Let's talk about menopause. Or as Dr. Angel Marie Johnson calls it, "puberty in reverse." Menopause affects half the human population. And yet, people don't talk about it nearly enough. It's time to change that. Let's normalize the discussion, shall we?
Below, Dr. Johnson answers common questions and concerns about menopause, including symptoms and treatments like hormone replacement therapy.
As with all content on our blog, the following is educational, not medical advice. Always consult your medical provider regarding your unique healthcare needs.
DR. JOHNSON: Menopause is a natural stage in a woman's life when her menstrual cycle permanently stops, signaling the end of her reproductive years. You've officially entered menopause when you've gone twelve consecutive months without a period.
The average age for menopause is 51, but the process can start anywhere from five to 10 years before that or go five to 10 years after that. Perimenopause is the name for this transitional process before menopause.
About 50% of women find menopause to be bothersome and could benefit from seeing a menopause expert: a urogynecologist or gynecologist. For the fortunate 50%, menopause is no big deal. They're happy not to buy pads anymore. Those women don't need to see a physician, as menopause is a natural stage of life that every woman will go through.
But for the unfortunate 50%, menopause can feel like it's turning their world upside down. Those are the women who shouldn't suffer in silence. The field of urogynecology is here to help improve a woman's quality of life.
DR. JOHNSON: Symptoms can be physical, emotional, and hormonal. Physcial symptoms include vaginal dryness, decreased interest in intercourse, and pain with intercourse. Some women are plagued by hot flashes multiple times a day. They suddenly have a wave of warmth that just washes over their body. Many will suddenly become red, flushed, and sweaty. Then, after that episode—which can last a short amount of time, but just long enough to embarrass and make the woman uncomfortable—the perspiration will evaporate, and the woman feels cold.
The body's temperature sensor in the brain is estrogen-mediated. When the body is overheating, all of the vessels vasodilate (widen), you sweat, and then the sweat evaporates. That process cools the body.
During a hot flash, because the estrogen level is low, the brain thinks it is overheating. The body thinks it is protecting itself by doing something normal and natural, although it is just being tricked. That's why treatments like hormone replacement or a medicine called Veozah can work on that temperature center of the brain to help prevent hot flashes.
Night sweats are similar. They're just hot flashes that happen at night. They're more commonly reported because you're more aware of what's happening in your body at night. Pain is worse at night, causing sleep disruptions. At night, all the distractions of the day are gone in that twilight period before you fall asleep, increasing your awareness of things.
Increased emotionality is another symptom of menopause. Women might notice they're more tearful than they usually are or quicker to become frustrated or angry.
The difference between menopause versus puberty is that a woman knows that it's them. They know their reaction to that scenario is outside the norm, yet they often can't control it. The lack of control is particularly bothersome, whereas a 12-year-old girl thinks the world is out to get them when they're going through puberty. They don't realize it's them.
DR. JOHNSON: The first step is talking to your doctor. You have to say something. Let them know you're having a problem. Because if you don't, we won't know. The reality is that many physicians don't routinely ask about menopause.
Part of the reason goes back to a 2002 study known as the Women's Health Initiative. It made headlines by suggesting that hormone replacement therapy (HRT) was dangerous. However, the study was poorly designed, and more importantly, it is widely misquoted and misrepresented in the media.
Unfortunately, the damage was done. Thousands of women were taken off HRT and told to just deal with menopause symptoms—no solutions, no support. It was another example of how women's health issues get minimized. Just grin and bear it, right? Wrong!
Thankfully, that narrative is changing, and hormones for menopause have been proven safe and effective.
Today, we have multiple treatment strategies. If a woman is dealing only with hot flashes, there's a new FDA-approved non-hormonal option called Veozah that can help.
But let's talk about estrogen. It gets a bad rap, but estrogen is not bad. There's nothing more natural for a woman's body than estrogen—it's been there since she was a few cells in her mother's womb. Like any tool, it just needs to be used properly and with the right guardrails.
There are some people who shouldn't take estrogen—like women with a history of blood clots—because estrogen can make you more likely to form clots in your legs (deep vein thrombosis or DVT) or lungs (pulmonary embolism). So, for those women, we use other options: Veozah, vaginal moisturizers, and more.
