Changing Bodies

Dr. Heather L. Johnson is actively practicing gynecologist and author of two books, who, after delivering more than 3,500 babies over 40 years, recently retired as an obstetrician. Below she shares with us some insights and information as well as a few teasers from her book, What They Don’t Tell You about Menopause: A Gynecologist’s Unofficial Guide to Premenopausal, Perimenopausal and Postmenopausal Life.

When should a woman first ask about menopause with her healthcare provider?

The average age of menopause, or last menstrual period, in this country is 48 to 52.  There are generally 6 months to 2 or 3 years of “fanfare” prior to that last period.  The time to ask is before this happens.

I cannot tell you how many panicked phone calls or messages via my practice’s patient portal I get from patients in their late 40’s or early 50’s because they have missed a cycle.  Heretofore they have always been “every 28 days, like clockwork.”  They are concerned they might be pregnant, or worse, have some kind of significant medical problem that has led to the missed menses.  At the other end of the spectrum, I have had far too many women in their early 40’s who have stopped using birth control because they are “old” only to find out that the missed menses was the early sign of an unplanned pregnancy.  While it is true that fertility declines rapidly after the age of 40, pregnancy is still a very real possibility.  Sadly, it is not real enough to justify putting off attempts at pregnancy until that time unless one is willing to avail themselves of assisted reproductive technology, donor eggs, or have their own frozen eggs from when they were younger, aka fertility preservation.  Just because your periods are regular, does not mean you can get pregnant.

Bottom line, once a woman reaches 40, she should reach out to her provider about changes that can be expected over the next decade.

What types of questions should she ask her doctor/healthcare provider?

During this last decade of reproductive life, cycles may change.  Even if they are regular, the bleeding pattern may change.  Women often complain of heavy bleeding the first day or so, “like a crime scene,” followed by light spotting/bleeding for the remainder of their cycle.  They may notice increased PMS symptoms or new ones if they never had them before.

If they are interested in getting pregnancy, they should seek help immediately because their fertility rate decreases rapidly after 40.  Their miscarriage rate and risk for chromosomal abnormalities such as Downs Syndrome increases significantly, and pregnancy complications such as pregnancy induced hypertension, gestational diabetes and fetal growth restriction increase.

Women in this decade are also more at risk for gynecologic disorders such as fibroid growths in the uterus and polyps which can cause abnormal bleeding, and precancerous or cancerous changes in the lining of the uterus which, if caught early, can result in minimal intervention rather than drastic surgery, chemotherapy and/or radiation.

What health issues should women be thinking about as they journey to and through menopause?

Prior to menopause, estrogen is mainly your friend.  Its decrease and subsequent absence after menopause can lead to a number of medical issues such as vaginal dryness, pain with intercourse and frequent urinary tract infections.  More importantly, with the loss of estrogen’s protection at menopause, women rapidly catch up to men in numbers when it comes to high cholesterol and heart disease.  They also begin to lose bone at a rate that can result in osteoporosis which can result in pathologic fractures from minor trauma.  Hip fractures with their sequela of surgery and immobilization become a frequent cause of death from blood clots, surgical complications and other morbidities. 

What are some of the “normal” changes a woman may experience with her body as she journeys to and through menopause, and what are some of the treatment recommendations?

Vaginal tissues:

Lack of estrogen results in thinning of vaginal tissue and loss of vaginal secretions.  This can result in difficult/painful intercourse.  Lubricants are helpful for most, but many will need addition local estrogen, which is NOT absorbed in the bloodstream, to facilitate intercourse.  Remember, the body has received the signal from the low estrogen levels that there are no more functional eggs.  It then wisely chooses to “shut down” the vagina as intercourse is considered no longer necessary.  Fair?  No.  But nature really didn’t plan for women to live as long as we now do.

