Interview with Tamsen Fadal, Journalist and Menopause Advocate: “How to Menopause” and Navigate Perimenopause Symptoms with More Confidence

There are stages of a woman’s life that get parties, flowers, cards, and rituals. Birthdays. First periods. Babies. Milestones everywhere. Then menopause arrives and, for far too many women, it is met with silence. That silence is exactly what Tamsen Fadal has been working to break.

In this conversation, Dr. Thais Aliabadi and Mary Alice Haney talk with Tamsen, Emmy Award-winning journalist, documentary filmmaker, and author of How to Menopause, about what happened when her own body blindsided her, why so many women are still dismissed or misdiagnosed, and what every woman should know about perimenopause, menopause symptoms, hormone therapy, sleep, brain fog, and long-term health risks.

What makes this conversation so powerful is that it brings together lived experience and clinical perspective. Tamsen shares what it felt like to go from a high-functioning news anchor to someone who suddenly could not trust her own body or brain. Dr. Thaïs Aliabadi adds the medical context that women often never receive in the exam room. And throughout it all, the message is clear: we cannot keep waiting for the system to catch up. Women need information now.

Table of Contents

• Menopause should not be the life stage nobody talks about
• Tamsen’s menopause journey started with a moment she could not explain
• The symptom list is much longer than most women are told
• Brain fog is real, common, and often terrifying
• Hormone therapy is not one-size-fits-all
• Before hormone therapy, know your risks
• Sleep can fall apart in menopause, and it affects everything
• Bladder symptoms and vaginal dryness deserve more attention
• Not every woman experiences menopause the same way
• The menopause research gap is still astonishing
• Why education is the real turning point
• What women can do now
• FAQ
• A better menopause conversation is finally happening

Menopause should not be the life stage nobody talks about

Why has menopause been treated so differently from other major phases of a woman’s life?

Tamsen points to something that feels obvious once you hear it. A woman’s life is often celebrated at every turn until menopause. Then everything goes quiet. No rituals. No shared language. No sense that this transition is normal, meaningful, or worthy of support.

Part of that silence is cultural. In some societies, aging and wisdom are respected, and menopause is viewed as a meaningful passage. In the United States, aging is often framed as something to resist or hide. Menopause gets wrapped up in those fears, which makes it even harder for women to talk openly about what they are experiencing.

Tamsen’s work, including her documentary The M Factor: Shredding the Silence on Menopause and her book How to Menopause, was built around one central idea: start the conversation. Once women begin talking, they quickly realize how much they share.

That community matters. Women everywhere are going through the same transition, but many feel isolated while doing it. Creating language, visibility, and sisterhood around menopause can be just as important as any prescription.

Tamsen’s menopause journey started with a moment she could not explain

What happened when you first realized something was wrong?

Tamsen spent nearly three decades in news, used to pressure, deadlines, and performing under stress. Then one day, during a commercial break, she was suddenly overwhelmed by heat, a racing heart, and a feeling that she might collapse. She had also been dealing with what she later understood was brain fog, trouble finding words, difficulty retaining information, and moments where language simply would not come.

She told the men in the studio, half-joking and half-serious, “If I fall over, somebody catch me.” Then she left the set, made it to the bathroom, and ended up on the floor.

She got up, finished the day, and began what is for many women a painfully familiar search for answers. She saw multiple doctors. At first, she did not even understand whether she was still having periods. She had endometrial polyps and frequent bleeding, which made everything more confusing. She had gone through a divorce and heavy bleeding in her mid-40s, so stress was blamed. Lexapro was prescribed. The real issue was missed.

Eventually, at age 49, she saw her OB-GYN, had bloodwork done, and received a note in her patient portal that simply said she was in menopause and asked whether she had any questions.

That moment was shocking, not only because of the diagnosis but because of how unceremonious and unsupported it felt. She was of average age for menopause. Yet she still thought, “I’m too young for that.” That reaction says a lot about how little most women are taught.

Why do so many women miss the signs of perimenopause and menopause?

