It can be overwhelming, especially if you’re still feeling the effects of the extreme thinness culture that dominated the 1980s through the early aughts — the supermodels and Snackwells and celebrities’ bodies being dissected in the media. And now, many of us are also parenting or playing important roles in the lives of school-aged children and trying to help them have healthy relationships with their own bodies.

So I called up some experts to get advice on how to help the younger people in our lives process what they’re seeing and hearing about bodies, and the size of those bodies, right now.

Tip #1: Heal yourself first

Charlotte Markey, PhD, a distinguished professor of psychology at Rutgers University who specializes in social influences on eating-related behaviors, said the struggle that moms in particular face as they navigate talking to their children about food and body image is very real, very common — and also very much worth talking about.

“I talk to moms a lot and everyone’s like, ‘Ah but I haven’t even healed myself. What do I do?,’” said Markey, who is also the author of “The Body Image Book for Girls.” The reality though, is that it’s never too late.

“You can still seek professional help. You don’t have to have an eating disorder,” she said. That might be a therapist, that might be a dietitian, that might even mean asking your primary care physician for a referral for a good place to start. “You can go out and get the support that you deserve because most of us were tormented by the last generation on this.”

Tip #2: Understand boomer culture — and boundaries

Jessica Wilson, a clinical dietician whose work focuses on structural inequalities and marginalized communities, said that a lot of the issues that middle-aged parents face when it comes to food and body image are rooted in the messages they received about their own bodies from their parents.

A lot of this has to do, Wilson said, with the culture that baby boomers were raised in, one that prioritized absolute trust in systems and doctors. Those doctors not only routinely weighed their patients and discussed their weights with them, but moralized around weight — and made correlations between weight and health — that have since been undone in the ensuing decades.

“That impacted our parents. They passed that on to us,” Wilson said.

It created a culture where it became incredibly normal for parents to talk to their children about their weight and compliment and reward thinness. Now, these children are adults — and many of us are still listening to the older generation talk about our bodies, now in front of our kids. (Did your aunt comment on your weight last Thanksgiving? Then you know this dynamic well.)

When Wilson is working with children with eating disorders, she asks their parents to set strong boundaries with their children’s grandparents. She tells them to explicitly ban talking about body size or weight in front of the kids — and impose consequences, like leaving a visit, if they violate that boundary.

Tip #3: Make diversity a core value

Wilson emphasized that we know how much kids make assumptions about people based on what they look like: Just as prejudice can exist with racial differences, so can it exist with body size differences, Wilson said.

“Even if we’re not saying things out loud, our children are picking up on our perceptions of body size,” she said.

You can begin to undo this by making diversity a core value of your parenting — and having age-appropriate conversations with children about the ways people are treated differently based on how they look.

“So many bodies are policed in so many different ways, so having body size included in those conversations that we’re already having about how some people are mistreated in society — including because of their body size — can be really helpful and normalize talking about it,” Wilson said.

Tip #4: Normalize that bodies can and should change

Markey said another really important lesson is that bodies change, and that’s normal.

More and more parents are normalizing explaining to their children in plain language the way their bodies will change during puberty; this is a perfect opportunity to also lay the groundwork for a lifetime of change, Markey said.

“Accepting change as the normal, appropriate response to life events and aging” is a lesson we can teach young people — and ourselves, she said. As we continue to move through midlife and beyond, it’s an essential body image lesson for us to take to heart, too.

“Everyone wants to try to get back to, like, their 14-year-old body, which is not realistic,” Markey said. “So talking about body diversity and body change is really, really valuable.”

Tip #5: Don’t moralize around food

Food is both “more important and less important” than most people think it is, Markey said.

“We just want to talk about food as being important for nourishing ourselves and for being fun and enjoyable,” Markey said. “I use the language of ‘food is just one way we take care of ourselves,’ like brushing your teeth is taking care of yourself, eating a variety of different foods also helps you take care of yourself.”

Wilson said that explaining that, for example, protein builds muscle and carbohydrates and fats give us energy can help us understand why all different kinds of foods are useful to our bodies in different ways.

“In the framing of food neutrality, not actively restricting your child from eating a certain type of food will then lead to the child deciding if they want to eat it or not,” Wilson said. “Rather than us telling a kid, ‘If you only eat cake for lunch, you’re gonna feel bad later,’ let them figure that out for themselves.”

Tip #6: Swap generic statements for genuine questions

If we hear a kid make a comment about their own bodies, our instinct might be to quickly tell them that they are perfect and beautiful. But Markey said that doesn’t actually accomplish much. “Kids don’t believe parents when they say that, so it’s not really that useful.”

Instead, she said, she encourages adults to instead ask simple and open-ended questions.

“It’s really important to ask, ‘Why are you saying that? What’s going on? Did something happen?’ because a lot of times — almost always if a young, pre-puberty kid, is expressing concern — someone said something and it might not even have been directed at them,” Markey said.

You can point out the way your own body might be similar to their own changing body, and to acknowledge that no matter our shape, our job is to take care of ourselves. For example, if a kid says they wish they had smaller thighs like a certain celebrity, you can make a comparison with your own body.

“I think it’s OK to just say, ‘I have thighs that are a bigger size too,’” said Markey. Then you can explain how your own body helps you live the life you want. In this case, you could respond, “My thighs are really muscular. They’ve helped me run a lot. Not everyone has the same-shaped legs and we don’t love every single aspect of ourselves always, but we still have to take care of ourselves.”

Validate that we may have a range of feelings about our bodies as they change — but pointing to the way that different bodies look different helps normalize our experiences.

Tip #7: No one’s perfect (not even — especially — you)

Markey also adds that for parents, it’s important to remember that sometimes, we’re going to miss the mark in talking to our kids about complicated things. If we catch ourselves making a comment that we wish we hadn’t about bodies — our own, a celebrity’s, anyone – we can acknowledge that.

You can always go back to your kid and ask for a redo. So often as adults, and especially as parents, we can be afraid to admit that we got things wrong — but there’s a really valuable lesson for children to be learned in watching us acknowledge a misstep and ask to go back and revisit a conversation.

“You can revisit it and you can try to make it better,” Markey said. “I think we have to give ourselves grace.”

Did I listen to Madeline Miller (author of “Song of Achilles” and “Circe”) on not one but two different New York Times podcasts? You bet! Did I ask my editor if I could create a “Contact Me” page mimicking the one of noted ancient Greek translator Emily Wilson — where she has a specific form for “misogynistic trolling”? You bet! (She hasn’t said yes…yet.)

Did I read Wilson’s much-discussed review (“no sex scenes, and all the food looks horrible”), Joyce Carol Oates’ takedown of Wilson’s review, and many a general survey of the discourse on the discourse? Come on, you know you don’t even have to ask.

And OF COURSE I also listened to Sam Sanders’ conversation with on the real elephant in the room about the film itself: “Does ‘The Odyssey’ Have a Woman Problem?” (Short answer: Probably!) But also, be sure to read her wonderful analysis of the Circe vignette in the film, too.

I haven’t seen the movie yet, but also have already mentally committed to paying a babysitter so I can actually see this in theatres, a real rarity for me. If you’ve seen it already, please write me and tell me what you thought!

And with that? Some links!

The grift (and not grift)

You know I hung onto every word of ’s report on her Substack from attending an event with a company that will be selling compounded peptides — and how she couldn’t get straight answers about safety. (You’ll remember that we talked all about peptide mania during Deinfluencing Month back in April!) (Good For Your Age, July 2)

I deeply appreciated ’ dive into the placebo effect — and the complexity that comes when there’s no science backing something that might make us feel really good. (The Maternal Stress Project, July 7)

Related? I love Taffy Brodesser-Akner on trying and loving cold plunges — and reflecting on how trying new things can in fact be deeply therapeutic. (You’ll remember we also talked about cold plunges during Deinfluencing Month!) (New York Times, July 8 & 12)

I spend a lot of time thinking about influencers: Life coaches! Wellness coaches! Menopause coaches! And if you start to follow any of them long enough, you’ll inevitably hear about how you, too, could start coaching. (aka Money With Katie) did a whole spiel on “Influencers Selling Sales” — and while she specifically talks about what this means for so many Gen Z women entering the workforce, I couldn’t help but think about women in midlife looking for a second act. (Money with Katie, July 8)

Last month’s AI grannies are this month’s AI middle-aged women…who are of course pushing supplements with all kinds of dubious claims behind them. did a gangbusters job on her Substack of explaining the full trajectory of the Instagram Reel rabbit hole of these faux midlife influencers, all of whom are somehow “57 years old.” (Charlotte’s Book, July 17)

And this conversation between Brittany Luse and Brooke Devard Ozaydinli about the optimization effect on beauty culture and its impact on Black women and agency is a perfect bookend to thinking about how we metabolize what we consume online. (It’s Been a Minute, July 14)

The rock and the roll

God bless and her righteous screed against Creepy Men in Music and the lack of consequences for their behavior. (Entering the Lung, August 2)

My inner punk screamed with glee reading ’s reporting on Menopunkpalooza! (The Guardian, July 7)

Which is why I of course had to read ’s first-hand account on Substack of taking the stage of that same aforementioned festival at the super punk age of 59. (The Imprecision of Memory: Musical DNA, July 7)

Oh what’s that you say? There’s a Radiohead cover band composed of perimenopausal women going by the name of Labiahead? God, I love middle-aged women. (The Persistent, July 8)

The way explained the Gracie Abrams blowback vis a vis a Carly Simon history lesson? [Chef’s kiss] (NPR, July 20)

The culture

I know that you, too, can smell Bath and Body Works’ Japanese Cherry Blossom at the mere mention of its name. (The New York Times, July 6)

I appreciated how freaking real Penelope Cruz was talking about perimenopause with Olivia Wilde. (Allure, July 7)

… much like Amy Poehler talking to Greta Lee about her frozen shoulder. (Good Hang with Amy Poehler, June 23)

Immense gratitude for ’s Substack — a phenomenal Gen X pop culture water cooler — for this interview with legendary costume designer Debra McGuire — and for teaching me that McGuire costumed Jennifer Aniston on “Friends” and is doing so now on “The Morning Show.” (Whatever Nevermind, July 14)

made a name for herself for her cutting, singular young adult novels and I couldn’t put down her debut work of adult fiction, “Pool House” — all about an adult daughter and her former TV star mother moving into the pool house alongside the house they can no longer afford. It’s all about identity and sex and grief. (Flatiron Books)

Also, Samantha Morton talked about menopause in relationship to her Circe performance in “The Odyssey”! (Vulture, July 22)

The poignancy of aging

I consider myself both a fan and student of Rachel Aviv’s work and, as the daughter of a mother and the mother of a daughter, am very much looking forward to sitting with her new book “You Won’t Get Free of It: Stories of Mothers and Daughters.” I also really loved this interview with her in The New Yorker’s newsletter. (What We’re Reading, July 8)

By now you probably know that I’m a huge fan of ’s NPR podcast Wild Card. This interview with writer, climate activist and professor at Harvard Divinity School Terry Tempest Williams is a profound and moving listen. (Williams’ new book is “The Glorians: Visitations from the Holy Ordinary.”) (Wild Card, July 9)

The Marshall Project

The Marshall Project recently released their guide to how to navigate perimenopause and menopause in prison. It’s a really informative resource on something you may not have thought about before, and a really wonderful compliment to the piece they ran on this topic (that we highlighted here!) back in April.

So it should go without saying that I’m a huge fan of Emma Straub — and bought her latest novel, “American Fantasy,” the day it came out. The plot: A middle-aged woman goes on a boy band reunion cruise.

I was all in from the jump — and dying to talk to Straub, 46, about writing middle age, being middle-aged, plus loving The Babysitters Club and NKOTB.

Conversation has been edited for length and clarity.

What would you like to see conversation about women and midlife look more like culturally right now?

Part of my project with [“American Fantasy”] was trying to show the parts of midlife that I feel like are rarely seen, which is the continued possibility of change.

I think that when you are in your 20s, especially if you’ve been conditioned by the patriarchy or just sort of the culture of our society, you have these things that you sort of expect and you expect to happen in a certain order, whether it’s getting married, having children, having a career, maybe taking a break from that career if you’re also taking care of your children.

But the thing is — there is this huge expanse of time between, say, having children and dying.

What I see in my own life and in the lives of women around me is, of course, that this idea of this order is completely false and ridiculous.

I was 37 when my husband and I decided to open a bookstore and our lives completely changed. I have so many friends in their 40s and 50s who have gone back to school, have changed their lives in lots of ways, whether it’s gotten divorced or gotten remarried or moved across the country or moved to another country — and I find all of that so inspiring. I think that the people who are most open to making those changes are middle-aged women because there’s not really a template for midlife, but women are so good at figuring things out.

What is most different about being the age you are than what you would have imagined 10 or 20 years ago?

Twenty years ago, I would have guessed that I would be a novelist and that I would have children — I always knew that I wanted to have children — and both of those things are indeed true. The bookstore would have been a surprise, but I still live in New York City, where I grew up, I just wrote a book totally inspired by New Kids on the Block, and just wrote a new Babysitters Club book, so you’re catching me at a point right now that would have been extremely visible to my 12-year-old self.

