Why We Can't Sleep

by Ada Calhoun

  “I’m sure men are in the same boat as far as having to be on antidepressants because of outside circumstances,” said a midwestern woman I talked to. “But looking at it from a woman’s perspective, it makes me even more angry. We give so much of our bodies to others already.” So much of womanhood just hurts: cramps, childbirth, mammograms, Pap smears, breastfeeding—not to mention eyebrow threading. “There’s so much wear and tear on us, yet we’re all expected to look younger than we are. Now we’re also fucking with our brains so that we can live in this world. It’s just so much.”

  Many of us are getting less help than we should be from our doctors. A 2013 Johns Hopkins survey found that only one in five obstetrics and gynecology residents had received formal training in menopause medicine.²² That’s 20 percent of gynecologists. Forget about general practitioners. Forty-two percent of menopausal women in one survey had never discussed menopause with a health provider; only one in five had received a referral to a menopause specialist.²³ The North American Menopause Society (NAMS) and other groups are fighting to change that. You can go to the NAMS website and plug in your zip code to find NAMS-certified menopause-trained gynecologists near you.²⁴

  One practitioner who will pop up if you live in New York City is the Menopause Confidential author and gynecologist Tara Allmen, who also happens to be a menopausal woman.²⁵ Dr. Allmen told me that there’s good news for Gen X: “Your generation will be the generation that is the most educated. Now everyone has taken a collective deep breath and really does understand who can benefit from hormone therapy. You are the hopeful generation. You should be thinking, ‘Lucky us!’ even though plenty of misinformation still persists on the internet and among the older generation of physicians or the younger ones who haven’t had the training.”

  As it turns out, the reason Generation X women have grown up believing that hormone replacement therapy—again, one of the only proven treatments for menopausal symptoms—is dangerous is something that happened in the medical community in 2002.

  In the 1990s, menopause was becoming a hot topic. Many Boomer women were getting treatment for their symptoms. It was in the news and on the talk shows, especially because in 1991, for the first time, the head of the NIH was a woman: Bernadine Healy. Two years later, she launched Women’s Health Initiative (WHI), a national, long-term study on the possible benefits of hormone treatment for postmenopausal women. But in July 2002, the NIH announced the premature termination of the estrogen-progesterone part of the study. The reason given was an apparent rise in the risk of coronary heart disease, stroke, blood clots, and breast cancer. There was a hitch in this: WHI had been looking at what the hormones did in women ages fifty to seventy-nine. The aim was to figure out if this type of hormone treatment could help protect these women from heart disease and other illnesses. It was not about short-term hormone therapy for treatment of symptoms in women in their forties and fifties. But many midlife women heard only “cancer” and went off HRT immediately.

  Dr. Wulf Utian, founder of the North American Menopause Society, wrote an editorial calling the manner in which the study was ended “poorly planned, abrupt and inhumane.”²⁶ In 2017, Professor Robert D. Langer, one of the original WHI investigators, said that errors in the 2002 report led to a lot of unnecessary suffering for women.²⁷ That same year, the North American Menopause Society’s official policy position called hormone therapy “the most effective treatment” for symptoms like hot flashes, adding: “For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS [vasomotor symptoms like hot flashes] and for those at elevated risk for bone loss or fracture.”²⁸

  However, this has done little to calm the fears of hormone therapy among women—and even doctors—that the misleading news stories about the WHI study instilled.²⁹

  “July 9, 2002, was the day the music died for menopausal women,” said Mary Jane Minkin of Yale, one of the nation’s leading experts on gynecological health.³⁰ “One of the things that were very bad about it is that no OB/GYNs were given advance notice this report was coming out. There was also a journalistic snafu. A WHI investigator gave the story to the Detroit Free Press on the grounds that it was an embargoed study due to appear the following week in the Journal of the American Medical Association. The Detroit Free Press broke the embargo.

  “Which is how Good Morning America got the story. It aired on a Tuesday morning. Everybody went insane. None of the OB/GYNs were prepared for this. And the JAMA article did not come out until July 17.

