In recent years, a burgeoning field of study has hypothesized a connection between adverse childhood events, also known as ACEs, and a more difficult menopause transition.
An ACE could be one of various circumstances, including physical, sexual or emotional abuse, physical and emotional neglect, and parental separation and divorce. In “Researchers Find Link between Childhood Trauma, Recent Abuse and More Severe Menopause Symptoms,” Madison Okuno, a Mayo Clinic researcher, said: “We found that women with a history of abuse, whether in childhood or recent, are more likely than women without these histories to experience more severe menopausal symptoms and more psychological symptoms.”
In their research, the Mayo Clinic studied more than 1,600 women between the ages of 40-65. Nearly 60 percent of research participants reported having endured a prior ACE. Similarly, researchers at the Perelman School of Medicine at the University of Pennsylvania found that “trauma and stress in the teen years increases the risk of depression during menopause.” Teen girls who had experienced traumatic events during childhood or adolescence were more at risk for perimenopausal depression: “In particular, women who experienced their first traumatic event in their teens are especially susceptible to depression during perimenopause, even if they had never previously had depression.”
Past Trauma Leading to Future Health Implications
To what extent are these women more apt to experience depression? More than two times as likely when compared to women who either experienced such events much earlier in life (as infants or toddlers), or never at all. The Penn State team determined that the timing of such events is a critical window into the significant and long-lasting effects on brain development, particularly in the areas responsible for emotions, mood and memory.
Penn State studied the women participants for a long time – 16 years. Each participant was assessed regularly for cognition and mood, and blood samples were collected to determine hormone levels routinely. Approximately 22 percent had experienced one ACE, and almost 40 percent had gone through two or more adverse childhood events. And most of the adverse events occurred before puberty.
Of these women, almost 21 percent experienced depression for the first time during perimenopause, while 22.4 percent were diagnosed with depression before perimenopause started: “Notably, women who reported two or more ACEs after the onset of puberty were 2.3 times more likely to have their first experience of clinical depression during perimenopause, compared to those who did not experience any ACEs.”
Sadly, ACEs Are Common Events
The most commonly reported ACEs were parental separation or divorce, emotional abuse, and living with an alcoholic or someone with another substance abuse disorder.
Unfortunately, adverse childhood events may seem like an outlier, but they are much more common than many would like to believe. According to the Crimes Against Children Research Center, 20 percent of all girls are victims of child sexual abuse, and during the course of their lifetime, 28 percent of all 14-17 year-olds (male and female) have been sexually victimized. Those most vulnerable to child sexual abuse are between 7-13 years old.
Then, beyond sexual abuse, are these sobering stats, which illuminate other potential types of adverse childhood events:
Why Now, If Not Then?
This is a logical question: If the groundwork for mental-emotional challenges was laid during childhood or adolescence, why does it wait to crop up when women are in midlife?
Given these emerging and new insights into the role of ACEs on future risk of perimenopausal depression, and the role of ACEs on brain development, I have a few of my own thoughts about why this happens to some women:
What to Do About It?
The past cannot be scrubbed clean and deleted. Women at this phase of life often have some housekeeping to do, and this is true even for those with no ACE history. During a woman’s 40s and 50s, she may be in a new state of flux, and anecdotally, this is a time when women begin making some critical life changes. They take an inventory of their past, present and future, and may start to redesign and revise life according to her terms. This may look like:
At the same time, these personal changes are not always enough, especially for women battling moderate to severe perimenopausal depression or anxiety, with a history of ACEs. In such cases, it is advised that they seek the help of a healthcare professional to consider therapy and other interventions.
I am a Black woman.
I am a Black woman in both the traditional, archetypal sense, but I am also a Black woman who has historically been a bit unorthodox, unconventional and different. I am my own person and have never, if not rarely, fit into any standard checkbox, including common, prevailing ideas of what it means to be one.
When I realized I was in perimenopause, after a multi-month torture of horrible symptoms, of which insomnia, low-level anxiety and night sweats were my most intractable problems, I sought answers. Not only did I seek answers from medical professionals, I led the charge by doing my own research. Most of those entrusted to safeguard and care for my health fundamentally were not prepared to do so. Out of nine doctors, only three took me seriously. Of those three, one agreed that it might be perimenopause; one nudged me further to consider it as the absolute diagnosis; and the final one declared it to be so and immediately put me on hormone replacement therapy (HRT).
