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.”

I’m in my 40s, she’s in her 50s and we know — and maybe even embrace — that there’s no way around it.

“I do claim it,” Bee told me of the term “middle-aged.”

“I think I hated it at first, but I don’t have time to think of a new naming convention. I don’t have a better phrase that doesn’t sound like some fun euphemism, like ‘better-than-ever-age.’ There’s no version of that that doesn’t make me want to say, ‘Oh God.’ I’m middle-aged and everybody knows it.”

Bee of course is not only middle-aged. She’s also nothing short of a comedy legend.

She became a household name while appearing as a correspondent on “The Daily Show” from 2003 to 2015 — the only woman correspondent for the first five years of her time there. In 2016, she debuted her own late-night satirical news show for TBS, “Full Frontal with Samantha Bee,” becoming the first woman to host such a show.

In 2024, she premiered her one-woman stage show “How to Survive Menopause”; the performance has been evolving, and touring, ever since. (Her website states that “she hopes the run will last as long as perimenopause — two to 14 years.”)

I spoke with Bee one afternoon last month about what it means to talk about menopause — how she came to it, how she has seen it evolve and what she still thinks is missing from the conversation.

No, it’s not just stress

Bee’s experiences with perimenopause became a huge part of her last major project, but not in a planned way; Bee started experiencing perimenopause symptoms just as “Full Frontal” launched. At first she attributed everything to stress.

“I stopped sleeping,” Bee said. “Actually, really stopped sleeping. It took me a really long time to go to the doctor and say, ‘It’s nuts — I never sleep. I wake up at the same time every night. I actually think I’m going crazy. I think I’m starting to see E.T. run behind the sofa. I’m starting to hallucinate shadow people in my apartment.’”

That’s when her doctor told her that she hadn’t lost her mind — she was just in perimenopause.

“Yeah, it was stress — but it was also my age so these things were happening in my body that were not within my ability to control or manipulate by just going to get a massage,” Bee said. “That was incredibly eye-opening for me, to be like, ‘Wait I have a medical condition.’”

Having language for it didn’t make it easier to talk about though, especially when it came to the big emotional swings she was feeling.

“I spent a really long time hiding it from everyone, what a topsy-turvy emotional state I was in. Like people would be in my office and everything was fine. I wasn’t out of control at work at all. But then everybody would leave my office and I would lock the door and just sob,” she said.

When she realized the reluctance to talk about it extended even to her husband, actor and comedian Jason Jones, she knew it was time to try to change that.

Nothing left unsaid

Her first effort at saying this all in a public way was an episode of “Full Frontal” devoted to the topic of menopause.

“It was really hard for me to do. It was really hard for me to sit in a room talking about this,” Bee said. “Everyone who worked with me at the show was younger than me. I was the oldest person on staff. It was really embarrassing to talk about. It was really embarrassing to joke about. I went with it, it seemed fine, but inside — I’m really shy about this. I’m vulnerable.”

It was an experience that left her with some sense of unfinished work, too.

“In a creative world where I really left no stone unturned, when the show ended, I thought — what should I be talking about? What’s left that’s been unsaid by me? Well, not too many things, really — except for this.”

A one-woman show about menopause was born.

Bee said that over the past decade, she has seen the conversation about menopause evolve to become one that validates people’s experiences and lets them know this wasn’t all in their heads, but something biological, real and normal.

But today, she said she feels a changing tide again.

“Now I feel like the pendulum has completely swung back and we’re in a state of almost denial. We’re actually reigniting shame on such a deeper level. Now it’s all about products and techniques and everyone is a kind of purveyor of products,” Bee said. “It’s all a grift, right? Just this gold rush of ‘menopause products.’ Why are we standing on vibration plates?”

Back to high school

Right now, Bee said she can’t shake the feeling that the conversation about menopause and women’s experiences with middle-age has become “regressive.” It also feels familiar.

“It feels like we’re pushing a deeper shame that reminds me of when we were all teenagers with this intense body shame.” Bee said. “I get that people want to stay youthful. You do want your skin to look dewy! It’s very, very hard. I want my skin to look dewy and my hair to stay put the way it is too. I don’t want dark roots.”

In her one-woman show, Bee said she tries to tackle this all with honesty and humility. She’s just as subject to the confusion that can emerge from social media. And yes, she said, “I also want to be fit and healthy and I do lots of stuff to keep me fit and healthy and fit into my pants. I absolutely do.”

But what she also tries to do with the show is move women away from the shame of it all.

“I strongly, always advocate in my life and in the content I create for untethering yourself from shame. That is just a core message that I try to drive home. I’m not going back to how I felt in those teenage years.”

You don’t have to like skiing

Bee also likes to point to the perks of aging.

“I do feel stronger. I do feel I have immense life satisfaction. I feel smarter, I feel wiser,” Bee said of her own midlife experience. “I don’t feel like I’m that wise, but I feel wiser than I used to be, for sure.”

That wisdom takes different forms. Sometimes, she said, it’s having the self-awareness to say no to people who keep insisting she would like skiing if only she tried. Sometimes it’s telling a friend she loves them, but wouldn’t love to go to their party. Sometimes, it’s finding new ways to challenge herself and learn new things, like yoga and dance.

“Not to be cliche about it, but there actually is like a new life on the other side. I really don’t love the approach of, ‘I’ve never been better!’ I mean, I’m in my 50s. I don’t know if that’s true,” she said.

“I was better — I was fitter, I was more flexible, I didn’t have aches and pains, I could stay up all night and I was fine the next day. But I was also probably an asshole? I was probably not that cool as a person. So, I don’t wish to be young again. I do wish for society to leave us alone a little bit and respect our time and wisdom.”

Seemingly overnight, they became abnormally heavy — she was wearing a level five pad and a super plus tampon and still had to change both on the hour. Her three-day, symptomless cycles were gone, replaced by an unpredictable schedule.

While navigating all of this, LaTisha got a major promotion at work — one she had worked hard for, knew she deserved, and was thrilled to take on.

Then the rage started.

LaTisha, a single mom and director of business and finance in Texas who asked to use only her first name because of the personal nature of her story, would wake up in the morning consumed by an unfamiliar sense of anger that would last for hours.

“It would take me until mid-morning to just emotionally calm down,” she recalled. “Mind you, this is all internal because I cannot present that way at work. And I’m still going to work every day, doing all the things.”

Her doctor didn’t even mention the word “perimenopause.” But after she gained 20 pounds in six weeks, a search for answers led her to a new telehealth provider who used the word and helped her find supplements that would ease her symptoms.

Within a month and a half she had lost 15 pounds and her moods evened out.

And she’s been promoted two more times in the three years since beginning to receive perimenopause care.

Let’s talk about menopause at work

Stories like LaTisha’s are exactly why we hosted a conversation in Austin last week about menopause and the workplace.

I spoke with Fatima Goss Graves, president and CEO of the National Women’s Law Center, and Megan R. Holmes, co-director of the Center on Trauma and Adversity at Case Western Reserve University, about how we can think more holistically about workplace culture, public policy and economic advancement for women in midlife and beyond.

“We’re caring for others. We’re often not caring for ourselves,” Holmes said. “We’re in the sandwich generation. … If you’re having to make a choice between caring for your kids, caring for your parents, making sure that you sustain at your job — you’re likely not going to choose yourself, which is detrimental because we have to be investing in ourselves.”

Holmes also pointed out that keeping this demographic in the workforce is good business sense. Companies should avoid losing institutional knowledge or mentors for younger women.

Goss Graves also asked that we contextualize this moment and what it means for women in midlife in the context of the larger cultural pushback against diversity, equity and inclusion. The unemployment rate for Black women, for example, is just over 7 percent: Layering on the stresses of midlife can compound the pressures pushing them out of the workforce.

“A lot of women around the country right now are feeling very, really very vulnerable in terms of their attachment to work, full stop. And when that happens, that’s not just about them: it’s about their entire families. It’s about communities,” Goss Graves said.

Because caring for this part of the workforce just makes sense, Goss Graves and Holmes said.

What could help? Employers could be more flexible with time off or breaks during the workday; they could be required to provide accommodations like a chair or a fan for those who need it. And more public conversation helps boosts awareness and makes these things more possible.

Goss Graves also pointed to protections against age and gender discrimination that already exist — and to laws being passed in places like Rhode Island that expand these by explicitly enabling workplace protections for those in menopause. Now’s a great time, she said, for other states to start drafting and passing their own equivalent bills.

(And to the person at our event last week who shouted out, “Make every room 62 degrees!” when I asked our panel what employers could do tomorrow to start enacting meaningful change? I salute you.)

Cue the expert

Lauren Smith Brody is the CEO of The Fifth Trimester, a workforce strategy firm, and the co-founder of the nonpartisan nonprofit Chamber of Mothers. The Fifth Trimester partnered with Midi Health, a telehealth menopause care company, to research the impact of menopause support on women’s work performance. (Midi has been a sponsor of this newsletter.) And what Brody found is that, first of all, women in perimenopause and menopause are “doing their whole jobs and doing them well.”

But when they do struggle, the real cost ends up being not to their employer but to their own well-being. And this in turn impacts their career longevity and own sense of ambition as they push through while feeling unwell and unsupported.

“They risked burnout. And they risked quitting. And since many of their symptoms — 93 percent had disrupted sleep, 92 percent had brain fog, 79 percent had anxiety or depression, all from hormone changes — were invisible to their colleagues, no one would even know until it was too late.”

As a result, many of these women ultimately drop out of the workforce to conserve their energy so they can direct it toward caregiving responsibilities they are also shouldering.

But what Brody found is that the right care really helps propel women at make-or-break moments in their careers: The survey indicated that people experiencing symptoms of perimenopause and menopause are four times more likely to report exceeding requirements at work after they begin treating their symptoms.

“To be clear, I’m not suggesting that everyone girl boss their way through menopause and try harder than they want to,” Brody said. But, it was notable that after getting care, people “had capacity to decide where to put their energy rather than burning it all up to work just trying to stay afloat.”

It’s why Brody sees a tremendous opportunity for employers to start thinking about menopause support as part of not only their benefits packages, but also holistic frameworks for making sure employees have the support they need to stay in the workforce and continue growing in their careers.

