The Change -- Baby-Boomer Daughters Share Stories About Menopause, The Midlife Passage That's Been Called The `Stigma Of Stigmas'

When you tell me your stories, you validate my stories and help me know who I am.

"Here's a funny story," offers a 47-year-old graphic designer with three kids, a marriage almost 25 years old and aging parents to look after.

She was at a counter buying makeup. The salesman was a good-looking younger guy. Suddenly she felt warm, her face turned red and a rivulet of sweat began running down her neck. From the clerk's sheepish expression she knew what was going through his mind: "Boy, am I having an effect on her."

"I was having a hot flash! . . . It had nothing to do with him at all," she blurts out with a laugh. "You don't have control of these things. You just start this . . . sweating . . . as if you're at the peak of aerobics. Only you haven't done anything . . . I just left as fast as I could."

Our mothers didn't tell us their stories, let alone joke, about being in "the change of life." Why would they, given society's view that menopause was a joke?

The depressed, increasingly unappealing housewife was expected to stoically "sweat it out," flinging open kitchen windows in the middle of winter and waking up with insomnia in the middle of the night, while her bewildered family wondered if she was going crazy.

Today, that dreadful, dried-up stereotype is being rejected by their brash baby-boomer daughters, who are speaking out with candor and humor about what writer Gail Sheehy maintains "may be the last

taboo, the stigma of stigmas."

They are doing so because they remember what their mothers went through, they expect more from life, and realistically can expect to live nearly half a life more - after "the change."

They are doing so because they are pioneers who've already reshaped what it means to be "female" - whether they've pursued a career, bucked the trends and stayed home with the kids, or done something in between.

At the same time, medical researchers have snapped to attention. Already about 43 million women in America are 45 or older, one third of the female population. By the year 2000, another 20 million will reach the age of menopause. These millions are going to demand to feel better. Even though menopause is considered a dominant factor in illnesses that hit women hard - including cardiovascular disease and osteoporosis (the thinning of the bones) - the answers are inadequate on how to safely treat the symptoms of this universal female life passage.

In response, the National Institutes of Health announced last April that it will conduct a 10-year, $500 million nationwide study primarily on the health of postmenopausal women - with special emphasis on the main causes of female mortality and impaired health.

Women, meanwhile, keep on living through it in their personal ways.

Some have a gentle, barely perceptible transition into menopause. For a few, it's horrible. The majority, though they don't feel great, can somehow control their irritability and anxiety.

It may be most disconcerting in the workplace.

"I hear a lot more complaints about memory loss. Being in an executive meeting and having a horrible hot flash or suddenly not being able to handle the thing they handled before," says Dr. Lori Marshall, reproductive endocrinologist at Virginia Mason Medical Center.

"Their (women's) level of function in the community is much higher now than it was for our parents. They have to be in much more top-notch shape in front of a group than they did 20 or 30 years ago."

Despite unpredictable hormones, many women tell researchers they feel creative and optimistic at midlife; indeed, in their prime. Children may soon be leaving the nest, income is at a high, birth control isn't a worry, and their sense of self is coming into its own.

Not that it's easy. It takes some working through.

"People carry around inside of them - even radical feminists - the negative sense of what middle age and menopause produces," says Susan Starbuck, director of the Women's Center at North Seattle Community College.

"It's a big job to turn those attitudes around."

Dealing with menopause and middle age "involves some suffering and letting go," she says. But it's not to be "fixed," like a disease. It's a natural part of the life cycle to be lived through.

Registered nurse Anne Fangman, 52, recalls the first clue.

"I kept waking up at 2 in the morning and was very warm. . . . I could feel my sleep was being disturbed. This went on for a long time. Several months. I was also keeping track of my periods and I was missing a few - about two a year."

When she went for her annual Pap smear, her physician revealed: "Well, guess what? You're going through menopause."

No one she knew was very verbal about menopause, though she remembered her mother saying "my life is over." Even a childhood friend she called long distance didn't want to talk about it, "didn't want to face the fact that she's 50."

So Fangman began making a big production out of turning 50 as a "healthy, normal thing to do." She celebrated all year, bought herself a cruise, and told several friends they needed to give her parties, which they did.

Then people began coming to her. "I know somebody who's turning 50," they'd say. "I'm going to send them to you for lessons."

She still does a double take when she thinks about being 52. But the evidence is undeniable. The texture of her graying hair is changing, from oily to drier and finer. She can't eat as much: "It sticks like glue." Her once-tough fingernails keep breaking. She doesn't get whistled at like she used to.

But she knows "I'm still attractive and very aware of my sexuality." Now when men notice her, "it's in a much more genuine way, with a much more integrated appreciation of who I am."

In the meantime, she's inspired by the many women "blossoming at age 50 and really getting into their own personhood."

