Dassie Abelson

I was born in 1944 in what was Palestine at the time, but is now Israel. We were still under British control. It was the time of the Second World War and there was very little we knew about what was happening in Europe. Immigrants to Israel were attempting to enter the country, but the British didn’t allow them. These were people who suffered tremendously, who were able to escape because they wanted to be alive and find a place of safety. They didn’t know anything about the country except they were hoping for freedom and a better way of life. My mother was one of those people.

My mother, Sara, was an artist designing clothes in Europe, in Hungary. Sara moved to Palestine in the late 1920s to be with her sisters. By the time she arrived, one sister had died and Sara’s life became chaotic when she became responsible for her sister’s children; their welfare and survival became her primary focus. She wasn’t ready for that.

Two of Sara’s brothers, David and Norman, managed to emigrate to the United States prior to the war and at the end of the war, they were the only 4 siblings to survive the holocaust—the rest had perished.

My father, Shlomo became a farmer when he came to Palestine from Poland in 1925 with his mother and stepfather. Amazingly, we found copies of his passport to confirm this passage. My father was a twin and his brother stayed in Poland to serve in the army but did not survive WWII.

Shortly after Sara’s arrival to Palestine, she was introduced to Shlomo and they married, mostly out of necessity. They respected each other. They had a good life. They were able to purchase some housing in the Tel Aviv area and open a bed-and-breakfast type of place. They were picking people from the street, more for generosity, and really didn’t charge them. My father was very outgoing and caring and my mother just wanted to help people.

I had two older brothers, Chaim and Dov, who were 10 and 12 years older than me. My mother always wanted a little girl so even though I arrived a bit later than my siblings, here I am.

When I was born, Israel wasn’t established yet so there were a lot of Zionists who were doing things to create a homeland. My father was one of them. He was like the American cowboy who went West and did “whatever it is, whatever it takes” to find the gold. He dreamed about having a farm, which he did, outside Tel Aviv. Back then it was just wilderness, right out to the ocean. They happened to have some groves of oranges. That was the dream.

My mother and father never told me, “Don’t do this, don’t do that, you should do that.” My mother was very quiet, a quiet woman. She never talked, she never hugged me, but she was always there watching me every second. So I always knew I was loved, even though there wasn’t real conversation, there wasn’t hugging and kissing and I love yous. But I knew; if there was a man who was suffering down the street or hungry, my father would bring him home for food. There was always food in our house.

As a child, I was not aware of the war in Europe or ongoing attacks in the area or how dangerous my surroundings were, because my parents and brothers were protecting me. I didn’t know any of that. The bomb shelter was my playground. I was a little girl playing in a bomb shelter with my friends and that was normal life at the time.

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In 1948, Israel’s independence was established following the end of WWII, and things began to change. When the country became independent, Hebrew became the national language. Until 1948, Jews lived here and there, scattered around the world. They maintained their identity with their religion and traditions, but this was the first time in thousands of years that they came to the land of their roots. The land was the size of New Jersey. Jews were arriving in the worst shape because of the war. They couldn’t even talk about the horror they went through and survived. Those who survived now had a place to go and begin again. Ben-Gurion became the first Prime Minister and he said, “Everybody must speak Hebrew. Everybody must have a home. Everybody must be able to make a living.”

As a young girl, I always knew who I was: I’m in Israel, I’m a Jew, and I’m free. Nobody hated me for these things. So I was a happy kid. My parents didn’t argue. There was always food on the table. When you experience starvation, the most important thing is food, not even clothing or anything.

The hospital where I was born in Tel Aviv was created in honor of a woman named Henrietta Szold who came to the country from Maryland in 1912. She saw how much sickness there was but no place to get healed. So, she organized volunteers to help create some kind of medical system for everyone, whoever they are, no matter what color, no matter what shape, whatever they need—because there was a lot of disease. She called this organization Hadassah. It comes from the Hebrew word for a healing flower.

I was born around the holiday of Purim, a big festival, which celebrates Queen Esther. The biblical book of Esther tells the story of a young Jewish woman living in the Persian diaspora who finds favor with the king, becomes queen, and risks her life to save the Jewish people. To hide her Jewish identity, she had changed her name to Esther, but her real name was Hadassah. So that’s how I got my name and in Israel, we don’t have nicknames.