That said, for most women, hormone replacement therapy is the most effective treatment for menopause symptoms. And here's something important to know: HRT is the number one treatment for menopause used by urogynecologists themselves.
In other words, the women's health doctors who see it all—the good, the bad, and the ugly—we take HRT too if menopause symptoms become bothersome.
Why? Because we know it works and it's safe. For many women, their body is simply starving for estrogen, and a little boost can make all the difference in helping them get through this transition.
DR. JOHNSON: The main goal of hormone replacement is to raise the level of estrogen in your blood. Once that happens, the estrogen circulates throughout your entire body, which is why it can help with such a wide range of menopause symptoms.
For example, it affects the brain, which helps reduce hot flashes and night sweats. It improves vaginal health, helping with dryness and discomfort. Some women even notice less joint pain and stiffness. That's because estrogen plays a role in joint lubrication. Without it, things don't glide as smoothly, making movement more uncomfortable and recovery from workouts slower.
Estrogen also helps to stabilize mood. If you've had menstrual cycles for 20 or 30 years, you already know how much hormones affect your emotional state. So it's no surprise that when estrogen levels suddenly drop during menopause, your body goes through a kind of withdrawal—physically and emotionally.
Estrogen also helps your body retain calcium and build stronger bones, which means hormone replacement therapy can help treat or prevent osteoporosis, especially when other treatments aren't working.
There are different types of hormone therapy available. Traditional hormone replacement therapy comes in standardized doses. It can be an oral pill that you take every day. It can be a patch that you change every week. Or it can be a gel that is placed on your skin and absorbed through your skin.
But there's also something called bioidentical hormone therapy, which can be more tailored. In that case, your hormone levels are measured through bloodwork, and the dosage is customized based on what your body specifically needs.
That said, it's important to note that bioidentical hormone programs like Biote are not FDA-approved, whereas standard estrogen supplements are. That's something to be aware of when weighing your options.
Another important note: vaginal estrogen cream is not hormone replacement. It's supplemental estrogen. It DOES NOT enter your blood. Instead, it improves vaginal dryness, pain with intercourse and helps prevent UTIs. See our blog post on vaginal estrogen for more details.
DR. JOHNSON: According to the American Cancer Society, breast cancer is the most commonly diagnosed cancer among women in the U.S., aside from skin cancer. It is also the second-leading cause of cancer-related death in women, following lung cancer. Approximately 1 in 8 women will develop invasive breast cancer during their lifetime.
That said, here's what many women don't realize: breast cancer becomes more common as you get older. The longer you have breasts, the more chances a cell has to become abnormal. Cancer usually starts with a genetic mutation or a misbehaving cell that begins growing in an uncontrolled way—that's what cancer is. So when someone says, "I can't take estrogen because my grandmother had breast cancer in her 80s," it's important to pause and put that into context.
Cancers diagnosed later in life—like in your 80s—aren't always tied to hormone use or even genetic risk. Sometimes, they're simply the result of aging. That's why we start breast cancer screening at age 40. In many cases, a diagnosis at an older age isn't something someone dies from. It's something we manage and monitor.
It's also worth knowing that breast cancer is incredibly common. Just having a family member who had it doesn't automatically mean you're at high risk. The women we are most concerned about are those with known genetic risk factors, like the BRCA mutation or Lynch syndrome—conditions that can raise breast cancer risk significantly. In those cases, hormone replacement therapy (HRT) is usually not recommended.
If a woman has been diagnosed with breast cancer, especially recently, we avoid giving hormone therapy. That's because estrogen from HRT enters the bloodstream, and in women with a history of breast cancer, we want to reduce estrogen exposure, not increase it.
In fact, one way we prevent cancer recurrence is by prescribing medications that act like estrogen sponges—they soak up any estrogen that's circulating to help lower the risk of recurrence. So, in that situation, HRT would be working against the goal of preventing recurrence. Instead, we would use other ways to manage menopausal symptoms.
Your quality of life matters. Let us help. Make an appointment with one of our urogynecologists.