The surprise would be my comfort and my self-confidence. I just feel quite steady in my life. I mean, I am an anxious person and a very scattered, total ADHD mess — but I have always loved what I love and I have done, I think, quite a good job surrounding myself with it in lots of different ways.

I feel like you are living every middle-aged woman’s fantasy: You not only own a bookstore, but now you have actually written a new Babysitters Club book — and one all about Stacey, my daughter’s favorite member of the Babysitters Club.

Listen, Boy Crazy Stacey — she was a blonde from New York City and she had cool clothes. I was like, “Well bing, bang boom! There I am!” Stacey is my girl, so when they asked me to do it, I immediately said, “Please give me Stacey. Please, please let me do Stacey.”

Ann M. Martin is just a legend. She’s soft-spoken. She’s a total introvert. She’s very quiet. But what I appreciate the most about her is that she really let us all in and let us do what we wanted to with our characters. She really gave us the reins to these kids who she created 40 years ago, which I cannot imagine is easy. Ann really trusted us.

What was it like to dip back into this mythology, this stage of life, and Boy Crazy Stacey especially?

“American Fantasy” is about a million Boy Crazy Staceys.

I can say as a bookseller that readers really respond to stories about longing and desire.

And I think there are so many interesting parallels between puberty and menopause, where you are transforming and you are becoming and you are changing.

I got my period when I was 10 and I was so excited. I was so excited. I was so excited to have training bras. I was like, “I am a woman.” I just couldn’t wait for all of that. And you know? I am also excited for that part of my life to be over now. I haven’t hit menopause yet, but I’m into it. I’m into new phases of life. I’m into learning how my body is going to work differently.

What has surprised you the most about your body as you’ve moved through your 40s?

I had two surgeries this year — one last spring, then one in the fall — and after that I realized I really had just been leaving my body alone for years. I just really had not moved my body in like six years and I had these two surgeries and I just decided, “OK I have had enough. I am really gonna start taking care of my body.” And so I did.

I’ve been lifting weights. I work out with a personal trainer twice a week. I eat so many vegetables. I have stopped drinking pretty much totally. I have a glass of wine maybe once a month if that and I enjoy it so much and then that’s fine. I really am trying to walk.

I want to be a strong old lady. I want to be active for as long as I possibly can be and I understand that the habits I build now will help me then.

What do you hope for the next 20, 30 years of your life?

I hope I get to keep writing novels. I want to write as many novels as I can. That’s really my goal: Just keep writing books.

I want to learn to enjoy things more. I want to learn how to celebrate things better and plan things just for fun. Travel more for fun. I’m terrible at doing things for fun.

What excites you the most about being this age and just not giving a shit about liking what you like and being who you are?

I mean that’s really exactly it.

When I went on [the New Kids on the Block reunion] cruise as research for the book, I was familiar with the New Kids fandom for sure, but I had never really participated in a fandom before. It really was paradigm-shifting for me to be on the cruise and to realize what it was actually about, which was women’s pleasure. I just didn’t understand.

I knew I wanted to write this novel and I knew that a cruise is such a perfect setting for a novel and I had all these ideas about the boy band and their peccadillos and complications, but I hadn’t really thought about the fan and the supremacy of the fans’ experience and the importance of women’s happiness and what it meant for this many middle-aged women from truly all income brackets and all different kinds of places — from rural places, from cities, from different kinds of lives — to prioritize themselves. And not just prioritize themselves in the way of, ‘I’m gonna start eating healthy! I’m gonna start lifting weights!’ but just to prioritize their own pure pleasure and that was incredible to behold and really has changed the way I think about fandoms, I think probably forever.

Last night I went with my middle-aged friends to see Louis Tomlinson from One Direction play at Madison Square Garden. I don’t personally care about Louis Tomlinson but my one friend, a bookseller from Texas, she loves him. And just to be there with her and watch her lose her mind was so satisfying. Everyone in the arena was watching him and I was watching her. And not just her — I was sitting there laughing with joy at all of the people around me who were so happy and I feel like that’s my new hobby: just being a witness to people’s happiness.

And French Gates was putting her money where her mouth was: Alongside the op-ed, a press release from her philanthropic organization, Pivotal, announced the details: The organization would be giving $215 million to fund research and resources connected to women’s reproductive and midlife health. The new funding announcement brings French Gates’s total philanthropic funding to women’s health to more than $600 million in the last two years.

(French Gates and Pivotal are also supporters of The 19th.)

I’ve been writing this newsletter for almost a year now, and the lack of funding for menopause research and education comes up just as much as hot flashes and brain fog. It’s clear: We can’t only think about symptoms — we also need to think about systems.

That’s why I wanted to connect with the folks at Pivotal and their funding recipients to talk about what this announcement really means.

Equity and impact

When I spoke with Renee Wittemyer, the vice president for program strategy at Pivotal, she said the guiding philosophy behind their work is simple: “Women can’t do well if they can’t be well.”

She mentioned the gender health gap — that women experience higher levels of illness than men, spending an average of nine years in poor health. Part of the problem? The lack of funding in the women’s health space.

Yes, yes, yes, yes.

Wittemyer told me that at Pivotal, decision-making is driven by an assessment of the funding landscape around a given issue — and getting a sense of where they could really make a difference.

“With menopause and midlife, we were like, ‘Oh — and there is no funding,’” she said.

YES.

A new vision for healthcare

Wittemyer said one of Pivotal’s goals is to see more menopause-specific training for healthcare providers, the integration of menopause education into a greater proportion of residency programs and expanding outreach in areas where access to menopause care is the most limited. It’s why one of the recipients in this new funding announcement is The Menopause Society, which received a $10 million grant.

With that money, The Menopause Society — a nonprofit that focuses on education for healthcare providers — wants to find new ways to normalize the conversation around menopause care and get more providers trained on it.

First, the group is developing a digital education resource platform for providers. Next, it will be looking into provider shortages in so-called “meno deserts” and creating plans to train providers in those areas — and train those providers to train others as well. The group also plans to look at systemic barriers within the health care system — things like issues with insurance billing codes, diagnoses being contingent on patient self-reporting — to tackle making treatment more accessible for more people.

Dr. Stephanie S. Faubion, the organization’s medical director, wants to make sure people aren’t thinking about menopause as a disease.

“It doesn’t have to be scare tactics, that we have women thinking that at 40 something horrible is going to happen to them.”

Faubion points to puberty as a reference point: Many of us are having normal conversations with our kids about their bodies changing and what it means to get a period. That same talk isn’t happening right now with menopause — and there’s room for growth on the provider side of that dialogue.

Faubion sees too much fear right now — especially online, especially on Instagram. It’s a fear that’s driving so many to treatments that range from unnecessary to untested to unsafe.

“If I were going into this without the knowledge, I would think I would have to spend thousands of dollars every year on supplements and that I would have to have x,y, or z treatment, which is simply not true,” she said. “I don’t think we need to be scaring half the population that something awful is happening.”

Thinking globally (literally)

Another grant recipient in this recent Pivotal funding announcement is Co-Impact — an organization that partners with local groups working in Africa, Asia and Latin America — on their work in women’s perinatal mental health. Co-Impact is receiving a $40 million grant from Pivotal to support locally led organizations embedding mental health services for women into maternal and primary care systems, with a focus on Africa.

It’s work that Yasmin Madan, the senior director of strategic partnerships at Co-Impact, said is not only critical for advancing equity, but is a natural complement to the work being funded domestically on menopause education.

The way Madan explains Co-Impact’s global work on women’s mental health echoes the work being done by The Menopause Society in their field: It’s about thinking intentionally about these huge moments of life change for women and the risk that comes with them.

“When there are hormonal changes, when there are identity changes, when there are societal risk factors like gender-based violence, poverty — that’s when this really peaks. And each of these inflection points then compounds further.”

Without the right support, healthspan — or the portion of a person’s life during which they are in good health — can be forever impacted. This is true during pregnancy; it’s also true during menopause.

The attention economy

Both personally and professionally, I’m constantly hearing stories from people about their experiences with perimenopause, menopause, and healthcare — or lack thereof.

I hear stories from people who say their doctor dismissed their symptoms. I hear stories from people who went to doctor after doctor, looking for someone, anyone, who would just listen to them. I hear stories from people who aren’t even sure they know when they should trust their own doctors anymore and are turning to alternative health practitioners who are ordering labs and peddling products their medical doctors have advised against.

That’s why it feels so significant that so many dollars from such a well-known source are now aimed at combating the noise, misinformation and grift that have coopted the menopause space.

“That we have somebody like Melinda Gates who thinks this is really important and has decided to put her weight behind this speaks volumes. I think even more she’s kind of thrown down the gauntlet as a call to action to others to do the same,” Faubion said.

It’s why Wittemyer told me that future stages of this funding work may also include supporting legislative work at the state level to make menopause care more accessible, too.

As Wittemyer said to me: “We want women to be supported across the arc of her life and the trajectory of her life through those moments when you can make or break your long-term health trajectory. If women can get the right care at the right time, it can just change everything.”

And while my eyebrows are still bushy and I am rarely seen outdoors without head-to-toe UPF clothing, a lot else has changed since I was in high school — especially when it comes to how we think about the sun and its impact on our health.

Cue the expert

That’s why I called up Dr. Angela Lamb, a New York City-based dermatologist to talk about how we should be thinking about sunscreen and skin health as we age.

The first thing that Lamb told me: It’s important to remember that 80 percent of visible signs of aging are due to the sun, or photo aging.

So what does excessive sun exposure really mean?

“If you’re going to be outside longer than five to 10 minutes, particularly on the face and any other exposed areas, wear a layer of sunscreen.”

Sweating, exercising or doing anything where that sunscreen might drip or be wiped off? Then reapply at least every two hours.

“Sunscreen is FDA-approved — even the ones that say ‘sport’ — to be good for either 40 or 80 minutes,” Lamb explained. “Even the most sporty, best sunscreen will only last up to 80 minutes — you really have to reapply after 80 minutes.”

Done and done.

Label hunting

Lamb said when it comes to buying sunscreen, knowing what to look for is easier than you may think.

First, buy anything that says “broad spectrum” on the bottle — that means it protects against both UVA and UVB rays. UVA rays are responsible for aging, and UVB rays cause burns.

She added that sunscreen in the United States requires approval by the Food and Drug Administration (FDA), so every product on shelves has gone through rigorous testing and evaluation. (In Europe, sunscreen is categorized as a cosmetic — so that’s why they have more options for sunscreen than we do.)

And that’s why it’s a really big deal that last month the FDA approved a new sunscreen active ingredient for the first time in over 20 years.

The new ingredient is bemotrizinol, which is also known as BEMT or Tinosorb S; the ingredient will be available in the United States under the brand name PARSOL Shield. And it’s what Lamb says is referred to as a “true broad spectrum.”

Often, sunscreens that bear that label designation combine two different active ingredients to protect against both kinds of ultraviolet radiation. But bemotrizinol does everything in one ingredient that also happens to be photo stable, meaning it doesn’t start to break down quickly when exposed to sunlight, the way many older ingredients do.

Chemically speaking, it’s also a large molecule — which means it does not absorb deeply into the bloodstream. It also doesn’t leave a white cast and has a consistency that really melts into the skin, giving it a luxurious feeling, Lamb said.

Not your mother’s sunscreen

When Shontay Lundy founded Black Girl Sunscreen almost 10 years ago, a few major factors made the conversation about sunscreen very different than they are today.

First, she said, was the lingering belief that sunscreen was meant to be worn in the summer and the summer alone — something she saw mirrored in how sunscreen was covered in the media.

“Even in 2021, there was no writer that would pick up a story after August — and even that was pushing it — talking about why people should wear sunscreen, the daily benefits of sunscreen usage and all that.”

The second major change? “Inclusivity — who is wearing it and how they’re wearing it.”

Essential to building her brand, Lundy said, was the messaging work to healthcare professionals, legacy brands, consumers, marketers and retailers alike “that Black and brown people do in fact have a need for and the money to spend on this product and are in a space where we have been underserved and ignored.”

Two big developments helped her company grow. First, work went into communicating that people with melanated skin need sunscreen. And second, developments in cosmetic chemistry have yielded new sunscreen formulations that are better for daily use for more people.

The work was fueled by Lundy’s own frustration at not being able to find a sunscreen that didn’t leave a white cast. Developing a product that worked for her skin tone helped her reach an even bigger market.

“We’ve said to this world that this is to honor Black and brown skin, but it doesn’t even have to just be for Black women,” Lundy said. “We also have allies of the brand, non-Black people, because it works on their skin, too.”

The message is resonating, as well.

“Many of our customers tell us they’ve never worn sunscreen before discovering Black Girl Sunscreen, and that’s one of the things that, you know, makes us most proud. We didn’t just create a product — we created a new habit around sun protection.”

Beyond aesthetics

It’s not just about aging, Lamb said: “We really do know and convincingly show scientifically that it is ultraviolet radiation that causes skin cancer of all types.”

In the past few years especially, though, Lamb says she’s seen a cultural shift — one moving away from a general acceptance of the fact that forgoing sun protection can cause cancer.

“Now you’ve got influencers and little TikTokers going around talking about using their UV filters, deciding how you know that the UV is going to be that day and then they go out when it’s highest so that they can get that exposure and this concept of a ‘base tan.’ I think that’s unfortunate because we really do know that — period — excessive exposure to the sun does create photo aging as well as skin cancer.”