Our house was built by a Turkish designer, a famous designer, but because of all the bombing there was a lot of damage to it. But on the floor there was a beautiful mosaic design; I was always looking at this mosaic. When you talk about Tel Aviv at that time, it was just 4 or 5 streets and the buildings were kind of unusual. Our building was higher than most of them, so I was able to see the ocean. There was a huge terrace in the back, it was where my brothers’ bedrooms were, and there was a railroad below. My brothers used to say, “If you misbehave, I’m going to throw you down there on the train!” That road started in Italy, went to Greece, to Turkey, to Syria, Lebanon, Israel all away to Alexandria, where Egypt is. Three different continents! In ancient times they went with camels and horses and buggies and whatever, you name it. By foot even. And what happened? The British made it into a railroad. And to think that in my backyard was that road!

By the way, in my house, we spoke German, English, Yiddish, Hungarian, Spanish, Russian, Polish, and of course, Hebrew. My mother’s native language was Hungarian and my father’s was Russian and Polish. But he also spoke some Yiddish and German, and so did my mother. But my next door neighbor spoke only Spanish. If I needed water, I asked in Spanish.

Education was the highest priority and I went to an all-girls school. But the teachers studied Hebrew in different parts of Europe—wherever they came from—and so they didn’t speak the same language, the same dialect of Hebrew. And some biblical Hebrew doesn’t have modern words. I’ll give you one example: television. How do you translate television into an ancient tongue?! When I came to this country, I didn’t even know what language to swear in!

So we learned poetry; we learned history. We had so much to learn over the 2000 years of journeys of Jews in different countries, different cultures, making different adjustments, different experiences.

There was no telephone or television at home, but I had lots of friends. We gathered daily to study and dance and that’s where I met my best friend, Tzila. She was blonde and I was brunette, and we were competitive and pushed each other. Music was a big thing. I remember it was Elvis at the time. I didn’t like him. I didn’t appreciate him. He was not someone I could relate to at the time.

But you know, the closeness you have with people—I can’t even describe—I never felt like I was missing anything. Honestly, it wasn’t about clothing and things; it was just being with people, being with friends who love each other.

In 1949, when I was 5 years old, I traveled to the United States with my mother to visit her 2 brothers she hadn’t seen in more than a decade, since before the war. Upon arrival, my mother became very sick and had to be hospitalized so they put me in a Jewish home. I was in first grade and went to school, but I hated it and ran away. I gave them a lot of trouble because it was difficult and foreign to me, but I learned English and actually almost forgot Hebrew.

We ended up staying a year in the U.S. and when I returned to Israel, I was embarrassed because I couldn’t remember Hebrew. My friends asked, “What do you know in English?” So, I sang “tea for two, two for tea. One for you, one for me” and I never forgot that song.

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When I was in high school, my mother’s health declined again, and by now she was blind from glaucoma among other ailments. It was hard to watch her suffer, but she didn’t want to hold me back and encouraged me to keep moving forward.   

Israeli citizens, regardless of gender, were required to participate in military service (and still are). I went with kids my age from all over the country and I hated it, because it was tough. But always, I still say, that was the best school I ever had in my life because you had to be disciplined. I learned safety, skills, and courage. I learned how to survive in the desert, pitch a tent, sleep with a gun, and how to shoot it. It was empowering and life altering.

I’ll tell you something about women and men in Israel: we didn’t have issues with equality. We had a woman Prime Minister, Golda Meir. In this country, you still can’t get a woman to be a president!

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Israel was evolving. People who come from different parts of the world with different cultures, different food, different ideas, they knew maybe one word in Hebrew. That was a difficult situation! How do you integrate all of these people and make them one? It’s impossible, right? So what happened? They built kibbutzim. The kibbutzim was all around. The settlers created agriculture, they built buildings, they lived a life of togetherness, and then we protected that.

While in the army, I was required to take tests and assessments to discover my best skills, and I was told I would be a good teacher. I was always interested in my education so I took courses at the University of Tel Aviv for 2 years, but life changed, and I was on to the next adventure before I was able to finish my degree.

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So in the year 1964 when I was 20-something, I came to this country. I always say I came with the Beatles. And I did like them very much. I stayed with my cousin, Rivka, in New York City. Her marriage was arranged by a matchmaker, and she lived in an ultra-orthodox  community in Brooklyn. It was culture shock for me, and the rules were too much. I couldn’t take it. So, I contacted my uncle David who lived in Los Angeles and got on a plane to stay with him and his wife, Evelyn. They didn’t have children and they weren’t accustomed to a young independent woman with experience serving in the army. The first thing Evelyn did was pray to God that I “find a doctor or lawyer and get married and get the hell out of my house!” That’s what she told me!