“Businesses have made real strides in taking care of new moms in recent years, but with menopause care they could provide a continuum of support that carries women through all stages of their careers.”

What could be

The past few years have really made LaTisha think about what it would mean to have a culture that understood the impact perimenopause can have on work.

She doesn’t blame her employer for a lack of support — she never even disclosed what she was going through.

But she wonders what it would look like if there were active outreach about mental health benefits, or even literature available through HR about perimenopause, when it can begin and what symptoms can entail.

“I’m an African-American woman and I think culturally, we don’t do the best job all the time of seeking help. We like to tough it out. So with that, I think that it’s a serious enough situation where if you don’t seek proper support, then it could ruin you,” she said.

LaTisha, now 46, keeps a mini fridge stocked with cold bottles of water in her office and has a fan in there as well. Both help with the hot flashes she’s started experiencing. Her office has become a place where other women come to cool off — literally and emotionally — while dealing with their own perimenopause symptoms, and she’s happy to provide a safe space for them. After all, she knows firsthand it’s what they deserve at this point in their lives.

“I would want every woman in the world to know that you can still have all the things that your heart desires.”

You can RSVP for the party here. Please feel free to share with anyone else in your network who will be in town and might want to join us — I hope to see you there!

Actor Rose Byrne is 46. In “If I Had Legs I Would Kick You,” she plays Linda, a therapist who is struggling to balance a demanding and emotionally draining job with caring for a largely unseen daughter with a pediatric feeding disorder, all the while her husband is away working as a ship captain. Her performance has been widely heralded as raw, expansive and nuanced, an extreme close-up of a woman who is trying so hard to care for others.

Kate Hudson is 46, too. She plays Claire “Thunder” Sardina in “Song Sung Blue,” a biopic about a husband-and-wife Neil Diamond tribute band. It tells the story of a tragic accident and the years of addiction, mental health crisis and physical pain that follow — and how Claire’s journey of self-discovery and recovery makes the seemingly impossible take shape.

They’re both Academy Award nominees for Best Actress in a Leading Role — a category whose winners have historically skewed younger. (Last year’s winner, Mikey Madison, was all of 25 at the time of her win.)

That said, in the past decade we’ve seen notable wins by women who are firmly in midlife: Frances McDormand, in her 60s at the time, won in 2018 and in 2021, and Michelle Yeoh was a 60-year old winner in 2023 for “Everything Everywhere All at Once.”

And they won for playing wonderfully complicated characters: McDormand’s vengeful, violent and deeply tormented Mildred Hayes in “Three Billboards Outside Ebbing, Missouri”; her turn as the van-life-discovering Fern in “Nomadland”; Yeoh’s kung-fu-fighting, multiverse-hopping Evelyn Quan Kang as an immigrant mom just trying to keep her family loved and safe.

These women were flawed, interesting, occasionally filled with rage and often deeply vulnerable. They were exactly the kind of characters that make me want to go to the movies. (Obligatory Nicole Kidman, “Somehow heartbreak feels good in a place like this” moment here.)

It also speaks to what’s resonating with people about Byrne and Hudson’s performances this year: They’re roles that show women can be just as messed up, despondent, striving and triumphant as any man.

Cue the expert

I wanted to know how to contextualize women’s representation on screen, so I called Madeline Di Nonno, the president and CEO of the Geena Davis Institute (GDI), which has been researching gender representation on screen for decades.

In December, the group released a report, “Missing in Action: Writing a new narrative for women in midlife on the big screen,” evaluating over-40 characters in films released from 2009 to 2024.

And what a surprise: They found real and persistent age gaps in storytelling when it comes to men versus women in midlife.

Di Nonno said women characters over 40 are twice as likely as equivalent men characters to have a storyline focused on physical aging — 15 percent vs 7 percent.

GDI also found that women are portrayed in a frantic chase of beating back these tell-tale signs of aging. Three-quarters of characters who engage with cosmetic treatments of any kind are women. And men? Well, they’re only ever shown dying the occasional gray hair or trimming a stray nose hair.

And the stereotypes go beyond the superficial, Di Nonno said. She pointed to “the sad widow trope,” when a character’s entire storyline is defined by the loss of their spouse. Nineteen of the films released over the past 16 years featured a “sad widow,” while only eight had a “sad widower.”

Of the 225 films reviewed in the GDI study about menopause representation, only 14 mentioned menopause. And when it was mentioned, it almost exclusively was there to serve as some kind of comedic device about women’s inevitable decline, Di Nonno said. “So, we have a lot of work to do in terms of this narrative culture change work.”

“When you think about midlife and aging, particularly with menopause, it’s positioned as the end instead of the beginning,” DiNonno said. “But we’re living so much longer. … By the time we hit midlife and menopause, we’ve got another 40-, 50-something years left to live. It’s the beginning of this age of wisdom and knowledge and should be celebrated.”

We’re talking about sex again

On screen, what’s often missing is the sense of hope, possibility, and, yes, sexuality that feels real to what most people’s midlife experiences entail.

Can midlife women be sexual on screen? The question reminds me of an infamous sketch from “Inside Amy Schumer.”

In the 2016 sketch, Schumer (then in her early 30s) is hiking through a lush California landscape when she comes upon a sumptuous picnic being enjoyed by Tina Fey, Patricia Arquette and Julia Louis-Dreyfuss, all playing themselves (and all in their mid-40s through late 50s at the time). Louis-Dreyfuss welcomes Schumer, also playing herself, telling her they’re celebrating the official moment when Hollywood stops considering her as sexual or desirable.

Who tells you when your “last fuckable day” — the sketch’s title — comes, Schumer asks.

“Well, nobody, nobody really overtly tells you, but there are signs,” Fey says. “Like, you know how Sally Field was Tom Hanks’s love interest in ‘Punchline,’ and then, like, 20 minutes later, she was his mom in ‘Forrest Gump’?”

Also, Louis-Dreyfuss says, there are a lot of long sweaters that cover your entire body waiting for you in wardrobe.

I love a big sweater, don’t get me wrong. And I love watching talented women play complex characters enduring hardship. But I also think we deserve to see women over 40 as sexual and powerful — not just facing insurmountable odds.

Violet Bridgerton and all of us

So much of the richness and complexities that come with aging are basically nonexistent on screen.

Men and women ages 50 to 85 agree that there are not enough characters on TV who are older, another GDI survey shows. And when they are portrayed, it is in ways that don’t feel representative. They wanted to see more love, marriage and romance for older characters.

That romance is part of what has made this season of Shonda Rhimes’ “Bridgerton” so appealing, as matriarch Violet Bridgerton finally is seen with a love — and sex — interest of her own.

She grapples with insecurity about having sex with a new partner and her feelings about her own body, while also feeling plenty entitled to an evening “tea.” It feels far from a coincidence that her storyline is the one resonating with everyone I know: Yes, we all love how opulent and beautiful the world of Bridgerton is, how lovely it is to get lost in the fantasy of it all. But with Violet? Well, it feels like we’re getting that fantasy and something very real.

What women want

Seeing more women in midlife play more dynamic, well-rounded roles makes good economic sense for studios too, Di Nonno said. The GDI survey of older viewers found that they stop watching when characters who are midlife and beyond are portrayed as frail, frumpy and sad. They want to see characters who look like them — and they want to see those characters thriving.

It’s why Di Nonno says she hopes that industry execs are paying attention to what audiences really want when it comes to women in midlife: “One, they’re fully in control of their destiny and not a victim. Two, they can experience romance and love and sex without guilt. And three, they have full awareness of their financial power and literacy.”

We’ll all have what Violet Bridgerton is having: looking our age and being celebrated for it — riveting sex scenes and all.

And in a new memoir, 62-year-old small screen icon and forever Real Housewife Lisa Rinna proclaims, “I will kill you if you take my hormones away!” (Who else here loved Rinna’s scene-stealing turn as Lynn Echolls on “Veronica Mars”?)

All of this is to say, what a time to be a woman of a certain age.

That’s why today we’re recapping the latest things that caught my eye in the world of midlife and beyond …

News flash

Here’s some very big news from a very big study about menopausal hormone therapy.

A Danish large cohort study featured in The BMJ found no connection between use of hormone therapy and an increase in mortality rate.

The study looked at 876,805 women born between 1950 and 1977; 11 percent of them filled a prescription for hormone therapy. Here are the highlights:

• Those who used any form of hormone therapy had a slightly lower mortality rate than those who didn’t over a roughly 14-year period.

• There were no unequivocal differences in deaths due to cardiovascular disease or cancer between those who used hormone therapy and those who did not.

• Mortality risk also did not vary based on the duration of time hormone therapy was utilized.

Going through a rough patch?

ICYMI, there’s a nationwide shortage of estradiol patches, one of the primary forms of estrogen used in menopausal hormone therapy.

For The 19th, I dug into what you need to know if you’re having trouble finding the medication, which is used to address symptoms like hot flashes, night sweats and mood changes. In brief: Estrogen can also be delivered transdermally (via the skin) with creams, gels and sprays, and for many people oral estrogen could be a good option, as well.

Not sure what’s best for you or what your next step is? Talk to your doctor. And you can read more about the shortage and how to talk to your doctor here.

I’ll be digging into…

These books:

“Hooked” by Asako Yuzuki, translated by Polly Barton (March 17)
Yuzuki’s previous novel “Butter,” about a gourmet chef-cum-serial killer who lures her male victims with her sumptuous cooking, was a much-buzzed about book in our newsroom last year. So there’s no chance I’m missing out on the office chatter sure to come when “Hooked” comes out this month, with a plot that is firmly up my alley: Lonely woman stages faux chance encounter with popular lifestyle influencer; friendship-to-obsession narrative soon emerges.

“The Keeper” by Tana French (March 31)

The only thing I love more than a new Tana French novel is a press cycle around a new Tana French novel. Listening to the immensely gifted Irish writer wax poetic on the power of genre writing, and subverting genre writing (nominally, the detective novel), gets me every time.

These shows:

“Vladimir,” Netflix (March 5)

I loved Julia May Jonas’ novel of the same name — and yes, the title is a nod to Nabokov — about a college professor who finds herself reevaluating everything when her husband (also a professor) faces #MeToo allegations. And then — oops — she soon finds herself in a very power-imbalanced relationship of her own. Rachel Weisz is taking on the lead role, and I cannot wait to see what she does with this acerbic, droll, deviant role about a postmenopausal woman with nothing short of a dangerous erotic imagination.