  “In that week, every American woman went to her cabinet and took out her hormone prescription and flushed it down the toilet. Which of course was ridiculous, because the WHI Part One was the only study that was stopped at that point. That was the estrogen plus progesterone. The estrogen-only went on for another two years. It eventually showed a decreased risk of breast cancer, not an increased risk of breast cancer. But the minute you say ‘breast cancer’ to an American woman, she panics, goes to the toilet, and flushes everything down.

  “As much as I love estrogen, and I love estrogen, I would not want to have been a fish in the United States on July 10, 2002. It’d have been awful.”

  In response to the panic, the North American Menopause Society started changing guidelines for estrogen use. The FDA issued warnings. American medical schools largely stopped teaching hormone therapy.

  “Now what do you have in the equation? You have Gen X ladies who are hitting perimenopause,” says Dr. Minkin. “People of this generation tend to be a bit demanding, and they’re having all these things happening to them. Why are they happening? What’s going on? Their OB/GYNs aren’t talking to them about it. They’re being told: ‘Just ignore it; it’s going to get better,’ or ‘You can take an SSRI [the class of antidepressants that block the reabsorption of serotonin], which will help your hot flashes—though, yeah, it’s going to make you love sex less and get fat.’ Your options are not too fabulous, but they don’t know how to handle hormonal therapy, because they think it’s going to give you breast cancer, and you’re going to die.

  “Then you have all the internal medicine people convinced that estrogen is bad for you, so even if I start somebody on something I have a young internist who’s telling you, ‘Minkin’s trying to kill you. Cut it out.’ This is the perfect storm, and the other part is the insurance companies are making it a real pain in the ass to treat people, because I have to get a preauthorization, and a lot of the products are expensive.

  “The other part of the problem is you have such authoritative spokespeople as Dr. Kim Kardashian, Dr. Suzanne Sommers, Dr. Oprah Winfrey, Dr. Gwyneth Paltrow.”

  Dr. Minkin took my notebook and carefully drew a jagged descending line. She labeled it, “Dow Jones Industrial Average, September 2008.”

  This, she says, is almost identical to the graph you could draw tracing a woman’s ovarian function fluctuation during perimenopause: “It’s going down, but it’s not a smooth line.” That up and down illustrates the erratic mood swings so many of us experience.

  She does not believe that women should grin and bear it. Here is some of her advice for us:

  Get daily exercise, especially weight-bearing exercise; a good diet; and plenty of sleep.

  For hot flashes, she advises layering clothes and keeping a dry set of nightclothes next to the bed so you can change quickly if you wake up in the middle of the night. She recommends keeping the bedroom cool and getting your partner an electric blanket if he or she complains.

  Other nonpill things can make life easier, like absorbent “period-proof underwear” and period tracker apps.

  She advises many women to consider estrogen-and-progesterone hormone therapy (or just estrogen, if you’ve had a hysterectomy), in the form of pills, patches, gels, or sprays, though it’s important to do so only under the direction of a doctor because there are risks, just as with birth control pills.
(Both Dr. Minkin and Dr. Allmen told me that a low-dose birth control pill could help me with my perimenopausal symptoms.)

  Low doses of an SSRI or SNRI antidepressant can combat hot flashes, as can gabapentin (Neurontin). For heavy or irregular periods, Dr. Minkin says you can take a birth control pill or get a progesterone IUD called Mirena. When it comes to herbs and supplements like evening primrose oil or bee pollen, there’s no proven benefit, though some women say that those things make them feel better. There’s been some encouraging research on the effect of black cohosh, a member of the buttercup family, on hot flashes, though as with anything there are potential side effects.³¹

  Sifting through all the advice is hard, especially because it can seem to change with every new headline. In her history of hormones, Aroused, Randi Epstein writes: “Those of us old enough to be in menopause can’t help but wonder if the experts are going to change their minds again.”³²

  The writer Darcey Steinke’s 2019 book Flash Count Diary is a search for meaning in a physically grueling menopause that had her flashing multiple times a day. She discovers that menopausal killer whales—yes, killer whales go through it, too—are the ones that lead others in their pods to food.³³ She finds comfort in identifying a reason behind the emotional and physical changes of middle age: some sign that it’s not for nothing.