It was the first time I ate cereal in my life, I have to tell you. And it was the first time I ate an apple. We didn’t have apples. And we didn’t have the cereals that puffed up and made noises. The only thing I ate that I loved was ice cream and fruit. I don’t know how I lived on that, but I just was not a big eater.

It was culture shock again just on a different coast. I used to go to the beach a lot, that was my escape. I babysat, waitressed, and did odd jobs at the Jewish Community Center. Evelyn introduced me to a friend who lived near Venice beach. This girl said, “On Sunset Boulevard there’s a coffee shop with Israeli food. I think you like very much to go there.” I said, “Anything Israeli, let’s go!” That’s where I was introduced to this boy Murray from Rhode Island who was in L.A. studying law. Murray had recently spent 6 months in Israel, so he was happy to meet me and practice his Hebrew. We went on a few dates and my aunt Evelyn was thrilled!

A few weeks later, I was at a house party with Murray, and he offered me a beer. I was not a drinker, but everyone around me was dancing, drinking, and getting crazy. Murray had too much to drink and got sick. I wanted to get the hell out of there. Murray’s roommate, Ken, comes to help me. The savior!

Ken and I started dating. While he was in law school, I began a course in hairdressing. I took a course in hairdressing because I wanted to go and have my hair done, so I might as well learn how to do this. You don’t live until you try it all. I moved out of my uncle’s apartment and roomed with some Israeli girls I’d met. But my visa was expiring, and I needed to return home to Israel.

That’s when Ken said, “No, you’re not going. We are going to get married. I’m going home to tell my family and they’re going to love you, the Jewish girl!”

Ken flew home to Providence, RI to share the exciting news with his family, transfer to a law school in Boston, and get things ready for my arrival. We had a small wedding on September 11, 1965. Only a few of my cousins from New York came to the wedding. We didn’t even have a honeymoon because he went back to school the next day. We had the weekend. But you know, to me, education was always first: education, education. So I’m telling you this: But I’m strong enough. I’m living with the love of my life.

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I didn’t know how to cook, and we didn’t have much money, but we bought some cookbooks so I could learn. Ken likes leg of lamb, so I get a recipe and it says to put rosemary on it. I put the whole jar on it! It was a disaster, the smell, the smoke! Then, suddenly, the lights went out! I thought Oh no, I shut the power down! But it was actually a black out in the entire city!

Never have I  used rosemary again!

We lived in Brookline, MA, until Ken graduated law school. After graduation, we moved to an apartment in South Weymouth because it had high ceilings and lots of light and was near beaches.

It was tough at first to find my way but then, I met Kelly in 1970. She and her husband, Ernie, lived on the first floor of the same apartment building, and we immediately bonded because we were both pregnant. Kelly came from a wonderful Greek Orthodox family who welcomed us. Kelly was a teacher and taught me all the nursery rhymes, “The Itsy Bitsy Spider” I remember. Ernie and Ken commuted daily to Boston together. Today, still, we are family.

Our 2 daughters were born a week apart and then we both got pregnant with our second children at the same time. We bought houses on the same street and delivered our second babies exactly a week apart. It’s 54 years later, and I can’t say enough about this beautiful person and the special bond of friendship that we continue to share.

When my kids were younger, I went through a terrible phase of depression. I wanted to learn the culture here, but it was very difficult for me because I had such pride. I’m a very big achiever. But I got very depressed and I suffered from tremendous migraines. I was in a store one day and was talking with a woman. I said, “I try, but I don’t know where I’m going and I am not sure about my future here.” This country, the golden land, whatever—money and the trees, and all this baloney—you know I just couldn’t find myself. She said, “You know what, you’re very lucky. You have a culture, a rich culture, and you have a culture here. You just have to cross the bridge when you’re here, learn about here. When you go home, take the bridge back home.” And that helped.

The bridge is okay with me. I can be myself. I have an accent, yeah. I speak other languages, yeah. I know about other cultures. This is who I am.

Sometimes I can misjudge, but I’m not perfect. I try to get to know a person and realize the goodness in them.

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With 2 young daughters, we were looking to connect with other Jewish families in the area. We saw the name Levin on a mailbox (“Are you Jewish?” “Yes!”). So one thing leads to another, we strike up a conversation, and they invite us to join the local congregation.