“The Bachelorette,” ABC (March 22)

Ugghhhh after letting this train wreck of a canonical reality show consume my life for too many decades, I finally wrote it off a few seasons ago. But now they’ve roped me back in with “Secret Lives of Mormon Wives” star Taylor Frankie Paul looking for love in literally the most wrong place ever.

These albums:

“Play Me,” Kim Gordon (March 13)

When Kim Gordon (72! Still making new things!) makes new music, I always stop and listen. The Sonic Youth alum is already luring me in with interviews saying that she “started singing in a way I hadn’t sung in a long time. This other voice came out.” I can’t wait to hear it.

“Creature of Habit,” Courtney Barnett (March 27)

The Australian singer-songwriter had me at the early single “Site Unseen,” where she partnered up with Waxahatchee for her signature sound marrying so much tenderness and bite.

This and that

A list of what caught my attention online this past month(ish).

• “Whoopi Goldberg Has Unfinished Business” (Interview, February 4)

• “The Rise and Fall of a Beauty Mogul” (The New York Times, February 11)

• “Should We All Be Putting Estrogen Cream on Our Faces?” (Gloria, February 20)

• “Higher Protein Recipes for the Reluctant” (The Smitten Kitchen Digest, February 23)

• “Bye-Bye, BBL: The Great Cosmetic Undoing Is Here” (Vanity Fair, February 23)

• “The boys’ club: How Epstein’s influence shaped the exclusion of women in STEM” (The 19th, February 23)

• “Christina Applegate Planned to Burn Her Journals. She Made a Memoir From Them Instead” (The New York Times, March 1)

• “Crying a Lot Is Good for You, Actually” (Self, March 2)

Next week we’re talking about the Oscars and what women’s midlife experiences look like onscreen (and also about a real icon, Violet Bridgerton). Have takes? Write me.

You can RSVP for the party here. Please feel free to share with anyone else in your network who will be in town and might want to join us — I hope to see you there!

Black people reach menopause earlier. They experience more severe symptoms. And they also experience more adverse health outcomes directly correlated with perimenopause and menopause: diabetes, hypertension, dementia, breast cancer.

Dr. Sharon Malone is the chief medical advisor for Alloy Health, the author of “Grown Woman Talk: Your Essential Companion for Healthy Living” and the host of the podcast “The Second Opinion with Dr. Sharon.”

And making menopause care more accessible to Black women is her life’s work. (Yes, you might have seen her talk about this with her friend, former First Lady Michelle Obama, too.)

Malone is a big fan of hormone therapy — something less than 1 percent of symptomatic perimenopausal and menopausal Black people are prescribed. (Overall, it’s prescribed to about 5 percent of symptomatic perimenopausal and menopausal people in the United States.)

While hormone therapy is not for everybody — obligatory “talk to your doctor” caution — Malone and many other experts believe it’s underprescribed.

And for Black women, Malone said, that’s a big problem.

“It’s unfortunate because Black women are the ones who actually suffer longer, they go into menopause earlier, and they’re more susceptible to the long-term health implications of lack of hormones,” Malone said. “And of course, here we are in another disparity situation, not because of biology, but because of access and information.”

Behind the disparity

First, she said, Black women tend not to have the same level of trust in the medical community because that trust has not been earned.

“Black women’s complaints are ignored generally,” she said. “Women’s complaints are ignored generally, but if you are a woman and Black, then you are getting the least of the least.”

Second are the persistent tropes and biases that continue to loom large in the American medical system, especially the idea of the “strong Black woman.” Some medical professionals believe that Black women are able to endure a higher level of pain and that they simply do not experience the same number of symptoms as their White peers.

“They do,” Malone clarifies. “They’re worse.”

Research has shown that Black women who grew up during the Jim Crow era faced greater discrimination and disparity when it came to the evaluation and treatment of their menopause symptoms. This means that as recently as the late 1990s and early 2000s, America’s history of racism was impacting the healthspan and lifespan of Black women. The cultural trickledown of this is very real.

“And so you have a situation where Black women who suffer earlier, longer and more severely are less likely to bring it up when they see a doctor. Even when they see a doctor and bring it up, that doctor is less likely to prescribe for you because of all these biases that we have,” Malone said.

“The cancer thing”

For a lot of people, many of the most disruptive symptoms of perimenopause and menopause can be treated with hormone therapy. But for Black women, a fear of breast cancer is often a driving factor in continued skepticism about that treatment, Malone said.

And with good reason — while breast cancer rates are similar between Black and White women, mortality rates among Black women are 38 percent higher. Among Black women under the age of 50, this disparity is even greater, with young Black women facing double the mortality rate of White peers.

So when the Women’s Health Initiative study in 2002 tied hormone therapy to increased risk of breast cancer, an increased level of caution was stoked in the Black community as well.

“We already know that we have disproportionately higher risks of dying from breast cancer and then someone tells you, ‘Here’s this medication and it’s going to increase your risk,’ that gets you to shy away from it,” Malone said.

But, Malone said, those fears have been blown out of proportion. More study is needed, but for many people, hormone therapy will help more than it increases the risk.

“The big message for hormone therapy that I also want women to understand is that hormones are the most effective treatment for the symptoms of menopause,” Malone said. “Menopause and perimenopause are way more than just hot flashes, and there are particular risk factors that Black women are more susceptible to. So when you’re talking about hypertension and diabetes and heart disease and even the risk of dying from breast cancer, these are all things that are also impacted positively by hormone therapy.”

History and present

Malone said she knows that in the absence of access to trusted doctors, many Black women are turning to alternative “cures” for their symptoms — many of which are ineffective at best, and pose new risks at worst.

But she also understands and has empathy for the history that is driving so many Black women down that road.

“For 99 percent of the time that Black people have been in this country, we haven’t had access to medical care,” she said. “It’s a recent thing — having insurance, being able to access care in a non-segregated environment. There’s always been this sort of two-tier system.”

Because of this, Malone said, Black Americans have a rich history of community-based care: healers, midwives and others well-versed in treatments that have been passed on from one generation to the next.

And this system has provided many important developments in women’s health care, often in life-saving ways. “Think about midwifery — this all came from Black women who ran that in the South. There is some communal, ancestral knowledge that is important,” Malone said.

But she wants the health care system to gain trust. And that takes intentional work from within the system.

Grown women talk

Malone hopes she can play a crucial role in what she sees as a key dynamic in addressing these disparities in the Black community by being a facilitator of intergenerational conversation.

It’s why her book is called “Grown Women Talk.”

“When I was a kid growing up, when my mother would be talking about things, they would make you leave the room. ‘This is for grown folks, you have to leave.’ So you never heard about all these things that happen. So we all walk into this phase of life completely blind.”

By constantly forcing a conversation, Malone hopes to address the disparities faced by Black women in the United States, especially when it comes to menopause care.

It’s also why she joined Alloy Heath, a telehealth company, and has overseen outreach to Black women there — “not because Black women are genetically or physiologically different from anybody else, just because you have to understand the cultural context of your patient to be able to treat them.”

She sees telehealth as a crucial measure in overcoming the real disparities faced by Black women.

“I tell family stories, I tell patient stories,” Malone said. All of this is to serve a mission of making sure that people understand that maternal mortality isn’t the only health disparity experienced by Black women — and that their experiences in menopause can fuel so many of the health outcomes that later become part of even more grim statistical reference points.

It’s where she hopes her work — at Alloy, on her podcast, through her social media — can help.

“They know there is someone there who looks like them, that has gone through this — and they feel safer inside,” Malone said. “We have to acknowledge the fact that bias is built into our medical education, in our system and how we practice medicine.”

Some nights I curled up on the couch with a peanut butter and jelly sandwich and a glass of red wine and watched on my own. But just as often, I tuned in with whatever peer group was most central to my life at the time: dorm hallmates, castmates from a college theater project, work friends. We would squeeze into a small apartment to see just what Tyra Banks, Ms. Jay, Jay Manuel and Nigel Barker had in store for the young women desperately trying to make it in the modeling industry.

But since those days, there’s been a broad cultural reconsideration of Banks and “ANTM” — and the version of beauty that was put forward. Which makes the new Netflix documentary “Reality Check: Inside America’s Next Top Model” — in which all the aforementioned judges participated — so interesting.

Banks has been asked to assume the vast majority of the blame for the discussion of bodies and beauty, now seen as harmful. She’s apologized for some parts, including a challenge in which contestants’ skin color was changed and darkened. But she’s also stood by much of what made the show so fascinating for so many of us.

“Did we get it right? Hell no. I said some dumb shit,” Banks said at the ESSENCE Black Women in Hollywood Awards last year. “But I refuse to have my legacy be about some stuff linked together on the Internet when there were 24 cycles of changing the world. And I am so excited that I, and so many of us, have opened that door for others to follow.”

Today, it feels like that appeal remains largely unheard. But why are we so mad at Tyra Banks when it doesn’t feel like we’ve progressed on women and their bodies, whether in their 20s or squarely middle aged?

I needed to unpack what it all means, so I did what I do best in these moments. I called some experts to weigh in on what we’re really talking about when we talk about “America’s Next Top Model.”

Cue expert #1

First I spoke to Victoria Pitts-Taylor, the chair of the department of feminist, gender and sexuality studies at Wesleyan University and the author of the books “Surgery Junkies: Wellness and Pathology in Cosmetic Culture” and “In the Flesh: The Cultural Politics of Body Modification.”

After all, the foundation of any season of “ANTM” was the makeover episode, with dramatic haircuts and lots of tears.

These transformations were meant to shock, sure, but they also put a point on something constantly underscored by the show: Wanna be on top? Then get ready to modify your face and your body in the process.

But the idea that your body had to look a certain way wasn’t confined to “ANTM.” And it still isn’t.

Pitts-Taylor said the proliferation of cosmetic procedures — especially non-surgical procedures like fillers and neurotoxins and the use of GLP-1 medications by those without clinical obesity — are all evidence of the ways that society certainly hasn’t moved past demanding a certain look. If anything, it’s more intense than when “ANTM” premiered over 20 years ago.

You look good for your age

And this expectation is aging right alongside us.

