For many women, midlife take the shape of a perfect storm: High-stress careers, kids transitioning out of the home, and then an onslaught of (sometimes severe) hormonal symptoms. For the protagonist of “Amazing Grace Adams,” it’s all too much. Author Fran Littlewood explains how her protagonist breaks out of the “good-girl narrative” and unleashes her suppressed rage, with expert menopause insight from Dr. Lisa Larkin. This episode was made possible by the generous support of Ken Stevens.
For many women, midlife take the shape of a perfect storm: High-stress careers, kids transitioning out of the home, and then an onslaught of (sometimes severe) hormonal symptoms. For the protagonist of “Amazing Grace Adams,” it’s all too much. Author Fran Littlewood explains how her protagonist breaks out of the “good-girl narrative” and unleashes her suppressed rage, with expert menopause insight from Dr. Lisa Larkin.
This episode was made possible by the generous support of Ken Stevens.
Fran Littlewood is the author of the New York Times bestseller, and Read With Jenna Today Show pick, Amazing Grace Adams. The novel, her debut, will be translated into thirteen languages, and has been optioned for television. She has an MA in Creative Writing from Royal Holloway, University of London, and before that, worked as a journalist, including a stint at The Times. She lives in London with her husband and their three daughters.
Dr. Lisa Larkin is a board-certified internist and midlife women’s health expert. Considered a national expert in menopause management, sexual medicine, breast cancer risk assessment, prevention and genetics, Dr. Larkin is Founder and CEO of Ms.Medicine, a national health care organization dedicated to advancing women’s health on a broader scale through innovation in care delivery models and consumer and clinician education through a weekly virtual education platform, ProvidHERS. She is also Founder and President of Concierge Medicine of Cincinnati, an independent, multispecialty practice.
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Dr. Denise Millstine: Welcome to the “Read. Talk. Grow” podcast, where we explore women's health topics through books. In the same way that books can transport us to a different time, place, or culture, “Read. Talk. Grow.” demonstrates how they can also give a new appreciation for health experiences. Books can provide understanding of health topics and provide a platform from which women's health can be discussed. At “Read. Talk. Grow.,” we use books to learn about health conditions in the hopes that we can all lead healthier, happier lives.
I'm your host, Dr. Denise Millstine. I'm an assistant professor of medicine at Mayo Clinic, where I practice women's health, internal medicine and integrative medicine. I am always reading and I love discussing books with my patients, my friends, my professional colleagues, and now with you.
Our book today is “Amazing Grace Adams” by Fran Littlewood. Our episode will again discuss menopause but we'll focus on some aspects that we've not previously discussed, including rage and mood, some skin changes, and other things as well. I'm so excited about our guests.
Fran Littlewood is the author of the New York Times bestseller and “Read with Jenna” TODAY Show pick, “Amazing Grace Adams.” She has an M.A. in Creative Writing from Royal Holloway, University of London, and before that she worked as a journalist. She lives in London with her husband and their three daughters. Fran, welcome to the show.
Fran Littlewood: Hi. Thank you for having me.
Dr. Denise Millstine: Dr. Lisa Larkin is a board-certified internist, business owner, and entrepreneur practicing internal medicine and women's health in Cincinnati, Ohio. She's the founder and CEO of the innovative Ms.Medicine. She also has Ms.MedEd,which provides information on the complex health needs of women. Dr. Larkin currently serves as the president of the Menopause Society. Lisa, welcome to the show.
Dr. Lisa Larkin: Thank you. So happy to be here.
Dr. Denise Millstine: “Amazing Grace Adams” is the story of essentially one day in the life of our protagonist, Grace, on her daughter's 16th birthday. If you've seen the cover, you will understand the tone of this novel. Grace has angered her daughter, Lotte, and so she starts the day trying to collect and deliver a cake that she envisions will be the magical reconnection between the two of them. Frustrated being stuck in traffic, she literally starts the book by just walking away from her car, angering the other motorists and starting a cascade of bad choices, while she makes her way across London.
Fran, Grace is a mess. Sometimes it made me uncomfortable. What inspired her character?
Fran Littlewood: Yeah. Do you know so many things, really. But I think mostly I was I was hitting these ages, you know, 40, 42, 45. Grace is 45 in the book and I just didn't feel how the popular perception of middle-aged women, that I didn't feel how I was supposed to feel, according to sort of societal messaging and I just felt that I wanted to write something.
I was so sick of the lazy representations of women at this stage of their lives, and I wanted — it felt quite a radical act — but I wanted to put a midlife woman at the center of her story and make her interesting and you know, write the women that I knew, the sort of interesting, funny, smart, nuanced women that were around me.
So, that was a starting point. Also a starting point was my own experiences that I was starting to have with perimenopause and just the fact that nobody was talking about this back when I started writing the book, which was May 2020, at the start of the very first lockdown, you know.
Dr. Denise Millstine:We are so glad that you did.
Lisa, I love that phrase, “The lazy representation of the women transitioning through menopause.” Tell us your reaction to that.