There was no actual synagogue, it’s just a group of people gathering in the Old Ship Church parish house and in peoples’ homes for services and holidays. It was cozy and welcoming at first, but as the group grew, we knew we needed a permanent home. The opportunity arrived to build a place for us to gather. Ken and others made a plan to find the money, the land, build a temple, and find a rabbi to make it happen. We finally got our home.

Teaching was never an interest of mine or in my plans, but with my second child, we needed to start a Hebrew school and no formal education plan was in place at our new synagogue. I knew what I had to do. And with the support and encouragement from then Rabbi Benjamin Rudavsky, I contacted the Bureau of Jewish Education in Boston, explained the situation, and they connected me with a wonderful educator and mentor named Esther Karten. Together we designed a curriculum and program to support the needs of our growing Jewish community.

Funny story: a few years ago, I was in South Shore Hospital, and a doctor came by again and again. He finally stopped and asked, “Are you Dassie Abelson?” And I said, “Yeah. Why?” He answered, “You were my Hebrew teacher at the temple in Hingham! Because of you, I moved to Israel. I made Aliyah. I joined the Israeli army. Do you know what you did for my family?”

I know as a person that I was teaching people. It wasn’t just teaching a language. I was giving these kids—who come from all kinds of backgrounds, who are Jewish, who didn’t understand the value of who they really are—their history. I had a mission to give them that. Because of parents like my parents, we’re still here. 6 million are gone. There could have been more and we would be over.

The best way I started my classes was singing the song [the national anthem]. When I was teaching, I realized the kind of treasure that comes from learning from people who escaped hardship and who were dedicated to their heritage. To the tradition. So yes, connection; I have plenty. The more I see that we aren’t alone, the more I feel blessed.

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I’ve had a passion and appreciation for art as far back as I can remember. I love experiencing art (in all forms) from other cultures, attending artist talks, going to museums, and supporting the arts. The walls of our apartment and just about every surface are covered in paintings, pottery, and sculptures that Ken and I have collected from all over the world. We love it!

I have also been a painter for more than 40 years and while I’ve tried a variety of mediums, I currently focus on acrylic on canvas. My favorite thing to do, and what keeps me going and motivated every day, is to set up an easel and paint outside in the fresh air, especially near the ocean. I also love painting anything with flowers. My favorite spots are in Hull and Provincetown. And I love to revisit the same places again and again to paint them from different perspectives.

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As I age and deal with health issues and losing lifelong friends and family, I’m grateful that I have a husband with whom I can share this journey, and we can kvetch to each other. Sometimes it’s not easy, but we do have each other. I take art classes at the South Shore Art Center in Cohasset, and I spend time with my daughters and grandchildren (kvelling!). My biggest issue is my connection to Israel and not being able to visit as often as I wanted. Tel Aviv is my special place and that’s where my heart is.

Nina Coslov

Data.

That is all Nina Coslov wanted. Data to explain the changes in her body (was she experiencing the change?) Surprisingly, she found there wasn't a lot of data for women to educate themselves on hormonal changes,  perimenopause, or menopause. She recruited a friend, doctors, and collaborators to create Women Living Better, a consumer-friendly research and education organization. Her work has become a movement, really, and a portal to the answers from thousands of women (All together now: "Thank you!")

Editor's Note: When we spoke to Nina this spring, the word "menopause" was in the air. There are stories everywhere about validating a woman's feelings about her body changing. But when Nina's data came across our desks, we knew there was a story about a woman who had to know more. We had to know more about this story.

Our conversation begins here:

Can you tell us how you and your co-founder started Women Living Better? As a young woman, you were sort of brushed off by your doctors about some symptoms you were experiencing, that you wondered could be related to menopause, is that right?

I want to be a little careful about the “brushed off” by doctors because I think we have to step back and realize that sufficient research about perimenopause just has not been done. So most of our medical providers are doing the best they can with what they know. The lack of validation of our experiences—that’s happening. Whether we call it being “brushed off” or dismissed by health care providers, it really goes back to the fact that there isn’t ample research to create a basis for medical education, to have them know that women could be starting this process while their periods are still coming monthly nor about the very broad range of symptoms that can occur. I think once you’ve skipped a period or have an irregular period, then healthcare providers will look at what you’re sharing and say, okay, this sounds like you might be in the menopausal transition.