With the advancement and increased availability of cosmetic procedures, the way women are expected to age has also changed. (Perhaps your group chat was also left reeling by seeing the gaggle of elite 90s celebrities in the Dunkin’ commercial that aired during the Super Bowl.)

“70 is the new 50,” Pitts-Taylor said. “As women are aging, what’s happening is that the celebrities we grew up with don’t seem to be aging along with us, and we’re also immersed in a social media culture that still privileges youth and still privileges the highly curated image, so we’re pressured to filter ourselves — whether it be through sort of careful curating of our photos or literally using filters on our phones and our apps or getting fillers and Botox.”

But just as problematic is that questioning women for choices about their appearance is deeply gendered, designed to vilify women for existing in the world.

“We place a lot of blame on individual women — whether they’re making good choices, whether they’re good cosmetic surgery patients or they’re turning into surgery junkies. We obsess over individual choices,” she said.

Instead of asking what larger systems — cultural, economic, political — are forcing people to feel they need to look a certain way, the problem (shocker) often is assigned to women themselves.

Society is telling women what Banks told Tiffany Richardson: “When you go to bed at night, you lay there and you take responsibility for yourself.”

In other words, no matter how you slice it, women are to blame — and that certainly hasn’t changed since “America’s Next Top Model” premiered. But it also isn’t because of “America’s Next Top Model,” either.

Cue expert #2

Raquel Gates, an associate professor of film and media studies at Columbia University who studies Blackness and popular culture, was also a hardcore “ANTM” fan.

“It lives rent-free in my brain, forever,” she said.

Seeing her Gen Z students discover the show through clips on social media has really put a point on another aspect of our current cultural moment: nostalgia for appointment television. Viewing parties for shows such as “ANTM” and “Sex and the City” brought us into constant conversation with our peers in meaningful, IRL ways.

What do we want our TV to do for us?

And that’s just one layer behind what Gates says makes her “uncomfortable” about how “ANTM” is being revisited.

“It feels like the show is being turned into a scapegoat for body issues and representations of women that are problematic,” Gates said. “This is not new. Body image stuff is not new. There’s something for me that is troubling about displacing the sins of our society onto this show, and specifically onto Tyra Banks, and thinking that if we can exorcize that demon, that we will be OK as a society. But it really just feels dishonest to me.”

The focus on Banks — and her legacy — feels especially sticky, Gates said.

“If Tyra were not a world famous supermodel, if Tyra Banks had not been able to cross over into television and film, if she had not already been a household name, there would be no show, or the show would have no credibility,” Gates said.

And while Banks was the face and the creator, plenty of other people were involved in making decisions about the show, Gates said.

Gates said she recently asked her students what they wanted from “ANTM” — an authentic look at the modeling industry or something that totally disrupts the industry? The second, she said, may be an unfair ask of a TV show.

We are all rooting for you

Which brings us back to the anger being directed at Tyra Banks.

“Our society still does not want to ever actually confront issues of racism or sexism head-on,” Gates said. “It’s easy for us to talk about body issues with ‘America’s Next Top Model’ because the show isn’t on anymore. It’s harder to talk about your favorite influencer, your favorite podcaster.”

Gates said she would ask those aiming criticism at Banks to interrogate why.

“I would never say that because Tyra Banks is a Black woman in America that she is excused from a criticism of the role she has played in promoting healthy body images, but what I would say is that I really think we need to question why we have made her responsible for all of society’s issues around body images. Why are we placing this onto her? What does that do for us?”

And she hopes that in the midst of all of this, Banks also gets her flowers. Banks was a pioneering TV executive who created content with a broad appeal.

“I am legitimately rooting for her.”

That may be easier for them than it is for some of us, though. Practicing nonviolence, which includes this kind of negative self-talk, is core to what they do.

Sadhvi Siddhali Shree and Sadhvi Anubhuti are Jain monks, practitioners of the ancient Indian religion that is about the renunciation of worldly possessions to achieve a kind of spiritual liberation. (Sadhvi is a term of respect for a holy woman in Jainism and several other Eastern faiths.)

Siddhali and Anubhuti both live and teach at a Jain retreat center in Texas; they teach others how to use breathing practices, yoga, meditation and mindfulness to live a more peaceful life. They’re also documentary filmmakers.

But when they both began experiencing symptoms of perimenopause, they realized that a new level of self-care was necessary to achieve the kind of spiritual peace needed to help heal the world.

They also realized there was so much more to learn about perimenopause — enough, in fact, that the topic deserved the documentary treatment. “Balance,” the four-part docuseries directed and produced by the pair, is now streaming on Apple TV and Amazon Prime.

In it, Siddhali and Anubhauti not only chronicle their personal journeys but look at why this remains such an understudied and misunderstood field of medicine and research — and the real toll that takes.

“When we talk about self-compassion and practicing nonviolence, which is what we practice and teach, it’s about having that understanding, having that knowledge that we can reduce that suffering within ourselves, start being kinder to ourselves, to know it’s not us,” Siddhali said when we spoke over Zoom just days after the series’ release.

The two say that making the docuseries opened their eyes to the extent of gender disparities within the health care system and the disproportionate impact to women of color. It also brought spiritual lessons.

Said Siddhali: “We can’t be mad at us. This is physiological. Understanding that this is what our body is going through and our mind is following — that helps to reduce that suffering.”

Finding the word

“Balance” follows Siddhali and Anubhuti as they try to evaluate and manage their perimenopause symptoms. Siddhali looks into menopausal hormone therapy. Anubhuti is more reluctant about medication; she starts to investigate whether supplements and other natural remedies can meaningfully change how she’s feeling.

It’s an experience that made the two realize that perimenopause could use a documentarian’s eye.

“Because we didn’t know about it. So imagine how many other women don’t know about it, not even the word, because even the word brings clarity when you don’t even know what’s going on with your own body. So having that clarity, having that word, you know, changed everything,” Siddhali said.

From suffering to change

In the series, the two monks interview a who’s who of nationally recognized menopause experts to inform not only their own health care choices but to better understand why perimenopause continues to be so underrecognized and misunderstood.

It wasn’t long before the pair realized that perimenopause was thematically aligned with their past projects on human trafficking and animal cruelty.

“We also get moved when we see that a group of people or a group of individuals are suffering a lot. In this case, it’s not just a small group. We’re talking about 100 percent of all women, 50 percent of the population,” Anubhuti said. “When we started to look at the actual numbers — how many women commit suicide during this time period, how many divorce, how many families this impacts because of this situation and what women are going through — it’s pretty drastic. It’s just a huge number that we’re looking at.”

Like with their past projects, their goal is not just awareness, but awareness that provokes change.

“I want people to feel comfortable starting to talk about it so that now you know what’s going on with your body. Now that you have that language — because languages change culture — and so if you have people talking about it, being comfortable discussing it, passing it on, talking to your mom even if they’re older, or to your daughters or children,” Siddhali said.

Don’t be ashamed to say ‘vagina’

Part of that change is also focused on eradicating the stigma that surrounds perimenopause and menopause, a shame that can be yet another barrier to accessing the right health care.

“There are a lot of symptoms that you feel ashamed about when you go through perimenopause — like the brain fog, you don’t want to be seen as weak or seen as this person who can’t do her job or perform her job properly now because of her brain and how she’s reacting to this, or she’s not sleeping, or — vaginal atrophy! These are words that we don’t want to even say out loud because we’re so ashamed saying the word vagina, right?” Anubhuti said.

(In the series, Anubhuti accompanies her own mother to see Dr. Mary Claire Haver, a boldface menopause specialist, to understand whether her mother might be able to use hormone therapy to treat any of her own symptoms — including vaginal estrogen to prevent UTIs.)

Holistic health

Further underscoring the focus of the documentary is Siddhali and Anubhuti’s lived experience as Jain monks, people whose day-to-day lives are rooted in the spiritual, from a vegetarian diet to daily breathwork and meditation.

Still, the realities of perimenopause come for them. In the series, Siddhali has a very vulnerable moment sharing about a time she snapped at someone while planning for their new retreat center, making the other person cry. It was the moment she finally realized she was not feeling like herself — and needed answers so she could change.

“For us as monks, I think we were already doing a big part of the list of things that doctors recommend that you do. You know, we live very peacefully, we do a lot of breathing techniques, we do yoga. We do all the things, lifestyle-wise,” Anubhuti said.

Even just learning enough about hormone therapy to decide whether it was right for them helped them think about their health in a new way. “This is a holistic approach that as monks we need to talk about spirituality, mental well-being, physical well-being and now, hormones.”

The experience of making this docuseries has in turn informed their spiritual lives, too.

“I think a lot of women want to avoid and skip the whole thing. And we thought as monks, maybe we would skip it and not go through the pain and suffering,” Anubhuti said. “But that’s a big lesson, even if you are quote-unquote ‘doing all the things right,’ this physiological change that we’re going to go through, it’s something that no one can escape and that we need to be prepared for because it’s going to impact us from our head to toes and these changes can have big consequences in our lives.”

In other words, if you’re feeling the realities of perimenopause right now, you’re not alone. If even Jain monks feel hormonal rage sometimes — it’s OK if you do, too. (And also — also! — it’s OK to seek out help when you need it, too.)

(OK, fine, that’s three questions — don’t tell my editor?)

Over the past year especially, I feel like I’ve heard more and more women ask how they are supposed to understand what’s happening in their bodies: What to chalk off to postpartum, what’s perimenopause, and if they are supposed to be doing something about what they’re feeling — yet alone which hormonal change to blame it on.

I hear you — and I also wanted to know the answers because these times of intense reproductive change can also be a time of big emotions. To understand our brains and our bodies a little better, I started making some calls.

Cue expert #1

First I called Anna Barbieri, MD, clinical strategy leader for the Rowan Center for Women’s Health and Wellness at Mount Sinai in New York City.

Traditionally, she explained, the postpartum period has been defined by the obstetrics and gynecology field as the first six weeks after childbirth, or the average time it takes for the uterus to return to its pre-pregnancy size.

But that’s just one part of a bigger story.

“If you look at some of the hormonal changes and postpartum symptoms like postpartum depression or postpartum hair loss, of course those extend beyond that six-week time frame, so the extended postpartum definition can even be up to 12 months,” Barbieri said.