Dr. Lisa Larkin:Yeah, so I think that hits the nail on the head, obviously. You know, certainly in the last four years, really since you've written the book, I think we all can agree that, you know, menopause is having a moment. And now there's much more discussion and emphasis in the public domain about actually finally recognizing that this is a time in a woman's life that we have completely neglected and has very significant impact on a woman's life and all of the aspects that you really touch on in the book, which I thought was tremendous.
So it really tells a great story, I think, of what I certainly see in practice as a midlife perimenopausal woman and some of the experiences that she's having at that time in life, including, you know, it's not just the physiologic changes that we're going to get into in and talk about in kind of mood and behavior, but, you know, the complexities of marriage after a long period of time, the complexities of raising a teenage daughter in the era of social media, the complexities of just aging as a woman and kind of the introspection that you have of that when you're really done your childbearing years.
Right? Like, I mean, as a woman myself who's now ten years post-menopausal, and having had lots of these transitions, both personally with parenting and then obviously with menopause, I think the book resonated on many, many levels. And I think it will resonate for many women on many, many levels.
Dr. Denise Millstine: I absolutely agree, and I was going to start with the opening scene of the book and the description of hot flashes. So you write, Fran. “Grace is hot. There's the sun like boiled breath on the roof of her car. But it's more than that, this feeling that from nowhere she's been set on fire from the inside out.”
In medicine, we call that a vasomotor syndrome, a hot flash. But, wow, what a fantastic description. We shared before we started recording that maybe this was a personal experience you've had. I think I'm actually having it right at this moment. Can you just talk about hot flashes?
Fran Littlewood:Yeah, yeah. Well, funny enough, I have only had very minor hot flashes. I've had many other symptoms but I thought it was such a good way into the book. I sort of use this long, hot day, this crazy journey that that Grace goes on, as a kind of extended metaphor, really, for the menopause. So she sort of has this day of kind of reckoning finally, so there's redemption at the end.
So that was quite kind of fun to look at that and the whole climate thing. And I think, yeah, at least we're talking about the sort of the backdrop to women's lives, the emotional burden that's on women's shoulders. You know, research shows this. And a lot of the things that I put into Grace was that it was in a way, a sort of day in the life of women and girls and all the microaggressions, the aggressions that that we face moving through our lives.
So there's sort of sexual harassment and beyond, but also that sort of backdrop of climate change. All those things I sort of touched on as well, all feeding into this chaotic maelstrom in Grace's mind when she's trying to also deal with her 16-year-old daughter, who she is estranged from. She turns 16 on this day. Her husband is divorcing her.
Quite often, I think at this point in our lives everything comes together at once. I think that is, we're all dealing with a hell of a lot, and I don't think you don't get to this age without sort of bearing the battle scars. So, yes, Grace was sort of the proxy for that, but, yeah, on this day she rises up. She is my fantasy self. She is quite the warrior.
Dr. Lisa Larkin: The description of the vasomotor symptoms are really great. And I think that's one of the things that's still so pervasive, at least in U.S. medical care, right? From largely male primary care providers who really haven't experienced what a vasomotor symptom is and the portrayal that it's mild and you just get a little hot and it's not a big deal.
Now, I can speak personally as a woman that had chemotherapy-induced menopause when I was still very pre-menopausal and the severity of chemotherapy inducing menopause, and then I've had very persistent, very severe vasomotor symptoms. I can tell you from personal experience, it's very much like you describe in the book, and it's much more and for women that are having these severe symptoms, it's not mild.
It is life altering when you're having them and my sweet husband is the first one to say — I have night sweats, even still I wake him up because I'm sweating and kicking the covers off — and he's the first one to just say, if men ever had any experience like this, they would recognize that this is something that really we need to study and evaluate and treat. And finally, we're having a little more research and drug development because it iss much more than a mild little, “You get a little damp” in women that are having severe symptoms.
Fran Littlewood: Yeah, yeah, yeah. And there's so much shame attached to it, which is the awful thing and what better way to silence women over these kinds of issues. Yeah, certainly. My mom I remember talking about having hot flushes at work and having to go into bathroom at work and being soaked through. It's so much to cope with.
In terms of my own symptoms, part of it, I think it starts an awful lot earlier than we kind of acknowledge or recognize. I look back to when I was 42 and having sort of terrible bleeding, terrible flooding. I remember being on my creative writing M.A. and thinking, am I going to get through this hour and subsequently talking to other friends of mine. These things that we're sort of trying to manage and, we're hamstrung by them. And yeah, as you say, you bring on the research that's going to help with this.
Dr. Denise Millstine: I just want to highlight a couple of things that you both have just said to make sure that our listeners are catching all of this wisdom. So, Fran, that's an excellent point about perimenopause and the onset of symptoms being much earlier and now extending much longer than had previously been appreciated.
We had an episode, with Heather Corinna for Heather's book, “What Fresh Hell Is This?” Such a great title for a book about perimenopause and really describes well how those early symptoms are often mysterious to the woman herself and also to the healthcare system that might embark on all of these treatments and workups, when really what's needed is the recognition that this is related to a hormone transition.