So yes, that was the situation for me. I was about 43 or 42 and the first thing that happened to me was I just stopped sleeping through the night. I’d fall asleep, but I’d wake up around 2 a.m. I joke that it was predictably somewhere between 2:08 and 2:11 a.m. and that went on for a long time. The other thing about it was I would be very awake. It wasn’t just like I’d wake up and get back to sleep easily or go to the bathroom and go back to sleep easily. I had a revving feeling; I had a lot of energy. And so I was awake for long periods of time. That led to some sleep deprivation. I had three young children at the time and it just seemed like something had sort of shifted for me, physiologically. Nothing really else in my life had changed. And so that was puzzling to me. Then I’d say maybe 3 or 4 months after that—and whether this was related to the lack of sleep, because certainly mood and stress responses are related to sleep—I noticed a feeling of fragility. I remember thinking, this isn’t me. I just don’t feel like myself. I was worrying about things I hadn’t worried about before. I think we tend to put these feelings in a kind of general anxiety bucket, but it wasn’t typical anxiety. I did not feel a sense of doom, my heart wasn’t pounding. I wasn’t sweating. I just felt less able to cope with things.

A really cool thing about it is that by virtue of creating Women Living Better for others, it helped me know that my experience was normal. Even the words others shared on the site about their experiences, helped me better explain what I was experiencing. Women Living Better does 2 main things. Primarily it offers information about how hormonal patterns change in perimenopause and what those changes can lead to (i.e. what symptoms can arise) for some people. But, we purposely also have many places on the website, polls and open-ended questions for women to share their experiences of and their questions about perimenopause. For example, women’s descriptions of feeling less able to cope were:

“I feel like I can’t calm down on the inside.”

“I feel like my fight or flight response is more sensitive.”

“I startle more easily.”

And those descriptors totally resonated with me.

So, back to how we got started. I mentioned these experiences of sleep disruption and what I’ll call a new, and not like me, fragility to both my primary care doctor and my OB-GYN. Prior to those appointments, I had done some digging in PubMed to see if I could find something that might explain my experience, and there wasn’t much, but there was a little bit to suggest that possibly my experience could be related to hormonal changes. So, I asked both providers that very question: “Could this be perimenopause?” The first question they asked me in return was, “Are you still getting a monthly period?” And I said I was. And so immediately they said, well, then this is not perimenopause.

My primary care physician offered me something for sleep and something for anxiety. And I left and I thought, this doesn’t make sense to me. My gut said there’s something else going on. I was telling all of this to my good friend, Jo, and learned she was having a similar experience. She was still getting a monthly period but was experiencing new irritability and she is a very even, calm person! It felt all of a sudden, out of the blue, and not like her. So I talked her into looking into this with me and that’s how Women Living Better started. In the process of trying to understand our own experiences, we learned so much even about our normal menstrual cycles that we didn’t know. And we thought, Gosh, our bodies have been doing this our whole menstruating lives, why do we not know this? We started connecting with experts who were interested in our idea that symptoms may start for some before noticeably irregular cycles and changing periods.

We did an initial survey in 2016 to test whether others felt like there was a gap in knowledge about perimenopause and menopause. We asked people, 35 to 80 years old, about their cycling status, what they knew about perimenopause, what they wished they knew, and so on. We got a flood of responses. In 3 weeks we had 400 surveys completed. And we had open-ended questions where people were writing and writing. And so we were like, “Wow, we have hit on something here. We’ve got to do something about this.”

The first thing we did was create the web site, an educational resource, with what we had learned. It’s the resource that we wish we had found. The site is evidence-based and cites and explains the relevant research in accessible language. Some people ask, “Can’t you just give me 3 bullets about what to do?” I can’t. Perimenopause is complicated. It’s different for each of us. And because we’re in a transition from a reproductive to a nonreproductive state, things are changing all the time. It helps to be aware of what’s happening in your body and be willing to tweak what you are doing to feel better over time. I like to say that Women Living Better is a kind of do-it-yourself, explore-for-yourself, educate-yourself resource.

It’s so interesting because as early as health class in high school, we’ve always been told that the menstrual cycle is all about bleeding. Right? Even though we know that hormones are involved, it’s always about bleeding.

It’s good point. So much is focused on bleeding, but there is so much more to know that I didn’t! Two key learnings for me that when taken together form an “Aha!” moment: first, that we have hormone receptors, estrogen, and progesterone receptors all over our bodies. They are in our skin, our eyes, our brains. Everywhere. We created an image of this on the site, Hormone Lady. It really drives the point home. Second, a wonderful study—that was done as recently as 1997, looked at hormone levels in a perimenopausal woman’s urine daily for six months. A graph of this, also on the website, illustrates the considerable fluctuations in hormones. This was the first study to challenge the narrative that estrogen declines during perimenopause. In many people, estrogen does not decline during perimenopause but actually rises higher and fluctuates more than it had previously. When you couple these fluctuations with the fact that there are estrogen and progesterone receptors all over our bodies, you start to see why perimenopause can be a really tricky time.

