Introduction

This book is intended for women in their thirties, forties, fifties, and beyond who may be experiencing unusual come and go memory, speech, attention, behavior, thinking, and time-tracking symptoms no expert ever prepared them for and who want help in understanding and possibly treating such symptoms. It is for all women who may in the future experience such symptoms and prefer to be forewarned and forearmed rather than be caught helpless. It is for women who want to know the latest research news on the estrogen and Alzheimer's disease evolving frontier.

This book is also for women's physicians who want to understand the plausible basis for cognitive, speech, and behavioral symptoms women experiencing perimenopause, menopause, or estrogen loss for any reason may be reporting to them.

Lastly, this book is for neuroscientists eager to mine not merely a good but a "great" research topic rife with the potential for yielding not only major pure science discoveries about the mind and brain but discoveries that will have life altering applications for millions and millions of women now and in the future.

In this book I make a rather dramatic revelation, I report that there is something new under the sun about women'sbiologythat has been missed before: a set ofinterior,sometimes visible symptoms that frequently occur in association with menopause and perimenopause in many but not all women that are as common, normal, similar in cause, and variable in pattern as hot flashes are. These symptoms have been previously overlooked because no one asked women the right questions. Most of the health and mental experts women see today, I maintain, now know virtually nothing about the symptoms, yet neuroscientists studying the brains of different species have been wondering expectantly how their findings would manifest in women. They have been looking for these symptoms. Here they are.

I link these symptoms to very recent but as yet little-known brain and clinical research evidence in the neurosciences that I argue explains why the symptoms occur, indicates that the symptoms can largely be reversed, and reveals how this may be done.

I present for the first time anywhere in symptomatic detail the lives of many women who have experienced these symptoms in great perplexity, isolation, and often fear and describe how they coped with and around them. I offer women multiple tools for assessing, speaking about, and getting competent help for treating their symptoms, if they need to -- and many don't -- and for assessing whether any proposed treatment is actually helping. For many women simply understanding what is happening may be all the help they need.

I also propose that I have detected the "larger meaning" of these symptoms within the framework of evolutionary biology. I believe these symptoms lead us to important clues about how our human psychology has been adaptively shaped, honed, buffed, and polished by evolution. I contend that the cognitive/behavioral/speech symptoms that commonly show up in women during perimenopause and menopause, when fertility sequentially declines and then ceases, are the opposite or flip side of the very traits of mind and behavior that "nature" most highly values and typically keeps tightly regulated, controlled, or "girdled" during women's reproductive years because they confer unique survival advantages to those who have them. When the stakes of reproducing the species, i.e., species survival, are no longer an issue, "nature," I contend, pragmatically draws an exhaling breath of relaxation and says in effect, "You no longer need to be as tightly tuned for hypervigilance as before. It's OK to just 'be' during this time." The subtle symptoms of what I have named the WHM Syndrome (WHMS), for Warga's Hormonal Misconnection Syndrome, I contend, are the outward signs of that relaxation, of that altered biological agenda.

For modern women who intend to live long and well beyond the end of their fertility and whose quality of life is affected by these symptoms, biology need not be destiny I say. I point to plausible ways for living longer well, presenting the input of neuroscientists, menopause, and memory experts, who offer scientific rationales for treatments. I offer self-help behaviors that can have neurological/physiological consequences, along with practical little-known self-help aids and tools.

I argue that these symptoms are now epidemic among women because the first waves of the baby boom generation have reached the maturational landmarks of perimenopause and menopause and will continue to hit those markers in great numbers for some two decades to come. Ignoring women who suffer most with this syndrome, I suggest may have important public health consequences now and quite possibly for the future of our nation.

My goals in this book are:

* First and foremost to help women with these symptoms understand what they are experiencing now

* To educate the medical and mental health professionals women see sotheycan help women now

* To put this syndrome on the scientific map so that researchers can investigate all facets of its basis and devise multiple safe strategies for helping women now

* To offer researchers a testable scientific rationale for the syndrome that has heuristic value, that can be aimed at and validated, or if need be, shot down

* To draw attention to an as yet unrecognized major public health epidemic affecting the lives of millions of women now that may have important long-term consequences.

BACKGROUND

In this book I report on a discovery I made in the fall of 1996 -- the WHM Syndrome -- after several years of initially detecting "glitches" in speech and behavior in women I knew very well in diverse settings.