Because the symptoms are broad, varied, and often dismissed.

Women are told they are stressed, anxious, overworked, depressed, burned out, or just aging. Sometimes they are given medications for isolated symptoms while the hormonal transition underneath it all goes unrecognized.

Perimenopause can begin seven to ten years before menopause. Since the average age of menopause is about 51 and a half, symptoms can start much earlier than many women realize. If menopause happens at 45, symptoms may begin in the mid-30s.

That is one reason this stage can be so confusing. A 37-year-old with irregular cycles, hair changes, anxiety, brain fog, and weight changes might be told it is stress or thyroid dysfunction. It might be PCOS. It might be perimenopause. Often, it takes a careful history and a doctor who really listens to sort it out.

The symptom list is much longer than most women are told

What symptoms can show up in perimenopause and menopause?

One of the most important points in this discussion is that menopause is not just hot flashes. It is a head-to-toe hormonal transition that can affect nearly every system in the body.

Dr. Aliabadi describes the symptoms as running from head to toe, and that framework is useful because it reminds us how wide-ranging these changes can be.

• Cycle changes: irregular periods, skipped periods, heavy bleeding
• Vasomotor symptoms: hot flashes, night sweats
• Brain symptoms: brain fog, forgetfulness, word-finding issues
• Mood symptoms: anxiety, depression, irritability
• Hair and skin changes: hair thinning, facial hair, itchy skin
• Sexual and vaginal symptoms: vaginal dryness, painful sex, low libido
• Body changes: weight gain, fatigue, lack of energy
• Sleep symptoms: waking at night, trouble falling asleep, poor sleep quality
• Musculoskeletal symptoms: joint pain
• Urinary symptoms: urgency, frequency, stress incontinence

And that is still not the whole list. Tamsen notes that when she wrote her book, she identified 34 symptoms, then later found research documenting more than 100 possible symptoms associated with menopause. That sounds extreme until you remember that estrogen influences the brain, bones, skin, heart, bladder, and more.

Brain fog is real, common, and often terrifying

What does menopause brain fog actually feel like?

For many women, brain fog is one of the most frightening symptoms because it does not just feel inconvenient. It can feel like losing yourself.

Tamsen describes it as severe enough that she struggled with conversation and language. Dr. Aliabadi points out that a large number of women experience this, and many are alarmed enough to wonder whether they have early dementia.

That fear is not irrational. If you are forgetting things, repeating questions, or staring at words you suddenly cannot process, it is easy to spiral.

Mary Alice shares a story that captures this perfectly. Her husband sat her down and seriously suggested she see a “brain doctor” because he thought she had early dementia. What was happening was perimenopausal brain fog.

This is one reason education matters so much. A woman who understands that cognitive symptoms can be part of hormonal change is less likely to panic and more likely to seek the right help.

Does the brain fog go away?

For many women, symptoms improve, especially when the underlying hormonal changes are addressed appropriately. Dr. Aliabadi says hormone therapy can help significantly, and many women feel as if a fog lifts.

At the same time, brain fog is not something to brush off casually. Sleep disruption, anxiety, mood changes, and overall stress can all worsen cognitive symptoms. It often takes a combination of approaches to feel like yourself again.

If brain fog is one of the most troubling parts of this transition for you, it may help to read more about menopausal memory loss and brain fog, including practical ways to support focus and cognition.

Hormone therapy is not one-size-fits-all

When should women consider hormone therapy?

One of the strongest themes in this conversation is that treatment has to be individualized.

There is no single age or symptom threshold at which every woman should automatically start hormone replacement therapy. Instead, the right question is: What symptoms is she having, how severe are they, and what are her personal risks?

Dr. Aliabadi offers a practical way to think about it:

• If a 45-year-old has irregular periods but few other symptoms, a birth control pill may be an option.
• If a woman in her early 40s is experiencing severe brain fog, poor sleep, anxiety, and a major drop in quality of life, hormone therapy may be appropriate.
• If decreased libido is a primary complaint, testosterone may be discussed before or alongside other therapies.
• If weight gain and insulin resistance are part of the picture, additional metabolic support may be needed because hormone therapy alone may not solve that issue.