THE MEDIAN AGE for menopause (defined as the last menstrual period) is about 51.

But the physiology of menopause can start much earlier than a woman notices, as early as her mid-30s, when her ovaries begin releasing fewer eggs and her body starts producing less and less estrogen.

The median age when recognizable symptoms begin - even while a woman is still menstruating - is about 47. The symptoms can be hot flashes (a spontaneous and uncontrollable flush of heat accompanied by profuse sweating) and vaginal dryness (the vaginal wall becomes paper-thin and less elastic, sometimes causing pain, even bleeding, during intercourse). It's estimated about 75 percent of women experience hot flashes.

Other symptoms include headaches, insomnia, memory loss, anxiety, irritability, skin sensitivity, heart palpitations, and loss of sexual desire.

The symptoms can go on for a time after menstruation stops.

So this is life's prime?

Here's what a few studies are showing.

One in progress is at the Center for Women's Health Research at the University of Washington, a five-year study of 500 midlife women ages 35 to 55.

It's still early, but what center director Nancy Woods can say so far is good news. Most of the women in the study aren't depressed. They may lead exceedingly complex lives, embracing varied combinations of marriage, children, career and parents or relatives to look after. But they still are able to function and feel good about themselves.

"This population seems to be juggling amazing responsibilities and not doing it with major consequences for their health," says Woods.

Such findings mesh with results from the Massachusetts Women's Health Study, conducted by the New England Research Institute and supported with a grant from the National Institute on Aging. Data, the last of which was collected in 1987, is still being analyzed. So far, the study is the largest in North America to deal specifically with menopause. But its participants were mostly white and from the Northeast.

Epidemiologists followed more than 2,500 Massachusetts women for five years; during that time, most experienced menopause. The study found that "menopause, as a natural event, appears to have no major impact on health or health behavior."

Only about "10 percent of the women were depressed at any given time," and rates of depression were highest for women who had a surgical menopause.

Depression also was linked to being depressed prior to menopause; stress and other life circumstances; poor physical health; and the symptoms of menopause.

Even with these findings and others, there aren't enough answers.

"Despite the ubiquity of menopause and the increasing research focus on aging, there are surprisingly large gaps in our knowledge of this event and its potential impact on women's lives," said Sonja M. McKinlay in hearings last April before the U.S. Senate Committee on Labor and Human Resources. McKinlay is the principal investigator for the Massachusetts Women's Health Study.

Many women who look for information get "mixed messages from their health-care providers," says Marshall at Virginia Mason.

"The most difficult thing is not knowing what's happening," says the 47-year-old graphic designer. In addition to hot flashes, she has insomnia, sometimes going without sleep for 24 hours. Her periods are irregular, and she's experienced heart palpitations so bad "you think you're going to have a heart attack."

When it all started she went to her doctor of 20 years.

His not-uncommon response - because she was still menstruating, however irregularly - was a verbal pat on the head: "You're a little young to be experiencing menopause." But eventually the nurse gave her a pamphlet describing symptoms. She had them all.

Since then, most of what she's learned has come from talking to other women. She now takes better care of herself, eats right, exercises every day - as experts insist is so critical for the midlife woman. And she's decided it's time to switch physicians.

TODAY'S WOMAN is far more likely than her mother to participate in decisions about treatment to relieve the symptoms of menopause.

Hormones - either an estrogen prescribed alone or in combination with a progestin (a synthetic form of progesterone, also a female hormone) - are the most popular options. Such therapy is surrounded by confusing debate over the benefits and risks, the amount of dosage and the length of time the hormones should be taken.

Studies show estrogen alone possibly reduces the risk of cardiovascular disease. It prevents or retards osteoporosis and also relieves vaginal dryness. Many believe it relieves depression, improves skin tone and general well-being, and helps with memory loss.

The most serious risk of taking estrogen by itself is endometrial cancer. The risk of breast cancer from taking estrogen continues to be controversial.

To greatly reduce the increased chance of endometrial cancer, estrogen is often prescribed in combination with progestin, a practice that's gradually come into use over the last decade. (This combination is commonly referred to as hormone replacement therapy, or HRT.) Progestin's effect on the risk of breast cancer induced by estrogen is not known.

Progestin carries its own risks. It is speculated that progestin might reduce estrogen's possible good effect on heart health, though that's not known for sure. And progestin also can cause irritablity, bloating and weight gain. In addition, women on HRT can bleed every month, even though they are not ovulating.

A woman's decision about HRT ". . . is influenced by her attitude toward the menopause, her knowledge about the long-term benefits of estrogen-replacement therapy, and her concerns about cancer and vaginal bleeding," wrote Marshall in an article about an ongoing menopause-education program at Virginia Mason.