Which Lisa, I want to go back to that because sometimes we treat menopause like it's a disease, but it's not a disease. It's a phase, it's a transition and if women are lucky enough to live long enough, we all will go through it. But you said something very quickly, which again, to highlight the severity of symptoms can be predicted by how you go through menopause and sometimes not predicted.
There are many women who have a variety of experiences with their vasomotor symptoms but particularly in the case of a sudden menopause, whether that's a surgical menopause, meaning your ovaries have been removed or you're given a medication that just immediately shuts down your ovarian function, those can be very, very severe symptoms and they can last for a long time.
So let's talk about Grace's rage. So she leaves her car because she's so frustrated in traffic. And then there are many cringy scenes as the book progresses. And I promise our listeners we won't spoil the book, but oh, Fran, which one is the one that was, you know, most powerful for you to write? I can tell you the one that I have to close my eyes while I'm reading it.
Fran Littlewood: Oh, I'll be really interested to see what you say. Actually, in the scene, that kind of instantly springs to mind for me — So she sort goes off on this journey. She's going to walk across London to go to her daughter's 16th birthday party, to which she hasn't been invited, but she's going anyway. She's picking up a cake, she's taking a cake. And this cake arrives, does finally arrive, sort of bloodied and battered like Grace herself. But she encounters a lot of people on the way. And her first interaction, and I was talking about this sort of crisis of violence against women and girls, this sort of backdrop to our daily lives, you know, amongst other things.
So the first sort of event of her anger, after she's abandoned the car is there's a guy up a ladder, a window cleaner, who catcalls her and we've all been there. And it's the start of this sort of explosion or rage. And it kind of escalates through the book.
And I really feel in talking to friends and talking to my sisters. I think there's an awful lot of we sit on this stuff and I will I'll be interested to know Lisa, whether it's sort of is it something to do with the estrogen dropping, or is it just to do with your sort of reaching, is this moment of reckoning in your life. You're in your 40s, you're in your 50s. If we're not going to break out of the good girl narrative now, if we're not going to, you know, really be ourselves now, then when?
Dr. Denise Millstine: Is it the estrogen? Is it a confluence. Is it, something else that, you know, we do see these extremes of mood?
Dr. Lisa Larkin: Yeah. So certainly we know that the hormonal changes that are happening in the perimenopause into the menopause transition definitely impact mood.
Right? So when we think about how women across their reproductive lifespan, we know the peak times of mood disturbance in a woman's life is puberty, postpartum, and the menopause transition and we know that again, there's variability in among women in terms of how much impact there is. So clearly there are some women that are more hormonally sensitive than others. But definitely the menopause transition period. Menopause is a time where I certainly see in clinical practice, it will be the first time that a woman is ever having mood disturbance, right? Meaning it’s anxiety, it's depression, it's panic disorder…
I think it's really goes back to is that you don't need blood tests to diagnose perimenopause. What you need is to actually sit and talk to your patient, because women will tell you very clearly based on the symptoms that they're having, where they are in their reproductive aging and mood is often a very common symptom. They just don't feel like themselves.
I also describe it, though, and I think what you're talking about and what I think about in the book with Grace is really it is what I describe to women, which is it's often a perfect storm at midlife. So it's women who have many things going on.They're often at the peak of their professional career. So they may have a lot of stress with that. They often have been in, you know, 20 to 25-year marriages, and marriage can be complicated. They often have teenage children or children that are going off to college. And there's that sense of loss and, you know, having relationship issues with your children. And, you know, then it's the impact of all the hormonal changes that are physiologic and are real, that are impacting sleep and mood.
And there's body changes. And I often think women all know about this. You know, men and women age very differently. At midlife women, and I can tell you for me personally as well, when I went through chemotherapy, the magnitude of physical changes, looking in the mirror happened almost overnight.
And we know women will talk about that, which is that they age very quickly. They noticed skin changes. They noticed hair changes. They notice body shape changes relatively quickly compared to men who certainly age, but they age more gradually over a longer period of time.
Women seem to have these periods of time where things happen very, very quickly, and midlife is really that. And I think, again, Grace in all of the amazing descriptive terms. Like I love your writing, right? Like there's just been all kinds of things I could describe for you in the book, but all of the experiences that she's having are really things that patients come in and talk to me about. And that's rage and the mood is really right up there.
Fran Littlewood: Yeah, yeah. It's so interesting to hear you say that. I've never heard a medical professional talk about that before, what you say about these almost overnight bodily changes. And that was something that had absolutely struck me, this ambush of age that it's that comes from nowhere, that I wanted to sort of convey through Grace in the book.
So there's a scene actually quite early on, and she goes into the bathroom and her 16 year old daughter, Lotte, has just got out of the shower, and she's there with her sort of perfect body and her perfect everything. And Grace sort of pokes at her boob and says, “How are they even staying up? Are they held up by magic?” And then her daughter leaves the room, and she looks in the mirror and she looks closely and looks at her lips and is like, what the hell is happening? My lips are vanishing. It wasn't like that yesterday. And it always feels like that, this sort of dropping. But it's almost happened overnight.