  For better or worse, we are undergoing a transformation.

  In her 2019 memoir, Deep Creek, Pam Houston gives a younger woman this advice: “I’m just saying, I guess, there’s another version, after this version, to look forward to. Because of wisdom or hormones or just enough years going by. If you live long enough you quit chasing the things that hurt you; you eventually learn to hear the sound of your own voice.”³⁴

  Perimenopause may last months or years; it may be more or less drastic; but one day it will be over. On the other side, we’ll be different—perhaps more focused on what’s most important to us and almost certainly calmer. Psychotherapist Amy Jordan Jones told me,³⁵ “This is the time of life when we learn that we don’t have to be pleasing; the work now is just to become more ourselves.”

  10

  The Very Filtered Profile Picture

  “We’re told: ‘It’s okay to be you!’ But enter Instagram. I don’t put up crappy pictures of myself. I use filters. We put a lot of filters on ourselves.”

  On my way to a party, I took out my phone, opened the camera, and tapped the reverse button. I was greeted with a sagging, weary face, so crone-like it made me gasp. I put on powder and lipstick. I changed filters and looked again. Still house of horrors. I put my phone away.

  In our mothers’ and grandmothers’ eras, phones and mirrors sensibly sat on tables or hung on walls. But Generation X women noticed their first wrinkles in a zoomable smartphone camera. It’s easy to obsess over that image.

  “Are you insane, man?” a middle-aged friend of mine said when a young man went to take our picture at an unflattering angle. “We aren’t teenagers. Shoot us from above. Here, stand on this chair.”

  Boomer friends of mine have profile photos that could double as their work ID badges. Millennials change out their avatars all the time. But few are the Gen X women with a social media photo that hasn’t been carefully planned, judiciously framed, and filtered. At school pickup recently, I looked around and realized that I could not recognize any of my fellow parents from their Facebook profile pictures.

  Seeing airbrushed faces all day has brainwashed many of us into believing that we should not have lined faces in our forties.

  “I will be the first person to tell you I am grasping,” a Silicon Valley executive told me. “I work out every day. I eat super-clean. I have had Botox. Because I don’t want to get old, right? I don’t want to be dismissed. And regardless of what anyone says, man or woman, when you walk into a room and meet someone for the first time professionally, there is an assessment of what you look like. I don’t want to lose that edge. And that’s part of the crisis: am I going to lose my edge because, ‘Oh look, here comes the dowdy middle-aged woman’?”

  This fear of looking old is not new, of course. The other night, I watched Sunset Boulevard for the first time in years. In the movie, the former silent film star Norma Desmond is holed up in her house, refusing to admit that time has passed and the world has moved on. She is a pathetic figure, mourning her lost youth and sex appeal. Do you know how old Norma Desmond is in that movie? Fifty.

  The average age for a facelift has historically been over fifty, but the age at which women get plastic surgery has been dropping. According to the American Society of Plastic Surgeons, in 2015, more than 7.6 million cosmetic procedures were performed on people aged forty to fifty-four. Between the years 2000 and 2016 procedures for soft-tissue fillers like collagen went up about 300 percent, usage of Botox and comparable brands by more than 800 percent, and upper-arm lifts by 5,184 percent.¹ This means that if you’re not getting anything done, you could look older not only than your younger colleagues but also than a lot of people your own age.

  “I was young for so long,” said a woman standing near me around a firepit at a backyard party. “It feels like I was young until five minutes ago.”

  Her Facebook profile is a photo of herself as a little girl.

  Gen X straddles the pre- and post-internet worlds. The youngest Gen Xers belonged to the last graduating class to finish college pre–social media.² Facebook was invented in 2004. The iPhone came out in 2007. How fitting that many younger Gen Xers and older Millennials were introduced to computing by the bleak Oregon Trail—which frequently ended with you and all your friends dying from dysentery.³ Personally, I loved the game. Again, again! Maybe this time we’ll get cholera!