Marshall says most doctors feel that hormone replacement therapy is positive for most women without contraindications (such as a history of breast cancer or abnormal bleeding). But it should not be pushed on a woman, and she should understand the risks and benefits.

Many experts also call for research into other forms of menopause treatment for women who cannot or wish not to undergo HRT.

Wrestling with the pros and cons of hormone treatment is hardly all there is to female midlife. Modern women are faced with an even bigger challenge: the myth that "the change" marks the end of their worth.

Sitting at a small cafe table warm with the morning sun, Janet Smith, 44, slim, long-haired and pretty in blue jeans and matching turtleneck, pours cream in her coffee and begins.

"The crack in my cosmic egg was when my doctor told me, `You are premenopausal. There is no way you can conceive.' "

She was around 40 then, feeling physically wonderful and professionally successful (already having been a teacher, a researcher of radio documentaries, press secretary to Dixy Lee Ray when she was governor, and co-owner of her own business).

There was no reason for her to think "the change of life" was upon her and the choice to biologically conceive was gone.

"It was the end of a dream."

The first big dream. Then her mother was diagnosed with cancer, as was a good friend. Finally, one of her best friends, in her early 40s, came down with a quickly progressing form of multiple sclerosis.

"As successful as you might think you've been in life, there comes a time - if the heart has been torn open - when you stop. You just stop and take a real hard look."

For the first time in her hectic but near-perfect life, she heard the clock ticking.

In came the big questions. What did she like about herself? What was she like in other people's eyes? How authentic was she in the world?

Smith remembered her first job as a teacher, a time when she felt the most alive and rewarded. Could she recapture that?

Today, Smith is pursuing a master's degree in psychology at Antioch University while working as a counseling intern with Group Health. She's probably the oldest intern by 10 years. With no kids and a well-paid husband, she probably can make such a switch more easily that most people.

She agrees, but doesn't believe such change is impossible for women less fortunate. Many of her fellow students are midlife women without a lot of resources, but so determined to make something more or different out of the last half of their lives that they've taken out huge educational loans.

FOR WOMEN who want counseling on broader midlife issues such as changing careers, spirituality and creativity, or medical information on menopause, help is available through hospital-sponsored classes, women's centers at community colleges and a few private counselors.

Smith is on the advisory board for the 2-year-old Copper Feather Institute for Midlife Enhancement in Kirkland. Copper Feather runs women's support groups in the Seattle area and retreats in Flagstaff, Ariz.

"Most people feel some sort of nudge at midlife to do a reassessment. Some will do the work that's needed. Others will put it off," says Alinda Page, a former transportation planner who's now the institute's clinical director.

Women come for counseling and spiritual rejuvenation. Often they have put a great deal of energy into mind and intellect at the expense of body and emotions, says Page.

Certain themes consistently emerge. Vitality and empowerment. Life losses and disappointments. No longer being seen in a society that prefers females who look like teenagers. Replenishing one's self after serving others.

They seek the tools to come through midlife ready for the last half of life. They want to be authentic, rather than externally defined.

"The important thing is standing into our own truth and moving ahead," says Page.

The day before surgery, Ama R. Saran said goodbye "to my last beloved ovary" at a healing ceremony attended by female friends from all over the country.

The house was filled with flowers. They used fire and water and music, invoked the spirits who would care for her, and told their stories.

The ceremony was distinctly a woman's, and distinctly African-American.

Many African-American woman have begun to ritualize these life passages, especially with storytelling, says Saran, a predoctoral fellow at the University of Washington who has also worked for eight years with the National Black Women's Health Project in Atlanta.

The stories, she says, allow a woman to say: "I'm in a new place. Talk to me. Confirm where my feet are planted. I'm parting company with a younger self."

When Saran came home from the hospital, she was immediately menopausal.

"With my first hot flash, I crawled into bed and cried."

That was the first day. As a woman whose mother raised her to "absolutely love my menses," who survived a partial hysterectomy at age 33, she wasn't about to let early menopause wreck her life.

She called on her women friends, who advised: wear cotton, stay comfortable, roll up your sleeves, keep a cool drink of water nearby.

"It's really not all that bad," she says, having decided for now against hormone therapy. "Not everyone is plagued by hot flashes. You can make sure the window is open and the air circulates. You can change the bedding and change your clothes. But, mainly, you change your head . . .

"This is something that belongs to us. If we can't celebrate it, who else will?" ------------------------------

RISKS VS. BENEFITS

"Should I take hormones or not?"

That may be the medical question most frequently asked by women at the age of menopause. But finding answers is tough because information from controlled studies isn't available to make all the risks and benefits clear.

What is clear, however, is that women should make the decision for themselves based on their individual medical history and the best advice their doctors can give.

So, in addition to today's story, which talks about Hormone Replacement Therapy (HRT), its risks and benefits, we have a piece about HRT and where it stands with the Food and Drug Administration.