It can vary based on a lot of factors, like your age when giving birth and whether or not you breastfeed.

Perimenopause varies, too — many people will begin perimenopause in their early 40s, but some will begin earlier and some later. And as people are waiting till later in life to have babies, the chances for an overlap between the postpartum period and perimenopause grow.

The postpartum period as a warning

Barbieri said she thinks a lot about how difficult the postpartum period can be for so many — and how limited screening for postpartum depression can be. We know there’s a link between postpartum depression and perimenopause depression and anxiety, too.

“Experiencing mental health challenges postpartum may again be a clue to how one is going to experience the transition of perimenopause. So, just like gestational diabetes increases the risk for diabetes later in life, just like preeclampsia or gestational hypertension increases the risk for chronic hypertension, same with postpartum depression and postpartum mood abnormalities,” Barbieri said.

On top of that, both the postpartum period and perimenopause are periods of transition. They often come with stress, lack of sleep and a shift in identity. Of course anxiety, depression or other mood or mental health disorders could crop up.

And, Barbieri said, while some of this can be treated, there’s no magical cure for the one constant: change.

“I think many of us spend a lot of time feeling very uneasy with these changes because we’ve been conditioned to believe that only a young body is beautiful, that only a fertile body is beautiful, and we need to look young to be worthy. I think my biggest message to patients is I can help a lot with sleep, with symptoms, with weight, with libido, with mood — but we cannot change the fact that our bodies are changing. Better health care starts with compassion, acknowledgement, awareness and interest.”

Cue the expert #2

Next, I called Dr. Lauren M. Osborne. She leads the PsychoneuroImmunology in Pregnancy and Postpartum (PIPPI) Lab at Weill Cornell Medicine in New York City, where she studies anxiety disorders at times of reproductive transition.

Osborne said that while often, patients may be searching for language — is this postpartum? Is this perimenopause? — those labels don’t matter much.

“Any reproductive transition for some people can lead to an instability in mental health, for both biological and psychosocial reasons. Some people are very vulnerable to hormonal fluctuations, and there’s no bigger hormonal fluctuation than pregnancy leading into postpartum,” Osborne said. “There’s a cliff that people go over hormone-wise, but every woman who gives birth goes over that cliff — and not every woman develops postpartum depression.”

Perimenopause further complicates things for so many people (because of course it does) by making those hormonal fluctuations more extreme and unpredictable. For some, those fluctuations can cause major mood symptoms: depression, anxiety, anger. You know how you feel the week before your period? Think that times a million — at least for some people.

Osborne, like Barbieri, pointed to nonhormonal reasons people can struggle at this time of life, too.

The fact is, the postpartum period, midlife and sandwich generation caregiving — these are times of big changes in identity, with lots of pressure and stress. They are times when relationships are often stretched, money is often tighter, and everyone is sleeping less. These aren’t your hormones, this is life — but yes, it can take a very real toll on your mental health.

And if you are feeling the impact of all these changes, physiological and otherwise, it’s not just OK to ask for help, but help is really critical to ensuring you can keep caring for yourself.

What you can do

Here are some of Osborne’s suggestions for exactly how you can in fact care for yourself:

• Find a therapist. Look into cognitive behavioral therapy (CBT), interpersonal therapy, and acceptance and commitment therapy (ACT): They’ve all been shown to help treat postpartum depression and mood disorder during perimenopause.
  

• Find a reproductive psychiatrist. Here’s a list of all the academic reproductive mental health programs in the United States, maintained by Marcé of North America, the professional group for health care providers focused on mental health care for pregnant and postpartum people.
  

• Know your medication options: Traditional antidepressants are very effective for both postpartum depression and perimenopausal depression, and a couple of antidepressants have been shown to be effective in reducing vasomotor symptoms (hot flashes and night sweats).
  

• Know what hormone therapy can and cannot do: There’s also evidence that for some people experiencing lots of vasomotor symptoms, menopausal hormone therapy can be really helpful — but it’s not indicated for people who are only experiencing mood symptoms without any vasomotor symptoms because though the risks of hormone therapy are not as great as once believed, they are still greater than for antidepressants.

Hormones can’t tell you everything

Another layer further complicating treatment of mood symptoms in midlife is the stigma around mental health disorders.

Osborne said so many women are begging their doctors to measure their hormone levels, looking for an answer in their labs to why they are feeling so bad.

“There’s no evidence that that’s helpful,” Osborne said of measuring hormone levels as a means of diagnosis. “It isn’t the level of hormone that’s the problem: It’s vulnerability to the fluctuation.”

There is some evidence, Osborne said, that the steepness of the decline in some of those hormones may be related to developing symptoms, but you would only be able to detect this if you were able to test multiple times over a number of different cycles: One blood draw at one random moment in time isn’t going to tell you that.

“I think people want it to make a difference because they want to have a hormone disorder. They don’t want to have a mental health disorder. Nobody wants to have a mental health disorder, so they latch on to the idea that, ‘Oh this is a hormone problem, therefore we must need to test my hormones.’”

Open that window

These are natural transitions — from pregnancy to postpartum, from ovulation to perimenopause — and a lot of us put a lot of pressure on ourselves to not only take care of others but make sure we still look fertile, young and virile while going through these transitions too.

Whether you’re postpartum or in perimenopause, the reality is that you are aging — your body may look different, your identity certainly may feel different. That’s part of getting older — and that’s OK.

While Osborne noted that most people go through menopause and do not develop disabling mental health disorders, it doesn’t mean they might not be affected by this transition. And key to getting through this is acceptance.

As Barbieri said when we spoke, “The body changes over time. It changes from the day that we are born, and the changes of pregnancy, postpartum and perimenopause are almost like accelerated phases of that change.”

Osborne stressed that feeling the impact and reality of that change is OK, too.

“It’s OK that it affects you. And it’s OK to have acceptance of that and say, ‘Oh I really need to open the window right now because I’m having a hot flash.’ That’s fine. Say that, do that, accept that as part of your life,” Osborne said.

But if it is all having a significant impact on your functioning, also ask for help.

“If you do only self-sacrifice, that’s not going to work out. Self-care is what we actually need,” Osborne said. “We need to prioritize women and their health, because women are the caregivers of the nation. … So, we have to cut ourselves some slack, I think.”

This and that

• “Antiheroine,” the new documentary about Courtney Love that just premiered at Sundance, has the Hole frontwoman proclaiming, “The most transgressive thing you can do in the world is be a female aging in public,” per The Washington Post’s Jada Yuan. Say less.

• Speaking of being hyperaware of your own aging, I loved former Sassy editor Jane Pratt’s ruminations on her Substack about all the things she’s done in the name of her health that have actually hindered it.

• Speaking of things you do for your health that maybe aren’t doing what you think, Liz Plosser’s deep dive on cold plunging and women on her Substack, Best Case Scenario, is a must-read.

• Speaking of staying warm, this essay by Suzanne Roberts about sweating to the oldies with her sister at a senior center in Oldster is downright heartwarming.

What counts as “oldies” on your playlist now? Write me.

And of those, anywhere between 20 and 50 percent will experience symptoms including abnormal bleeding, intense pelvic and abdominal pain, urinary frequency, constipation and even infertility.

Of course it’s underresearched. Of course there is misinformation. And of course (of course!) it all becomes more complicated when your hormones start acting up in perimenopause.

Simply, fibroids are non-cancerous growths that occur in the uterus. They can vary in size and the number and severity of symptoms they cause (most commonly, abnormal bleeding and pain).

The numbers are even more staggering in Black women, 90 percent of whom will develop fibroids before the age of 50. They often develop fibroids starting at younger ages and have larger and faster-growing fibroids, too.

Because of all of this, they also experience more severe symptoms than other demographics, often grappling with pain and bleeding so intense that it can become disruptive to their daily lives: They are three times more likely to be hospitalized for fibroid-related issues, seven times more likely to undergo surgical removal of their fibroids, and twice as likely to have a hysterectomy to remove their uterus, and fibroids, altogether.

Even if you haven’t had symptoms before, sometimes perimenopause can lead them to rear their ugly head. And since 80 percent of us have them — across all races and ethnicities — I wanted to dig into what we should all know.

Cue the expert

I called Dr. Taraneh Shirazian, the director of the Center for Fibroid Care at NYU Langone Health (yes, you probably heard about it from Venus Williams) and the director of the division of women’s global and community health in the department of obstetrics and gynecology at NYU Grossman School of Medicine. She said that every single day, she fields questions about perimenopause and fibroids.

Fibroids feed on estrogen, so it makes sense that the big hormonal fluctuations that come with perimenopause would make them worse.

“Fibroids have a definite growth spurt or growth increase in these key years with all this hormonal fluctuation. This doesn’t happen for every woman, but it does for many,” Shirazian said. “All of a sudden, their fibroids weren’t bothering them and now they’ve reached age 45 and they’re bleeding all the time, they feel more pressure, they feel more pain, they feel more urinary frequency and other symptoms of fibroids.”

And then on top of that, they’re also experiencing all the classic symptoms of perimenopause, like hot flashes and night sweats, brain fog, and mood swings. And many are being told that hormone therapy isn’t right for them because of the fibroids. But Shirazian said that’s not true — it’s just a matter of finding the right hormone therapy, and fibroid treatment, for them.

“What I think is very important for women to know is that they can treat their perimenopausal symptoms and also treat their fibroids.”

So, what about hormone therapy?

Shirazian said there are a lot of myths about hormone therapy, or hormone replacement therapy (HRT) — a prominent one is that people with fibroids can’t be on hormone therapy because it will grow their fibroids. But, she said, there’s no proof of that — and actually, the fact that hormone therapy keeps estrogen steady means it’s less likely to make the fibroids bigger, compared with the fluctuations that come with perimenopause.

“We don’t need for women to suffer unnecessarily. If you are symptomatic for perimenopause, you should treat the perimenopausal symptoms and we’ll figure out how to manage the fibroids,” she said. “The key teaching point that I would like women to know is that they do not have to sacrifice their HRT.”

‘A whole other way of thinking about screening’

Shirazian said she also hopes that more women will feel more empowered to be proactive in their health care — and that when it comes to fibroids, she would love to see a cultural and institutional shift on screening.