Some of the women I knew well from my work as a New York state-licensed psychologist treating patients with health and stress-related problems with the tools of health psychology and behavioral medicine. They told me things, which at first I didn't understand, but which I mentally tucked away somewhere.

Some of the women I knew well from belonging to two reading groups that met monthly for over a decade -- that still meet -- and that included, on average, eighteen to twenty women, some my age, some older, and some younger, spanning in recent years ages from about thirty-eight to sixty-two. I knew these women to be highly bright and verbal. And the monthly spacing of our meetings provided sufficient distance to "see" changes in some of them over time. The intimate familiar nature of these groups also made it possible for me during my initial inklings of discovery to get individual confirmation from more than a few women in private about the reality of the symptoms I was detecting. I received more of the same confirmation from interviews with women I had come to know while living outside of New York City for a number of years, who were, on average, four to seven years older than me. The women I collectively observed in these settings were all either perimenopausal or menopausal. Considerable trust I believe is essential for discussing these symptoms, though sometimes need alone will suffice.

Confirmation of what I was detecting fueled my later drives to obtain interviews with many women I did not know about what cognitive or behavioral or speech symptoms they associated with perimenopause and menopause. I solicited interviews with these women through advertisements and referrals made by ob/gyns. I also interviewed women I did not know who responded to an article I wrote inNew Yorkmagazine in 1997. But I am getting ahead of myself.

At some point in the fall/winter of 1996 I could stand it no longer and set off one evening to find out if science knew anything about the symptoms I was detecting in women. I went to do a computer search at the medical library of New York University Medical Center, where for three years I had done research on Alzheimer's disease years before, as a clinical research psychologist testing Alzheimer's patients on a neuropsychological test battery before and after experimental treatment with hyperbaric oxygen.

I loved the medical library and knew it well. Fishing to see what would turn up, I typed into the computer such paired terms as "menopause" and "mind" and came up with very little if anything. I persisted typing in different terms until I suddenly hit gold. I had typed in "estrogen" and the "brain" and out poured a wealth of references and abstracts mainly from the 1990s from leading research laboratories that represented a virtual revolution in prior thinking about both the brain and the roles of estrogen.

Estrogen loss, some of the studies noted, could produce detectable changes in parts of the brain having to do with memory and attention and could affect multiple neurotransmitter systems involved in thinking and memory. Other clinical studies found small but consistent (reliable) evidence of changes in verbal memory and learning in women with estrogen loss. I'll let you read about these discoveries in chapters 3, 4, and 5.

I didn't initially understand the overall significance of many of these studies, but what I did understand was that they could easily dovetail with the observations about unusual symptoms I had made in women -- they dealt with overlapping areas of function. In my readings later I discovered that neuroscientists had actually been wondering how their basic-science discoveries in animals about the potential effects of estrogen loss on the brain would show up in women.

After reading through these studies, facilitated by my earlier study of the neurophysiology of sleep and wakefulness with the eminent scientist Dr. Raul Hernandez-Peon, and later research on the psychophysiology of sleep, dreams, and sexual arousal, I next started calling for interviews with the experts who had published the research I had discovered in the medical library. I had learned that I could pretty much call any expert for an interview, when I had adventitiously stumbled into a side career as a medical/science broadcast and print journalist, during a return to graduate school for a doctorate in psychology at New York University, after a near decade engaged in exciting research as an experimental psychologist. (I had a master's degree in experimental psychology and additional graduate courses.)

My interviews with these experts convinced me that the symptoms I thought I had detected were not merely a figment of my imagination and that there was a plausible scientific basis for them. Dr. Bruce McEwen, an eminent research psychologist and neuroscientist who had done much of the important research in this area with students and colleagues at Rockefeller University and was president of the Neuroscience Society that year, in particular, surprised me by being aware that women were having these difficulties. He urged me on in my efforts.