This process involved reading peer-reviewed studies, scientific publications, results from clinical trials and other rigorous, academic materials. I also mined stories of what real women were experiencing by watching YouTube videos, engaging in online forums, reading blogs and listening to podcasts.
Sadly, most women I know of in real life remain silent about perimenopause and menopause.
In my pre-HRT life and before I began consulting physicians, I explored many natural or easy-to-access things first. As one supplement or tincture failed after another, I began to spot a rather glaring chasm: White women seemed to be using pharmacological agents and treatments way more than Black women. While White women were using HRT to replenish their estrogen, progesterone and sometimes testosterone levels, Black women were using over-the-counter vitamins marketed as menopause remedies, in addition to tinctures that had black cohosh, sage, chamomile and chasteberry (vitex) in them.
While White women were taking antidepressants like low-dose Celexa (citalopram), Lexapro (escitalopram), Zoloft (sertraline), Wellbutrin (bupropion) or Effexor (venlafaxine) for their vasomotor symptoms (night sweats, hot flashes), hormonal anxiety / depression and sleep problems, Black women were taking Nyquil, meditation and St. John’s Wort for the very same constellation of symptoms.
Indeed, in a post that appeared in a Black women’s wellness group I follow, someone asked what women were doing for their perimenopause and menopause symptoms, and some of the responses included: dandelion root tea, black seed oil, turmeric, elderberry, vitamin D, wild yam root, red ginseng, valerian, horny goat weed, dong quai, CoQ10, prunes, flaxseed, primrose oil, hibiscus tea, lemon water, burdock root and cranberry juice.
For those women who look to conventional pharmaceuticals as a last resort (and I was one of those women at one time), a few ideas seem to be consistently hailed by both Black and White women. They include melatonin for sleep, magnesium for sleep and muscle aches, and ashwagandha for anxiety and promoting calm.
But still, there is a definite gulf between the percentage of African-American perimenopausal / menopausal women using prescribed medications and HRT vs. White women in the same boat. While I have not uncovered any research that explores why this is, I have my own hypotheses:
Lack of information. It can be very difficult to get accurate, useful information about perimenopause and menopause, especially if one only seeks out help from her primary care physician and stops there. Most general medicine doctors receive minimal information, if any, about menopause during their medical training. Even OB/GYNs’ training focuses more on birthing babies than treating women beyond the reproductive stage. Many physicians will disregard perimenopausal symptoms and instead link them to stress or burnout, or treat / test them as other problems related to thyroid, migraine disorders, or depression, rather than viewing it is the multifaceted perimenopausal condition that it is.
Dismissive doctors. Even when women perform a root-cause analysis and figure out that their condition is likely perimenopause, their doctor may dismiss this as a possibility, often claiming that the 40-something year-old woman in their office is “too young.” Even though hormonal changes in women begin happening from the mid-30s onward, far too many physicians don’t understand that symptoms of hormone change happen way before periods stop. It also doesn’t help that many Black women don’t appear to be the age that they are. So a 45-year-old Black woman may look 35, but have night sweats, emotional turbulence, migraine headaches, hot flashes and irregular periods – only to be told that she is way too young for perimenopause to be a consideration.
Inadequate medical treatment. Even if a doctor agrees that a woman is in perimenopause, they may prescribe ill-suited solutions, like birth control pills when she really needs HRT. Most patients really respect their doctors’ opinions and believe whatever they recommend to be absolutely valid and true. So, if a perimenopausal woman fares poorly on birth control pills, she may think the problem is not the prescription, but her instead. She may seek no further solutions and wing it from that point on.
Medication stigma. Multitudes of women are prescribed antidepressants when they hit perimenopause and menopause. In the U.S., one out of every four women in their 40s and 50s is on an antidepressant, and the uptick in their use at the time perimenopause happens is likely not accidental. There are many reasons for this, including the rationale that this class of drugs helps with vasomotor symptoms (hot flashes and night sweats), insomnia, anxiety, depression and panic attacks – all of which are perimenopausal symptoms. And though antidepressants are now used to treat various issues, such as nerve pain, headaches, low libido and smoke cessation, in the Black community, the common idea remains that if someone takes a drug in this class, they must be “crazy.”