She feels that this is especially true for Black women, who so disproportionately experience symptomatic fibroid disease. Too often, they are left without treatment until their symptoms become so significant that their daily lives are being disrupted and they need more invasive treatment. It doesn’t have to be this way.

“We should be screening differently for fibroids disease. If you have family history — and you should talk to your family, if your mom had fibroids, if your aunts had fibroids, you have sisters with fibroids — you should start screening early. You should get an ultrasound. You should keep an eye out for those symptoms,” Shirazian said.

So, about those fibroids …

The other main point Shirazian wants people with fibroids to know? That there are a lot of avenues for treatment outside of a hysterectomy.

“We can treat the category of abnormal bleeding in so many ways, even without treating the fibroids themselves sometimes,” she said.

For instance, if a person has very small fibroids that might be causing a heavy amount of bleeding, a doctor can freeze the endometrium so it doesn’t bleed so much. For others, placing an IUD might treat irregular bleeding, while radio frequency ablation (a minimally invasive procedure that uses heat from radio waves to destroy targeted tissue) might be utilized in other cases.

And at some point, she said, menopause will mean the fibroids go away. But it’s just not always as speedy as we might hope.

“Once you enter menopause and have a full year of no periods, you should know that your fibroids will slowly shrink, so they will get better — but if they’re very big to start with, it will be a slow process. It will be years of them shrinking if they’re very large,” Shirazian said. “I think sometimes women wait until menopause only to be disappointed by the fact that the fibroids don’t just go away.”

From stigma to treatment

Too many people are scared off from seeking evaluation and treatment because they don’t want a hysterectomy, Shirazian said.

“The only bad option probably is to do nothing if you’re suffering. Any other option could at least make your quality of life better,” she said. And more often than not, that treatment is not going to be a hysterectomy.

“Even if you choose a medication, an IUD, a minor procedure to help your bleeding, coming in and being evaluated and choosing something — anything is probably the right choice. I want women to have the permission to choose other choices, to have other choices and know that they can make those decisions. That’s important.”

And for those who do end up needing a hysterectomy, there are some myths she would like to dispel there, too.

“A hysterectomy doesn’t have to involve removing your ovaries. If they don’t remove your ovaries, you will not go into surgical menopause,” she explained. She added that studies show that people who have hysterectomies without ovary removal typically experience menopause about six months earlier than the average onset of natural menopause, but not much earlier than that. “You can leave your ovaries if you don’t have family history, if you’re an age that you prefer to keep them, or we think they would benefit you for longer.”

Likewise, not removing the cervix is also an option for some patients and can mean fewer changes in terms of the onset of menopause, as well.

But regardless, Shirazian wants people with fibroid disease to know one thing most of all when it comes to treatment.

“No option is a bad option.”

This and that

• I really loved this very honest, very thoughtful essay on aging and beauty (and aptly titled “Aging Out of Beauty”) by Mindy Isser, over at Gloria.

• Speaking of thinking about my own face, I’m grateful that the New York Times explained who is and who is not a narcissist for me.

• Speaking of self-indulgence, I also enjoyed this take in The Cut on the sex scenes in the new “Lolita”-adjacent novel “Half His Age” by former child star Jeanette McCurdy.

• Speaking of icons of the small screen, my 19th colleague Marissa Martinez was there to watch “Real Housewives of Salt Lake City’s” very own Angie “You do french fries, I do franchise” Katsanevas testify before Congress in favor of a rule that defines the relationship between franchisors and employees.

• Speaking of french fries, what would you do if you found a beach covered in french fries and onions, as discussed in the latest Food News podcast at The Ringer?

Would you eat a beach onion? Write me.

This past season on the “Real Housewives of Orange County,” multiple women discussed how they routinely have testosterone pellets injected. Gretchen Rossi was even shown pantless, butt in the air as a doctor injected pellets into her rear. The women bonded, or maybe commiserated, saying the hormone revved up their sex lives — maybe a little too much.

They’re not the only ones talking about taking testosterone during perimenopause and menopause, though: The New York Times wrote about it this fall, and then again just a few weeks ago. New York Magazine’s The Cut had a recent feature on the topic. So did Vox.

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With the media onslaught about the use of testosterone as a course of treatment for menopause-related health symptoms, I needed to understand why this was happening — and what it actually meant for people’s bodies.

Cue the expert

So I called Dr. Margaret Wierman, the chief of endocrinology at the University of Colorado-Anschutz and senior author of the position statement on testosterone therapy for women issued by the Endocrine Society and 10 other medical societies.

First, Wierman gave a quick definition: Most simply, testosterone is an androgen — a sex hormone that plays a key role in developing male sex characteristics and also helps with bone density, muscle development, red blood cell function and sexual desire.

In cisgender women, testosterone is mostly produced by the ovaries. It’s converted into estrogen by aromatase, an enzyme that is necessary for sexual development in both sexes and can impact cognition, mood and bone health.

We know that testosterone is important for cisgender men’s bodies and directly impacts their sexual health. And lately, many people have wondered about whether it could play a role for cisgender women’s health as they age.

Scientists and health researchers largely agree that for the average cisgender woman, testosterone should measure somewhere between five and 40 nanograms per deciliter. And yes, postmenopause these levels decline — but everyone’s testosterone levels decline as they age. That’s not necessarily the sign of a problem, Wierman said.

“Over the last 50 years, people have looked for a role for testosterone in women and tried to define an Androgen Deficiency Syndrome,” similar to how the deficiency has been defined for men, Wierman said. But so far, they haven’t made that connection.

What the research found

One study in the 2010s showed that for a very specific demographic — postmenopausal women with abnormally low sexual desire who had no cardiac risks, risk of hypertension or risk of breast cancer — testosterone supplementation via a patch resulted in one additional episode of sexual intercourse per month that was satisfying.

“People had suggested that maybe if we just looked hard enough, we could find a role for testosterone,” Wierman said. “If we were in the right range for supplementation, we could find a role for testosterone on cognition, on bone density, on all of these kinds of things. But the data really showed that it had an effect on this subset of hypoactive sexual desire disorder” — but nothing else.

When the data was taken to the Food and Drug Administration (FDA), the agency found the benefit was very low compared with the risk, as they had concerns about both breast cancer and cardiovascular risks. The FDA panel that reviewed this patch for American women unanimously rejected it because of safety concerns. At the same time, the testosterone patch was taken off of the market in Europe. Currently, it’s only available in Australia.

“And yet it keeps coming back,” Wierman said of the topic of prescription testosterone for women. “There have been no studies since we did the review. I was part of the international review where we met across the globe to look at the data, and it’s just not there.”

In the 2019 position statement, the Endocrine Society concluded that while testosterone therapy may be appropriate for women with hypoactive sexual desire dysfunction, or extreme lack of sex drive, the available evidence does not support the use of testosterone for any other symptoms or medical condition.”

“Off-label must be good”

Some patients, though, are still seeking out testosterone to address everything from declining sex drive to muscle mass protection to maintenance of a youthful appearance. Many turn to unapproved treatments because they don’t feel heard by doctors about the challenges they face — both physical and emotional — as they age.

This means some people end up receiving off-label, compounded testosterone or other prescription testosterone products like creams or gels from health care providers. That sometimes means prescriptions for small doses of drugs formulated for men, with doctors closely monitoring to see how well patients tolerate it and how it helps with things like libido and fatigue.

More common, though, are the injectables and pellets that have become so widely available — many offered through various kinds of anti-aging or alternative health clinics, and not mainstream doctors’ offices, and without ongoing clinical supervision. Those pellets deliver testosterone at way higher levels than any body produces naturally. Because of this, Wierman said the Endocrine Society doesn’t even suggest that cisgender men use them.

Like athletes on steroids

But might testosterone make you feel better? Maybe — but that doesn’t mean you should be taking it.

“So does it treat depression with an activating sort of effect? Well, there’s a lot safer medicines available to treat depression than taking testosterone,” she said. Changes in how you might feel because of testosterone are a result of it being a natural steroid hormone. (If you’ve ever taken prednisone, you know how even that can make you feel revved up.)

Taking it also can mask the actual causes of why women are experiencing certain symptoms and further delay them from the most effective, specific course of treatment, Wierman said.

“Do you have sleep apnea? Are your estrogen hormones out of whack? Do you have a mood disorder? Do you have a problem in your relationship? Are you anemic? All those kinds of things that somebody would go to the doctor for which do happen at perimenopause or menopause — but now everyone is looking for this silver bullet that’s not there.”

The side effects

Wierman pointed at a host of well-documented side effects when testosterone is used outside the normal range. They include male pattern balding, the development of facial hair and body hair, and changes in fat and muscle that can result in a more stereotypically “masculine” physique.

She said there has also been research showing marked worsening of the cholesterol panel, with higher bad cholesterol (LDL) and lower HDL (or good cholesterol).

There have also been reports of impacts on mental health, not dissimilar to the stories of “roid rage” we often associate with athletes and anabolic steroids.

So what about your sex life?

Wierman said that a lot of the conversation she hears about testosterone being necessary to help women’s sexual satisfaction in midlife is misguided, too.

“Sexual function in women is different than in men,” Wierman said. For women, it’s not a straightforward switch — sexual desire is more like a circle, where there’s a starting point and then a number of factors contribute to where you are on the circle’s arc.

“You have whether you fought with your husband this morning, whether your kids are calling in the middle of the night, whether because you’re menopausal you’re having painful intercourse that hasn’t been treated — and then because the actual act is painful, you don’t really feel like it. There’s also whether or not you feel sexy because you’re going through menopause — maybe you’ve gained some weight and that whole innate self-love is off. Then there’s the act of being able to have an orgasm. Sexual desire is this big circle and actual satisfaction can be interrupted at all of these different levels.”

What women really need, she said, are good doctors who want to listen, ask questions and identify what’s really at play. That includes ensuring that the people who would benefit from estrogen therapy — which can help with vaginal pain, urinary tract infections, and mood and sleep disruption, among other symptoms associated with perimenopause — get that.

“There are safer ways. That’s where the science is,” said Wierman when it comes to thinking about hormones and midlife health and how testosterone fits into this conversation. “Where the science is, is giving us all these pieces of data that now allow us to give the right hormones at the right time to the right people and also treat all the rest of the things that are happening in midlife.”

Help some journalists out!