Dr. Lisa Larkin: Yes, yes, yes. I'll tell you a personal story. Funny, which is during a meeting. You know, a lot of my patients have been my patients for 25 years. I was in a Zoom meeting during Covid, an education meeting, and I literally had a patient put in the chat, “Your lips are disappearing. You need to wear a brighter color lipstick and more lip liner.” I was like, okay.
Fran Littlewood: Just say what you mean. But again, I think it is just thing. The shame attached to all of this, the shame attached to female rage, the shame attached to aging that makes us feel particularly at this point in our lives, but actually as women throughout our lives, that we're failing at everything, and especially in a culture that kind of prizes youth and beauty above all else. It is something that I have really, really grappled with, this real shame attached to what's happening to my physical appearance, you know.
Which is so awful and I hope that, you know, opening these conversations and talking about it, this is what the you know, the things will be better for our daughters when they get there and they're struggling enough. I think my three teenagers certainly are in terms of the impossible standard that we are all being held to.
Dr. Lisa Larkin: I think part of it that I try to talk to my patients — and some of this is self-talk to myself too —about aging. I've lived my own patient population that I'm taking care of, and I have all of these. I can relate so to this menopause transition.
But there has to be some kind of defining healthy aging and accepting that aging is really going to happen and we can't completely prevent it and make ourselves crazy if we really keep trying. And so there has to be, to your point, some kind of acceptance, really trying to dispel this ageism thing and all of us becoming more comfortable in our own skin.
And I think the laughter about it. Some of the physical changes are, I mean, we have to laugh, right? Like, what else are we going to do? You can't completely reverse this. And again, I talk to patients, and I say, you know, it's not that I want you to give up right? You don't give up and not take care of yourself anymore. And of course, we want to still exercise and eat well and get enough sleep. And all of the kind of things we know for healthy aging. But there has to be some acceptance and, you know, some of it, you know, again, we have to kind of laugh. Right.
Fran Littlewood: Yeah, absolutely. And actually that was right at the beginning and I knew that I wanted to write this with some dark humor, because I think you can say an awful lot more if, if you're kind of putting it in in a wrapper of humor. I remember actually sitting around a kitchen table with my eldest daughter, who's now 20, but she was 16 at the time, and my husband is sort of saying, this is going to be so fun to write. This is going to be a real cathartic write.
So there’s a scene. I mean, it's the difficult itch that I like to call it. So there's a scene in the book which is, do you call it a pap smear? Yeah. you know, it's that every woman has been through this. You know, nobody looks forward to it. So I really felt so strongly that I kind of wanted to try and smash the taboo of all of the sort of the medical stuff around it and really kind of tackle it in quite the head on fashion throughout.
So there's a moment when (Grace) she's set off on her walk and she says and now her vagina is itching. You know, it's been itching for the last two minutes, scratch that, it's been itching for the last two years.
This is something that I had talked to a friend of mine about. I've written this scene as well where she goes and has it has a (test) finally and is handed a steroid treatment, but the whole issue of “this might raise your risk of cancer” is raised. But yeah, that was one of the symptoms that I suffered that an awful lot of women suffer. I went to see my doctor about it, who was, one of the doctors at my practice because you don't see the same person, who was a woman in midlife. And I remember saying to her, I think this is probably something that can happen with perimenopause and menopause.
And she said to me, and I was 46 at the time, you you're not old enough, which I was. Going back, what 5 or 6 years. So there’s little kind of training knowledge around this.
In fact, I was dismissed so many times over different symptoms. I also broke my elbow and I'd never broken my elbow before, similar sort of age. And I was having it set by the orthopedic consultant and I said, again, “I know this is something that can happen, issues with bone density at this time of life,” and he looked at his colleague across the room and sort of smirked, actually. And I say he panicked at the mention of the “M” word and dismissed it out of hand and actually, because ridiculously, even though I look back and I think I knew, I thought, “Well, okay, he's told me, it's nothing.”
But in fact, once, ironically, after I'd finally finished writing the book and I got to the top of my to do list to go and visit the GP about the various symptoms I've been having for so long, because we push it right down the list, don’t we? I requested a DEXA scan, a bone scan I mentioned it to her and I had to push for it, but I got it, to discover that I have osteopenia, which I feel so annoyed about because this is a couple of years further on and I immediately went on HRT, but would have absolutely started HRT years earlier had, you know, my concerns about my own body been taken seriously at that time.
Dr. Denise Millstine: Wow Fran, that was a lot of information. It was fantastic. But I think the first thing we need to talk about is the importance in educating about menopause. And, this is why Dr. Larkin is the president of the Menopause Society. This is why she's created Ms.Medicine. Lisa, can you talk about that part of what you do?
Dr. Lisa Larkin: So, you know, I've been practicing for more than 30 years now, right? And I say that the journey of midlife women's health and what's happened with our understanding of menopause and hormone therapy has defined my entire professional career because I've lived through all of these ways in which we thought about menopause.