Vaginal issues can, in most cases, be addressed by vaginal estrogen products.  These are NOT absorbed into the blood stream and work locally to increase tissue turgor and vaginal moisture.  Most oncologists will let their breast cancer patients take these medications after they have finished treatment.  There are many options which you should discuss with your provider.  Sadly, because of the increasing age of the population, the popularity of these products has increased along with the price.  Many insurance companies now proclaim them to be “lifestyle medications” which means they don’t have to cover them, although many do cover Viagra.  No further comments on this inequity.  In any event, copays for some of the medications have gone from $30 to almost $700 in some cases, so you will need to check which medication your insurance company “covers” at whatever rate they deem appropriate.

Weight gain:

Let me just say at the outset that those who take estrogen blame it for their weight gain.  Those who don’t take estrogen blame its loss for weight gain.  End of that discussion.

This is another shocking reality of menopause By 40, many realize that even when they watch what they eat, they gain weight.  By 50, the game is over.  Simply looking at food seems to put on pounds.  There is a maddening tendency for weight to deposit around the middle during peri- and postmenopause as a result of lower estrogen levels.  Even if you don’t gain a pound, the distribution of your weight will change as you approach and go through menopause.

Hair Loss:

The body continues to secrete testosterone in limited amounts after menopause.  With the decrease in estrogen production, there is a relative testosterone dominance which results in more facial hair and less scalp hair.  There is also generally a decrease in pubic hair.  This is not pathologic.  It is the expected consequence of testosterone dominance. If the changes are extreme, you should have your provider check your testosterone levels to rule out an unlikely testosterone-secreting tumor in an ovary or adrenal gland. Sadly, hair loss is not something than can readily be addressed by hormonal replacement therapy (HRT).  You may wish to discuss Rogaine or other such medications with your provider.

How can we best avoid some of the “not so healthy” changes, such as weight gain?

This is a very unpopular answer.  Given the metabolic changes discussed above, women need to exercise MORE and/or eat LESS simply to maintain their current weight.  Weight loss requires an even more rigorous approach.  The best approach is to nip the weight gain in the bud as soon as it appears.  Waiting until you have already gained 15 to 20 to 30 pounds makes it so much harder.  Sitting still at 50, you burn far fewer calories than you did when you were 30.  You need fewer calories to live so you need to take in fewer calories and/or burn more with aerobic exercise.  You can like it or not, but those are the rules.  Any addition weight not only makes you more uncomfortable, but increases your risk for diabetes, high cholesterol, hypertension and heart disease.  You can accept the rules and do what needs to be done which is, I admit, close to, but not, impossible.  Or you can gain weight and watch your lab values and the number of medications you take to normalize them increase.  Don’t shoot the messenger!  I’m just telling you what nature’s rules are.  I didn’t make them, nor do I like them, but neither you nor I get a vote on this.


Dr. Heather L. Johnson is an award winning, actively practicing gynecologist AND author of two books, who, after delivering more than 3,500 babies over 40 years, recently retired as an obstetrician. Her second book, What They Don’t Tell You about Menopause: A Gynecologist’s Unofficial Guide to Premenopausal, Perimenopausal and Postmenopausal Life, was released in late November of 2020. Dr. Johnson discusses the various stages of menopause and what to expect throughout this natural aspect of life for women. From perimenopause to postmenopause, and everything in between, this book offers practical, fact-based information that will be your guide through this daunting period of womanhood.

In both of her books about pregnancy and menopause, Dr. Johnson shares what she has learned throughout her career, fact-filled and up-to-date medical insights, humorous anecdotes, and “Dr. J’s Pearls” of bite-sized advice & information. Her books are available in both Paperback and eBook on,, and 

She is the senior partner at Reiter, Hill & Johnson, an Advantia practice, with offices in Washington, DC, Chevy Chase, MD and Falls Church, VA. Dr. Johnson attended Yale University School of Medicine and trained at The Walter Reed Army Medical Center in Washington, DC.  She has two children and is a proud grandmother of two granddaughters.

To learn more about Dr. Johnson, her books and Dr. J’s Pearls of bite-sized advice, please visit her website, and follow her on Instagram (@askdrheatherjohnson), Facebook (@askdrheatherjohnson) and Twitter (@askdrjohnson)!