Why We Can't Sleep

by Ada Calhoun

  Sometimes my perimenopausal moods are more rage than anxiety. I woke up the other day and felt that the walls were closing in. My apartment felt too small, my clothes too tight. I noticed that my husband had placed a couple of champagne corks on top of a picture frame. It made me want to start breaking things. What is this, a goddamned dorm room? I muttered while I made coffee. In this state, I noticed things I had missed before: bags spilling out of the closet, stacks of receipts and change on a table, my son’s Magic the Gathering cards everywhere. “It’s like living in Hoarders!” I ranted before leaving the house. By nature I am usually relaxed, even cheerful, but on this particular morning I felt that if I’d had a pack of matches and some kindling I could have burned the place down.

  When I open 1955’s How to Face the Change of Life with Confidence, I see a question from a thirty-seven-year-old woman who has wild mood swings before she gets her period. The expert male gynecologist author tells her: “Man reaches physical maturity at twenty-five years of age, and emotional maturity at thirty-five years. Unfortunately, you seem to have missed the boat somewhere along the line, and you are still in your childish stage of emotional reactions.”³

  Decades of that sort of condescension have kept us from asking certain questions twice.

  “Almost every woman I know of my age is feeling confused and in a state of transition even as most of us are at the top of our game in our careers, financially stable, and pretty comfortable with being parents,” said Yvette, a forty-three-year-old California woman who is the COO of a major video game company. “It’s a strange state of vacillating between having our shit together and feeling less and less like we give a damn about what the rest of the world thinks. I spend a lot of time with other friends of my age. We talk about what’s really going on—the worry that we’re self-medicating too much with wine or Xanax, the anger that seems to creep up more and more. Is it hormones? Perimenopause?

  “The fact that we are widening and softening where we don’t want to and don’t know if it makes us shallow or not feminists to do something about it; the fear that we don’t know how to monitor our children’s screen time; the fact that we don’t really like or need sex very often anymore; our worry that we are losing time to try our ‘dream’ job …

  “I just had breakfast with a friend last week who runs a very successful law firm. One of the things we were talking about is rage. We’re getting frustrated and overwhelmed. You are literally seeing red, and you want to throw your phone against the wall. So now, on top of everything else, it’s also like, ‘Did you meditate?’”

  I can’t even count how many women have confessed to me that they’ve flung something against a wall—their phone, a book, a plate—though it seems telling that in nearly every case, once the fit was over, the woman who threw the object then cleaned it up.

  There are well-publicized tricks, of course, for handling such moments of rage. Deep breathing. Downers. One popular mantra is HALT, meaning that when you’re about to start flipping tables, you should ask yourself if you are hungry, angry, lonely, or tired and take appropriate action (eat a sandwich, go to therapy, call a friend, take a nap; then flip the table). Still, in midlife these feelings can assume a primal character: not moodiness but despair, not irritability but something deeper and more dangerous.

  Sometimes the only thing that helps is screaming. On a particularly rough work trip, her marriage foundering, a friend of mine rented herself a private karaoke room that had a three-person minimum. She lied to the staff, saying friends were coming to join her, then spent two hours alone singing as loud as she could. She ordered enough food for several people so the waiters would stop asking her when her friends were arriving. She felt the freedom to scream at the top of her lungs for two hours was worth the cost of twenty-four mozzarella sticks.

  In The Change, her book about menopause, feminist scholar Germaine Greer says that women’s midlife suffering comes in two forms: “One I have called misery, which has no useful function and should be avoided, and the other grief, which is wholesome, though painful, and must be recognized.”⁴ According to Greer, misery is “a grey and hopeless thing, born of having nothing to live for, of disappointment and resentment at having been gypped by consumer society, and surviving merely to be the butt of its unthinking scorn.” But grief is something else. It’s the natural mourning period for our fertility, something that a woman can emerge from “stronger and calmer, aware that death having brushed her with its wing has retreated to its accustomed place, and all will be well.”