So when I started practicing in 1990, at that time, we had data, and most of us, my internal medicine colleagues and Denise knows this as well. We were prescribing a lot of hormone therapy to women because of observational data that really suggested that we were doing benefit for women. So we believed we should use hormones.
And then it was the big year of 2002 when the Women's Health Initiative data came out, which was a large randomized trial, that was not a study looking at early younger menopausal women, but really trying to look at the impact largely on cardiovascular disease and so was, we looked at older women not just younger women. And the data came out that study was stopped early, that there was harm, that there was risk. And the messaging to patients. This was long before social media, this is 2002, in the dark ages, the headlines were all about how hormones are bad.
I can tell you almost overnight I watched every single one of my internal medicine colleagues say hormones are bad and stop prescribing hormones. Even gynecologists really largely heard that, didn't really understand the data, stopped prescribing menopausal hormone therapy. But the bigger thing, in my opinion, now, fast forward 22 years, is that we've spent the last 22 years and we haven't educated doctors.
Suddenly, hormone therapy became, “Nope, hormone therapy is bad, it causes breast cancer, it causes heart disease, it causes stroke. Hormone therapy is bad. We've been wrong.” So not only did women become fearful, doctors became fearful and we stopped educating doctors. So we now have a generation of doctors that were trained without any knowledge of the real data of hormone therapy.
And even in 2002, we knew, those of us that were in the space, that the data was not representative when we parsed it based on age, was not representative of the younger women going through menopause. The data looked different in younger women compared to older women, and that we shouldn't translate the data to the entire population. But the problem was there was no way to disseminate the information very well.
The Menopause Society— at that time it was the North American Menopause Society — was much smaller than it is today, and it's grown dramatically, but still, we didn't have the ability to get that information out there. And again, doctors were not trained. And so we created this void for women who then were struggling to find information about hormone therapy, were very symptomatic and when they would go to their doctors, would get dismissed.
And it's only been in the last two years, maybe, and it's even more accelerated now where the magnitude of deficit in education of physicians and nurse practitioners and clinicians taking care of women has been recognized. Now in the United States, and I certainly know in the U.K. as well, there's a big move to fix this that we've done wrong.
But the truth is, it's been 22 years that we haven't trained clinicians, and we're not going to be able to train enough clinicians and get up to speed very quickly. This is actually going to take a longer time. And so your experience as a patient is what I hear from women coming in to see me now.
It's changing. Social media has been a mixed blessing. I think there's more positives in terms of the messaging to women than negatives, but it is kind of an unregulated mass of information out there, so it is hard for women to kind of sort out what's good information from bad information. But it has certainly elevated the conversation. And so women are coming in. But the problem is there still aren't enough doctors actually who know the data and who are comfortable with this.
I just had a patient come in who was told by her — she's having a blepharoplasty, you know, an eyelid lift — and her plastic surgeon told her she had to stop her vaginal estrogen for two weeks before her surgery. Right. Like there's that level of lack of understanding on the data out there. And so women are harmed by this whole issue, which is, you know, we've really created this huge gap.
Fran Littlewood: And there needs to be structural change and it needs to be taken seriously, a governmental level. I know over here there's this fantastic lobby group, The Menopause Mandate, set up by women who have all gone through this, it's a campaign group and there was a consultation with government, and they obviously submitted lots of stuff and an awful lot of it was looked at. And the recommendation that they came back with was CBT (Cognitive Behavior Therapy), you know, as a sort of front line to it. And CBT is amazing and wonderful in so many ways, but it isn't going to prevent, you know, heart disease, osteoporosis, etc., etc., etc..
And this was within the last year. So like you say, I feel like it's extraordinary to think when I was writing this back in 2020, I feel like couldn't even define the word perimenopause myself so much has moved on since then in terms of the discourse and the conversation and that's amazing and so positive. But now that needs to translate into real kind of structural and systemic change. That's the battle. I'm sure.
Dr. Denise Millstine: Well let's talk about treatment for menopause. Grace has a prescription for hormone therapy, I think in her bag. She's picked it up already. So somebody had thought to treat her with some estrogen as she's going through this transition. I think one of the points I wanted to highlight is that there are treatments and while CBT has been shown to help with vasomotor symptoms, Fran, you raised the point about when you are transitioning that you are typically, as a woman, going to lose bone density at this point in your life. And not that this is the reason we use hormone therapy. But we do know that in women who are able to take hormone therapy and take it for other reasons, that there is prevention of osteoporosis or maintaining bone strength when they are on hormone therapy and then clearly hormone therapy is effective for vasomotor symptoms and there are so many potential health benefits with hormone therapy.
We could spend the rest of the day talking about this, but, Lisa, would you just comment on that briefly? And then also, would you highlight what you said about vaginal estrogen, which is very different than the patch that Grace has in her bag.
Dr. Lisa Larkin: Right. So again, and in thinking about Grace. So she is a young, otherwise healthy woman who is transitioning through menopause, who is having significant symptoms. And so when we think about who's a candidate for hormone therapy and where we think about benefits versus risk, Grace is the right candidate, Grace is someone that I would be prescribing hormone therapy to, right?