The Marshall Project, a 19th News Network Partner and a nonprofit newsroom that covers the American criminal justice system, is beginning a project exploring what the menopause experience looks like for incarcerated people — and they’re looking for folks who can help inform their reporting.

The team there is looking to connect with women’s health experts, formerly incarcerated people, health care providers or others who provide support to people in prison, and relatives and friends of someone going through menopause while incarcerated. Survey responses will be used for the creation of a guide that The Marshall Project Team will make available to incarcerated people experiencing menopause.

Have something to share? Participate in their survey here.

We’re trying to unpack what might have happened. We’re analyzing Hilary Duff’s husband’s TikToks. We’re wondering what might inspire someone to write a public screed against some moms they don’t like.

It’s been elite-level bonding for our group, only some of whom have met IRL. But even as we breathlessly track the public mess of celebrity friendship gone awry, we bring to it some perspective. For so many of us, our friendships only get better and richer and less about mean girl drama (real or perceived) as we settle into midlife. (Hi, group text, and thanks for reading!)

That’s why I wanted to dig into the magic of midlife friendship and what lies ahead once you make it past the phase when your relationships may be largely shaped by swapping potty training tips.

I know firsthand that it can be hard in midlife to meet new people and then actually find the time to see them — but that relationships formed now can feel uniquely real. And I wanted to know what all of this meant about how friendship evolves as we age.

Cue expert No. 1

I met Debra Whitman, the chief public policy officer at AARP and the author of “The Second Fifty: Answers to the 7 Big Questions of Midlife and Beyond,” at an event in November.

We instantly bonded when we found ourselves sitting out the optional fitness challenge, choosing instead to discuss our love of contemporary fiction and our trauma from the Presidential Fitness Challenges we endured as children. I called her up this week because I knew she had data about friendship — and its absence.

Just last month, AARP published a new survey finding that 40 percent of American adults aged 45 and up report feeling lonely, five points higher than in 2010 and 2018.

The 2025 survey was also the first time AARP found a gender gap when it comes to loneliness: 42 percent of men versus 37 percent of women reported feeling lonely.

Whitman emphasized that loneliness isn’t a measure of how many people you know, but how much you self-report feeling a lack of connection to other people in a meaningful way.

And when it comes to loneliness, there are some harsh truths to swallow about midlife. Whitman said data show that we’re lonelier in this stage than we are as we get older, likely due to caregiving for both children and parents and the stress that puts on our time and our finances.

But, there’s good news.

“The data is clear: Happiness improves as we age. Loneliness decreases as we age. That is something to look forward to,” Whitman said. “I think so often we think aging is going to be just this negative time in our life, when actually, the data doesn’t support that.”

And, she said, nurturing our friendships — or even connecting with the people around you, even if they’re not “Anne of Green Gables” bosom friends, can get you through this phase. Whitman said that data shows that even taking the time to ask the person ringing up your groceries about their day can be a real moment of connection.

Not feeling lonely is literally important for your health as you age. Recent research shows that being isolated has the same impact on your physical health as smoking 15 cigarettes a day.

“Relationships of any kind — close relationships — really determine our health and longevity,” Whitman said.

Cue expert No. 2

I also wanted to talk to Suzanne Degges-White, PhD, professor and chair of the department of counseling and counselor education at Northern Illinois University and an expert on women’s friendship. She said midlife, even with its stresses, is a great time to find great friends.

“The beauty of friendship once you hit your 40s and your 50s is that you know yourself really really well — and you also know that your job isn’t to please anyone but yourself, basically. When we know ourselves better, we can be a much better friend to other people because we can be more authentic in our relationships.”

Moving away from the mirror

Starting in high school and often well into our 30s, she said, friendships among women often looks like “basically finding mirrors for ourselves” — befriending those who reflect our current or desired social standing and where we imagine ourselves, achievement-wise.

This changes when you hit your 40s, she said, as you gain confidence and comfort in your own skin. “We don’t have the same need to please or reflect everyone around us. That doesn’t mean that we don’t reflect others — we just do it in a different kind of way.”

In midlife, friendships are often rooted in shared values versus identical tastes or experiences. As Degges-White put it, “You don’t have to love the same music, but you have to appreciate music as an art.”

That doesn’t mean making or maintaining friends at this age is necessarily easy, she said, especially because so many of us are caregivers. But it’s important to remember that as uncomfortable as it can feel to put yourself out there, everybody else wants friends as badly as you do.

As we age, we also have the chance to get creative in how we maintain our relationships, especially given that our closest and most magical friends might not be people who live nearby.

Degges-White has encountered women in her own research who have nurturing and sustained friendships with people they see in-person only every few years. One of her favorite anecdotes is about a pair of friends who lived in different cities who scheduled a daily early morning walk, each in their own neighborhood and time zone, on the phone together.

Why you should watch Real Housewives

Tisdale French hasn’t revealed who is in the mom group she wrote about, but many have speculated that it’s a celebrity-filled one.

Crystal Mikoff, formerly of “Real Housewives of Beverly Hills,” added fuel to that fire. And while acting like toxic celebrities or Real Housewives might not be helpful to your relationships, Degges-White said, watching Real Housewives can be. (No, really.)

“We watch them and we see it’s performance,” she said. “We don’t have to perform with our friends, we can be ourselves and let ourselves be vulnerable.”

And yes, the Real Housewives can also help normalize our own experiences.

“It’s wonderful to watch them and say, ‘Well, OK, in my life, I had a big fight with my husband today — but it’s nothing like what this woman’s having right now with her friends.’” They help us normalize how wild and weird our lives can be as we age — and also “remind us what to avoid,” Degges-White said. “Gossip is a good thing because it tells us what not to do, because if you do do this thing, you’re going to be talked about and be a pariah.”

Degges-White said watching and discussing the week’s antics can serve as a form of what’s known as bibliotherapy, or studying a work of literature to glean lessons from others’ dramas.

“You’re taking lessons from what you’re watching.”

It also, she said, deepens your relationships when you watch shows together and discuss them as a group. “Having the Real Housewives in your life means you might want to talk about them with friends — so you’ve expanded your work of connections to people and have this way of deepening the relationships you have in real life.”

This is timed perfectly for the airing of Part 1 of the “Real Housewives of Salt Lake City” reunion tonight, which will surely be all about who has and has not been a good friend to whom and what these words even mean.

Also, if you have a take about what really happened with Meredith and Britani on the plane, please write me.

Here we are at week 12 (!) of this newsletter, and as we approach the holidays (and The 19th’s annual holiday break), I just wanted to let you all know how much fun I am having with you and how grateful I am for this engaged, thoughtful community.

Please know I have read every email, every Instagram comment, and if you’re sending a message via carrier pigeon, rest assured I’ll read that when it gets here, too. Thank you for sharing so generously — your voices have made each issue all the richer. Truly truly: Thank you.

I wanted to share three takeaways from what I have learned over these past few months of reporting and writing this newsletter.

1. We really need more research. So much more research. There is still so much we don’t know. Anyone saying they know definitely that “x” fix is guaranteed to give “y” result because of ”‘z” irrefutable fact? I would largely proceed with caution.

2. We really need better representation — in all the ways. This is also about research — but it’s also about the faces we see talking about menopause, both the health and science and the cultural conversation.

3. We really need one another. Talking to one another, and keeping it real, is essential: The more we share, the more we normalize.

This newsletter was planned as a 12-week experiment, but the enthusiastic reaction from you all means we’re going to keep going in 2026. We’ll be back in your inbox on Tuesday, January 13.

I cannot wait to connect with you all again and keep at this exploration of all things menopause with you! In the meantime, you can read all 12 issues of the newsletter for free on Substack.

As we move into the chaos (let’s just call it like it is) of this time of year, I wanted to share what I’m most excited to read, listen to and watch this holiday season. (Psst — this is 100 percent affiliate-link-free.)

📚What I’m reading

“If You Love It, Let It Kill You” (Hannah Pittard)

I have been waiting a full six months to have the time and headspace to take on this autofiction-esque romp through one woman’s divorce after she discovers her husband is having an affair with her best friend. (Yes, this really happened to the author.) Then she learns that she and her ex are both writing novels about what happened. (Yes, this really happened to the author.) Enter: a midlife crisis and a talking cat.

“The Pelican Child” (Joy Williams)

I like to think of myself as a (reformed?) punk kid … but I am a total rule follower and complete nerd. All of this is to say, the work of Joy Williams (inveterate punk, absolutely masterful writer) always speaks to me with its mix of the weird and the mundane and her constant questioning about the boxes society likes to put women into. The New York Times described Williams’ latest, a collection of short stories, as “delightfully unhinged” and truly — say less.

“The Harder I Fight the More I Love You” (Neko Case)

I kicked this newsletter off talking about my excitement for Case’s new album, so you know I am equally excited to finally sit down and read her memoir about how a childhood marked by poverty, the rural Pacific Northwest, and loneliness led to a life of such immeasurable creativity.

“Origin Stories” (Corinna Vallianatos)

I always saw myself as a novel girl — until a few years ago, when suddenly all I craved were short stories, with their flashes of narrative that find new ways to illuminate daily life. This collection has been getting rave reviews — and when do I not want to read about what it means to be a woman who is also a mother and a wife and a writer figuring out what all those words mean when held together?

“Katabasis” (R.F. Kuang)

The holiday season is made for novels that get slapped with the “dark academia” label. (Try Mona Awad’s “Bunny” and its just-released sequel, “We Love You, Bunny” while you’re at it.) Kuang is a fantasy writer for people who don’t think they like fantasy writing. I can’t wait to dig in to her latest, a doorstopper of a novel about some grad students at Cambridge who accidentally kill their professor through unintentional usage of dark magic and now must effectively journey through hell to rescue him — and get some letters of recommendation.

🎧 What I’m listening to

“Javelin” (Sufjan Stevens)

I’ll die on this hill: “Javelin” is a Christmas album. Since Stevens released this beautiful, aching, melancholic, hopeful and reflective album in 2023 following the death of his longtime partner, Evans Richardson IV, this has been coded as holiday music for me. It is elegiac, it is precise, it is about what it means to navigate the way that love and loss are inextricably intertwined. If that doesn’t say holiday season, I don’t know what does.