The key is symptom-driven care. Listen to the patient. Treat the person, not just the lab value or her age.

Why are so many women still afraid of HRT?

A lot of fear still traces back to the Women’s Health Initiative. Before that study, hormone therapy was widely prescribed. After it, prescribing dropped dramatically, and the message many women absorbed was simple and terrifying: hormones are dangerous.

But as Dr. Aliabadi explains, the conversation has evolved. The original study had important limitations, and menopause specialists now take a more nuanced, individualized approach.

Still, the fear remains. Many women either do not know that hormones may be an option or assume they are automatically unsafe.

If you want a broader overview of how menopause nutrition, symptom management, and hormone therapy can be approached in a more personalized way, this related guide is helpful: The New Menopause: clinical guide to menopause nutrition and hormone therapy.

Before hormone therapy, know your risks

What should women understand about breast cancer risk before starting hormones?

This part of the conversation is especially important because it goes beyond the usual generic warnings.

Dr. Aliabadi argues that every woman should know her lifetime breast cancer risk. Not just whether she has BRCA1 or BRCA2, but a broader understanding of inherited risk and screening needs.

Here is what she emphasizes:

• BRCA is not the whole story. There are many gene mutations associated with breast cancer risk beyond BRCA1 and BRCA2, including genes like PALB2 and CHEK2.
• Family history matters. A family history of breast, ovarian, or pancreatic cancer should prompt a more thorough evaluation.
• Risk calculators matter too. A model such as Tyrer-Cuzick can estimate lifetime breast cancer risk based on factors like age, family history, breast density, reproductive history, and more.
• Twenty percent matters. If lifetime risk is 20 percent or higher, that generally places a woman in a high-risk category and may change how she is screened.

For high-risk women, mammograms alone may not be enough. Dr. Aliabadi discusses adding breast MRI and alternating imaging every six months in some patients.

She also explains that if a woman’s risk is very high, hormone therapy may not be the best path. In some cases, anti-estrogen therapy may be more appropriate. In very high-risk situations, prophylactic surgery may be discussed before hormones are considered.

That does not mean every woman with a family history of breast cancer cannot use hormones. It means the decision should be informed, specific, and based on real risk data, not assumptions or fear.

If hereditary cancer risk is part of your story, it is worth learning more about genetic testing for cancer risk and what different results can mean for screening and prevention.

What other health risks should be considered before starting HRT?

Breast cancer is not the only factor.

Dr. Aliabadi also highlights two major areas that should be part of the conversation:

1. Dementia risk
2. Cardiovascular risk

She discusses the APOE4 gene, which is associated with increased dementia risk and is carried by a significant part of the population. In her approach, knowing whether a patient carries APOE4 can influence how she thinks about hormone therapy, especially timing.

She also pays close attention to cardiovascular risk factors such as coronary artery disease, lipoprotein(a), and ApoB. Her point is simple: when we talk about menopause treatment, we should not be thinking only about symptom relief. We should also be thinking about the long-term health landscape of the individual woman in front of us.

Again, the message is not that hormones are unsafe. The message is that thoughtful medicine beats blanket medicine every time.

Sleep can fall apart in menopause, and it affects everything

Why is sleep such a major issue in perimenopause and menopause?

If there is one symptom cluster that can make everything else worse, it is poor sleep.

Many women start waking up repeatedly. Sometimes it is hot flashes or night sweats. Sometimes anxiety spikes at night. Sometimes there is no obvious reason at all. There may also be bladder symptoms, urgency, or the need to urinate more often because estrogen loss affects the tissues of the urinary tract and vagina.

Tamsen admits she used to treat sleep as optional, almost as a badge of toughness. Like many high-achieving women, she bought into the culture that praised functioning on three or four hours a night. Menopause forced a reckoning.

What she learned from sleep experts was refreshingly simple and practical. She wanted information that was “brain fog proof,” and that is exactly what she sought out.