Again, I obviously don't know her entire medical history, but the assumption in the book is that she's really otherwise healthy. Right. And so for all of the symptoms that she's having and again, then for prevention of bone loss, we certainly know that it's effective. And again, I think she got the right prescription.
Now my sense is she probably didn't get a lot of education on that visit. I didn't hear that she got a lot of education. So she's not really all that well informed about all of the benefits and how it might even help her in terms of some of the mood symptoms and the sleep symptoms that she's having.
But again, going back to, you know, there's still been this messaging for the last, you know, two decades that hormone therapy is bad. And I don't know if you were intending if that was kind of the subliminal messaging in the book, is that still somehow Grace was fearful of taking hormones, which is why she hadn't started it. But again, I think Grace is a good candidate and she would have, had she started it in the book, gotten a lot of benefit out of it.
I think at least in the United States, I don't know how it is in the U.K. in terms of what the package labeling says when patients pick up prescriptions. But in the United States right now, it doesn't matter what type of hormones you pick up, whether it's oral contraceptives, whether or not it's the type of patch or systemic hormones that Grace picked up, or whether or not it's vaginal estrogen.
You get the same boxed warning, which really comes from that study, the Women's Health Initiative study from 2002, which is really all related to one formulation of hormones that was used in the study and systemic hormones. And the issue in the United States that I see in practice all the time, is that box warning is very terrifying. It talks about all of the risks. It doesn't really highlight benefits.
It really is a patient population that really again, if you separate out the younger women closer to menopause, it doesn't completely apply. So that for me, when I prescribe hormone therapy to women, it involves a lot of education that I have to do because women get this package label and are terrified.
But the big thing for me is that vaginal estrogen in terms of dosing, is completely different than the patch, right? I really would argue that, in my opinion, vaginal estrogen is safe for everyone. There's no data to suggest, negative outcomes in any of the trials that we have, including the Women's Health Initiative. There's no signal for increased heart disease, increased dementia, increased clotting, increased stroke risk, increased breast cancer risk.
And yet the vaginal estrogen even contains the same package labeling, which terrifies women and prevents women from using something that is so safe and so beneficial for preservation of sexual function and prevention of urinary tract infections. That again, it goes back to, we just continue, there's unintended consequences of this big clinical study that continues to harm women. But so far, we haven't been able to get that label changed, although there's still work going on in that.
Dr. Denise Millstine: We're talking about the vaginal estrogen that's intended for vaginal use and that is only active in the vagina. Because there are some estrogen products.
which are inserted vaginally that are systemic. But we are talking about your typically vaginal estrogen creams and there's a vaginal estrogen tablet, again in the U.S. at least, that is only going to be active on the tissue locally.
But I don't want to move away from talking about Grace's experience there when she does go for her exam. And because I thought, Fran, what you were talking about is a condition that occurs in women.
I have the description written here, “Her doctor says, it's basically a condition where your vulva is slowly subsumed by your vagina. And linked to this condition is a slightly raised chance of contracting cancer.”
I mean, it's very cold. You've depicted this exchange as a very cold, like she comes in, she does her pelvic exam and she's like, oh, this is not just vaginal itch from dryness. You may also have this other skin condition. I'm fearful over time that will never have another novel that depicts this, so, Lisa, will you talk this?
Dr. Lisa Larkin: I have to tell you, so grateful for you bringing this in. Right. So I think anyone is in women's health knows, right, that this is a condition that is overlooked all the time. I believe that what you're describing is lichen sclerosus.
I can't tell you the number of times that patients have been seen by a doctor, given a prescription for vaginal estrogen. Their vulva has never been really looked at. Right? We often say that sometimes the vulva and the vestibule is just the gateway to, you know, the vagina for a pelvic exam, and it completely doesn't even get examined. And so we see this all the time, but it's a very important condition.
I use this description actually to talk to patients. Every time I have a woman up in stirrups, I'm getting out a mirror. I'm actually showing her own anatomy. Because a lot of times women will come in with that itch and that description, they've never actually even looked.
Again, it goes back to the difference in men and women. Men see their genitals multiple times a day, right? They see it all the time. They look at it. Women often, most of the time, never really look. So they don't actually understand that they have a skin condition. And then it gets missed by doctors as well, and they get mistreated and it's a very important condition and I was very happy for your description. Again, very unhappy with kind of the way the doctor treated, but it was depicted well.
Fran Littlewood: Yeah. Well, I have to tell you, this is taken from some real-life events and. Yeah, it's everything you're talking about that's sort of the mixed messaging and the confusion. And is it estrogen-related, or is it this other condition and just the sort of bomb drop of information and particularly, I think, where at the end of this thing she says, well you know, this raises your chance of having cancer. That sort of fear for women without kind of adequate explanation around these conditions that we don't talk about and we don't discuss.
And actually, I have had quite a response. I've had people getting in touch me to say exactly that. I'm so pleased to see it depicted because it's a horrendous and debilitating condition for older women.