I wanted to find out if women were being told by anyone about these possible symptoms, since the research evidence supporting their existence was "out there." And so I next called officers of the American College of Obstetrics and Gynecology and the North American Menopause Society to see if their organizations formally recognized any speech, memory, attention, or cognitive/behavioral symptoms in women, in the educational materials they made available to women patients in doctor's offices. They didn't, I soon learned. I decided to find out why. So I called the presidents or scientific directors of these organizations to find out if they were aware of the estrogen/mind/brain research. They were, I discovered. Why then, I asked, weren't they informing women that cognitive changes could be associated with the hormonal changes of perimenopause and menopause. "It was too soon," the leader of one group said. They were waiting "to develop consensus," a leader of the other group said. Meanwhile, as I saw it, millions of perimenopausal and menopausal baby boomer women in the midst of high-demand lives were floundering in the dark, silently wondering what was happening to them. I felt I had to act in some way.

I contacted the director of the New York City branch of the Women's Health Initiative, the huge government-sponsored national study assessing among other things the effects of estrogen on women, and met with her, presenting a list of the symptoms I had by then enumerated. She was very interested in what I had to say, appeared to recognize the merits of what I was describing, and suggested I write up an "ancillary study" for her to submit for review to the national head of the Women's Health Initiative Study at their upcoming meeting in two weeks. The ancillary study was submitted and ultimately rejected.

I decided to use my sideline skills as a published medical/science journalist to get word out to women about these possible symptoms, which I had discovered could vary in intensity and inconvenience in different women in much the same way that hot flashes did. On August 11, 1997, I succeeded in having published a cover article inNew Yorkmagazine titled within the magazine "Estrogen and the Brain" and "Can Estrogen Make You Smart?" on the cover. The focus of the article was the little-known new research on estrogen and the brain and a conference titled "Estrogen and the Brain" that had been held recently at Mount Sinai Medical Center to present the new research. At that conference the president of the Mount Sinai School of Medicine and the Mount Sinai Hospital, Dr. John Rowe, himself a leading researcher on aging, had opened the proceedings by saying that on the basis of the new research "The equation for taking estrogen has now changed....We know now that women taking estrogen after menopause reduce their chances of getting cognitive impairments" -- not a wishy-washy statement.

My article alluded briefly to the symptoms perimenopausal and menopausal women were experiencing and that I describe in detail for the first time in this book. After the article was published, I received countless phone calls from friends and friends of friends -- total strangers -- who said they were so relieved that there was a basis for their symptoms and that they didn't, as feared, have Alzheimer's disease or a brain tumor. For months after the article came out, at parties and meetings, women with the symptoms came up and told me conspiratorially what had happened to them. The president of the Ms. Foundation, Marie Wilson, who had experienced some of the symptoms I described, reported that friends of hers too feared they were developing early Alzheimer's disease or a brain tumor, in a letter to the editor atNew Yorkmagazine published September 9, 1997, in response to my article. (In my article, the president of the National Organization for Women, Patricia Ireland, also had acknowledged experience with word loss and uncharacteristic scheduling errors -- WHMS symptoms -- before treatment reversed her symptoms.) Shortly after the article came out, when I attended a meeting of the North American Menopause Society in early September in Boston that year, I was amazed to discover how many people there were suddenly familiar with the article. At a party at the New York Academy of Sciences I discovered that copies of the article had been distributed by the academy at a fall meeting on estrogen and the brain. I was delighted that the message I had sent out was finding an audience. That message is presented in much greater detail in this book.

Looking back it seems to me now that virtually everything I have ever done professionally as a basic sciences researcher, and as a clinician interested in seeing how "adaptation to stress" really works in people from the "laboratory" vantage point of a private practice (in health psychology), has been relevant to my detecting these symptoms and what I suspect they mean. Even many of the readings I did as a science journalist in preparation for radio interviews with leading scientists, while working toward my doctorate in psychology were interviews in the fields of sociobiology, evolutionary psychology, anthropology, and physiology: interviews with Edward O. Wilson, Donald Symons, Niles Eldredge, Donald Johanson, Mary and Richard Leakey, Tim White, Rene Dubos, Sir John Carew Eccles, and others. Even the many articles I wrote for medical and popular magazines on women's reproductive lives, infertility treatments, and other aspects of women's health have proven relevant.

Reviewing the work I have been engaged in most of my adult life has revealed to me that unwittingly I have been virtually "tap dancing" around topic areas that border on the study of the science of perimenopausal and menopausal women in virtually a connect-the-dot fashion that leads to the present picture. In the study of adult life development my life would make an interesting case example of something, I'm not certain what, since not only self-direction but factors I had no control over -- the deaths of two relatively young people I worked for -- shaped the course of my work.

