English Version | The woman who lived twice

Menopause. “It happens when we are old, and we get hot flashes, but it is what it is and we have to bear it.” It seems like a fallacy that this reductionist notion of the topic could cross someone's mind, but it is one that many people live with, including women. Once upon a time, it was also the definition I myself gave it, particularly when I was young. And then I didn't even gave it a second thought. But, then again, I was also the person who thought that having period pain was normal and that things went away with a Ben-u-ron or a Trifene. Few people contradicted me on the matter. Most likely I‘ve never talked to the right ones myself. Or, more precisely, didn’t ask enough questions. Or none at all. As menopause is ubiquitous, why do we know so little about it, as a population, but most of all, as women? And why is there a certain resistance to talking more about the matter? Not bringing menopause into the discussion only perpetuates the diminishing notion above, which couldn't be further from the truth. But the reality is that these women's issues still have an aura of mystery, and not in the endearing sense - more in the sense of ignorance.

This isn't the first time we've done this with issues related to women's bodies, more specifically their health. Menstruation has also been increasingly brought into an open debate, but continues to deal with myths and doubts that seem to remain in the shadows if the discussion about period is not normalized. One of those responsible for accelerating, in recent years, this need for conversation is Patrícia Lemos, author of, among others, Não é só Sangue – a conversation about the menstrual cycle, which, launched in 2021, continues to accumulate new editions. The book, which was widely recommended to me by my circle of friends (and, though not lacking in knowledge about women's health, they were - we were all - impressed by what we discovered) is not Lemos' only credential: menstrual educator and fertility consultant, has a master's degree in Society, Risk and Health, she is also an accredited Natural Family Planning instructor in the United Kingdom, she is certified in the Fertile Body Method, in monitoring medically assisted procreation, birth hypnosis and menstrual education for girls, and also a member of the Society for Menstrual Cycle Research and the International Association for Premenstrual Disorders. In 2010, she founded the pioneering Círculo Perfeito - Anos Férteis, a project whose ultimate purpose is menstrual education, fertility maintenance and body literacy. Menopause, it is expected, will gain the same airtime as menstruation in question - and it was easy to think of the expert to encourage the debate: “Most women have no connection or understanding of what menstrual health or body literacy are. Inevitably, menopause appears as a separate event, at the end of it all, in a timeline that we always think is much further away than it is, and linked to the aging process, which is an immense stigma in this society that insists on not wanting to grow old.”, contextualizes Patrícia Lemos. “The fact that we are getting pregnant later and later, and the offer of medically assisted procreation that has contributed to the (wrong) idea that we can extend our fertility sine die end up moving us away from the idea of ​​a perimenopause that can set in as early as late 30s. Furthermore, menopause is far from being the 'tourist destination' we would choose because it is sold to us as the end of everything: beauty, youth, fertility, thinness, attractiveness, ability in general... Currently, the number of women in Portugal (and in the world, in general) over the age of 45 is so high that the subject seems to be on the agenda: on the one hand, because we have women wanting to talk about it; on the other, many companies want to market their products and services aimed at this group that has purchasing power very different from that of their mothers and grandmothers, and is now very interesting as a target”, she adds. But if it is such an inevitable, universal and, on top of that, profitable women's event, why the secrecy? “There is, without a doubt, a combination of historical, cultural and social factors that contribute to this silencing”, says the menstrual educator, “but it is important to reflect on how it is impossible to dissociate the processes of objectification of the body and sexuality from this issue of invisibility of female health. There has always been no shortage of women's bodies everywhere – from art, to magazines or, now, to social media; the body is not hidden. Your most primary experience, in terms of health, is what’s hidden – and that's why we have difficulty talking about menstruation, infertility, abortion, sexually transmitted infections or menopause. The visible and socially accepted body is the body removed from function, it is an aesthetic exercise, a product for consumption – we want beautiful photographs of pregnant women, but we ignore those of childbirth, for instance; We want to see women who age gracefully, not those who let themselves be carried away by the inevitability of the years. Anything that makes the body too real or ‘sick’ is not accepted in this social narrative we have normalized. Inevitably, these topics will be dealt with in secret – 'women's issues' - in real or virtual closed groups, often anonymous, or, alternatively, in the clinic where someone specialized has the knowledge and power to unravel such mysteries of the body, since this personal authority remains to be rescued by the majority of women.” In fact, it is not difficult to intuit why this mystery has continued over time - now gradually being “rescued”, as the specialist points out - if we think about the meaning of women in society and their consequent constraints: a historical secondary role and expectations that relegate it to a more demure, beautiful and delicate category, are variables that leave no room for the discussion of these unattractive potential unpleasantness. With menopause being associated with aging, I would even say being connoted with a sense of expiration date, also linked to the end of fertile life, it is no wonder that women have been so discouraged from speaking out and even wanting to know more about this.