Dr. Lisa Larkin: Yes, I think really, even the way you describe. Right, the, you know, the involution of the labia and, you know, consumed by the vagina, right. I mean, you know, how violated is that? Right? Can you imagine if that statement was said to men, right, that their penis was involuting and being resorbed. Right? I don't know that men would love that description or accept very well.
Fran Littlewood: And I think and as well, I mean, this is when I say I really wanted to try and pack all these things in a head-on way that I don't think I have seen written in fiction before, which is why I've headed some chapters. One of the chapters is headed with a list of menopause symptoms, but a very truncated list, I have to say, because they sort of go on and on, don’t they, until sort of 40, says how many.
And another chapter had, I think it is probably the one before that, pap smear, which is an HRT leaflet which I took in that leaflet is exactly what you were talking about, this complete she sort of looks at it. And on the one hand, if you take hormone replacement, you'll be protecting yourself from various forms of cancer. On the other hand, it will raise your risk of cancer.
So Grace is sort of sitting in this waiting room looking at this leaflet that anyhow, she feels she too young to be looking and thinking, this is just a Hobson's choice. What? You know, what do I do? Where do I go with this? And it's this, you know, and I have put dark humor around in the book, but it really underneath that, is the fear and anxiety that so many of us obviously feel this and the lack, again, of information and information sharing, which is starting now, I think.
Dr. Denise Millstine: I could talk to you ladies all day long, and I want to make sure we talk about one more important aspect of Grace’s journey, which is the relationship between menopause and work.
So while Grace is navigating her day, she knows she's very far behind on a deadline and she actually gets called by her boss and fired effectively. And again, love your writing, love your approach. Fran, because you have him say, you're our best freelancer in a long, long way, and yet he still fires her. And this impact of menopause, menopausal symptoms on women's productivity is something that's finally getting some attention and being quantified because for those of you who don't know, it's economic impact is really astronomical. So, thank you for, firing her while she's brilliant and doing her best to navigate something, not taking her (what would have been) effective therapy, is to just show all of the ripple effects of her transition.
Fran Littlewood: Yeah and again, it's something I think people are starting to talk about in the workplace and I don't want to be too skeptical about it. But how very difficult to sort of go in and say these symptoms that I'm having, which are brain fog, you know, and forgetfulness and exhaustion, to the fear that being taken seriously in the workplace. And yeah, people are, in some organizations, beginning to talk about it. I don't know how it could really be implemented in practice.
Of course, you know, you hope that that will be the case and that we will become more enlightened because, as you say, this is a hugely overlooked part of the workforce, you know, where women in their 50s is so powerful, which is something that, 40s and 50s, that I wanted to try and show in the book. It's the moment, really, that we meet her. She looks as though she's losing control. Grace, finally, actually in many ways, it's the start of her wresting back control. You know, she's had enough, she's going to go out and going to make things right for herself. It's a sort of return to self, actually, in a sense. The work thing is absolutely huge.
And I don't know how that's an issue that we solve really. I know some women have seen such desperate measures and suicide rates going up and the anxiety at such a level that women can't continue to work.
Dr. Lisa Larkin: So I actually think that part of what has to happen is right. We have to educate men, right, who are in control of lots of these companies and help them understand, in addition to women. But they're just frankly, women aren't knowledgeable about really what's happening and that's our fault. But men certainly are not knowledgeable about what's happening to women.
And again, we talked about the lack of physician knowledge about it. So there's this huge void. And I think when I talk to my patients about is it's really a bumpy time during the transition.
And I think empowering women to recognize, A) If we listen to them, they know what's going on. Number one, they are perimenopausal transitioning. But B) That there's real ways that we can impact and positively improve their symptoms and their life.
So women who are suffering with lots of these symptoms, the mood, the sleep disturbance, the vasomotor symptoms, the fatigue, the palpitations, all of the things that women talk about, right.
Like empowering them to be able to find a clinician who can give them help is number one, but also with the information that a lot of times women, once they transitioned through, they are much better. They feel better, they return to a new baseline.
Right. And part of that when, and I actually am doing an educational event for a group in Cincinnati, here in the not-too-distant future, trying to educate the corporate HR leadership, that they should be able to empower their workforce.
But also the other thing and I would love to just talk to all employers. Just like women age differently than men, I think women's career trajectories are very different than men. And we should be able to acknowledge that and recognize that. Right? If you support a woman through pregnancy and childbearing, she'll become your most loyal employee.
And the same thing, like if you can help in the workplace, support a woman through some of these real physiologic transitions, get her the help that she needs, occasionally make workplace accommodations or whatever this looks like. Recognizing that this is a real physiologic transition for women, you get them to the other side. They're going to be your most loyal workforce, and they have decades of productive, wonderful years ahead to be that employee and women feel better, like they feel better.
And so from my standpoint, it's hoping to message to employers again what we can do for this fixed period of time, relatively, getting women the help they need to empower them and support them so that they remain in your workforce. That's the economic reason that employers should take it seriously.
Fran Littlewood: Yeah, yeah. yeah. Hallelujah. Lisa. It's also trying to take the stigma away from that. And I would say that cultural shift, that's the biggest hurdle there.