My earliest research was at Bar Harbor's Jackson Laboratory for Mammalian Genetics Research. There under a National Science Foundation fellowship I independently studied what pregnancy, over its course, does to the self-regulation skills of the body -- its bounce-back ability (homeostasis). I examined the effects of different stages of pregnancy on the ability of mice to get their body temperature back to normal after exposure to cold, a stressor. For this research I studied reproductive endocrinology and the physiology of temperature regulation, both areas that prefigured my present interest in the effects of hormonal changes in women (hot flashes). I later did research on the psychophysiology of sleep, dreams, sexual arousal during sleep, insomnia, and the effects of different emotions on the body at the Psychophysiology Laboratory of what was then Downstate Medical Center and is now known as SUNY Health Sciences Center in Brooklyn.

After the fifty-three-year-old leader of our research group unexpectedly died, I studied sleep and dreams again in research at New York University's Research Center for Mental Health. Both research positions again entailed study of topics that bear directly on the many mysteries that still surround the experience of perimenopause and menopause for many women: potential sleep disruptions, potential changes in sexual arousal, potential changes in emotional lability and baseline mood.

When yet again the relatively young leader of our research team died unexpectedly at fifty-four, I became involved in research on an experimental treatment for Alzheimer's disease and studied the research literature on memory, aging, and Alzheimer's at NYU Medical Center's Rusk Institute for Rehabilitation Medicine. I observed "up close and personal" all the cognitive/behavioral/speech "glitches" of patients in different stages of decline during lengthy hours of testing and of interviewing them and their relatives, before and after treatment with hyperbaric oxygen.

Familiarity with these patients primed me for "thinking about thinking" and for detecting WHM Syndrome symptoms. Familiarity with Alzheimer's patients also prepared me for noting the distinctions between Alzheimer's disease and WHMS symptoms even when they appear related.

A return to graduate school for a doctorate after this research led to my doing a doctoral dissertation in the field of neuropsychology on the role of the two hemispheres of the brain in the expression of positive and negative emotions and how these can show up in subtle differences between the two sides of the face during the expression of emotions. The topics of brain-control-over-emotion and neuropsychology again bear upon issues central to my interests in understanding perimenopausal and menopausal women.

After receiving my doctorate from NYU in 1982 1 became director of research programs at the new Institute for the Advancement of Health, then in New York City. It was devoted to funding and giving prominence to the then-emerging interdisciplinary mind/body/health field of psychoneuroimmunology. I began to fund research, organize and attend conferences, and write about developments in different facets of psychoneuroimmunology. At that time psychologists/psychiatrists didn't know or read much about immunology, and immunologists didn't know or read much about the mind and brain. I loved my work and in relation to it even studied immunology at Mount Sinai's School of Medicine. I was immersed daily in research findings that described the negative compromising effects of stress on different aspects of the body, brain, and mind. But while the research was highly credible and intriguing intellectually, the fact was that it didn't mesh with my personal experience in living. I had long thrived on stress. Stress made me feel intensely alive, and I enjoyed rising to the occasion of it, having "Mission Impossible" tasks to accomplish in "x" number of minutes or hours. I enjoyed the "rush" of skiing and even liked to play the piano and type fast, even if I did both badly. I had long enjoyed the excitement of working on multiple projects at once, e.g., the science journalism while in graduate school.

Intrigued by conferences I had been part of, and experts I had heard, to make sense of it all, I decided to become retrained in the "applied" end of psychoneuroimmunology, the then also emerging fields of health psychology and behavioral medicine, and see how life really played itself out in relation to stress. My prior research in psychophysiology related directly to this new work. Over the course of three years I received training in biofeedback; cognitive therapy; hypnosis; pain management; and the self-regulation tools of progressive relaxation training, imagery, breathing and meditation techniques (initially being as much of a skeptic and an unrelaxed person as one could be). Before starting my own private practice I trained in the offices of a neurologist who had many car accident patients suffering profound headaches, backaches, and post-traumatic stress reactions. My main interest was in wanting to hear and understand what happened to people with life stresses -- acute and chronic illnesses, pain states, panic attacks, headaches, irritable bowel problems, upcoming surgery -- how they managed, what they said to themselves, what made things better, what made them worse.