What sleep hygiene strategies actually help?

Some of the most effective strategies are not glamorous, but they matter:

• Go to bed at the same time each night
• Wake up at the same time each morning
• Get outside early in the day for light exposure
• Keep the bedroom cool
• Darken the room as much as possible
• Avoid caffeine too late in the day
• Reduce or eliminate alcohol if it worsens sleep

Tamsen also found progesterone to be a game-changer for her deep sleep and ability to stay asleep.

Dr. Aliabadi adds an especially memorable line: midnight should be the middle of the night, meaning the middle of your sleep, not the beginning of it. For women who wake early, that often means going to bed much earlier than they think they “should.”

For a deeper look at why sleep disorders become so common in this phase of life, and what can help, this resource on menopausal sleep disorders is a useful companion.

Bladder symptoms and vaginal dryness deserve more attention

What do vaginal dryness and urinary urgency have to do with menopause?

More than many women realize.

As estrogen declines, the tissues of the vagina and urinary tract can become thinner, drier, and more sensitive. That can lead to vaginal dryness, painful sex, urinary urgency, frequency, and waking up at night to urinate.

Some women notice stress incontinence, leaking with jumping, exercise, or sneezing. Others notice urge incontinence, where the bladder contracts and creates a sudden need to go.

Dr. Aliabadi explains that treating vaginal dryness can also improve bladder symptoms. Vaginal estrogen may help reduce urgency and frequency in some women. Cutting back caffeine can help, too, especially if bladder irritation is part of the problem.

This is exactly the kind of symptom that women often tolerate in silence because it feels embarrassing or inevitable. It is neither. There are treatments, and women deserve to hear about them.

Not every woman experiences menopause the same way

What did you learn about differences in menopause experiences across groups of women?

One of the strengths of Tamsen’s documentary is that it does not treat menopause as a single universal story. She wanted to talk to many different women and many different kinds of providers because there is no one menopause narrative.

She highlights the work of Omisade Burney-Scott, founder of Black Girls’ Guide to Surviving Menopause, and the reality that Black women often experience menopause earlier, with more intense symptoms, and for longer durations.

That point matters enormously. Menopause research has been underfunded, and not all women have been equally represented in the data that does exist. When some groups of women have more severe symptoms and less support, the gaps in education and care become even more harmful.

Tamsen’s point is not that one group has a “correct” menopause experience. It is that the medical system has to stop assuming all women are affected the same way, or that one standard script will fit everyone.

The menopause research gap is still astonishing

How underfunded is menopause research?

The numbers discussed are hard to ignore. Of roughly $5 billion in federal funds allocated for women’s health research, only about $15 million went to menopause research.

That is startling when you consider the scope of the issue. Around 20 percent of the U.S. workforce is in active menopause. Menopause affects health, work, relationships, sleep, cognition, sexuality, and long-term disease risk. Yet the research investment has historically been tiny.

No wonder women have been left to piece together care from social media, online communities, and trial and error.

As Tamsen says, we cannot wait another 20 years for the perfect study while women are suffering now.

Why is education the real turning point

What do women most need right now?

Tamsen’s answer is direct: women have to take their power back.

That is not because they should have to do all the work. It is because, at this moment, many still cannot rely on the healthcare system to recognize, explain, and appropriately treat menopause.

That reality shows up in several ways:

• Doctors may have had very little formal menopause training
• Symptoms may be brushed off or misattributed
• Women may not know what to ask for
• Many still do not understand the difference between perimenopause and menopause
• Risk assessment before treatment is often incomplete

Education changes all of that. A woman who knows her symptoms may be hormonal can advocate for herself differently. A woman who understands her family history can ask for genetic testing. A woman who knows sleep disruption, bladder changes, anxiety, and brain fog are part of the picture is less likely to feel ashamed or alone.

This is exactly why Tamsen created both a documentary and a practical, accessible book. She wanted the information to be easy to absorb, even for women whose concentration is not what it used to be.

What personal experience drove your mission most deeply?

