It's not always menopause

A doctor shares what symptoms you shouldn't just chalk up to menopause.

If Dr. Kemi Doll could tell you only one thing about your health as you move through middle age and beyond, it would be to not forget about your uterus.

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

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

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

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

What to watch for

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

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

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

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

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

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

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

What Black women need to know

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

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

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

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

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

Hormones and aging — and nuance!

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

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

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

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

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

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

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

About those hormones

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

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

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