Strong Black Woman Syndrome. Black girls are raised to become Strong Black Women. We are groomed and nurtured to believe in ourselves, never trust anyone too much, always be ready to provide for and fend for ourselves, and to “tough out” some of the most irreconcilable and devastating situations, from racism at the workplace and marginalizing beauty standards to everyday micro-aggressions and undeniable assaults on our humanity. Perimenopause is a time of vulnerability, and Black women are not given much space in this society (or in our families or communities) to take that sorely needed time for our own selves and sanity during this phase of life. Sadly, doing so can even seem like a sign of weakness.
Hormone Replacement Therapy (HRT) can be expensive. Sadly, most women who would really benefit from HRT never receive it. Part of the reason for this is its cost. Honestly, it can be expensive, even for those with ample insurance coverage. Some women are spending at least $70 out of pocket each month for their estradiol patches and oral micronized progesterone capsules, even after insurance pays its part. Others are paying $130 or more a month out of pocket, with no insurance coverage. And some women are spending even more if they pursue alternative HRT routes, such as pellets or custom-compounded HRT. In an inflationary economy and with many vital monthly expenses, and where incomes aren’t keeping up with the cost of living, some just don’t have the financial bandwidth to comfortably afford HRT.
Downplayed by doctors. Sadly, maltreatment within the medical industrial complex is still a major problem for Black patients. All too often, our concerns are sidelined; our pain complaints are maligned as “pill seeking” or complaining; and many of our medical problems just aren’t taken too seriously. Consider how bad White women are treated when seeking help with perimenopause, and for Black women, it’s probably at least 10 times worse. Mainly, it is only the most well-researched, the most valiant and the most well-funded (or willing to spend the funds) women who get proper, timely perimenopause treatment. And by virtue of circumstances, including implicit bias and a lack of healthcare equity, those women who get the care they desperately need usually aren’t Black.
Belief in God. Now, don’t get me wrong. There isn’t a thing wrong with having a belief in a Higher Power, and standing firm and resolute in the promise of healing, restoration and deliverance from our mortal ails as a result. But sometimes our characteristic spirituality and faith cause us to delay treatment and scoff at medical interventions – seeing such as a sign of weakness, a lack of faith and evidence of a soul too focused on worldly, or ephemeral, things. I believe in God, pray every day and feel that God has given human beings the information, capability and talent to create interventions and medicines to treat the frailties of the human condition. I believe that God wants us to have quality of life, not merely quantity of years.
Midlife brings about many changes in a woman’s life – the maturation or ending of marriages, the stride or disruption of careers and the emergence into adulthood of their children, just as their senior parents may begin to show serious indications of true aging and decline.
As if these dichotomies weren’t enough, then enters weight. As women enter their mid-30s+, some begin to realize they must take intentional steps to preserve their health. The habits of their teens and 20s no longer serve them, and they assume all kinds of practices to stem weight gain and lose size. Yet many find that despite all their efforts, including clean eating and exercise, weight loss proves more challenging and fluctuates throughout the month.
But why? What factors drive the sometimes wild changes in a woman’s weight all within the same 30 days, even with steadfast practices to stay in shape?
It turns out that it’s not entirely women’s fault. Some of it is purely out of their control.
It’s hormonal, to a large extent.
Throughout life, women contend with hormonal shifts, swings and changes. Think of puberty. Consider the menstrual cycle. Then there’s pregnancy, postpartum and, now, perimenopause.
According to a professor at Michigan State University, women’s appetites unconsciously rise as they prepare for the possibility of pregnancy, even during perimenopause when women are still capable of conceiving: “Each month, the female body undergoes a menstrual cycle marked by changes in the hormones estrogen and progesterone. Monthly fluctuations in hormones cause women to increase the amount of food they eat and also causes emotional eating, which is the tendency to over consume in response to negative emotions.”
The shift in hormones that happens during perimenopause – usually a woman’s 30s to 40s – can play a part, too. Less estrogen can lead to more visceral fat in the abdominal area, and this is a common complaint of perimenopausal women – that they gain a spare tire they never had before, and it’s harder to lose than ever.
It's also a matter of what you eat and drink.
Aside from premenstrual indications, a woman’s weight can go up and down by as much as five pounds within 24 hours. In such cases, the explanation is usually attributable to water weight and sodium. Cutting back on salty foods and consuming foods high in potassium and magnesium can blunt the impact of sodium.
A casual scientific experiment in which several women tracked their weight over the course of a month is pretty interesting. Even with various levels of exercise, and a mix of “clean” diets to so-so, less disciplined eating, all the women’s weights changed over the course of 30 days.