  In Zero Hour for Gen X: How the Last Adult Generation Can Save America from Millennials, Matthew Hennessey delivers a tone poem of sorts about our precomputer world: “We were raised on analog technology—pencils, pens, notepads, books, index cards, the Dewey decimal system, newspapers, magazines, back issues, posters, mail order (sorry, no COD), records and record players, cassette tapes and boom boxes, video stores, landline telephones, answering machines …”⁴ As nonnatives to the internet world, we have no natural immunity to the internet. Our poor 1970s and ’80s brains, formed in the primordial ooze of the Sony Walkman, Columbia House Record and Tape Club, pay phones, and typewriters, must now contend with Instagram Stories.

  Hold on. Just one sec.

  On Instagram, Jenny C. is now following me. Who is she again? Oh, right. She had a baby? Wow, that is a cute baby! I sort of wish I’d had another kid. Too late. Oh well. Good meme about the video game Fortnite! Heh. Alana’s baby is getting big. So many babies. Sigh. Why is Waylon in Paris? Jami is in Italy. Liesl is in India. I want to go to Paris and India and Italy. Why do I suddenly feel lousy?

  Social media doesn’t just make us feel bad about our looks. It also—as we hear so often—makes us ashamed of our imperfect lives. Facebook does this,⁵ experts say, “by showcasing the most witty, joyful, bullet-pointed versions of people’s lives, and inviting constant comparisons in which we tend to see ourselves as the losers.”⁶

  “As we know more now than ever before,” writes psychoanalyst Adam Phillips in Missing Out,⁷ “about the kinds of lives it is possible to live—and affluence has allowed more people than ever before to think of their lives in terms of choices and options—we are always haunted by the myth of our potential, of what we might have it in ourselves to be or do.”

  Social media rewards us for adopting the self-congratulatory tone of holiday letters, all chipper spin-doctoring. If only someone would write an honest one of those: “We’re disappointed the kids aren’t doing better in school. We haven’t had sex in a year. We fought with Brad’s sister at Thanksgiving and haven’t spoken to that side of the family since. I hate my job, but money is tight. Happy holidays!” If only there were some way to be genuine online and unaffected, too.

  A Gen X friend of mine told me she had a question the other day f
or some of the Millennials she works with: “You send each other memes all day. Aren’t you worried that the people who get them won’t find them funny?” She says they looked at her as though she was insane.

  That was when she realized that we are the only generation to overthink communication. “Our parents and grandparents have always sent newspaper clippings without worrying that people would find them annoying. Now kids send memes without a second thought. And you know why? Because they’re not joyless. They aren’t subjecting themselves to constant self-scrutiny. Meanwhile, we would agonize over a mixtape for weeks and then hand it over saying, ‘It’s nothing. It’s fine if you hate it.’”

  One North Carolina woman told me that social media, for her, has been an opportunity to perform a perfect life—a life she does not actually live: “No one knows you might be on your third shirt of the day at eight a.m., because the first one your toddler used as a napkin and the second one got splattered with coffee because you forgot to tighten the lid on your travel mug. No one knows that the perfect family beach photo you posted on Facebook was preceded by a dozen reject photos of your kids throwing sand at each other’s faces and your baby trying to eat seagull poop.”

  Psychotherapist Deborah Luepnitz told me her Gen X clients suffer greatly from comparing themselves with others. When she tells them that everyone struggles, they tell her: “‘But you don’t know the couple next door.’ Everyone has an example. ‘The couple across the street, they have a beautiful house. It’s always clean. They both are at the top of their professions. The children are award-winning gymnasts. They never seem stressed out, and they don’t have to cry to a therapist, and they never complain. They just entertain, and they seem so comfortable and low-key!’ My advice is: Don’t ever compare your insides with their outsides. There are people, I guarantee you, who think you have the perfect life because they don’t know what you’re struggling with.”