Now that you are educating a woman about her own body, the things she didn’t know she needed to know, how is this affecting the practice of medicine? How are the doctors taking this information?

That’a good question. I mean, I hope that most healthcare providers are glad when someone comes in with more knowledge about what’s happening to them, their hypotheses about why it’s happening, and what things they are interested in trying to feel better.

We are the experts on our bodies and how we feel and what has changed for us. We need to know that. I wouldn’t be comfortable with a health care provider that wasn’t willing to have a discussion about a path forward. They are the experts on what the options are and have a knowledge base of all the women they’ve seen go through this phase. That is important, relevant information but it’s half of what needs to be considered.

For that reason, in addition to the site offering education, we strongly recommend tracking menstrual cycles if you are still menstruating and any symptoms and their frequency.

An addendum to my story: Had I been tracking my periods, I would have noticed that they were coming closer together. That shortening of your cycle is a sign that hormonal changes are afoot. I’m still not sure whether my health care providers at that time would have seen my shortening cycles and said, “Oh, maybe it is perimenopause,” but they might have. We sort of dumb it down to either regular periods or irregular periods but it’s more subtle than that.

Detailed information about changes to periods, like heavier or lighter bleeding, changes to days of flow, amount of flow, and changes to cycle length can provide an opportunity for a more informed discussion with your health care provider as well as shared decision making if there are therapeutics to be considered.

While it seems like there is much more information about perimenopause out there, and there is, so many people still don’t know what to expect and don’t know what is happening when it begins, so there is lots to be done. There aren’t enough healthcare providers trained in perimenopause and postmenopause care. And, to your question, if you read much of the coverage in mainstream media, many stories are about women still being dismissed. I’m hopeful that the increased discussion about perimenopause has highlighted the need for much more support.

I hapen to believe that normalizing a patient’s experience can be a big help. I know it would have helped me to know that sleep and mood are often wonky during perimenopause. And I think for some people, just coming to Women Living Better and spending time on the site can do just that.

So tell me about your research.

After we got the first version of the site built, Jo moved on to another project. It was around the time I was realizing how vast the knowledge gap about perimenopause was. There were—and are—so many unanswered questions. I wondered whether I could do something to help fill that gap.

My biggest question, based on my personal experience, was whether for some people symptoms start before noticeable menstrual irregularity, that is while periods are still coming monthly. I wondered whether symptoms before a noticeable change in cycles were similar to or different than those later in the transition, closer to menopause, the final menstrual period. I decided I wanted to do some research. I was lucky to be able to connect with Dr. Marcie Richardson. She is the founder of the Atrius Menopause Clinic in Boston.

I asked her questions about what research there was on symptoms starting early and she put me in touch with an amazing researcher from the University of Washington in Seattle, Dr. Nancy Woods. Dr. Woods has been a pioneer in midlife women’s health research. I shared my idea about symptoms starting before menstrual irregularity and that some people were getting brushed off or dismissed and turning away from mainstream medicine because of it. Dr. Woods thought this was interesting and related to her previous work, but she hadn’t explored it directly. She agreed to look into it further.

So in 2019, we started a research collaboration, the 3 of us, that is still going on today. We started with a very large, cross-sectional survey in 2020, and we’ve now published 6 papers in peer-reviewed journals based on that data. We are currently working on a 7th paper. Our first paper really answered the question: What is the symptom experience for some people while they’re still getting monthly periods and how does that compare to once they’ve started having much longer cycles or a skipped period?

That survey and the whole paper are on the WLB website. Interestingly, we had to do a GoFundMe campaign to make it open access and available, because I never thought about it being stuck behind a paywall. I was just so focused on getting it done. Now the whole paper is out there and I tell people, go look at tables 3, 4, and 5. They strongly support the message “you are not alone.” There is really such a broad range of symptoms that arises during this time. It’s important to note that at the same time we are making this reproductive transition, we are also aging. Research hasn’t yet linked many of these symptoms to hormonal changes per se. But we know that many midlife women report them.

So if I had to say the top 3 things that the first paper found, they would be: 1. For some people, symptoms start before periods are noticeably irregular. 2. The symptom experience is very broad. We all expect it to be a hot flash or a night sweat. It isn’t. It’s in fact, much broader. 3. 59% of respondents said they expected changes associated with menopause to begin at age 50 or later. So, we’re not expecting them until 50. And, we’re really just expecting hot flashes. So when other things arise well before 50, we’re thinking, something is really wrong with me. We don’t have an explanatory model for what’s happening.

