MUCH NORMAL WOMEN CAN DIFFER FROM EACH OTHER BIOLOGICALLY AROUND REPRODUCTIVE HALLMARKS
It is my goal in this book to communicate what the WHM Syndrome is and what it feels like, but it is also my express goal not to do harm, not to paint all women broadly with the same brush since WHMS symptoms affect some women not at all, some only mildly, and some seriously. I believe that central to any woman's or health expert's understanding of WHMS symptoms, perimenopause, menopause, research on menopause, and the treatment of menopausal symptoms is a considerably heightened appreciation of how much normal women can differ from each other with respect to any of the stages on the time line of women's reproductive events.
Consider for the moment what you already know about otherwise healthy normal women. Some have a monthly momentary twinge that announces their period is coming, whereas some go through days of premenstrual syndrome (PMS) agony with intense and disruptive mood and physical symptoms hammered in often by grueling migraine headaches. I have treated such women. Some women during pregnancy are sick to their stomachs practically every day while others fall in love with the psychological state pregnancy induces and keep wanting to repeat it over and over. Some women suffer postpartum effects that lead to thoughts of suicide and infanticide while others experience postpartum euphoria and bliss.
When I first heard about PMS and later postpartum depression as states that could induce dire mood alterations in women the truth is I suspected that some poor male psychiatrists had had the wool pulled over their eyes by females who were malingering for some unknown reason. I doubted that women could experience such intense reactions since I was a woman, after all, and assumed I knew what the universal experience of having a period was like. It was a "nothing" experience for me. Nothing to balk about. Only with time have I come to truly appreciate how diverse and divergent the experiences of women in this regard normally can be.
Let me share with you one moment of insight when this appreciation forcefully embedded itself in my psyche. Since graduate school I have used medical/science journalism as a means for extracurricular graduate study, for developing expertise by getting paid access to experts I wanted to interview in relation to my work as a research psychologist and later as a clinical health psychologist. I could ask the experts "up close and personal" what I wanted to know. When I was working with patients with chronic pain I proposed to the editors of Psychology Today doing a profile of one of the leading research psychologists of our day, Dr. Ronald Melzack. Melzack and a colleague, Patrick Wall, had put forth an important theory on pain -- the gate control theory -- that ultimately stimulated generations of research and progress in the field of pain. Melzack had studied the experience of pain in women during childbirth and had earlier developed a novel pain questionnaire that helped in the communication of a difficult topic -- how much and what kind of pain a person had. When I interviewed him at McGill University in Montreal, Canada, he told me that the pain of giving birth could be compared to the acute pain of having a finger cut off. On the other hand he said there were some women who gave birth with no pain whatsoever. "No pain whatsoever?" I asked in amazement. "No pain whatsoever," Melzack said. I just couldn't believe such a thing was true so I asked the same question again in an even higher-pitched tone: "No pain whatsoever?" "No pain whatsoever," he said. Melzack indulged me this back-and-forth dance several times till I finally desisted and decided to store the information away, uncredited, in the back of my mind for some other day. It just seemed too amazing to be true.
Then one day into my office walked a woman who came to see me in my role as a health psychologist. In taking a history somehow the fact emerged that she had given birth with no pain whatsoever. "No pain whatsoever?" I again asked incredulously. "No pain whatsoever," she answered. I asked if this had ever occurred to anyone else in her family and she said, "Yes, to my grandmother. Maybe it skips a generation." At that pivotal moment of confirmation I "got it" -- the bigger picture about the variability among normal women. I accepted as true what Melzack had told me and what this woman had told me. More important I "got" the message that a rose is not a rose is not a rose. Menstruation is not menstruation is not menstruation in the same way for every woman; pregnancy is not pregnancy is not pregnancy for all women; delivery is not delivery is not delivery for every woman; that menopause and perimenopause are often far from the same experiences from woman to woman to woman. I realized that these reproductive biological hallmarks can and often do vary enormously among women so that, to overstate the case somewhat, there are virtually different species of women when it comes to the "fine-tuning" of their brain and body's reproductive infrastructure.
The morals: (1) You can't know the interior experience of the woman sitting next to you by knowing your own. (2) You shouldn't be intolerant of women whose experiences in this regard differ from your own. (3) You can't characterize the experiences of all women by knowing the individual experiences of some women. Some women first experience WHMS symptoms in their thirties, some in their sixties. Some never do.
The existence of many distinct biological subgroups of women means in terms of research on perimenopausal and menopausal women that very large-size samples are needed to get accurate findings that detect accurately what is true in nature about women. Small-size sample studies may obscure and find insignificant what may be very true in nature. What this means in terms of treatments for perimenopausal and menopausal women is that possibly very different forms or intensities of treatment may be needed to help women with different biological natures.
I became familiar with the research literature on menopausal women only after first detecting the symptoms of the WHM Syndrome via interviews with women. What I discovered in my interviews with ultimately some 160 perimenopausal and menopausal women did not correspond with what I later read in the professional "menopause research literature." I had interviewed women who reported being hot all the time, like Sherry Strumph and her friend. The menopause literature made no mention of such women -- though they might be in there somewhere I haven't yet read. Menopause experts I interviewed about such symptoms didn't know what I was talking about. Some even told me that women only developed hot flashes during menopause, not during perimenopause, which entirely defied what informants had told me.
I discovered there were more than a few women who were now menopausal who had never had a hot flash or only one to date, but who had lots of WHMS symptoms to one degree of intensity or another. These women didn't have physical symptoms to speak of. Their memory wasn't blinking from nighttime awakenings. Their relationships, their diet, and their exercise were essentially the same. Their ability to recall where they had just put something down wasn't. The menopause field said women with lots of complaints around the time of menopause who went to menopause clinics for help were having secondary reactions to their body symptoms and tended to overuse the mental health and health systems altogether, i.e., they were crackpots, so to speak, and couldn't be assumed to be representative of most menopausal women who didn't go to doctors. To the contrary, I discovered that quite a few women with many WHMS symptoms and other mood complaints rarely or never went to doctors for help and that women who did seek out help were not typically crazy; but likely resourceful or desperately bothered by biological systems, which weren't doing what they expected them to.
This insufficiently recognized biological variability among women with regard to perimenopause and menopause, together with the lack of awareness of the biological effects of estrogen loss on behavior, thinking, and physiology, has rendered invalid, to my mind, many of the present "findings" produced to date by the professional menopause survey research literature. Researchers haven't asked the right questions of women so they haven't learned sufficiently what is happening to them and what is affecting them. Though this may sound like criticism my intention is not to be carping. It is my intention to spotlight what needs to be added to future research. Anyone involved in science long enough knows from personal experience that most knowledge in science is provisional, that etched-in-stone dogmas diligently learned in graduate school or medical school can be overturned in a night. Future research in this field, I hope, will routinely acknowledge women's evident biological diversity and work toward finding markers that predict that diversity. The field of menopause research needs to first observe women better and describe women's perceptions of change no matter the political fallout from either those who don't want menopause "medicalized" or from women fearful of finding biological differences among women or between women and men. It is time to acknowledge that not only do the sexes differ from each other in some important ways but that women can differ from each other in important ways. Understanding those differences, and in medical terms learning how to accommodate individual needs dependent on such differences, is where we should be heading.
Copyright © 1999 by Claire Warga