Beyond sunscreen

Still holding out because you just hate how sunscreen feels? Lamb has great news for you: You can always wear UV-protective clothing!

Lamb stressed how important it is to especially keep your face, neck, and head protected — which is a great opportunity to lean into an accessorizing moment.

“Hats, hats, hats,” Lamb said — they really help (and are so fun to wear).

Shop around

If you want to not hate sunscreen but just haven’t found one you like yet, Lamb says to just keep trying.

If it feels good on your skin, you’re more likely to use it — so keep looking until you find something you actually enjoy applying. Have sensitive skin? Look for products that are fragrance-free — they’re more likely to be less irritating.

She said most people are getting more sun exposure than they think. For your day to day life, wear SPF 30 sunscreen. On vacation and outdoors 24/7? Then go ahead and opt for something with at least an SPF 50 on it, she recommends.

“Sunscreens have really evolved — they’re trying to meet the consumer where they are. If you want an organic sunscreen, if you want a fragrance-free sunscreen — there are just a lot more options than what we used to have,” Lamb said.

And most importantly, she said, “it’s never too late.”

“If you used to smoke, that doesn’t mean it’s a wrap and you definitely should just continue. Any change you can make for you to better your health and wellness is really important,” Lamb said. “Don’t just continue not using sunscreen because they didn’t always use it.”

(And if you want to feel 20 all over again, in ways both good and bad, may I also recommend keeping the new Olivia Rodrigo album on loop, which is all I’ve done since it dropped last month.)

Boundaries

Ever since I listened to on Amy Poehler’s “Good Hang,” I’ve been trying to abide by the wisdom Dunham got from her brother: Make sure your replies to emails have fewer words than the one you got. A practical, attainable lesson on boundaries? We love to see it. (Good Hang with Amy Poehler, May 26)

I have been thinking a lot about the impact that Laverne Cox has had on The Culture and the way she’s modeled caring for yourself and protecting your truth — and how she’s modeling midlife now as she promotes her memoir, “Transcendent.” (The New York Times, June 10)

88-year-old Joyce Carol Oates takes a daily three-mile walk through the woods. This also feels like boundary goals for me: yes to protecting your time to move your body. (Of course her new short story collection, “The Frenzy,” is as subversive as ever.) (Vulture, June 17)

Shot: A great reminder from over on her Substack that there’s no one right way to age and no one right way to have a body and your mileage may vary on all advice and takes and that is extremely OK. (Unapologetic Aging, June 21)

Chaser: CNN’s Audie Cornish and Ari Shapiro’s too freaking real conversation on their podcast about how menopause influencers have become the latest iteration of the “Can women have it all?” trope that simply will not die. (Added bonus: They also talked about NPR’s Rachel Martin being tired of menopause diets that are clearly not for her — just like we did two weeks ago!) (Engagement Party, June 19)

Bodies

I cannot deadlift 180 pounds and reading about these kids who can and are achieving Internet stardom for it was a very specific kind of humbling and fascinating. It was some real food for thought when it comes to how we share our bodies and in what mediums. (Written by the one and only Danielle Friedman, who talked to us for this newsletter about vibration plates!) (The New York Times, May 30)

More GLP-1 debate surrounds us. The latest? Whether they should be considered performance-enhancing drugs as part of the coverage of Serena Williams’ return to professional tennis. (The Atlantic, June 20)

Veteran health journalist Michele Promaulayko has been my editor-in-chief twice (at Yahoo Health and Cosmopolitan). So her latest on caring for her friend during her facelift recovery was always going to be automatic (and voyeuristic) reading for me. (Allure, June 17)

Obviously I had to also read the behind-the-scenes commentary on the Allure story by , the friend in question, on her own Substack. (Charlotte’s Book, June 19)

I have had a love-hate relationship with Vogue for decades — and have been an admirer of NPR’s Michel Martin even longer. In other words, Martin’s sit-down with new Vogue editor in chief Chloe Malle on her desire to curate a more accessible, more inclusive version of the fashion bible was a must-listen for me. (NPR’s Newsmakers, June 18)

Trad Wives

It’s hard to explain how much time I spend thinking about the impact of “Lean In” and the so-called Girl Boss era — so this episode of the Diabolical Lies podcast (co-hosted by “Yesteryear” author ) really scratched a certain itch. (Diabolical Lies, May 31)

Related: Hannah “Ballerina Farm” Neeleman said she hasn’t read “Yesteryear” — allegedly inspired by her online persona — but knows “what’s going on” in regards to the so-called trad wife novel of the summer. (Vulture, June 16)

And I extremely appreciated weighing in on Substack about the “all trad wife novels are the same” discourse that has recently emerged … about her own novel! (Over the Influence, June 23)

Brains

I loved listening to Emily Jacobs (whom we spoke to about ADHD and menopause back in October!) talk about sex hormones and the brain and how to make sense of what we do and don’t know about all of this yet. (Radiolab, June 19)

… but then my brain melted altogether after reading the always excellent on the rise of the “AI granny” influencers over on her Substack and what they’re selling and what this even does to our psyches to be force-fed this kind of fake (aspirational???) imagery. (Good For Your Age, June 25)

That’s why she started hosting a series of conversations with women in her state about financial wellness and economic challenges. She expected to hear about housing costs, low wages, the challenges of saving for retirement. But she was surprised by what she actually heard a lot about: menopause — and how much it was costing.

Stratton and her team quickly realized that menopause was creating such a financial burden for so many people because they couldn’t get the care they needed. There was work and productivity lost to untreated symptoms. There was bouncing around from doctor to doctor, taking time off of work each time, trying to get answers. There was the money spent on alternative treatments found online, in the absence of actual medical care.

That’s when Stratton also learned that 70 percent of women who seek medical care related to menopause symptoms do not receive treatment. Menopause symptoms that affect worker productivity result in over $150 billion lost globally. Black and Latina women disproportionately experience more severe symptoms — and are also less likely to receive hormone therapy from a healthcare provider.

The stories Stratton kept hearing about the financial and physical impacts of poor access to menopause care made something immediately obvious to her: “There’s a real policy solution for this.”

At the end of May, the Illinois state legislature unanimously passed a law amending the state civil code so that beginning January 1, any licensed healthcare professional in the state can take specialized training in perimenopause and menopause care for their required implicit bias awareness training.

The bill doesn’t create a new continuing medical education (CME) hours requirement but rather finds a creative way to put the option of menopause training in front of all licensed providers in the state. Illinois is the first state to create this type of incentive for menopause education among healthcare professionals.

That’s why I wanted to connect with Stratton to hear more about the Illinois bill, how perimenopause and menopause should be part of the larger conversation around affordability, and what she sees as the legislative road ahead — especially as she is likely to win the race for an open U.S. Senate seat in November.

Mind the gap

Stratton tells me that this legislation was prompted after her team discovered that fewer than 200 physicians in Illinois were certified as menopause health professionals.

“When I think about a state of almost 13 million people and half of the state being women — 200 people being certified just wasn’t enough,” she said.

But she said she knew that any solution needed to not only address that women weren’t getting the care they needed, but also ensure that it didn’t add an impossible burden to physicians.

“Having all physicians being able to get this, you never know who you’ll have that conversation with. It could be your primary care physician, but it could be another physician that you’re seeing and you’re talking about your symptoms and what you’re feeling — the brain fog, the hot flashes, not being able to sleep — and it could lead more physicians to say, ‘Hey have you checked out to see whether this might be that you’re experiencing perimenopause or menopause?’”

Knowledge is power

Pauline Maki, PhD, is director of the Center on Health, Awareness and Research on Menopause at the University of Illinois College of Medicine (UICOM) and a leading menopause researcher who worked closely with Stratton’s team on Illinois’ menopause bills.

“We’ve been trying for decades to underscore the importance of having providers trained in this universal experience for women who live to late life,” Maki said. “Every organ system in the body has estrogen receptors and although 27 percent of women sail through menopause without a problem, I think it’s really important that we recognize that for a lot of women, it represents a very challenging time.”

It’s a challenge that not all healthcare providers are equipped to address, which can mean patients turning to therapies without any scientific basis that can sometimes be harmful. That’s why the Illinois bill is so important, she said — and is gaining attention.

“My inbox is blowing up with people asking me to consult with them on their legislation.”

Maki is helping design an Illinois CME menopause education course and said it will focus on things like the basics of prescribing hormone therapy, the basics of prescribing non-hormonal FDA-approved therapies, and how to address the needs of various patients.

Not the last

Illinois is not the first state to address menopause legislatively. As of 2026, 10 states and Washington, D.C., have enacted a menopause law of some kind; 60 pieces of legislation related to menopause have been introduced in state legislatures this year alone.

These new bills tend to fall into three categories: workplace accommodations, insurance coverage and healthcare provider education.

Rhode Island was the first state in the nation to pass a menopause law; a bill signed into law in June 2025 mandated workplace accommodations for menopause symptoms and banned discrimination against employees seeking these accommodations.

Red, blue and purple states alike — including Illinois, Louisiana, Maryland, New Jersey and Virginia — have enacted insurance coverage laws for menopause care.

Maine requires its state Department of Health and Human Services to provide informational materials on menopause to clinicians.

But the approach of the Illinois bill is novel: Outside entities, like UIC Health, can now create CME courses on menopause that can be distributed for healthcare professionals to take to fulfill their implicit bias training requirement.

When the political is personal

Stratton, 60, understands the toll that perimenopause can take because she lived it.

“I have a fantastic doctor, but I do not remember a proactive conversation that said, ‘Juliana, we need to talk about perimenopause and menopause, what the symptoms are, what your treatment options are, what’s possible.’”

She said that now she thinks back to the years of feeling exhausted after not being able to get a full night’s sleep, her primary symptom. “The impact that it had — to get up and have to push through for work, feeling just sluggish all day, because I wasn’t sleeping, and there was not really a solution that was tried. When I would talk to my doctor, it didn’t come up.”

She said she thinks a lot about the 94 percent of women who report being inadequately informed about menopause and the health issues surrounding it.

“I’m a mom of four and working, and to have a position that requires my full attention and focus — it’s hard to do when you’re not sleeping or when you feel like no one cares that you literally are having symptoms of menopause but it’s never been identified as that,” Stratton said. “It’s not treated as a public health issue, it’s treated as a personal issue. We need to change that.”

What’s next

Stratton said this bill isn’t the end of this work.

She wants more investment in women’s health, on the state and federal levels, and a focus on what it costs both people impacted by perimenopause and menopause symptoms as well as what it costs society when their work is impacted.

“Women are spending so much just to be able to get the relief and the care that they need and they deserve,” Stratton said. Accessible healthcare, she said, can save patients real time and real money.

Echoed Maki, “I can’t think of another condition that affects more citizens in the state than menopause. … I think the return on investment for this training for the state and the health of its citizens is huge.” It’s why Maki said she thinks Michigan will soon follow with a similar bill; she also pointed to work in California and said there’s related momentum in Massachusetts.

Stratton said she also is thinking about the fact that the equity gaps in menopause care disproportionately impact women of color — women who often are already less likely to be having conversations about menopause at home and also disproportionately experiencing more severe symptoms and for longer periods of time.

In the Senate, Stratton hopes to be a leading voice on this issue — and to champion the fact that investment and attention must be paid to women’s health beyond their childbearing years.

“Older women fall woefully behind when it comes to the attention and the research,” she said. “We need national, federal policy that elevates an issue that will affect every single woman in this country. Every single woman will go into menopause. So why are we not talking about it?”

If I have learned one thing from nine months of writing this newsletter, it’s how important that is. Healthcare is not one-size-fits-all, and what might be good for your best friend or favorite influencer might not at all be right for you. The only way to figure out what you need is talking to your own healthcare provider — or providers.

But I also know that saying this time and time again can ignore the reality that talking to your doctor isn’t always simple. Our healthcare system is complicated on a good day, and access to a well-informed provider isn’t always a given. We know how woefully underresearched menopause is and how few providers have training in menopause care. Layer on top of that the kinds of systemic bias that some patients also face, and talking to your doctor is far from a simple charge.

That’s why I wanted to talk to someone about how we all can best advocate for ourselves in the exam room.

Cue the expert

Dr. Uché Blackstock spent 17 years as an emergency care physician before founding Advancing Health Equity, a consulting firm that works with healthcare leaders and organizations to create more equitable and more accessible systems of care. She’s also a 48-year-old Black woman — so when it comes to thinking about how to navigate the challenges of midlife healthcare, this work isn’t just theoretical.

“Even with my medical training, I didn’t immediately recognize what was happening to my own body in my early 40s,” Blackstock told me. One of her earliest perimenopause symptoms was insomnia — a symptom she wrote off as stress from the balancing act of midlife as she raised children, built a company and was increasingly involved in public-facing work.

“What I didn’t realize is that these sleep changes that I was having were early signs of perimenopause, and it came to the point where it was really profoundly disrupting my quality of life and also my functioning. Looking back, I wish someone had helped me connect the dots earlier.”

What she wants others to know first and foremost is that it’s OK to feel overwhelmed and confused.

“Here I am, a highly educated, medically-informed individual, and I’m still struggling to recognize what’s happening to my own body as it is going through this stage of life.”