Let's start breaking this chain now with the most basic question. What is menopause? It is a natural biological process in a woman's life that corresponds to the end of spontaneous menstruation and can be confirmed after 12 consecutive months without any menstrual period, therefore marking the end of fertility. What happens is a reduction in the activity of the ovaries, which stop releasing eggs monthly and, at the same time, estrogen begins to be produced in smaller quantities. The first expression of this is the appearance of menstrual irregularities, which can last for several years: initially, cycles become shorter, maintaining some regularity; then, they become irregular, with cycles of very variable duration occurring; and, finally, the definitive absence of normal menstruation (amenorrhea) appears after some time, when ovarian failure occurs. On average, in the Western world, women reach menopause at approximately 52 years of age, but it can occur between the ages of 40 and 58 and even occur very early, close to 30, or later, around 60. Naturally, the changes associated with menopause have an important impact on several aspects of a woman's life, making this stage a very difficult period. Diversity is also evident in the way it manifests itself from woman to woman, which makes the conversation even more difficult, because not everyone experiences the process in the same way. This range of situations happens because “in the same way that we do not all enjoy the same menstrual health because the menstrual cycle responds to the dynamics of the body in which it occurs, menopause will occur, in each body, also responding to its idiosyncrasies – this includes lifestyle, diet, weight, health conditions, genetics, etc”, explains Patrícia Lemos. “It should come as no surprise that perimenopause will be different for each of us, however, most women have been medicated their entire menstrual lives, thinking they had a period on the pill, that regular menstrual cycles are 28 days long, and that we ovulate each and every time in the middle of the cycle... It is this ignorance about the menstrual cycle that makes it surprising to see various expressions and symptoms of this phase, and that also creates blind spots for health professionals who expect to see a perimenopause like in the books, taking one’s experience out of the context in which it occurs”, points out the specialist, adding that “from what I observe in my practice, the biggest misinformation is about how menopause happens: most people are unaware of the concept of perimenopause, which is a period that can last several years, (two, four, ten) with different symptoms, until the last menstrual period occurs. Another very popular misconception is that menopause is having hot flashes, which is not only very reducing (there are women who have been in perimenopause for years, but as they have never felt a hot flash, they think their time has not yet come), as it does not correspond to everyone’s experience.”

The multiplicity of experiences does not lessen the discomfort of a less positive process when this is the case. Demystifying them all is also important to create some prevention here to mitigate these afflictions. After all, only knowing how to identify its various manifestations can solutions be addressed. When we asked Patrícia Lemos about prevention and options - such as, for example, the issue of hormone replacement therapy, which consists of administering hormones to replace those that are no longer produced (or are produced in smaller quantities) - she admits that “I like to start with two things that are the Achilles heel for many people, and that should have come from the pre-perimenopause years: good sleep regime and adequate physical exercise. We know that perimenopause can bring changes to sleep quality, so learning how to sleep and prioritizing sleep quality before you get there is essential. Perimenopause is accompanied by a series of transient changes in cognitive terms, memory, ability to focus, sensory and emotional processing. Sleep is therefore essential. Then exercise: as we lose muscle mass quickly during these years, we will want to focus on strength training and balance exercises, which will be very useful to prevent falls in later life. Finally, eat well, everything, without restrictions, understanding what fat, protein and carbohydrate are; manage stress, which is missing in life, but needs to be maintained at healthy levels; and no less important, the creation and maintenance of quality social, interpersonal and loving relationships, with meaningful exchanges, as this can be a phase of general redefinition for many, and having an active and available network of affections can make all the difference. I feel that people, in desperation, really want to take things (and it can indeed be useful to take specific supplements and/or medication in certain circumstances) but there is no supplement that can replace or beat the positive effect of lifestyle changes. Quality of life starts here”, she concludes.

Quality of life starts in this article, we add. An assumption that seems arrogant, but does not intend to be: this article is too meager for the mystery that menopause still seems to mean for a large part of the population, but if this text is a good starting point, it was already worth the arrogance at the beginning of this paragraph. Because it is important to continue learning and building knowledge around this perfectly normal phase of a woman's life, previously disregarded wisdom. “The gender health gap is real, that is, the discrepancy in the approach to health issues for men and women. We now know that the complaints of the female body have been neglected for centuries in terms of research and medicine. There is a lot of work to be done”, warns the fertility consultant. “But we cannot forget that History is made at the pace of each generation and each country... In Portugal, we have witnessed a strange phenomenon in the last perhaps fifteen years: we have gone from an active demand for reproductive rights (legalization of voluntary interruption of pregnancy, “humanized” wards for hospital births, etc.) which had concrete results, leading to widespread apathy on these issues and a silent erosion of previously achieved rights. I can't understand exactly what is happening, but I know that if women don't demand more information and more and better answers, they won't come…”, Lemos predicts. At a time when the female voice is wanted and heard outside of its secondary role in various movements, women's health cannot be an exception. “We need multiple approaches that come from multiple places. We need a discourse that is not pathologized, but that is serious in its approach, because we need to understand what this phase brings us, and how we can prepare for the next 30 years with maximum quality of life and health”. Patrícia Lemos's activism in this area never takes away from her speech, sharing with Vogue what still needs to be done to put the issue on the agenda. “We need to be able to look at this transition phase from fertile to non-fertile years as a physiological, natural, multifactorial and interdependent process of the sociocultural context of each woman and even the country where she lives. And we need health professionals capable of listening and learning from the subjectivity of patients’ reports and complaints, so that they adapt the objectivity of their knowledge to the story in front of them.”

Translated from the original in Vogues Portugal’s “The Mystery Issue” Issue, published October 2024. Full stories and credits in the print issue.