  The experts in gynecology who spoke with me said that hormone replacement therapy (HRT) remains the single most effective scientifically proved treatment for the symptoms of menopause. And yet, fearing the increased risk of cancer, stroke, and blood clots that we’ve long heard comes with a hormone therapy regimen, we’ve gone rogue. And that, perhaps, is why Gwyneth Paltrow’s online community Goop can get away with selling us $66 jade eggs to stick up our yonis.⁵

  It’s also, I believe, one reason why women around the country are looking into treatments like the use of LSD or psilocybin mushrooms as antidepressants or mind-expanders.⁶ In her book A Really Good Day, Ayelet Waldman describes how minuscule doses of LSD produced in her a feeling of contentment.⁷

  Those for whom hallucinogens feel too extreme may seek an altered state of consciousness by drinking wine. A downside of this indulgence is that alcohol is a known sleep disrupter. Comedian Bridget Everett describes the curse of the “chardonnay shocker”—when you’re woken up by the booze wearing off at four in the morning. In my experience, this is often followed by what a New Yorker cartoon depicts as your own private movie theater hell: “Now playing … Everything You Said at the Party.”⁸

  When Kristi Coulter quit drinking, she had an epiphany: “I realize that everyone around me is tanked. But it also dawns on me that the women are super double tanked. I see that booze is the oil in our motors, the thing that keeps us purring when we should be making other kinds of noise.”⁹

  Or we may try health-food crazes. One friend of mine told me she’d started taking a high-dosage vitamin called Optivite P.M.T., even though so far the only thing it’s apparently done is turn her pee neon yellow. Middle-aged drug experimentation might be even more reckless than the teen kind. “It’s funny, right?” my friend said. “How in college maybe we’d be trying pot or whippets, but now it’s Optivite and collagen smoothies? ‘It’s made of some weird gland oil or poisonous plant? Who cares! Gimme that! I heard it gets rid of belly fat!’”

  Gynecologists I spoke with said they weren’t surprised that women were casting around for exotic or illicit fixes to their perimenopausal woes.

  Jacqueline Thielen, who has been working at the Women’s Health Clinic at the Mayo Clinic in Minnesota for twenty-three years, said that life for a Gen X woman today is “just much more complicated.” She sees many women in their forties and fifties who tell her they’re scared of hormone therapy but they’re also made miserable by symptoms and swamped with responsibilities. “You used to go to the store,” she said, “and you could buy either Crest or Colgate. Now you go to the store: Is it whitening? Is it brightening? Is it tarter control? Is it sensitive teeth? There are so many other choices and influences now that I think it’s harder for women to just figure out what they should do.”

  This makes them vulnerable, Dr. Thielen said, to controversial things like subcutaneous hormone pellet therapy, inappropriate ovary removal, or pricey “vaginal rejuvenation,” which can cost several thousand dollars and may involve labial surgery or shooting lasers into your vagina¹⁰—one more thing I guarantee you our mothers did not have on their to-do lists. She notes that the so-called compounded hormones promoted by certain celebrities are not FDA-approved.

  “Women will say, ‘Why do I feel like crying?’ or ‘Why do I feel like screaming if I’m still having my periods?’” said JoAnn Pinkerton, executive director of the North American Menopause Society and professor of obstetrics and gyne
cology at the University of Virginia Health System.¹¹ “If your levels of both estrogen and progesterone are fluctuating, in any given cycle you might have too much or too little of either or both of them.”

  Perimenopausal women often complain of sleeplessness, painful intercourse, breast pain and cysts, changes in appetite and energy level, mood swings, bulging midriff, trouble concentrating, and so on and so forth—all symptoms connected in one way or another to hormones.¹²

  For some women, it’s not a big deal. For others, it can be crushing. In a survey by AARP, 84 percent of participating women said that menopausal symptoms interfered with their lives.¹³

  “You know,” Dr. Pinkerton told me, “we tell people who are grieving not to make major changes for a year. I don’t think anybody’s ever said, ‘Don’t make a major decision when you’re perimenopausal.’”