A system not designed for us

Giving yourself grace is a prerequisite to the often necessary act of advocating for yourself, she said.

“I always struggle with this self-advocacy part because it feels so unfair to put the burden on patients,” Blackstock said.

But it’s there because often medical providers don’t get training in treating perimenopause and menopause — because these changes are underresearched, and because perimenopause often begins earlier than many assume — which can lead clinicians to dismiss symptoms.

“I’m not knocking any clinicians,” she added. “We love our clinicians — but we want to recognize where the system can improve. The fact is that you have many physicians and clinicians that have received very limited education about the broad range of perimenopause symptoms, about how to even counsel patients around things like hormone therapy and knowing that the non-hormonal treatment options are.”

How to be your own best advocate

The first step to being your own advocate, Blackstock said, is tracking your own symptoms. Maintain a physical log you can share with your provider at your appointment. Regularly writing down data on your sleep, mood, hot flashes, libido, night sweats, brain fog and energy levels will help both of you see patterns and changes.

In a vacuum, just one of these symptoms may not immediately point to perimenopause, but a written record can tell a bigger story. Blackstock said it’s important to be as detailed as possible in your notes and outline both symptoms and their impact.

“Say, ‘My sleep has really gotten worse over the last six months. I’m waking up at three in the morning and I can’t go back to sleep, and now it’s affecting my work and ability to function.’ That specificity really matters.”

The next tool that Blackstock recommends is bringing a support person with you to a clinician visit. Having a trusted loved one or friend there — for moral support or to help be a spokesperson — can be especially helpful for women of color who have a history of being treated poorly by medical providers. It can also help if you’re not feeling your best and it’s harder to communicate.

Blackstock said to check with your provider’s office to confirm that they are OK with you bringing a buddy — but also that if they aren’t, you should find a new clinician.

“No one should have a problem with that,” she said.

There are other ways to prepare for an appointment, too: Role play with someone you trust so you can feel comfortable and confident communicating about your symptoms and their impact. You can also ask those you love and trust for their impression of what your symptoms are and how they are affecting you to get additional data points about their impact.

Understanding reproductive health

As both a patient and a physician, Blackstock said there are a few other important dynamics that are important to name: one, the inherent power dynamic in medical appointments and two, a culture of assuming that reproductive health is confined to a person’s childbearing years.

Both patients and providers alike can be reluctant to discuss a person’s reproductive health history and how it may influence the way they move through perimenopause and beyond.

“If there’s a history of postpartum depression, anxiety, your fertility, your hormonal history, history of fibroids or heavy bleeding — all of that matters,” Blackstock said.

All of this is also why Blackstock said it is so important that when you’re thinking about how to talk to your doctor, you first think about the doctor you’re talking to. It’s worth it, she said, to take the time to seek out providers of any specialty who have experience caring for people in perimenopause and menopause, and feel comfortable doing it.

This applies to your primary care provider and your gynecologist — but also your cardiologist, dermatologist or any other specialist you see. You can check the Menopause Society’s provider directory; many other medical societies also have directories and guides that will help you determine who has the training and expertise you need.

And if you’re repeatedly dismissed? “Find another provider,” Blackstock said. “Women deserve partners in care who will listen. You shouldn’t have to convince someone that your symptoms are real.”

Conversation starters

Blackstock stressed that “trust shapes communication.” That’s hard when so many patients are carrying with them decades of being dismissed or belittled, rushed or talked over. They have seen diagnoses missed or delayed — and their fear of it happening again is real and justified.

“If patients don’t feel heard, they’re going to delay care, they’re not going to ask the questions they need to ask, and they’re going to feel less empowered,” she said. That’s why it’s so important that you as a patient feel that you have all the tools you need to effectively communicate with your clinician — and ensure that they are listening.

Blackstock said some key questions she would recommend patients bring with them to a conversation are:

• Could this be perimenopause or menopause?

• What is your management plan or next steps for me?

• What is my follow-up care going to look like?

• Are there any treatments that we need to discuss or that you’re thinking about for me?

• Is there anything we discussed today that would make you want to refer me to another specialist?

Getting these answers, she said, is one step toward making sure “that our system is able to deliver the care to women in midlife that they need and to make sure that they can thrive throughout these transitions. Because if we don’t — it’s so unfair. It’s unfair to us as women.”

But what I might respect about her the most now is her defense of what she has dubbed Trashy Tacos. On June 11, Martin filmed herself exiting the grocery store, clutching a bag of Old El Paso taco seasoning.

“This post is for all of my fellow geriatric moms — you know who you are — I’m talking about those of us who had kids when we were maybe 38, 40 — older — because guess what, all the health and wellness people in my feeds recently are talking about, you know, menopausal weight gain and how to avoid it or make it go away, and so much of it is about diet,” Martin says, running through the rain to her car.

“But guess what? I still have a 12-year-old and a 14-year-old at home, and they want to eat Trashy Tacos tonight. And do I have time to make a separate meal of tofu and steamed vegetables for myself? I do not.”

Her words — her rage! her taco seasoning! — felt deeply resonant.

This time of life is exhausting, and can feel even more so if you have school-age children while going through it. You run out of hours on the best of days. The last thing we need on top of all of it is to feel shamed for not doing menopause correctly.

So I called Martin up to scream into the abyss alongside her.

About those tacos

Martin grew up in Idaho without a lot of Mexican food around, and taco night — with Old El Paso taco seasoning and ground beef — was a cause for celebration. But she was reluctant to make her favorite tacos for her own kids when she became a parent, she said. “I was trying to live up to some standard, that mythical standard of parenthood — and that was not feeding my kids ground beef tacos with Old El Paso seasoning.”

But then sometime last year she had run out of dinner ideas (again, relatable) and thought, “You know what? I’m making those Trashy Tacos. And I went out and bought hamburger and sodium-packed seasoning stuff and my kids loved it and now it’s in the regular rotation, and it’s so easy and, I have to admit, quite delicious.”

Last week, as she was en route to the grocery store to buy the Old El Paso taco seasoning, she came across an Instagram post from a women’s fitness and strength expert she’s followed for years suggesting a dinner of roasted tofu and steamed vegetables as the ideal meal for people in perimenopause and menopause.

“The menopause influencers are talking to me ad nauseam about what I should be eating and then I look over at the Trashy Tacos — something’s misaligned.”

And you may ask yourself, ‘Well how did I get here?’

“We worked so hard to get to a point where we could even talk about menopause,” Martin said.

“This was not a thing my mother would have talked to me about, and we had a really open relationship. It was a kind of private suffering,” she said. “So the fact that it’s out there is something to be celebrated. It’s awesome, it’s liberating, and it gets it in the conversation.”

And yet, with the newfound openness has also come a set of expectations that for many are unreachable. Martin feels this as an older mom who’s not out of the stage where kids’ tastes and schedules are dictating many choices and reallocating her time.

Taking care of herself and her body the way the menopause influencers say to and managing the lives of a tween and teen, plus her own work, can feel impossible.

When it comes to ground beef tacos, Martin is happy that she found an easy meal that can feed the whole family and make them happy. But increasingly, she feels that the menopause influencer space isn’t telling her to take the wins.

“I’m now inundated with all these messages that I can be my best self despite menopause — like it’s something that needs to get fixed and I need to fix it and I’m failing if I’m not fixing it.”

But it’s hard to find the time.

“I’m not a priority,” Martin said of this phase of life. “Let’s be honest — I’m not gonna be a priority till my kids are grown, right? That’s not for a few more years, and so I have to hold out.”

You don’t have to like aging

One nice thing about a job like Martin’s — I know because my job is similar — is getting to mine other people for their wisdom. So I asked Martin if the many thoughtful conversations she has had hosting “Wild Card” over the past two years have influenced how she thinks about aging.

She immediately brought up her conversation with writer Zadie Smith in March 2025.

“I find it really hard getting older. It’s really hard and melancholy,” Smith told her.

When Martin asked why, Smith said, “Because I loved being young and I’m really gonna miss it.”

She heard echoes of this in her recent conversation with singer Amy Grant, who talked about aging as a form of grief, discussing how she went so far as to write a eulogy for her younger self.

In contrast to the way that so many menopause influencers make Martin feel, hearing these kinds of comments from these two women “doesn’t bum me out.” Acknowledging the hard parts about aging is “really liberating,” she said.

“It is OK to not have the same wonder as your youth, or possibility as your youth — it’s just different, because now in exchange for the possibility that I had when I was young, I have the wisdom that came from living my story,” she said. “I have the wisdom that came from making a bunch of mistakes and I have all this appreciation for who I was and I wouldn’t be who I am now had I not made those errors and gotten to live the lives that I then got to live.”

Time is a gift (and also a bitch)

Martin acknowledged some grief about aging — but said it goes hand and hand with a kind of reverence for the fact that you get to get older.

“My mom died when she was 60, so every day I’m still alive, I’m like, ‘This is such a gift.’”

It’s why, Martin said, the influencer’s post about tofu and steamed vegetables set off something inside her.

She saw it — between juggling karate practice for one kid, a baseball game for another, work, trying to make dinner, trying to just live her life in her body — and, “I just sort of lost it. ‘This is not made for me. What you’re making is not made for me. This content is not made for me.’ I felt left out of this menopause moment.”

Martin tells me that she is 52 years old and that she very much wants that fact reported.

“I like where I am. I can feel sad about what I used to be and also like my age and where I sit in my life right now. I feel good in my skin. I feel like I’ve earned my place here and I’m into it.”

After all, she tells me, “Time is a crazy, crazy, crazy fickle bitch.”

Doll, the author of “A Terrible Strength: The Hidden Crisis of the Black Womb & Your Survival Guide to Healing,” is the founding director and principal investigator of the Gynecologic Research and Cancer Equity (GRACE) Center at the University of Washington. She specializes in the surgical and medical treatment of uterine, ovarian, cervical and vulvar cancers.

She’s also worried that the uterus is being left out of the larger conversation we’re all having about menopause and midlife health — and especially the implications for Black women’s health.

“I am fascinated by how much conversation there is now about perimenopause, menopause and that whole transition and how comparatively little of that conversation is devoted to the actual uterus, the womb,” Doll told me when we spoke last month.

Doll isn’t trying to make us afraid of uterine cancer — but she is trying to make sure we’re aware.

What to watch for

The vast majority of uterine cancers are diagnosed after menopause; 93 percent are diagnosed in people over the age of 50.

Doll said the “cardinal sign” of uterine cancer is post-menopausal bleeding.

Such bleeding means you should be promptly evaluated by a gynecologist, Doll said. The workup needs to include an ultrasound and an endometrial biopsy — particularly for Black women. Doll’s research found that an ultrasound alone often failed to catch uterine cancers in Black women.

Irregular bleeding is also the main symptom for people who develop uterine cancer or a pre-cancerous condition called hyperplasia before they enter menopause. This can get confusing because perimenopause also causes irregular bleeding.

In normal perimenopause, Doll explained, your periods basically begin to space out and get lighter. It’s a phenomenon many describe as their period being “consistently late.” Once you are going 60 days between cycles, Doll said, you’re likely in your last year before officially entering menopause, or when your period stops completely. A third of people will experience one final, heavy period as their last period — and that’s perfectly normal.

Uterine cancer or hyperplasia can also cause irregular periods — but instead of spacing out, they’ll suddenly come closer together and be heavier.

Worried that your irregular periods during perimenopause might be abnormal? Yup — go see your doctor and ask for an endometrial biopsy and ultrasound.

What Black women need to know

Doll wants more people to know what to be on the lookout for.

She said that so often people come in saying they feel bloated — that they feel heavier in their pelvic area or stomach.

And for many of these people, a cursory scroll on Instagram leads them to believe that this is menopause — weight gain, hormones changing, the ambiguous “inflammation.” What they’re not thinking about is cancer.

Black women are more likely to be diagnosed with more severe forms of uterine cancer and at later stages — and their mortality rates are more than double those of White women, Doll said.

The lack of awareness can be deadly for some, and for Black women most of all. It’s an issue further compounded by a healthcare system already primed to dismiss Black women and their concerns about their health.

Hormones and aging — and nuance!

This is further complicated by the popular discussion around hormone therapy now.

“The last thing you want to do to a uterine cancer is give it estrogen,” Doll stressed.

Doll said she wants to see more nuance in the conversation about midlife health. We can talk about menopause and its symptoms and their impact and the other things that happen to our bodies as we age that aren’t actually related to menopause.

And part of that conversation should include what exactly hormone therapy can and cannot do. Having hot flashes and night sweats? Hormone therapy is great for that.

But is everything menopause? No, of course not. Some of the changes we see in our bodies as we get older is just simply aging. Assuming everything is menopause diverts from productive conversation that can be had about what else happens as we age: risk of cardiovascular disease, decrease in muscle mass, metabolic changes, and yes — increased risk of certain cancers.

Right now, Doll said, she sees a lot of conversation about health optimization: how to tweak your diet, exercise routine and supplement regime to maximize your health, all tied to the idea that decreasing estrogen levels are to blame for everything. A lot of the rhetoric around this also feels coded for White women on a mission to look younger and get smaller and excludes Black women and other women of color.

