(QUICK ASIDE: MY BOOK IS OUT!!! BUY IT HERE AND TELL YOUR FRIENDS BECAUSE THIS BOOK IS GOING TO NEED LOTS OF HAND SELLING FOR ANYONE TO UNDERSTAND IT’S AN ANGRY BOOK, NOT A SAD BOOK. CLICK HERE FOR GOOD SCIENCE AND RIGHTEOUS FEMINIST RAGE.)

Was that a little too graphic for you? I’m sorry. No actually, I’m not, because as a perimenopausal woman I’m done making other people feel better at the cost of my own wellbeing.

Instagram has served me endless memes to this effect. Are we hormonal, or is our rage justified? Have we spent our lives contorting ourselves to have it all, only to find ourselves underappreciated, underpaid, and a sandwich generation caught between endless caregiving responsibilities?

I mean, yes.

And I suppose it is a question worth asking: are the frustrations, symptoms, and experiences of fortysomething women, those acculturated as such, and/or those with ovaries a result of these unprecedented times, aging, the life history transitions so common to this stage of life, sexism, or our hormones?

The answer has real implications for what to do about it. As a biological anthropologist trained to understand environmental stressors, that’s where I always look first. I am wary of any story that blames internal hormonal changes over a better understanding of energetics, inflammation, and psychosocial stressors – I even wrote a whole book on it.

Of course, that was before I started going desperately to PubMed, my PCP, specialists, and finally my gynecologist because I stopped sleeping, my health anxiety was making it difficult to attend in person events, and I was dealing with facial flushing and night sweats. My fatigue from hours of insomnia led to daily afternoon naps and legendary levels of irritability.

It took me going to my gynecologist because my bike seat had grown uncomfortable and I thought something was structurally wrong with my pelvic floor to realize, instead, that I was in perimenopause.

Estradiol supplementation (alongside in my case, a hormonal IUD that offers progestins to counteract potential ill effects of unopposed estrogen – something I have pretty mixed feelings about) has saved my life. I am not being hyperbolic. And I’ve been on it enough years now (and through a few different dosages and brands) that I am confident it is the estradiol, not a placebo, not some other life conditions changing at the same time.

So when I saw an article in Wired today discussing perimenopause as a “buzzword,” a “transitional phase as universal as puberty,” and as something that has “a remarkably long list of ailments.” Patients are “in perimenopause or think they are.” And, said with a significant side-eye: “Hormone levels too low or too high didn’t just cause issues, they influenced everything.”

What if I told you hormones do influence everything?

So here’s the problem – again, as a literal expert in ovarian hormones. Hormones do influence everything. We have receptors for these hormones on nearly every cell type in our bodies. That’s why gender-affirming care that includes hormonal treatment creates so many bodily and psychological changes; it’s why puberty, well puberties. If the author of this piece understands perimenopause as a life history transition that leads to major changes in ovarian hormone output, predictability, and more, why is it remotely a surprise that the related symptoms are so wide-ranging?

The focus on much of my lab’s research over the last eighteen years has been on how environmental stressors influence ovarian hormones, less so on how ovarian hormone changes influence one’s lived experiences. This is because, for most of my career, I have focused on adult menstruating people before the age of forty. To ask questions about fecundability and fertility, it’s been important to focus on the part of the reproductive span most taken up with pregnancy.

In the adolescent and perimenopausal period (so before and after the more-studied life span), there is a ton of variation in how that transition is experienced, and in the hormones themselves. In fact, if I were to characterize either of these transitions at all, I’d say they were most marked by irregularity and pain. That is – the most typical experience of adolescence is irregular, painful periods caused by the initiation of the hypothalamic-pituitary-gonadal axis. The most typical experience of perimenopause? Irregular, painful periods alongside a number of other symptoms caused by the dysregulation and eventual senescence/quiescence of that same axis.

Looking at that latter stage in particular, understand that for decades the body was used to a fairly significant amount of estrogen and progesterone. The patterns were different depending on whether there was any childbearing or contraception, but on the whole there’s plenty of hormone to go around (except postpartum – which is a time where you can see increased risk of depression, anxiety, and psychosis – get the picture yet?).

Then the highs get higher, and as a result the lows get experienced as lower. Estrogen and the gonadotropins elevate to try and ensure some last gasp reproductive attempts (the ovaries become less responsive, eggs have more genetic anomalies, but it’s also the final years of reproductive capacity so the body is trying to pump out these eggs as much as possible). Only after that phase of elevated attempts at ovulation do we then start to see a decline in ovarian hormones – first no more progesterone because no more ovulation, then no more estrogen either. A lower body fat person may even be hit with stronger side effects because there is no hormonal cushion from the estriol produced from fat cells.

Now imagine all this dysregulation is happening all over your body, because you have receptors for these hormones everywhere. Your brain, your bones, your breasts; your muscles, your bladder, your skin. NO WONDER perimenopause has a laundry list of symptoms: these hormones used to influence every system of your body.

The grifter and the mark

If we want to understand and problematize the grifter – by which I mean tech companies who probably care very little about perimenopausal people – we have to understand that the concerns of the mark are real. If we do not start with that premise, we are no better than the grifters.

This is why that Wired piece was insulting. It started from a place of asking whether perimenopausal treatment was really all that necessary, whether it was overprescribed, whether women were imagining symptoms after seeing too many ads on Instagram. The piece did not ask doctors why they were shit at being doctors. It did not take on medical betrayal, or medical distrust. No, it only asked, with mock astonishment, why there are so many symptoms of perimenopause and whether some people simply “believe” they have it.

Like adolescence, like any life history stage, the experience is variable. Not everyone has a rough go of perimenopause, and it’s very likely that stress (as from war, climate catastrophe, and authoritarianism) exacerbates symptoms. But enough of my friends and colleagues are really Going Through It right now that to minimize this experience is offensive.

If perimenopause symptoms weren’t so destabilizing, so impactful, and so all-encompassing – and if the medical industry had at any time showed real concern for mid-life people with ovaries – there would be nowhere for grifters to go.

The next journalist who would like to take this on, perhaps look at the literature on physician attitudes, medical mistrust, and medical betrayal – or talk to the scholars who do that work. I talk about this quite a lot in Pregnancy Interrupted in a chapter on clinical trials during pregnancy, and how their lack makes it so hard for pregnant patients to know which medicines are safe to use.

But if you can’t start from a position of believing suffering people, maybe this isn’t your beat.