  Good idea, I think. We can just take it easy until perimenopause ends.

  “How long is that, anyway?” I asked Dr. Pinkerton. A year, I thought she’d say. Maybe two.

  “Anywhere from a few months to ten to thirteen years,” Dr. Pinkerton said.

  “Oh my goodness,” I said.

  “On average, they call it four years,” she said. But she added that what’s important for women to know is that menopause “is actually a lot easier than the perimenopausal transition.” Why? Because perimenopause “is unpredictable. It’s based on ovarian fluctuations. You might have six months of severe hot flashes, skipping periods, and then your cycles come back for three to five years before it happens again.

  “How well your ovaries function depends on your cycle and your mental and emotional state,” said Dr. Pinkerton. “It’s all tied together. Women need to recognize that it’s a time of vulnerability, and there are some things that they can do to help.”

  Dr. Pinkerton gave me an example: “A woman came into my office and said, ‘I hate my husband. I hate my marriage. I need to get out of this.’ The husband had called me earlier and said, ‘I’ve noticed that my wife is really having exaggerated responses to things around the time of her periods.’

  “We ended up getting her into counseling as well as on oral contraceptives. The oral contraceptives calmed the hormones down, and then doing some counseling let her start to see some of the stressors that were hidden. I just saw her and she said her marriage could not be better. She recognized that the perimenopausal hormonal fluctuations were making the problems seem incapable of being solved. Once we were able to calm down the hormonal fluctuations, which for her involved suppression with oral contraceptives, and she did counseling, she could start to see some of the stressors that were coming from his work and her work and their family issues. I guess what I would just say is if you’re in perimenopause, recognize that hormonal fluctuations may make the problems at work or at home seem larger. Maybe you need to calm down the hormonal fluctuations so that you can see the problems in perspective.”

  Women also benefit exponentially from sleeping more, Dr. Pinkerton said. “How many women get seven hours of sleep a night? How many women keep their exercise going when they’re mentally or physically stressed? It’s often the first thing to go, but it’s absolutely one of the things that can help you navigate this time. Then, stress reduction.¹⁴

  “In my clinic, we draw a circle, and I turn it into a wheel. As I listen to perimenopausal women I put a dot in the center, and I draw a line, and I say, ‘Okay, now, let’s give a percentage to how much time you’re spending at work.’ And then I’ll say, ‘Okay, how about caretaking for children? You get extra credit if it’s teenagers.’ ‘How about your parents and your in-laws? How much caregiving are you providing?’”

  Dr. Pinkerton said that looking at that wheel helps women understand why they might be feeling the way they are. If she hears a woman say, “Why am I irritable at work?” she says, “Well, you don’t just have work. You have work at work and work at home and work in the family and work in the community.”

  Race may be a factor in the duration or intensity of menopausal symptoms. The Study of Women’s Health Across the Nation, an observational study, found that the median white woman’s experience of perimenopausal symptoms, including hot flashes and night sweats, is nearly seven years; for Japanese and Chinese women, about five years; African American women, about ten; and Hispanic women, nine.¹⁵

  Other research has shown that women in Japan have far fewer hot flashes and night sweats than women in the United States and Canada. There could be both biological and cultural factors.¹⁶ One theory as to why Japanese women seem to experience far fewer hot flashes than other women is all the soy in their diet.¹⁷ It makes sense: hormones are affected by diet, stress, exercise, and sleep. While it’s not easy for all of us to maintain a healthy weight, sleep eight hours a night, or go back in time and spend our whole lives eating a soy-rich diet, it’s nice to know that at least theoretically some of that might help.

  But here’s what I want to know: why are American Gen X women arriving in their forties knowing something is going to happen, but without a clear idea of exactly what that is?

  One answer is: denial. We have had incentives for a long time to pretend we are the same as men in every way. For decades, women have had to argue that they could still work and function through those messy period-, pregnancy-, and menopause-related symptoms, and as a result we’ve minimized them, both to others and to ourselves. So as not to call attention to ourselves as women, we pretend it’s not happening.