“I think it’s a little dangerous because it makes people attribute aging changes to too little estrogen and then think that there’s the fix for that — more and more and more estrogen.”

About those hormones

This isn’t to say that menopausal hormone therapy is bad or the increased awareness and conversation around menopause is bad, either. About 1 in 30 American women will receive a diagnosis of uterine cancer in her lifetime, and the risk has been steadily on the rise. It’s why Doll says it is absolutely necessary to extend the midlife women’s health conversation beyond just menopause and hormones.

She also wants to remind people that if they’re taking estrogen, they need progesterone to protect the uterine lining from cancers like the kinds she treats.

“Women are smart. If they understand why it’s there, then we will also have less of this concern I have about people playing fast and loose with these hormones, not recognizing what each one is doing specifically.”

If you loved Deinfluencing Month, have enjoyed getting evidence-based takes from expert sources on midlife health and menopause, and enjoy my yapping about all that is weird and interesting about the culture of aging, today is a great day to support my fundraiser for our independent nonprofit newsroom!

While you’re reading this, I’m away for a scheduled break — but I didn’t want to leave you all hanging while I’m OOO! Here are some links for you till we’re back per usual next week.

Listen

Rita Wilson on her mid-career pivot to music: ‘Completely liberating.’This interview struck a chord as it touched on creativity, courage and finding strength in our parents’ stories. (Rachel Martin’s Wild Card podcast on NPR, May 14)

Did The ’90s Kill Feminism? Sophie Gilbert’s book “Girl on Girl: How Pop Culture Turned a Generation of Women Against Themselves” is an absolute must-read, and this interview gets at so many things I’m feeling right now about how we all never escaped the ’90s. (The Sam Sanders Show, May 1)

Read

Saying ‘Me Too’ in an Empty Courtroom. A gut punch of a story that leaves you wondering how we got here. (New York Magazine, May 3)

The Audacity of Nene Leakes. All about two of my most favorite things: Atlanta and Bravo! (Vulture, May 5)

Women lead as health and wellness influencers. Why do so many men have more followers? No but really WHY? (The 19th, May 7)

The Grandmothers Who Became Mothers Again. I will warn you that I started crying as soon as I saw the photo at the top of this. (The New Yorker, May 9)

Why So Many Men Are Obsessed With Testosterone. Once again, I ask no but really WHY? (New York Times, May 12)

When M.F.K. Fisher Met Michael. Ruth Reichl is one of my favorite writers ever; on her Substack, she shared that she just lost her husband. In her grief, she posted this beautiful story about him from her book “Comfort Me With Apples.” (La Briffe, May 15)

If You Were a Hair Accessory, What Kind Would You Be? I’m still talking about Lena Dunham! Great words from her on women, their hair and aging. (Good Thing Going, May 18)

93% of Productivity Books Are Written By Men. She had me at this line: “Where are the time management books written by Cal Newport and Adam Grant’s wives? Now those I would read.” (Read Against the Patriarchy, May 19)

Pap smears are designed to screen for cancer. Why are people afraid to get them? Spoiler alert: Cancer is worse than a pap smear. (The 19th, May 21)

Going Gray and Abandoning Botox. The life and times of a midlife beauty influencer and what monetizing anti-anti-aging means. (Good For Your Age, May 21)

Why are “longevity bros” so icky? Great contextualization about the longevity bro movement (again, yes, WHY) from an internal medicine doctor. (Your Doctor Friend by Mara Gordon, May 21)

If you loved Deinfluencing Month, have enjoyed getting evidence-based takes from expert sources on midlife health and menopause, and enjoy my yapping about all that is weird and interesting about the culture of aging, today is a great day to support my fundraiser for our independent nonprofit newsroom!

When we asked you all during Deinfluencing Month what other topics you wanted us to dig into, we heard one thing over and over again: cortisol.

You asked: What is it? Is it bad? Am I supposed to be getting rid of it? Am I doing all the wrong kind of exercise that’s somehow causing it and now my face is puffy?

Friends, I have been down these Instagram rabbit holes and I understand the deluge of questions it can trigger.

Which is why I called up Dr. Tina Zhang, the co-director of the Women’s Wellness & Healthy Aging Program at Johns Hopkins University and an expert in menopause care. And best of all — she’s someone who spends as much time poking around on Instagram as I do.

Cue the expert

Zhang told me that she understands why cortisol keeps coming up online within the context of perimenopause: Cortisol is a hormone.

More specifically, it’s a steroid hormone produced by the adrenal glands and is referred to as the body’s “stress hormone” because it is released in response to stress.

Stress management is one of cortisol’s primary roles. In high-stress situations, it provides energy, breaking down fat to fuel the body. Cortisol also helps to reduce inflammation, controls our blood pressure and blood pressure levels, manages the fight-or-flight response, and regulates the sleep-wake cycle.

In other words, it does a lot of really important things in your body! It is definitely not something to be eliminated altogether, as some influencers would have you believe.

And here’s where our midlife changes come in.

During perimenopause, we see a decline in estrogen and progesterone — two hormones that are key for regulating cortisol. This means cortisol levels can also become less balanced and there can be real concern about them getting too high.

When cortisol is too high, Zhang explained, it becomes harder to fall asleep and stay asleep — two things essential for healthy aging. It can also promote weight gain. That’s because cortisol is there to help you be ready to respond to stress — it cues the body to store more fat, especially around the midsection, so you can have all the energy you need to do hard things. That’s why higher cortisol levels can also increase appetite and trigger cravings.

The stress of this time of life and the lack of sleep that can result from that can also raise your cortisol levels. High cortisol levels can make sleep even harder — and now you’re in a cycle of stress, sleep and weight gain.

What not to do

And that’s when so many influencers enter the proverbial chat.

First things first: Zhang says she does not recommend testing for cortisol. Lots of people inquire about that after seeing influencers insist it is a crucial need.

“I always validate my patients and acknowledge that their symptoms are real. And yes, cortisol does play a role in stress and sleep and weight — but just checking a cortisol level does not give us any helpful information,” Zhang said. The test is just a snapshot as cortisol shifts in response to so many things. “It fluctuates so much that it’s really hard to interpret.”

This doesn’t mean that cortisol may not be influencing your symptoms — Zhang adds that even if a cortisol test came back normal, it wouldn’t mean it had nothing to do with what you’re feeling — but rather that getting that test done isn’t going to provide information that can move the needle in a meaningful way.

What to do

Zhang said that “every single day” she has conversations with patients about cortisol — and explains that the best way to address the symptoms associated with it are through better sleep hygiene, good stress management, regular exercise and a low-inflammation diet.

And despite what you might have read or heard on social media, exercise is not the enemy when it comes to cortisol. At all.

“If I were to check a cortisol level right after you exercise, it’s going to be high,” Zhang said — again, because cortisol is a stress hormone and exercise, by design, stresses the body. But that’s not the whole story. “Consistent exercise over time actually helps reduce your overall cortisol trends.”

Zhang said this duality often feels confusing.

“If I check right after they exercise, yes it’s going to be high — but regular exercise will help manage weight, will improve your sleep and help with stress relief.” And all of these things will reduce your cortisol levels.

If exercise helps reduce your stress, do it. The same is true for other things that can help reduce stress — maybe a breathing practice or meditation.

Sweet dreams

The other biggest factor for reducing cortisol is sleep.

For some people, Zhang said, getting better sleep will be as simple as limiting caffeine, alcohol and screen time before bed and staying on a consistent sleep schedule.

For others, sleep is harder to come by — and she recommends that these people talk to their healthcare providers about things like magnesium and melatonin or the use of cognitive behavioral therapy.

If sleep feels harder during perimenopause, you aren’t just making that up. The decline of estrogen changes how sleep is regulated in your brain.

“You naturally are going to have issues with sleep just because of perimenopause. On top of that, when you have hot flashes and night sweats, you’re not going to be sleeping. And then on top of that, people are stressed and that’s not good for sleep either.”

It’s why talking to your provider about your sleep — and how to get more and better sleep — is so important in midlife.

Supplements? Thank you, next

Zhang also cautioned against the use of supplements that claim to lower cortisol. It’s not that all supplements are bad, per se, but rather that supplements are so much less regulated than prescription medications. And anyone promising they can sell you something that lowers cortisol doesn’t understand what the hormone is anyway.

When it comes to supplements, Zhang recommends that women take vitamin D and calcium for bone health and reiterated that magnesium can be very helpful for sleep and muscle relaxation.

So forever reminder: Talk to your doctor about your medical history to determine any deficiencies that might need to be addressed through supplementation and what makes the most sense for you and your health needs.

The bottom line

“It is so awesome that women are eager to learn more and have more information about their health and the menopause transition, but there is a lot of misinformation out there with regards to cortisol,” Zhang said. “Importantly, I think cortisol is not all bad. We need cortisol in our body for all of the functions that I mentioned. It’s about balancing it.”

The best way to keep cortisol levels healthy in midlife and beyond?

“Focus on sleeping better, controlling stress and exercising.”

After 30 years with Planned Parenthood, including nine as the national president and CEO, in 2014 Feldt co-founded Take The Lead, an organization working to eliminate the gender gap in executive leadership across the United States.

I spoke with Feldt for a series we are launching here, connecting with people over 75 about what they’ve learned and all the good stuff that comes after the midlife crunch.

“Advice is worth what you pay for it,” Feldt warned me — but she was game to chat about how she’s changed, how she hasn’t and the advice she stopped taking that made her life richer.

This interview has been edited for length and clarity.

How old are you and what is the best thing about being the age that you are?

I am 84, and the best thing is being able to concentrate on the things that really matter and not worry about the things that don’t matter, things that would have bothered me in the past but not just kind of can roll off my back because, like, who cares?

This is the rest of my life. This is not the rest of your life. It’s the rest of my life and I want it to be good.

The things that matter most to me right now are, in no particular order, raising a whole ton of money so that I can put Take The Lead on a sustainable path and enable myself to really pass the baton.

The other thing that’s very important to me is that I have two amazing, little, small great-granddaughters. I just feel like I’m more thoughtful about it at this stage of my life, really wanting to make memories while I can and be present.

The other thing — and this is the selfish part here, which is perfectly fine to have because I think we should be selfish at some times in our lives — is that I really love being in New York. I love the energy of New York. I love the diversity. I love being able not to drive and get to go wherever I want. I love that I’m looking out at Central Park right this minute and I can walk there every day if I want to. I love the theater very much. And I love the fact that people here are intensely interested in everything that’s going on in the world.

What led you to found Take The Lead at the time in your life when you did?

I had wanted to be a writer since I was 5 years old. I would carry my little notebook around and write stories. But then life got in the way.

After I left Planned Parenthood, I wrote a book called “No Excuses: Nine Ways Women Can Change How We Think About Power,” about a big meta study on how despite women being half of the workforce, women were stuck at 18 percent of the top leadership positions across every single sector.

I looked at the research and the research said — which is bullshit, in my opinion — that women have less ambition than men. I just knew this wasn’t the case.

I did quite a bit of research and came to the conclusion that actually, it has to do with our culture, that women learn ambivalence about power. So I wrote this book.

Other people recognized that it was actually a leadership book, and not just a social commentary, and started asking me to teach workshops using it. I realized that I was on to something that could really help women if I could scale it. So that’s basically when I turned the book “No Excuses” into the organization Take The Lead.

What was the hardest thing about being younger and what has made you feel the most proud as you have gotten older?

My late husband and I, we always used to have a laugh about this, because we both came to the same conclusion that 35 years old was exactly the perfect age, because you’re old enough that people have some respect for you and young enough that you can still do everything well.

Well as it turns out, the same things are true when you turn 50. And it’s not far off when you turn 60, if you’re lucky.

I was recruited for the national Planned Parenthood position when I was 53. The first time they tried to recruit me, I said no. But the second time they tried to recruit me, my husband was actually the one who said, “You need to do this. You’re the one who knows how to do this.” And he was right. It was the right thing at the right time.

I was old enough that people respected what I had accomplished and believed in what I could do and my judgment and my leadership, but I was definitely still young enough to have the energy and the ability to work 20 hours a day, which I did for way too long.

What are you the most proud of about how you have changed as you have aged?

I was somebody who never played sports, never had any physical prowess. And now I find that a day when I can start my day with a five-mile walk and then have a Pilates class later in the day is a perfect day.

When I was in my 30s, jogging became a thing. I tried jogging. I hated it.

I never consistently did exercise, but then I got to be in my 40s and two things happened.

Number one, I started doing Jane Fonda videos. She changed my life with those exercise tapes.

Number two, that was also the age when I started to feel like I was losing some muscle tone. In my early 40s was about the time I started having grandchildren and I actually hired somebody to teach me how to do weightlifting, because I felt like I needed upper body strength to keep up with them. I had just a couple of private sessions and I’ve continued to integrate that into my routine ever since.

What are you the most proud of about how you have not changed as you have aged?

What has stayed the same is my passion for making sure that women have an equal place in this world. That has been the driving force for me. Everything I have ever done has been in service of that mission and I’m proud of that mission and I’m proud of the progress that has been made.

I am of course distressed right now by some of the backtracking that’s happening, but I have the blessing of seeing how the arc of change happens. You do go backward sometimes, but you’re never going back — we are never going back — to where we started.

What are you most excited about what’s still ahead for you in life?