Alcohol can also cause bloating and impose a state of dehydration that makes the body hold onto weight. This can cause puffiness in the face, the waist and elsewhere. Aside from the aesthetic effects, too much alcohol consumption can lead to a state of inflammation in the body, of which weight retention is a symptom.
Additionally, many people – when enjoying a glass of wine or a cocktail – don’t consider the caloric impact of this indulgence: A regular, 12 oz. beer contains 153 calories, and a small glass of wine (five ounces) clocks in at 125 calories. Many drinkers have more than one drink in a sitting – say, two beers while watching the game or a glass of wine followed by a mixed drink while enjoying a night on the town. Drinking on a regular basis (several days a week) while eating regular meals, snacking and drinking other high-calorie beverages, like frozen coffee drinks or fruit juices, can stack on the calories fast.
It’s about your activity level, too.
Exercise and strenuous activity rev up the heartrate, boost the metabolism and lead to perspiration. Exercise routinely, and you’ll drop water weight more consistently. And you’ll also reap the benefits of calorie burn, too.
According to Harvard Health, during a 30-minute workout of the following activities, a 155-pound person burns 108 calories when weightlifting, 144 calories from water aerobics, 144 calories during hatha yoga, 198 calories doing low-impact aerobics, 216 calories on a stepper machine, 324 calories on an elliptical machine and 360 calories doing step aerobics.
Metabolism with age may play a role.
It’s been said time and time again that metabolism slows with age. According to science, much of this has to do with the loss of muscle mass with age, not just getting older by default. Beginning around 30 years old, lean muscle mass starts to decline unless the person takes action to prevent it through weight bearing exercise and strength training. Researchers estimate that people lose 3-5 percent of muscle mass each decade if they don’t stay active. With less muscle mass, you burn fewer calories. And the weight you gain will be based on fat, not putting on muscle.
Despite this, recent studies published in the year 2021 reveal that metabolism and age don’t necessarily go hand in hand. Researchers found that between the ages of 20-60, metabolism actually didn’t change. Instead, it slowed down after the age of 60 by about 0.7 percent every year.
This evidence shows that the adage of metabolism getting sluggish with age is an unproven maxim. Instead the weight gain is attributable to a loss of lean mass and a reduction in physical activity, leading to weight gain.
Medications that help with conditions but can harm what the scale says.
Some people never needed any medications on a sustained basis until midlife hit.
Unfortunately, some of the medications women are apt to begin taking in their 40s and beyond can be associated with weight gain. Almost 25 percent of women in their 40s and 50s are on antidepressants, and many drugs in this class have been connected to weight gain. Frequently, the antidepressants themselves do not cause weight gain, but they can induce an increase in appetite that leads to more eating.
Aside from antidepressants, there are other medications connected with poundage. They include steroids, which are used for arthritis, asthma, lupus and other health conditions, and antihistamines, commonly used for allergies. Meds for epilepsy and nerve pain, like Lyrica, and beta blockers, which are prescribed for hypertension and anxiety, can also lead to weight gain.
Weight gain at midlife as a woman is a complex thing. As you can see, there are various clues and causes for it, from monthly hormonal changes beyond one’s control to lifestyle factors that are in one’s sphere of influence.
Some strategies for coping with age-related body changes include adopting a wellness-focused lifestyle that prioritizes feeling good more than fitting into a socially acceptable model of beauty. Developing this mindset doesn’t mean foregoing exercise and sound nutrition for French fries and sugar binges, but it does acknowledge that doing well by one’s body turns the focuses to maximizing its function for the long haul vs. short-term gains in unhealthily obtained weight loss.
Other methods include becoming even more cognizant of diet and exercise if you’re on medications associated with weight gain. Taking a drug that heightens appetite is not necessarily carte blanche to eat whatever, whenever. Rather it can be a sign to be that much more disciplined because an increase in desire to eat due to a medication doesn’t mean the body physiologically needs more food to fuel it.
With age comes change, as most of us can attest. Change in our lives, change in the world, change in our spouses and children, and change in our philosophies, ideals and goals. This can be a time to be more forgiving and tolerant of those changes, holding a mirror of acceptance and goodwill to ourselves as much as we extend that to others.
“God, grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference.”
The Real Peri Meno is devoted to all things perimenopause - the science, treatments, care, understanding, personal experiences, relationships, culture and more. The brain child of Keisha D. Edwards, The Real Peri Meno developed out of her own shock-and-awe experience with perimenopause and navigating the disjointed U.S. medical system in search of answers, support and relief.
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