For Tamsen, part of the urgency is personal loss. Her mother died at 51 after breast cancer, a double mastectomy, radiation, and chemotherapy. Only later did Tamsen fully understand that her mother had been pushed into early menopause. She remembers her mother sweating constantly and joking about it, but now sees the loneliness underneath that experience.

That realization is heartbreaking, but it is also part of what fuels this work. If previous generations suffered in silence, this generation does not have to.

What women can do now

If someone suspects perimenopause or menopause, where should she start?

This conversation gives us a clear, practical framework.

1. Pay attention to symptoms. Do not reduce the conversation to hot flashes alone. Brain fog, anxiety, sleep changes, dryness, hair changes, bladder symptoms, and heavy or irregular bleeding all matter.
2. Know that symptoms can start early. Perimenopause can begin years before periods stop.
3. Track what is happening. Patterns help, especially if your cycles are changing or symptoms fluctuate.
4. Find a clinician who listens. Not every doctor is equally trained or comfortable in menopause care.
5. Ask about individualized treatment. The right plan depends on symptoms, goals, and personal risks.
6. Know your family history. Especially for breast cancer, ovarian cancer, pancreatic cancer, dementia, and cardiovascular disease.
7. Support sleep aggressively. Because poor sleep makes almost everything worse.
8. Do not normalize suffering. There are options.

FAQs

What is the difference between perimenopause and menopause?

Perimenopause is the transition leading up to menopause and can begin seven to ten years before menopause. Menopause is officially defined as going 12 months without a period.

Can brain fog really be caused by perimenopause?

Yes. Brain fog, forgetfulness, trouble finding words, and difficulty concentrating are common symptoms during perimenopause and menopause. For many women, this is one of the most distressing symptoms.

Are hot flashes the main symptom of menopause?

No. Hot flashes are common, but menopause can also involve sleep disruption, anxiety, depression, brain fog, joint pain, hair changes, vaginal dryness, painful sex, urinary urgency, weight changes, and more.

Should every woman start hormone replacement therapy?

No. Hormone therapy should be individualized based on symptoms, medical history, and risk factors. Some women benefit greatly, while others may need different approaches or more evaluation first.

Can women with a family history of breast cancer ever use HRT?

Sometimes, yes. A family history of breast cancer does not automatically mean hormone therapy is off the table, but it does mean risk assessment is important. Broader genetic testing and lifetime risk calculations may help guide decisions.

Why does menopause affect sleep so much?

Hormonal changes can contribute to hot flashes, night sweats, anxiety, bladder symptoms, and unexplained awakenings. All of these can disrupt sleep quality and duration.

Can vaginal dryness affect bladder symptoms?

Yes. Declining estrogen can affect the vaginal and urinary tissues, contributing to dryness, urgency, frequency, and nighttime urination. Treating vaginal dryness may improve some urinary symptoms, too.

Why is menopause still so misunderstood?

It has been under-discussed, under-researched, and often under-taught in medical training. Many women grew up without hearing their mothers talk about it, and many clinicians received limited formal menopause education.

A better menopause conversation is finally happening

The real takeaway from this interview is not just that menopause is complicated. It is that women have been expected to navigate that complexity with far too little support.

Tamsen Fadal’s work is helping change that. She is taking a life stage that has long been minimized and giving it language, visibility, urgency, and humanity. Dr. Aliabadi’s perspective reinforces that menopause care can be thoughtful, evidence-informed, and individualized, but only if women know what to ask and clinicians are willing to look at the whole picture.

Menopause should not be a mystery. It should not be something women discover by collapsing on a bathroom floor, getting a one-line portal message, or wondering whether they are losing their minds.

It should be part of standard education, standard medical care, and standard conversation.

Until that is true everywhere, we keep talking.

For more from Tamsen Fadal, visit tamsenfadal.com and howtomenopause.com.

This article was created from the video “How to Menopause” Navigating Perimenopause and Menopause Symptoms with Tamsen Fadal | SHE MD for Dr. Thais Aliabadi’s website.