I’m going on a writer’s retreat this summer because I know in my gut that it’s time for me to start working on the book that I have been avoiding, which is more of a memoir. You have got to tell your own story because your story is going to get told and don’t you want to be telling your story the way you want to tell your story?

And my grandsons are likely to get married in the near future — I actually got to officiate at one of my grandson’s weddings a couple of years ago. I loved doing that. I’m hoping that somebody else asks me to officiate.

What I’m most excited about is seeing how this next generation is — having grandsons who are very much assuming that they’re going to be equal partners, no question, in their marriages.

What’s the advice that you are most grateful that you did not take?

I’ll say that the worst advice that I’m glad I stopped taking was the kind of advice that said, “You can’t. You’re a woman.”

The problem is, I did take that advice for a while — for years. But by the time I got to be in my late 20s and 30s, I did not take that advice anymore and I’m very glad I didn’t.

OK so maybe it shouldn’t be surprising that hormones are hormones — but it still kind of is, right? Given the way they’re discussed, you may be wondering what they do and when you need them. You’re not alone.

I knew who I had to call.

Cue the expert

Dr. Wen Shen is the director of the Women’s Wellness and Healthy Aging program at Johns Hopkins University in Baltimore, the clinical director of their Menopause Consultation service, and a renowned expert on the whole range of treatments and complementary therapies that can help a patient manage symptoms as they navigate midlife.

Shen said that starting in perimenopause, many people will begin to experience symptoms that impact quality of life. Significantly, many of these symptoms can impact your ability to sleep, which can lead to fatigue and brain fog and mood changes — not to mention increased risk of heart disease and early-onset dementia, Shen said.

“It’s not just ‘Hahaha — hot flashes!’ It is actual medical risks. So for women who are having severe night sweats, severe hot flashes — those need to be addressed because they can carry severe medical complications later in life,” said Shen.

Which brings us to birth control and hormone therapy, which are both medications that could be good solutions for many people.

Birth control

The primary difference between hormonal birth control and menopause hormone therapy is that the former can prevent pregnancy, by delivering higher doses of hormones, and the latter cannot. And for many people, contraception is a really important part of navigating midlife health.

People who conceive after the age of 35 are considered to have high-risk pregnancies; the risks of diabetes, preeclampsia and chromosomal abnormalities increase with age. There’s also the reality that after the age of 45, 50 percent of all pregnancies will end in miscarriage.

It’s why hormonal birth control can be such a good option for so many people throughout perimenopause. Not only does it prevent pregnancy, but the higher level of hormones designed to stop ovulation can also help provide relief for people experiencing severe symptoms.

Shen said she often prescribes birth control to her patients who are perimenopausal — people who still have ovarian function, if not regular ovarian function. Because birth control pills have higher doses of hormones in them than menopause hormone therapy does, they can be better at helping stabilize the big hormonal swings that are a defining part of perimenopause. The form of estrogen in birth control pills is also better at protecting against bone loss than that found in transdermal menopause hormone therapy products.

“Birth control pills are very good options, and there are such a huge range of birth control pills out there now,” Shen said.

But they’re still not a perfect fit for all people, since they may increase a person’s risk for blood clots, which in turn increases the risk of stroke and heart attack. This rare side effect is caused by estrogen being metabolized by the liver. Further complicating this is that the rates of high blood pressure, Type 2 diabetes and high cholesterol — all things that can increase the risk of blood clots — also increase with age.

“You need to be able to weigh the risks,” Shen said. And a conversation with your own provider about your medical history and symptoms is a crucial first step in determining whether birth control pills might be a good option for managing your perimenopause symptoms.

Menopause hormone therapy

Menopause hormone therapy doesn’t have the same risks for blood clots that hormonal birth control does, though, which can make it a good option for those who don’t need contraception or are at higher risk for developing clots.

Most estrogen used in menopause hormone therapy prescribed today comes in a transdermal 17β-estradiol format. These are the estrogen patches, gels, sprays and rings you have heard about — all products that do not have to be metabolized by the liver, and thus are lower risk than birth control pills.

If a patient doesn’t need contraception, Shen said she’ll suggest they try menopause hormone therapy first.

The transdermal products have lower doses of hormones than birth control pills since they aren’t aimed at suppressing ovulation.

And if you’re already on birth control and experiencing perimenopause symptoms? It’s time to talk to your provider about what else could work. Shen said that this might mean a different birth control, with a different hormone dosage. It might be an alternate form of contraception combined with menopause hormone therapy. It’s all about finding a provider who wants to work with you and is willing to stick with you to find the best way to help address your symptoms.

Shen stressed that there’s no one-size-fits-all solution that magically works for all people, so working with a skilled provider who knows the options and can think dynamically about potential combinations is critical.

What if hormones aren’t right for you?

Can’t take estrogen in any form because of your medical history but looking to manage your perimenopause symptoms? Great news — you still have non-hormonal medication options.

Shen points out that there are a few new medications known as KNDY agonists, Veozah and Lynkuet, that are approved by the Food and Drug Administration and are very effective for treating moderate to severe vasomotor symptoms like hot flashes and night sweats.

She also adds that a number of older medications have off-label applications for night sweats and sleep: SSRIs, gabapentin and Oxybutynin.

The real takeaway: Talk to your doctor, review your medical history and find the right medications for you. If your symptoms are impacting your quality of life, you deserve some relief.

How to figure out what you need and when

And if you are experiencing symptoms — recurrent urinary tract infections, sleep disruption, night sweats, mood changes — that are impacting your quality of life, don’t feel like you need to wait to be a certain age to discuss options with your doctor.

Shen recommends staying on hormonal birth control until you are 50 or 51, then stopping them for seven days to then get your hormone levels checked. If two months in a row, labs show that someone’s hormones are in the post-menopause range, they can stop the pills and see how they feel.

If they’re still having some symptoms, then they can evaluate what kind of menopause hormone therapy might help them.

No symptoms? Then you don’t necessarily need hormone therapy!

Yes, there’s a lot of talk about menopause hormone therapy and its benefits, but Shen reminds that it’s really intended for symptom management.

“Menopause hormone therapy is not meant to be a magic bullet to keep you forever young,” Shen said.

And right now, I’m definitely thinking about Mother’s Day — and how much of my mom’s take on this day I have inherited.

“A Hallmark holiday!” she likes to shout. “If you love your mother, tell her every day but don’t buy me a card! I don’t want a brunch!”

Now I say all of these things too.

But I suspect that what my own mom is saying (hi, Mom – I know you’re reading!) is that these kinds of days are just so complicated. That’s true whether you are a mother or not, whether you wanted to be one and couldn’t be, whether you are reckoning with any kind of loss, or whether you’re in the thralls of difficult, humbling work of parenting or able to sit back and admire the person you raised.

Maybe it’s also OK to lean into that.

Maybe Mother’s Day can be a time to celebrate that life is in fact messy and heartbreaking and astounding in ways you could never imagine. Maybe this is a great chance to take a moment to embrace our capacity to feel so many different kinds of things and remember that hard isn’t necessarily bad. We’re never worse off for letting ourselves feel all the things.

(PS hi again, Mom — I love you!)

Winner winner chicken dinner

We have some news we want to share with you because it really is a win for you too: This newsletter won a National Headliner Award last week!

I really love the wonderful community we have created here, getting your emails, reading your Substack comments and hearing exactly what you want to learn more about.

Thank you so much for sticking with us — there’s no newsletter without readers!

News flash

Coming off Deinfluencing Month, this new research on Emotional Freedom Techniques (EFT) on menopausal symptoms, quality of life and depression featured in the the journal Menopause really caught my eye.

I’ll admit, I wasn’t familiar with the acronym “EFT,” but when I looked into it further, I realized it was all over my Instagram feed by another name: tapping.

Tapping, or EFT, involves tapping specific parts of your head, hands and torso with your fingers in moments of anxiety or distress, often with statements of affirmation that both acknowledge the anxiety and your ability to move through it.

In a randomized controlled study of 105 menopausal participants who were divided equally among a control group, an EFT practice group, and a “sham” group that did not practice actual EFT, a group of Turkish researchers found significant differences for the EFT group in measures of menopausal symptoms, perimenopausal depression and quality of life.

This data led the researchers to conclude that EFT can be considered an effective complementary intervention for reducing menopausal symptoms, alleviating depression and improving the quality of life in women going through menopause — a real win, considering there’s no cost to it and it can be done easily at home.

So tap away, friends.

Menopause and incarceration

I also wanted to share with you this story, by The Marshall Project, a nonprofit news organization covering the U.S. criminal justice system, on what it’s like to go through perimenopause and menopause in prison.

In the article, published in partnership with The 19th, reporter Rebecca McCray digs into the stories of several incarcerated women and their experiences managing menopause.

In what McCray calls a “Kafkaesque journey,” one of these women faced countless doors as she struggled to first get a diagnosis, and then actual care. Even an eventual prescription for menopausal hormone therapy — finally issued after months and months of symptoms and visits to three separate providers and countless points of negotiation within the prison health care system — was never refilled once it ran out.

The whole piece is a sobering read and well-worth your time.

I’ll be digging into …

I know spare time is precious! Here’s what I’m spending mine on this month.

These books:

“Famesick” by Lena Dunham

I’m absolutely knee-deep into the press tour surrounding Dunham — best known for her work as the creator and star of HBO’s “Girls.”

I’ve been really struck by how Dunham — now 39 and decidedly on the cusp of being firmly middle-aged herself — is turning an eye on her 20s and what they meant to her as a woman, as a professional, as a creator and as someone who grapples with chronic illness. She talks about her understanding of how chronic illness ages with us and what it means to take time to acknowledge the flaws of your youth while also giving your younger, rawer self grace.

“American Fantasy” by Emma Straub

A boy band. A midlife crisis. A cruise ship.

Honestly, I don’t need to know any more than this to know that the latest from Straub — a storied chronicler of women’s interior lives with honesty and generosity and a great sense of humor and wordsmithing — is very much for me.

These TV shows:

“Beef,” Season 2, Netflix

I’m filling the “White Lotus”-sized hole in my heart by watching Carey Mulligan and Oscar Isaac engage in some elite country club drama. It’s a great reminder that yes, even in midlife, you can act like a petulant teenager.

“Bait,” Amazon Prime

I cannot wait to marathon Riz Ahmed’s limited series about a British-Pakistani actor who is struggling in his career — and then lands an audition to be the next James Bond. Ahmed has always done an amazing job of using his work to push on questions about representation, intersectionality and popular culture, and I am very excited to see this latest installment.

This album:

“Middle of Nowhere,” Kacey Musgraves

I’ve had this preordered on vinyl since the day it was announced and no, sorry, I haven’t listened to anything else since it dropped Friday. Now 37, Musgraves is returning to a more traditional country sound after some twists and turns into Christmas music, pop and folk. It’s an album all about the avenues we take to figure ourselves out — and the new questions we’re still left with — as we age.

This and that

The stories this past month that caught my attention:

• Our (Mothers’) Bodies, Ourselves (Oldster, April 24)

• Dealing with Midlife Anxiety (Gloria, April 24)

• The Year All My Friends Got Botox (The Cut, April 24)

• Where Did ‘Let Them’ Come From (The Atlantic, April 20)

• Ciara Miller Will Let the Universe Handle It (Glamour, April 17)

• Domestic violence organizations turn away thousands each day. Julia was one of them. (The 19th, April 16)

• The 82-Year Old Jump Rope Queen of Beverly Hills (New York Times, April 10)

• ‘Crossing guard diva’ with remarkable past is a social media star in her 80s (Washington Post, April 10)

After talking to all of our experts, I realized a really easy thing I could do to improve my health was as simple as stepping outside of my front door.

“Take a walk,” they all said.

So I did. I started taking a brisk walk, several days a week, several miles a day.

I regret to inform you all that it makes me feel really good and gives me so much energy and leaves me sore in a good way the next day. (If I have texted you about how much I love listening to the birds chirping in the morning while I walk and have scared you with this kind of disconcertingly earnest message, I’m so sorry.)

My walks have become such a part of my personality now that my mom even ordered me a weighted vest, I presume just to introduce some novelty into the conversation.

How I learned to stop worrying and love being influenced

It was so easy to feel influenced in this case: A bunch of people told me the same thing, so I tried it.

The barrier to entry was low. I didn’t have to buy anything. I didn’t have to master a new skill. I didn’t even have to suddenly possess an athleticism that has evaded me my whole life.

What I did have to do was get over the mental hurdle of committing to lacing up my shoes and opening the door.

And that mental hurdle is not nothing. It’s a good reminder that even “easy” advice isn’t always easy — or right — for everyone. But it did feel empowering to be reminded that when it comes to wellness, it’s OK to get a nudge in the right direction from others, that it’s not wild that we’re all looking for someone to tell us exactly what we should be doing.

Fortunately for me, my job is calling people and asking them about what they advise. What I heard overwhelmingly was that the best way to age well was to stick to the basics: Move your body in a way that feels good to you. Eat a balanced diet. Get a good night’s sleep.

It can seem like there are infinite choices to be made about how to maximize our health. But I found it is possible to tune out the noise and stick to creating a manageable plan that works for each of us as individuals. You can be your own influencer.