And this isn’t to say we don’t still have to rule out other things—other issues crop up in midlife, other health conditions that are important to rule out. But, I think if we can understand what is normally associated with this hormonal transition, we’re just so much better prepared.

Women are thinking “Do I need an antidepressant? Some of these women could be facing mental health misdiagnoses.

Yes, I want to be very careful to say that if anything interferes with your life, you should seek advice from a health care provider. But if you’re noticing mood change, feeling more tearful or more irritable, and you’re tracking when it occurs and you notice these mood changes are ebbing and flowing with your cycles, which are also changing in length, just having the knowledge that this can happen in perimenopause can provide an explanation of what’s happening. I mean, this answer is unsatisfying for some people who ask, “What can I do and how can I feel better and what pill should I take?” That’s not really what I’m doing. I am trying to sort of change what we know, how we educate, and how we frame this period of life, so we know more what to expect. I’m not saying it’s all going to go away, because it’s a transition and, you know, it’s the reverse of adolescence. That’s not an easy transition either. But we didn’t have families depending on us. We weren’t trying to balance a million things. We can kind of just be a teenager and let those changes take place. And it’s much harder at midlife to do that.

You specifically mentioned antidepressants. I think there is some data related to antidepressants and their role in treatment. In our research about how perimenopausal health care interactions went, many women were unsatisfied because they were offered an antidepressant when they were sure their symptoms were due to hormones. For hot flashes and night sweats, collectively called vasomotor symptoms, there are antidepressants that in research are close to as effective as hormone therapy (estrogen or estrogen and a progestogen, if you have a uterus) in terms of treating hot flashes. For women who can’t take hormone therapy or with health care providers that aren’t comfortable prescribing hormones, this is often offere

Not to mention what we do know about menopause before we do the research is what we learn culturally. Is it Golden Girls or is it Sex in the City? Then we start looking online, going to doctor Google and we’re inundated with these products that relate menopause with sexiness. Because that’s what we’re all thinking when we’re bleeding for 21 straight days and putting on 10 lbs, right? “How do I get sexier right now? [laughing]

Oh, exactly. Yeah. [laughing] It’s insulting really, the suggestion that we should be concerned with being sexier just as we’re dealing with this wide range of changes. It can be a vulnerable time and many products marketed to us at this time are just taking advantage. It makes me mad.

The other thing I should do, because we haven’t covered this and it can be confusing, is talk about definitions. The technical definition of menopause is 1 day. It is the final day of your menstrual period. It’s a very weird “look-back” definition because you don’t know that you have had your final period until you have not had another period for 12 months. Technically, even in those 12 months, you’d say you were perimenopausal because you don’t know that you’re in the last 12 months. After you’ve had your final menstrual period, you’re postmenopausal. That is the very technical definition but often the term menopause gets used very broadly to cover everything related, the whole lead up to menopause and all the symptoms. Everything before is perimenopause. Also sometimes called premenopause.

Now, the strict definition of perimenopause, also called the menopause transition, is that you have persistent seven-day differences in your cycle length. So that would mean you have a 35-day cycle followed by a 28-day cycle. For it to be persistent, it has to happen twice within ten months. My belief is that we should change this definition to include the time when cycles start to shorten and symptoms arise for some. But as of today the persistent 7-day difference is the technical definition of when perimenopause starts.

We should be educating women when they’re a little bit younger.

Yes, I think we should start educating before all of these things begin. I would love to see some kind of education around 35. To your point, how much better equipped would I have been if I had gotten information about perimenopause at 35? Now, I had a child at 35, and many of us are having kids later and people say, “Nina, 35 is way too young for this message, people don’t want to hear this then.” But I don’t agree. I think we do women a disservice by not preparing them for what might come. Maybe the right age is somewhere between 35 and 38. But, by 40 for sure!

The ideal script goes something like, “Listen, in the next 10 years, your body is going to begin to make this transition from your reproductive years to your nonreproductive years. For some people, that is a non-event. Their bodies kind of absorb the fluctuations and they just suddenly realize they haven’t had a period in 12 months and they’re done. But for other people, those fluctuations have impacts all around their bodies (brain, bones, muscles, skin, hair). And here’s the range of symptoms we’re starting to uncover in research. I just want you to be aware of them. If any of them start to get in the way of your relationships or daily life or work, please come see me. We don’t have perfect solutions to them, but we can try things and then tweak them, and I’m here to support you.”