  Boomer women arguably started this, entering the work world in shoulder-pad armor. It makes sense that they felt they had to hide the inconvenient fact of their womanhood, particularly in middle age. In 1970, Representative Patsy T. Mink of Hawaii, who was pushing for women’s rights, fell into a battle with Edgar F. Berman, a retired surgeon from Maryland and member of the Democratic Party’s Committee on National Priorities, over what menopause meant for women’s competence in the workplace.¹⁸

  “As far as national priorities,” Dr. Berman said, “women’s rights are not high on the list,” because “their hormonal states could endanger the world.” Just think, he said, of a menopausal woman president who had to make the decision on the Bay of Pigs, a bank president “making a loan under these raging hormonal influences,” or a pregnant female pilot making a tough landing. Female hormones are powerful enough, in other words, that they could tank the economy, kill hundreds in a ball of fire, or start a nuclear war.

  Even the dissenting voices quoted in the New York Times didn’t seem particularly reassuring. One expert quoted said nuclear war was going a little far: “A woman might be bitchy as hell, but not make serious errors in judgment.”

  After taking our children to see the latest Star Wars movie, a friend and I sat at her dining room table while the kids ran around her house.

  “It’s just too hard,” she said about her menopause. “I thought it was best to do it naturally, so I’ve just been riding it out. But it’s been two years and finally I thought, This has ruined my life! Two years without sleeping through the night! Two years with hot flashes! Two years with no energy.”

  I’d had no idea. I asked why she hadn’t told me before.

  “I hate talking about menopause,” she said. “It’s like saying you’ve closed up shop as a sexual being. It’s embarrassing.”

  Behind us, the kids raced up and down stairs—laughing, oblivious.

  Ultimately, her doctor put her on antidepressants, which she said helped her.

  They do not help everyone. A TV news producer in the Midwest told me that she felt numb when taking them, and her weight shot up: “I struggled with some depression and some anxiety in my late thirties, early forties,” she said. “You’re dealing with these feelings, and then you hear, ‘Oh, you’re a forty-year-old woman, you seem depressed. I’m going to give you medication that will make you gain weight.’”

  Johann Hari’s 2018 book Lost Connections argues that our culture has come to medicate depression first and ask questio
ns later, without recognizing that some discomforts are not medical emergencies. He tells the story of how when he begged for antinausea medication in a jungle hospital in Vietnam, the doctors said, “You need your nausea. It is a message, and we must listen to the message. It will tell us what is wrong with you.”¹⁹

  When I felt depressed in my thirties, I was prescribed an antidepressant. I wish that I had also done more to explore why I was depressed. Now I can see it more clearly: I was working more than full-time for people whose values I didn’t share. I had a young child at home whom I missed horribly when I was at work. I had the pressure of being the breadwinner. Dreams of doing something meaningful with my life felt out of reach.

  One of my oldest friends, Asia Wong, now a clinical social worker in New Orleans, told me: “When I, as a clinician, talk to people about depression, we talk about how three things contribute: your biology; your inner landscape or psychology, which we can work on in therapy; and then your life circumstances. If your life circumstances really suck, you are going to be sad most of the time. You’re going to feel anxious and overwhelmed. If you say, ‘I’m taking care of my aging parents, and I’m working full-time, and I have these little kids, and my husband still has some traditional gender-role stuff,’ you’re going to be sad. Not because you ‘have depression,’ but because your life is debilitatingly difficult. And what I think has changed is that we used to think this was true for poor people. And now it feels true for all of us.”²⁰

  In her 2015 book Moody Bitches, psychiatrist Julie Holland says our moods are “our body’s own amazing feedback system” and that we are using “comfort foods, lattes, alcohol, and an expanding array of neuromodulators like antidepressants, painkillers, energy drinks, and amphetamines in an effort to maintain our unnatural pace.”²¹