As Liz Baker Plosser said when we talked about cold plunges a few weeks ago, what it all comes down to is listening to your own body. Full stop.

(That said, if one of you could help with some tips on how to influence me to actually drink more water, I would be very grateful.)

The siren song of stuff

But of course I also understand how easy it is to fall into the quicksand pit of worrying that you’re not doing enough.

While writing and researching this series, I found that the more I started poking around the Internet for answers, the more paranoid I felt.

Creatine, amino acids, fiber, protein, mouth tape, magnesium — should I be using them? In some magical just-right amount? Am I destined to slowly rot away if I don’t?

(And for those of you who wrote me about these things — message received, and I’ll be digging into them more for you in the future too!)

There were so, so many Instagram reels about lowering cortisol levels and healing my vagus nerve, random people with no medical background offering up lipedema diagnoses, and women with glistening skin and slicked-back ponytails boasting about the benefits of various types of massage, from lymphatic drainage to buccal.

We shouldn’t be ashamed about wanting to age well, to feel good in mind and body. But also it can feel like nothing is ever enough.

There’s a real dearth of high-quality information about midlife women’s health, so often what we’re being pushed isn’t about making us healthier but rather just about making us buy things. The message: You’re failing if you’re not fully engaged in the consumerist project of health.

But you don’t really have to buy one more thing to feel better.

(My personal favorite hack for not buying The Thing: Add to cart and then leave it there. Sometimes just moving it to the cart scratches the itch — and reminds you that you actually don’t really need this.)

No one is coming to save you (from judgmental people)

People going through midlife and beyond deserve to make the choices that feel right for them, and they deserve to have high-quality information to make those choices.

Reporting this series also reminded me that the world is often uncomfortable with the very notion of women having bodies and aging in them.

A journalist friend summed up this series as “people being weird about how women move their bodies.” It felt right.

There’s a surplus of advice — many of which originates from the longevity / biohacking / bodybuilding bro corner of the Internet, some of whom have recently been revealed to have some problematic ideas about women and their bodies and agency — and also a surplus of judgment. (Perhaps you have heard about the men who like to tell women to do Pilates. Important context: I do Pilates! And not because a man tells me to.)

I’ve also had to reckon with how much of the judgment is self-inflicted. If you’re reading this, you’re probably also still grappling with the messages we received from the 1980s to early aughts about our bodies and our identities and worth. And yes, you’d better believe I’ll be writing more about what continuing to unpack this looks like as we age too. (I was struck by this recent New York Times story on the rise of older women in high fashion modeling — and how all the women featured in it had the same body type.)

Which again, is when I have to remind myself about the agency I do have: I can move my body in a way that feels right for me. I can trust myself. I can get older. And hey, I can even like myself too.

And that actually is a pretty good start.

(So far, we’ve covered vibration plates and cold plunges in case you have FOMO.)

If you walk down any given aisle at Sephora, you see the word. If you listen to any podcast having to do with wellness or longevity, you’ve heard about them, too. And you may have caught wind that Secretary of Health and Human Services Robert F. Kennedy Jr. is moving to lift restrictions on certain injectable forms of them.

But still — still! — you may be wondering what the hell *are* peptides

I was, too. That’s why I called Jackie Giannelli, a board-certified nurse practitioner and clinical strategist at the Carolyn Rowan Center for Women’s Health and Wellness at Mount Sinai Hospital in New York City.

Every day, she told me, she encounters people in perimenopause and beyond asking her about peptides of all stripes. And for many of these patients, she prescribes peptides, too — with some caveats.

A biology lesson

Peptides, Giannelli explained, are signaling molecules that amplify the work your body already does. More specifically, they’re short chains of amino acids that create signals for different parts of the body, helping specific molecules do what they do — but more intensely.

Peptides don’t all do the same things — or even exist in the same formats.

Insulin? A peptide! (Tells cells to absorb more glucose from the bloodstream and helps convert glucose into energy that can be used by muscles.)

A GLP-1 like Ozempic and Wegovy? Also a peptide! (Tells the body to make even more of the GLP-1 hormones it makes naturally to stimulate insulin secretion and signal fullness to the brain.)

And GHK-cu copper peptides? Well, you might have heard about how they can boost collagen production, in turn reducing the appearance of fine lines and wrinkles and make you look like a forever-35 glowing angel.

Giannelli explained that while there are in fact a lot of things peptides can do, they’re not a panacea.

Buyer beware

You can get peptides from all sorts of sources — but that doesn’t mean you should. Some are topical, some come in pill form, and some are injectable.

Giannelli said that if you think a peptide could be right for you, the first thing to do is ensure you’re working with a reputable, educated, vetted medical provider who can review your medical history, determine what makes sense for you — and then write a prescription for you that will be filled by a regulated pharmacy.

“It’s super important that nobody gets these peptides from a website that says ‘add to cart,’ where you can get these delivered to your door without a prescription,” she said.

It’s possible to get peptides without a prescription — but these, referred to as research-use-only peptides, have not gone through a rigorous safety testing process.

Any that come from a non-licensed compounding pharmacy should be avoided.

“Even my own patient base, I have to really deter some people from using specific websites they brought to me. It’s not easy to tell — the marketing is very good, right? And so it’s not easy to tell if that cute little influencer who’s selling her peptides online is getting it from a reputable source,” Giannelli said.

So to simplify: Interested in using peptides? Make sure you’re working with a licensed clinician who has expertise in peptides, are getting a prescription for them and are getting your peptides from a licensed pharmacy.

The skin we’re in (and putting things on)

GHK-cu — one of the peptides that comes up most frequently for women in midlife — is also one of the more researched and understood peptides among the newer wave of “anti-aging” peptides.

“We actually have some reasonable clinical data around the safety and efficacy of using topical GHK-cu for things like collagen building, wound healing, etc,” Giannelli said. That’s why you may have heard about just how amazing it can make your skin look.

Some products with copper peptides are available at stores, while some topical products can be procured only via prescription from a licensed provider. Those are a lot more potent, Giannelli said.

She uses retinol as a point of comparison.

“You can get kind of watered-down retinoids at Sephora, but they’re not going to be as strong and cause the same cell turnover that you’re going to get with prescription retinol, right?” Giannelli said.

Looking for more dramatic results? You’re going to want a prescription-grade product.

But while GHK-cu could help your skin, Giannelli cautions that it can’t replace the basics. Those basics are as simple as you think they are — proper sleep, diet and exercise.

“Just putting skincare on and then not taking care of your body in all the other ways? Your results aren’t going to be there.”

Topical to injectable pipeline

But here’s where things get complicated.

Many patients have heard about the efficacy of topical peptides for skincare. And now they’re hearing more about injectable peptides generally. So they start assuming that if something is good topically, it’s even better when injected. But we don’t always have the testing that could back that up (or disprove it).

“We don’t have any good, long-term, randomized control, gold standard data to prove that this is safe,” Giannelli said of injectable GHK-cu.

While GHK-cu has become well-known for its topical effect on skin quality, when injected, it does a lot more than that, actually changing gene expression. Some of the early data on this looks promising, but again, none of this has been replicated in reputable human trials. So today, with the available data, it’s something she wouldn’t recommend.

“Everyone’s got a stack”

Giannelli also said the current social media landscape can make it seem like “everyone’s got a stack” of multiple injectable peptides they take as part of “fancy bio-hacking, precision, longevity protocols.”

Giannelli called this approach “silly.”

Which isn’t to say there isn’t a place for some peptides for some people. Giannelli said some specific peptides pair very well with hormone therapy for those in perimenopause, boosting the efficacy of hormone therapy’s ability to ease symptoms — but that she personally always counsels patients to nail down the hormones before introducing peptides.

She points to the efficacy of GLP-1s like Ozempic as an example, a peptide with FDA approval that has been found in early research to be even more effective when used in conjunction with estradiol-based hormone replacement therapy.

But that doesn’t mean we should all be injecting lots of peptides forever, without talking to medical providers who are able to monitor our labs and stay up on all the latest high-quality data.

“There are very unique and specific ways of using them that can be beneficial — but almost never long term,” Giannelli said, “Most peptides are meant to be cycled on and off and you’re using them for a specific reason and then you’re giving your body a little bit of a break to heal or recover or regenerate.”

They can also increase blood flow or change the way cells grow and divide, which could be a risk factor for those with a history of high risk for cancer.

“In a healthy person, that can have incredibly beneficial outcomes, but in somebody who has pre-cancerous cells growing that may sort of promote the growth of cancer instead.”

What’s next

Giannelli said she doesn’t believe that peptides are all bad — it’s why she herself prescribes some peptides for some use cases to some patients.

“I feel really passionately about having these fair and honest conversations about everything in women’s health, and peptides are just sort of at the pinnacle of the conversation,” she said.

She also understands why she sees so many women in midlife suddenly asking for them as they look for answers about their health and hormones.

“They’re really coming to me and begging for some of this stuff, not only because it’s marketed to them so heavily at a vulnerable period of their life — midlife, perimenopause, where they’re not feeling like themselves anyway — and they feel a little gaslit or misled or depressed and they’re just willing to try anything to not feel bad. And I get that. I understand why someone would ask for these things.”

The conversation around peptides right now actually reminds her a lot about the conversation around hormone therapy a decade ago, with some calling it a magic cure-all and others pointing out things to be scared of.

“It may not go viral on social media when we have more nuanced conversations, but personally I think that’s what we need. We dumb things down for women because we think that they can’t understand or we want to market it to them and use simplistic language. And I feel like we can do better than that.”

Given the relationship between hot flashes and menopause, I had to look into whether literally sitting in a tub of very cold water could cure all that ails you. After all, who among us has not been drenched in sweat at 3 a.m. and thought, “Hmm, maybe a bath tub filled with icy water would cure all that ails me?”

Except that’s not exactly what cold plunging is, nor what it is intended for.

Though the practice has never been more pop-culture-forward — New York City blocks are dotted with boutique cold plunging studios — it’s hardly a new trend. It’s a practice long used by high-performance athletes to reduce inflammation after intense physical activity, something that in turn can reduce muscle soreness and help expedite recovery.

But not all of us are elite athletes. Not all of us can afford a boutique cold plunge membership. And, well, not all of us hear about sitting in a tub of cold water and think, “Wow that sounds like so much fun!”

So once again, I got on the phone and asked my favorite question: Do I need to do this?

Cue expert #1

First, I spoke with Dr. Deborah Kado, a geriatrics specialist and the co-director of the Stanford Longevity Center, whose work has long focused on helping people develop individualized protocols to help them age happily and well.

Kado said that one thing that makes her a little nervous about the buzz around cold plunging is how the practice is increasingly offered at unregulated “longevity clinics.” Such clinics are purported by influencers to have all kinds of almost magical anti-aging benefits — though the science and medical supervision are often lacking.

“Two comments that I can make with confidence in terms of increasing health span and lifespan is that there are no studies to demonstrate that doing regular cold plunges can do that,” Kado said.

There is good evidence for one benefit of cold plunging: stress reduction. And reducing stress is definitely good for quality of life. Cold plunging can also help trigger a kind of endorphin response that can give people more energy afterward. But Kado cautions that there isn’t good data looking at these benefits specifically for women, and especially not specifically for women going through menopause.

And that can be a problem, Kado said: “We have increasing evidence that men and women do differ biologically.”

Risks versus benefits

Kado also said it’s really important that people think about how they feel when they cold plunge, versus just following what someone on social media tells them to do. There are risks to it, too.

“For some, the benefits are that they feel it — they do the cold plunges, they feel great, they have more energy. They feel like, ‘OK, I’m dealing with my inflammation and my stress and it’s worth it.’ But for others, it may not be and they may not be realizing that there could actually be harm associated with investing in a cold plunge,” she said.

The main risk is related to the cold shock response: There’s the potential for cardiovascular stress and a spike in blood pressure. And this risk does increase as you age, so it’s a caution many women may want to heed as they enter midlife and beyond.

Cardiovascular events are a real concern for women as they get older — and cardiovascular disease is widely underdiagnosed in older women — and the shock of cold plunging can present risk for those with underlying conditions.

Kado said supervised cold water immersion by healthy, fit individuals may be safe when practiced carefully and reasonably if it is something you enjoy, but — like so many things when it comes to midlife health — checking with your doctor about whether your own health history makes you a good candidate for it is important too.

Not into cold plunging and want to reduce inflammation and stress? Kado recommends one of my personal favorite pastimes: taking a nap.

Cue expert #2

I also wanted to talk to someone who is all about that cold plunge life — and has brought a journalist’s eye to her practice. That’s why I called Liz Baker Plosser, the former editor in chief of Women’s Health, a veteran health journalist and the author of the Substack Best Case Scenario, in which she parses fact from myth when it comes to the latest trends in the women’s health space.

She started cold plunging in her 20s, when she was routinely doing triathlons, and has continued with it in different ways over the past 20 years.

As she dug more into the research on cold plunging in her own work, she found vocal advocates — but also doctors encouraging caution.

She also found a real lack of data on women.

“The research might bear out that it’s every bit as powerful and beneficial, it’s just that unfortunately we don’t know because women haven’t been studied in a lab the same way. It tends to be men. And even within that subset, it’s almost all been done on athletes specifically, which is a very different demographic.”