But I'm so interested to hear you say that it seems to me, that you're saying that perimenopause actually can be the trickiest time because this is the conclusion that I'm sort of coming to.
Dr. Lisa Larkin: Yes, yes.
Fran Littlewood: And again, I think that's just not known. And that again, goes back to it starting it all beginning earlier than we've been led to believe. I was, you know, 51 is the average age that you go through menopause, so you feel it's like this is when it's going to happen. But actually it's before that.
Dr. Lisa Larkin: Your experience is exactly right. Right. Like, I mean you felt different at 42 and you were noticing your periods were heavier and just weren't feeling right. That's perimenopause. You are correct. This goes back to we don't need to do blood tests, we need to trust women. They actually know their body’s. Like, this is correct. You were having the early beginning hormonal changes, right? We know your ovaries were starting to fail. Your hormone production from your ovaries was becoming inconsistent. You were starting not to ovulate every cycle. Right. Like all of these things were starting changes.
And again, from the outside. Right. You think that you're too young. But no, it's time of hormonal instability is often when women feel the worst. And if you get them to the other side, when now they're post-menopausal and they're hormone levels without taking menopausal hormone therapy, are consistently low.
Still, many, many women feel better. Their mood stuff is better. They start to get their sleep patterns back. The physiologic consequences of having arm fat and back fat and more belly fat and like that, all of that often persists, right, does persist, like hair thinning, that kind of stuff, but kind of from a mood, productivity, feeling like themselves again, many women feel much better, if we can get to the other side.
Fran Littlewood: Yes and in fact, I read and there's a scene in the book that I wrote, and it's someone who Grace meets on her on this long journey, at a point when she really is down on her and she's sort of a fairy godmother type character who buys a bottle of water for Grace in the shop because Grace has lost everything.
Dr. Lisa Larkin: She’s a mess.
Fran Littlewood: Yeah. And she sort of sits down and talk to her and she just says, I see you. You know? I know you think that no one sees you. I'm here telling you that I see you. And actually, I've had so many incredible responses to that scene. So as well as Grace sort of having these awful encounters and these rage filled encounters that are also these sort of moments of kindness on her journey. But yes, I wanted to show you that this woman who is a little bit older, who is out the other side of it and is kind of imparting her wisdom, saying this will end.
But mostly I think there is that feeling of invisibility, that no one is seeing us or understanding us. There has been no dialog around that certainly at the time that I was writing that. But I have had so many messages from women saying, this is me and thank you and I feel seen, which has been amazing because when I was writing it, you know, at the kitchen table, not knowing whether, you know, you sort of — it's very insular. It's a very insular experience. Will this chime with anybody else? Will this be anyone else’s experience? And yeah, it most certainly seems that it is. But as I say there's hope.
Dr. Lisa Larkin: I think we could do a better job supporting each other as women. And recognizing that our friends and colleagues are going through this. Like, not it's not the men that are missing the boat. Like I think just even education and knowledge and supporting that again, it's a time of life that’s bumpy, like many times of life are bumpy and you can get to the other side and do well.
Fran Littlewood: And I wonder if an additional factor as well that I've sort of thought about. So I explore in the relationship this sort of the ironic timing of Lotte, is a 16-year-old daughter who is kind of in the full flush of adolescence, and all the hormones and the brain rewiring that goes with that, just as Grace is having her own kind of, at the other end of the spectrum, rewiring.
Yeah. I feel like, is this something that maybe didn't used to happen because our mothers had us an earlier age? In general? I think so I feel as though we would mostly have left home. Probably we would have been. They would have been through those awful teenage years by the time we left. They wouldn't have had that kind of terrible clash of hormones, which is kind of near comedic sometimes. But yeah, quite the kind of struggle to live with day to day.
Dr. Lisa Larkin: And mother daughter relationships in general.
Dr. Denise Millstine: That's going to be a whole other episode, I think. I love to end on this idea that there's hope and that this is about a transition that needs to be supported and can be better supported than it has been historically.
We have gone from the menopause transition, into mood and rage. We've talked about osteopenia. We've talked about vaginal health, including a specific condition called lichen sclerosus. This is so much information that listeners can access some more detailed information in the show notes, including connecting to Ms.Medicine and all of the educational information that's available at the Menopause Society.
I really want to thank Dr. Lisa Larkin and Fran Littlewood for being here to talk with me about “Amazing Grace Adams.” Thank you both.
Dr. Lisa Larkin: Thank you.
Fran Littlewood: Thank you so much.
Dr. Denise Millstine: Thank you for joining us to talk books and health today on “Read. Talk. Grow.” To continue the conversation and send comments, visit the show notes or email us at readtalkgrow@mayo.edu.
“Read. Talk. Grow.” is a production of Mayo Clinic Women’s Health. Our producer is Lisa Speckhard Pasque and our recording engineer is Rick Andresen.
The podcast is for informational purposes only and is not designed to replace a physician's medical assessment and judgment. Information presented is not intended as medical advice. Please contact a health care professional for medical assistance with specific questions pertaining to your own health, if needed. Keep reading everyone.