“A Christmas Album” (Barbra Streisand)

It’s the most Jewish Christmas album of all time. I love the way the album opens with a frenetic “Jingle Bells” and then moves into a “Have Yourself a Merry Little Christmas” that would make Judy Garland proud. If you’re not in tears by the end of “The Lord’s Prayer,” sorry, I can’t relate to you.

“The Kacey Musgraves Christmas Show” (Kacey Musgraves)

I feel very strongly that the only thing harder than starting a religion is writing a contemporary holiday song that sounds like an instant classic. And by these terms, this album is a religious event. “Present Without a Bow” with Leon Bridges, “Glittery” with Troye Sivan, the utter bop that is “Ribbons and Bows” — this album is a major one in my family.

“Saya” (Saya Gray)

I won’t shut up about this Japanese-Canadian artist’s album that came out this past spring. It’s a breakup record in art pop perfection, taking detours through country and indie and electronica and spinning magic out of each track. The songwriting is impeccable, and Gray does not hold back for one second about how she is processing the end of this relationship. Your mouth will just hang open as you go along for the feelings ride.

“Snocaps” (Snocaps)

Hey, the title and band name even make it seem seasonable! This new project by sisters Allison and Katie Crutchfield (aka beloved alt-country-folk icon Waxahatchee) has been in constant rotation for me since its surprise drop last month, and I don’t see this changing any time soon. It’s everything I want an album to be: literally a little bit country, a little bit rock and roll.

📺 What I’m watching

“The Diplomat” (Netflix)

I finally got around to watching this latest project to star beloved elder stateswoman of old Millennials and spry Gen Xers everywhere, Keri Russell. Russell is career foreign service officer Kate Wyler, who finds herself serving as the ambassador to the United Kingdom after a long stint in Kabul. Pressing matters of national security constantly abound, but the most interesting plot line is about Kate’s relationship with her husband, Hal. The third season premiered in October, and it’s time for me to marathon it after blowing through the first two seasons in no time.

“Oy to the World!” (Hallmark Channel)

I absolutely love a Hallmark holiday movie and cannot wait to watch this one about a synagogue youth choir director and an Epsicopal church youth choir director, former high school rivals, who must share a space while competing to perform at the joint interfaith holiday service. Obviously they are going to fall in love and everyone will learn the real meaning of the season, and I for one cannot wait.

“Fallout” (Amazon Prime)

I am extremely ready for the second season of this show based on a beloved video game — and, trust me, I never thought I was going to be a “show based on a beloved video game person.” Get caught up on season 1 if you haven’t seen it yet so we can watch our favorite scrappy characters trying to navigate a post-nuclear hellscape through a stylistically delightful, high camp, genuinely comedic action romp together.

“The Real Housewives of Beverly Hills” (Bravo)

We are so back. (For season 15, that is.)

“Happy and You Know It” (HBO Max)

I am sat for this latest in the Bill Simmons-produced Music Box series of documentaries. This latest feature turns its attention to children’s music, asking why this genre is so terminally uncool, wildly popular and perhaps even grossly underrated. If the names Laurie Berkner and Caspar Babypants mean anything to you, you can sit with me.

But based on what I’m hearing, maybe those don’t really exist. What I did hear was something more universal: You just didn’t hear a ton about menopause growing up. Maybe you watched your mom struggle with hot flashes, but mainly you walked into this phase of life cold (pun intended).

I had also reached out to people who think directly about questions of menopause and culture. They talked less about tradition and more about what they’re working to change and what those new models can look like. It gave me a lot to think about — and a lot to feel hopeful about.

Who gets to look like menopause

I talked to Kamili Wilson, the founder of Menopause Made Modern. Wilson’s site is dedicated to helping women of color navigate their midlife health experiences and was born out of a personal need she saw based not on cultural differences, but a fundamental lack of representation.

When Wilson turned 43, she started experiencing “weird symptoms,” everything from hot flashes to bouts of rage. She soon understood that she was in perimenopause — and discovered a problem outside of her new symptoms.

“Why, when I am Googling, are all of the images of old, White, white-haired women in their 80s and 90s, looking out the window and having a hot flash?”

(I’d like to note that while I am a White woman writing this newsletter, I’m not in my 80s or 90s and I hardly ever am photographed looking out windows.)

As she learned more about menopause and discovered that women of color — particularly Black and Latina women in the United States — tend to have more severe menopause symptoms over a longer period of time, she started to think about those countless stock photos. Not one of them looked like her, a professional Black woman in her 40s.

The conversation we’re having about menopause today isn’t culturally specific, Wilson said, but fueled by a generational shift. We’re all stumbling our way into midlife with our sweaty clothes and itchy ears, desperate for information. But as menopause has become more and more a part of the cultural zeitgeist, some people are still quite literally not seeing themselves reflected.

Compounding barriers

We have talked before about how research disparities impact women’s health outcomes in midlife and beyond, an issue that is compounded for women of color. That racial gap is being replicated even as menopause becomes a big business.

Wilson said the absence of meaningful diversity in the menopause industry only creates further barriers for women of color, especially Black and Latina women who often have a “fundamental distrust of the health care system, have experiences either of medical racism or not feeling heard or included or taken seriously.”

What trust looks like

Dr. Sharon Malone is the chief medical adviser at Alloy Health, a menopause-focused telehealth service, and a leading voice in the space to change the menopause conversation for Black women in particular.

The recent discourse around hormone therapy showed why that’s needed, she said: When the black box warning was placed on estrogen products for hormone therapy in 2003, the share of eligible patients who used it dropped from 30 to 40 percent to about 5 percent. For Black women, it dropped to less than 1 percent.

“The unfortunate thing is that Black women suffer the symptoms of menopause disproportionately,” Malone said: Their symptoms are more pronounced and last longer than any other population. They’re also less likely to recognize their symptoms as being tied to perimenopause, and thus also less likely to ask for help or treatment, she said.

“And unfortunately even when they do present with these complaints, they’re half as likely to get a prescription for hormone therapy as another person walking in with the same set of complaints. To make it even worse, when you take that prescription home, you are only half as likely to take it,” Malone said of Black women. ”These are the women that need it the most and get it the least. So I am trying to be that voice and get that message out to communities.”

Who those faces are

Malone said that having a range of diverse faces getting that message out is critical.

“You see Michelle Obama, you see Halle Berry, who is really out here, and that’s great — but these are people at a remove,” she said, adding that while it is important for celebrities to use their platform and voice, it often does very little to move the needle for real people.

Something Malone has heard is, “Well that’s a famous person.” In other words — not someone whose experience looks anything like their own.

“We need more images of people who look like regular people,” Malone said.

She herself is a member of Delta Sigma Theta, a historically Black sorority, and regularly speaks at events held by member groups, as well as at women’s groups at Black churches. “Anytime I have an opportunity to be in front of a group of Black women, I go. … The message matters and the messenger matters and the images matter.”

Privilege and power

Reshma Saujani has also made diversifying the faces of midlife her business.

Saujani is Indian American and said that while the movement happening around menopause — and all the media attention around it — is incredible, it’s also important to recognize that “why you’re seeing mostly White women doing it is because they have that privilege.”

Saujani, the CEO and founder of Moms First and the host of the popular podcast My So-Called Midlife, said she has been thinking a lot about why her mom never spoke with her about menopause. But then she realized it was obvious.

“She was a working-class immigrant — she didn’t have the privilege to go to her employer and say, ‘I’m having hot flashes and need menopause benefits.’”

Impacts beyond health

An inability to access care can have huge implications. Wilson thinks about her experiences with flashes of rage when she was perimenopausal and didn’t know it.

“It’s that intersectionality,” Wilson said. “I was deeply concerned when I was navigating my workplace bouts of rage and not having confidence that I could regulate myself well and how that would intersect with the Angry Black Woman trope — it was very top of mind for me at the time and I thought, ‘How can I get a handle on this’ and ‘ I’m experiencing this, there must be other women who are experiencing this too.’”

Wilson said she hopes more people understand that having holistic conversations about representation carry huge economic impacts. Many women — and women of color — might be shut out from professional opportunities or advancement just because they are going through menopause and don’t know what’s happening to them and how to advocate for themselves.

“It’s affecting women’s earning potential. It’s affecting their professional credibility,” Wilson said. “I can only imagine if I hadn’t given voice to my symptoms over the years, how would people be perceiving me? ‘She’s off.’ ‘She’s forgetful.’ ‘Why does she just break out in sweats all the time?’”

A new script

Saujani said that one of the motivations behind launching her podcast was that “we literally need to have a new script for women in midlife” — including, but not limited to, showing a diverse set of faces and experiences who can show exactly what potential midlife can hold.

“Zarna Garg became a comedian after 16 years of staying home. Ketanji Brown Jackson made her dream since she was a child come true. Yvette Nicole Brown has a love of her life at 53. You’re seeing women who are actually entering the best stage of their life and they’re rewriting those norms. The thing is, we don’t always hear about them as the norm, we hear about them as the exception,” she said.

As a woman of color with a platform, Saujani said that she understands the privilege she has to shift the narrative. She hopes more women — and more different kinds of women — start to talk about midlife and quite literally put a face to.

“You don’t have to have it all happen in the first half of your life. I’m excited about this being the best time of my life, the period of my life where I accomplish the most, because I don’t feel anywhere close to being done.”

I almost forgot

A new report from the Geena Davis Institute analyzed films released from 2009 to 2024 to see how menopause narratives are portrayed on screen.

What they found? Menopause is nearly invisible.

Of the 225 films in that span featuring a 40-plus female character, only 6 percent (14 films) mentioned menopause, and usually through some kind of side comment. Only one film featured a prominent menopause storyline.

Menopause most commonly showed up as a punchline, playing to stereotypes about emotional volatility in this phase of life.

They also found that menopause storylines have not gotten more common in recent years, with a steady drop-off in films that mention menopause in the past nine years in particular. It’s gone hand-in-hand with a decline of women over 40 as characters in comedies.

This dearth of representation has a real impact on people’s understanding of menopause. A nationally representative survey of adults of all ages in the United States conducted as part of this analysis asked respondents about their perceptions of menopause on-screen.

Fourteen percent of American adults — and 1 in 5 people of color — said that TV and film were their first exposure to the concept of menopause.

So a friendly reminder to those who decide what media gets made: Representation matters.