If it feels good, do it

Her investigation into the science of cold plunging brought Plosser right back to one of her guiding principles when it comes to all things health and fitness: She would like to see more women, especially in the health and fitness space, hold the duality that we both want to age well and that we should do what feels right for us.

“Some of the biggest voices in the podcast space who talk about health and health protocols are men and some of them are very problematic,” Plosser said. Many rarely have women experts on. Changing this landscape could have a real impact on the choices women get to make.

“The more voices, the more prominent voices, we have who are talking about this stuff — whether longform podcasts, newsletters, media articles, or shorter form social media — the better because I think it helps normalize it for women and hopefully gives them more places to seek really good information and have these conversations.”

In the absence of this, she recommends approaching cold plunging — and other health and fitness trends — with the kind of advice my own Pilates teacher gives: Don’t like this? You’re an adult, you don’t have to.

Plosser adds: Hear you need to eat before you work out, but you’re not hungry and eating before you exercise makes you feel sick? Great — then don’t do it.

Told you should be lifting really heavy weight to help with bone density and muscle mass but you were up all night with hot flashes? Great — lift some lighter weights today.

This philosophy still feels slightly radical, Plosser said. And the current conversation around cold plunging is a perfect distillation of all of the complexities around how we talk about healthspan and gender.

“Something that women really have to learn to do is to trust their bodies and their instincts and to always prioritize that over whatever the cool new trend on social media or the latest study is saying.”

And yes, she’s still cold plunging — but only when she feels like it.

Is there a health trend you’re seeing everywhere and want to know more about? Leave a comment!

If I open Instagram, I’m virtually guaranteed to see some woman standing on a vibration plate, insisting that she’s shaking her metabolism back into the compliant, fast-paced state of her youth.

She’s burning fat! She’s getting rid of pesky cellulite! She’s definitely making claims about bone density and lean muscle mass! And I don’t really know what’s happening but she’s saying something about lymphatic drainage.

With so many claims about a machine that typically retails for less than $150 and requires only 10 to 15 minutes of daily use, it almost seems too good to be true.

I needed to find out why so many women are trying to quite literally shake off their age. I also wanted an answer to my forever question: Wait, am I supposed to be doing this too?

Cue expert #1

First I called Dr. Michael Fredericson, the founder of Stanford Lifestyle Medicine, which is all about digging into the science of healthy aging. He’s a professor of orthopedic surgery and medicine and is a co-director of the Stanford Center on Longevity and is also the head team physician for Stanford’s track and field and swimming teams. In other words, he’s no stranger to training and results.

And what he told me is that you could use a vibration plate if you wanted to — but to think of it as “the sprinkles on the icing on the cake” of choices to support bone health, lean muscle mass and balance — three of the factors essential for healthy aging.

“If the goal is to build bone density, you’re going to get much more benefit from just doing traditional resistance training,” Fredericson said. “You can get some additional benefit from vibration plates, but it’s pretty modest. It’s not going to take you from osteoporosis to non-osteoporosis.”

The same goes for balance work.

“If you’re doing balance work on the vibration plate, it’s sort of another challenge to your balance.” So can it help? Sure. But is it the only way? Not at all.

Stand on one leg; do it with your eyes closed if that’s too easy. You could also stand on a pillow, barefoot on plain grass or on a Bosu ball — all just as, if not more, effective ways to incorporate balance challenges into your exercise routine.

Vibration plates also are certainly not a replacement for lifting weights or doing body weight exercises that help keep bones strong and lean muscle from atrophying. He said they can boost blood flow to muscles and help with stretching but also “there’s so many better ways to do that.”

Static stretching — or, holding a muscle stretch for 10-60 seconds to improve long-term flexibility — is just as effective.

And a vibration plate doesn’t replace one of the most important things for your health, getting two total body strength workouts and at least 150 minutes of moderate aerobic activity a week.

Fredericson also pointed out that it can’t do something we know is definitely beneficial: take you outside. “Something about being in nature, outdoors, is just so much more powerful for you than just going to the gym.”

It also doesn’t address one of the other main components of healthy aging: social connection.

So, want to get aerobic activity, get outside and connect with others? Take a walk outside with a friend. No purchase necessary.

Cue expert #2

I also wanted to know how these vibration plates had even become a thing. I called up Danielle Friedman, the author of “Let’s Get Physical: How Women Discovered Exercise and Reshaped the World” and a journalist focused on the history, culture and science of women’s fitness.

Friedman told me that the vibration plates you’re seeing all over Instagram are far from a new trend.

“There is a long history of women turning to vibration, specifically with the goal of losing weight or losing fat,” she said, adding that throughout the 1970s and well into the 1980s, most gyms would have a vibrating belt in the women’s locker room. It’s a device that first started to gain popularity as early as the 1930s, when they were marketed to women as a way to “shape their figure.”

Throughout the 1940s through 1960s, she added, there were even national chains of “vibrating salons,” where you could secure a membership to go a certain number of times a week to allegedly “vibrate your fat away.”

We love (and hate) a quick fix

The other long-standing trend that the vibration plate of today speaks to, Friedman said, is gadgets that promise a quick fix. She’s fascinated by the moment these products are having right now.

“In the past, the focus was not so much on building muscle — it was just on fat, losing weight, shaping your figure. Now we’re in this moment, especially for midlife women, where we are bombarded with messages about protecting our muscle, our bones, navigating our hormones,” she said.

“We’re quick as a society to kind of turn our noses up at the ‘get fit quick’ solutions out there, but the reality is that so many women are struggling to find the time and energy to move and exercise and care for themselves in this way,” Friedman said.

It’s a situation that’s only exacerbated in midlife, when so many women’s lives are shaped by caregiving responsibilities, she said. All the sandwich generation-ing means that, on a practical level, women just don’t have time for exercise — and something being marketed as having some benefits in just 15 minutes a day is really appealing.

“We’re in this pendulum swing toward women just being bombarded with solutions or messages about how they need to care for themselves at this stage of life. We went from a place where perimenopause and menopause were completely overlooked and it was just like ‘deal with it,’ to now everywhere you look, if you’re in this demographic, people are offering solutions for your health,” she said. “It can feel so overwhelming.”

And a vibration plate? Well, it can feel convenient.

“You can hop on it while you’re watching TV or while your kids are playing or if you didn’t sleep the night before or if you don’t have the energy because you’re physically exhausted from child care or caring for others combined with whatever physiological changes you might be going through,” she said.

The quickness to judge women for engaging in a fitness-related activity rooted in efficiency feels convenient too, especially given how women disproportionately shoulder so many caretaking responsibilities and thus have less free time.

The mixed messages women receive — take care of everyone, look young, prioritize your health, don’t be selfish, don’t be stupid and taken in by a fitness fad — are as timeless as the vibration trend itself.

“It’s so frustrating because we’re told we have to look hot and there’s this anti-aging market for women in midlife that is just exploding, but there’s also sort of a little bit of a maybe cultural judgment about devoting time to it, especially when you could be caring for others,” said Friedman.

The real takeaway, she says, is simple — and judgment free: “Everybody benefits when women are able to devote time to moving their body in a way that feels good.”

In this job, sometimes it seems all roads lead to hormone therapy.

But even as it’s a huge topic of conversation in the perimenopause and menopause world, hormone therapy is still used by only about 5 percent of people who could be eligible. That is in part because of a link between hormones and breast cancer — though we now understand the data on this to be more complex than how it was understood 20 years ago.

I am about to dig into that, but first, a quick(ish) rundown of the complex way we got here:

• Hormone therapy is medication that replaces the estrogen your body no longer makes on its own as it ages. Systemic hormone therapy — like estradiol patches, pills, gels and sprays — help treat vasomotor symptoms like hot flashes and night sweats and can also help with mood, sleep and brain fog. Research now indicates it can also help with bone and heart health long-term too.
  

• In 2002, the Women’s Health Initiative (WHI) study reported a heightened risk of breast cancer among hormone therapy users. In response, the Food and Drug Administration (FDA) issued a black box warning on the estrogen products used for hormone therapy, the strongest safety warning.
  

• Some providers disagreed that the risks of hormone therapy were that high for most people in perimenopause and early menopause who were suffering from disruptive symptoms. (They often point to the fact that the average age of WHI participants was 63, past the average age of menopause and thus already at a higher risk of developing breast cancer.)
  

• More recent research has shown that the risk of developing breast cancer doesn’t seem to be higher across the board, though it is for those who start hormone therapy after the age of 60 or are on hormone therapy for more than 10 years.
  

• In November, the FDA reversed the black box warning. This doesn’t mean the medication has no risk, just that it didn’t warrant the highest level of caution in prescribing.
  

• Many providers are still very cautious about prescribing hormone therapy to someone with a history of breast cancer because of the way that some hormones can feed some forms of cancers in some patients — and also because of continued stigma from the WHI study.

So what should people with a history of breast cancer and perimenopause symptoms know about hormone therapy and risk?

If you run anxious like me and just want to know the topline takeaway — and don’t worry, I’ll still spin out the longer answer below — I’ve got you: Hormone therapy can increase the risk of breast cancer, and it can increase the risk of recurrence in certain breast cancers. For some people, this risk is higher. For some people, this risk is lower. Hormone therapy is not for everyone. But it could still be a good option for many — including some breast cancer survivors, who should feel empowered to talk to their doctors about their risks and options.

Cue the expert

I wanted to talk to Dr. Sarah Glynne, a London-based menopause specialist and general practitioner and the lead author on a new review of the evidence on hormone therapy and breast cancer survivors.

Glynne and the other authors concluded that some survivors may choose to take menopausal hormone therapy (also known as hormone replacement therapy, or HRT) and accept some increased risk of relapse in exchange for relief from menopause symptoms — and that real conversations between doctors and patients around these trade-offs need to happen more frequently.

“The gist of the paper is not that we are trying to encourage use of HRT after breast cancer, because there will be a degree of risk,” Glynne said. “But for some, that risk will be very small. For some, that risk will be more substantial. What we’re trying to get over is that every woman deserves to have a conversation about what the risks for her are likely to be based on her history and then, depending on how she views the risk, be supported to decide for herself what she wants to do with that information.”

Glynne told me that there’s not a lot of recent, high-quality data on how breast cancer survivors do on menopausal hormone therapy long-term.

She also notes that the WHI study found that women using estrogen-only therapy had lower risks of breast cancer after 20 years of follow-up and that for women on combined hormone therapy (both estrogen and progesterone), the absolute increase in risk is small: one extra case of breast cancer per 1,000 women each year. And there are potentially other benefits to hormone therapy.

Glynne said she would love to see more conversation between doctors and patients about risk-benefit analysis, empowering patients to make choices they feel comfortable with.

Oncologists are trained “to prevent and slow down cancer at all costs,” Glynne said. “For some women, that will be the most important thing, in which case they shouldn’t take HRT after breast cancer. But there’s more to it than that: brain health, bone health, heart health, quality of life.”

Relative risk vs. absolute risk

Glynne mentioned a patient she saw recently who decided to not take hormone therapy after the two had a lengthy in-office conversation about its potential risks and benefits given her medical history.

“She said she felt so much better because it was her decision — she understood now what the risks and benefits were and it was her choice. It wasn’t being told, without anyone thinking, ‘Well no.’’”

Essential to this conversation, Glynne said, is more education about relative risk and absolute risk.

Relative risk compares two groups — so, for example, those who have had breast cancer vs. those who have not. Absolute risk is the probability something will happen in general. So if absolute risk is minuscule, for example, doubling it still gives you a small number.

As to why understanding these terms matters — and why she thinks more patients should feel empowered to ask their providers about them — Glynne said that often headlines just point to relative risk.

To use an example from the Breast Cancer Research Foundation, heavy drinkers have been found to have a 61 percent higher risk of breast cancer than non-drinkers. This doesn’t mean that 61 percent of women who have more than three drinks a day will get breast cancer, it just means their risk is higher.

The absolute risk of a 35-year old woman developing breast cancer in America before the age of 90 is 12.9 percent. So for those heavy drinkers? Their absolute risk is now 19 percent — higher than 12 percent, but a number that also sounds really different than 61 percent.

This framework could also benefit those with higher background risks, like patients with the BRCA gene or other family history. They deserve to understand how likely it is that they get cancer and how much more likely hormone therapy might make that, too.

It’s why Glynne is working with Jayant Vaidya, professor of breast surgery and oncology at University College London, setting up a clinical trial to study outcomes in women who choose to take menopausal hormone therapy after breast cancer. More data means more informed choices.

What’s next

Glynne said too many people have confessed to her that they have lied to their oncologists about using hormone therapy, for fear of their reaction. She’s also met patients who say they’ve had oncologists refuse to see them after they report using hormone therapy after breast cancer. Both of these outcomes concern her.

“Women aren’t taking HRT just for their skin and their hair. They’re taking it because they’ve got severe symptoms and they can’t function without them.”

That’s why Glynne hopes her work can at least be the start of a new conversation.

“As far as I’m concerned, every treatment option that is available to a woman who has not had breast cancer is also open to women who have had breast cancer. Every woman, I think, deserves to have a conversation about what it means for them in terms of their level of risk versus benefits,” she said. “And if you decide not to take HRT, there are actually still lots of options. … If your doctor is making you feel shut down, you need to find another doctor who will listen to you and talk you through those options.”