That could be a game changer and it is a super simple conversation. It’s 3 minutes during a well-visit. And maybe here’s a pamphlet, here’s a website—these are evidence-based. If you have questions, go there first. But again, reach out to me if anything interferes with your daily life, relationships, and/or work.

The other thing that we’re up against here is that the Office of Women’s Health wasn’t established at the NIH until 1990.

There’s an Office of Women’s Health? [laughing]

Well, yes, I’m here to deliver some good news—there is an office of women’s health. [laughing] But, the bad news is, it wasn’t established until 1990. Soon after that, these really important—the first longitudinal—studies about midlife women began. And then it takes research, on average 17 years, to make it to clinical practice so that is a long time. What I’m trying to do with Women Living Better is fill that in a little bit. Now, I’m not going to change clinical guidelines, but if I can take a study or a couple of studies and say, “Look, this is what this research is showing,” I think that can help women. Again, I’m trying to normalize and validate what women are experiencing, but we need more data on the experience of the path to menopause—much more! There’s just so much to be learned.

I sort of joke that Women Living Better is crowdsourcing the menopause transition. We’re collecting lots of data from women about their experiences but we’re not taking blood samples and correlating the symptoms reported with hormones which needs to be done. What we can say is, “a lot of women are having this experience.” That is what I can do with my resources: raise questions, do this kind of research, and share it back with women to help them.

So now there are going to be a ton of questions like, “Is that why I can’t drink wine? Is that why I’m gaining weight? What else do we need to know about menopause?

Many women report not being able to process alcohol in the same way in perimenopause. It is certainly true for me. Weight gain is very tricky. I don’t think we have the answer yet to what causes it at midlife. A recent study showed that metabolism doesn’t change until we reach 60. Research does document a loss of lean mass and an accrual of fat to our mid-section, waist area, during the menopausal transition. There is no one reason that is understood to be the reason behind weight gain, so many of the diets/programs promising weight loss based on some definitive understanding about how things work are unfounded. I think there is too much focus on women’s weight to begin with. Also, there’s chronological aging and there’s reproductive aging happening at the same time. It’s very hard to tease out what causes what.

You spoke about how it affects our bodies and the importance of physical fitness. What we need to know about is what will naturally happen to our bodies in a healthy way versus what we think we need to do to keep lean.

From what I’ve read, this is not my area of research, continued movement, lifting weights heavy enough to build bone and preserve lean muscle mass, and anything that helps with balance to prevent falls will allow us to be able to do the things we want to do into our later years. We’re learning that perimenopause and menopause are both a body and a brain thing. I think our future health is more linked to our midlife health than we knew before.

It all starts with questions. You’ve got to keep asking.

You have to, really. I just did a post trying to help women be wiser consumers of studies. So many kinds of media outlets grab a study and add a sensational headline to get clicks. When we read about new research, we should be asking how many people was that? Was it 30 people or several hundred, several thousand? Usually the more the better. What kind of study was done? Was it randomized controlled? You get interesting information from an observational study, but it only tells you that 2 variables are associated. Only a randomized controlled trial can tell you about cause and effect. It’s really tough to be a perimenopausal woman right now. You brought up the whole thing with products and programs. With social media there’s all this stuff out there and a lot of them are just not tested to prove they work or that they’re safe. It’s just an influencer or a marketer’s claim. And we’re vulnerable.

We’re vulnerable because we’re all feeling like we’re supposed to look like this. And how do I get there? Is there a magical pill? Is it because of this?

Well, you don’t feel well and you read about something that purports to help with what you are dealing with. In the beginning of my perimenopausal journey, I tried a bunch of different supplements. I would take them and think maybe I’d feel a little better. It’s tricky.

It’s so hard to make time, but I think our bodies need a little more support during this time. It’s all in the “self-care” realm but not spa-type self-care, more the basics. If we can create a little more downtime, get outside for a walk, eat and drink more selectively, be really deliberate about sleep, and find a way that works to manage or calm our nervous systems. Just learning to breath, with deep belly breaths, for 5 minutes at a time can go a long way. We are starting to learn that these hormonal changes affect our stress response and our stress resilience. Whether it’s walking or running or yoga or breathing or mindfulness meditation or some kind of breathwork—I think it can be a helpful and important part of trying to find some balance and feel better during this transition.

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