I was very interested in what happened to patients' lives around their symptoms, and over time, I became adept at teaching and applying the tools of health psychology and behavioral medicine and looking for patterns. You could say I became a sick person's delight. I didn't easily tire hearing the details of symptoms. I wanted to understand their subtleties, detect their sequence in relation to other events, understand what thoughts and feelings they triggered. I enjoyed demonstrating how even a fast-talking, hyper child of wound-up Holocaust survivors could relax in an instant, becoming a puppeteer over my nerves and muscles and mind when I needed to. I enjoyed teaching patients how they could make use of a "medicine shelf" of behavioral tools that could be "popped" in an instant, anywhere, once learned, that could adjust and "tune down" their physiology and mind efficiently and with multiple levels of "payoff."

The relevance of this work to the present is that I became a fairly good listener and observer tuned into observing people and trying to understand the subtleties of their symptoms from their perspective. Biofeedback, for example, taught me not to trust my first impressions. From working with it I learned that people who could look outwardly cool and calm could be highly tense when measured with muscle-tension and temperature-monitoring devices.

So here I am.

It is my hope that this book helps many women now and over the long run. In the course of researching it I have also come to the suspicion that for similarly hormonal reasons, having to do with estrogen's newly discovered roles in both men's brains and bodies, that some men at similar ages also experience at least some WHMS symptoms. In chapter 14 of this book I explain what I have uncovered in this regard.

I also believe that WHMS symptoms are "normal" in the way that hot flashes are "normal" and use new evidence I present of WHMS symptoms existing in estrogen-deprived breast-feeding women in chapter 6 to frame the claim of "normality." I also propose that the experience of women with WHMS symptoms may offer us a novel perspective on one possible basis for the symptoms of attention deficit disorder in children. So stay tuned. This is an evolving story that will have many ramifications.

The postwar population boom we commonly refer to as the baby boom generation lasted for an amazing length of time -- twenty years according to some sources, eighteen according to others. In 1997 the first wave of baby boomer women reached the average age of menopause. For the next eighteen years millions of baby boomer women will be hitting that marker if they haven't already. Many of these women during years of perimenopause have already been experiencing in great perplexity the on-and-off array of intermittently flashing symptoms I have named the WHM Syndrome, without knowing what was happening to them or who they could turn to for help.

These women need to understandnowwhat is happening to them. Before they give up careers and jobs they have often spent long years training for and striving at. Before they start sidelining themselves out of dreams and plans and hopes from a sense of despair and hopelessness. Before others needlessly sideline them out of a salary they and their families may be depending on for survival.

At present, as I see it, the world of science knows virtually nothing about the many kinds of WHMS symptoms that are possible with estrogen loss. The research "pipeline" of science could take years to investigate and credit this syndrome with the gold-standard imprimatur of double-blind, placebo-controlled trials. The results of the Women's Health Initiative Study will not be out until the year 2008. And at present in this study the effects of estrogen on some aspects of cognitive functioning are only being examined in women sixty-five years and older. While interest in women of menopausal age is growing at the research level, it will take a long long time, I fear, before researchers in turn discover that some proportion of women, even in their thirties, can be affected cognitively by hormonal loss (as you will see in this book).

It is my belief that the converging evidence on what estrogen does, in different animal models, in women deprived of estrogen for different reasons and given replacement hormones, in women at different hormonal tides in their menstrual cycle, in cell culture, from epidemiological studies of the effects of estrogen therapy on the risk of developing Alzheimer's, collectively offers a sufficient basis for alerting women now to what may be happening to them and to their options, particularly since estrogen replacement therapy is already an available treatment with many other proven benefits to women.

In view of the epidemic number of women potentially affected by WHMS symptoms today and in the near future, in view of the evidence of the potential reversibility of the symptoms by estrogen and in the future likely with yet-to-be designed estrogen substitutes, in view of the fact that knowledge alone can relieve the suffering of women fearful about the meaning of WHMS, and in view of the potential personal and public health costs of not doing so, I believewomen need to be informed of their options nowso that they can become health research advocates acting to secure the research they need now. So they can educate each other and, if necessary, their doctors. To do otherwise, to not inform women in light of what I know, for me would constitute neglect.

Lastly, as you read this book I ask you to ponder, as I often have, the question "How could this syndrome have been kept a secret for so long?"

Claire L. Warga, Ph.D.

Chapter 1

What Are These Strange Symptoms I'm Experiencing in the Middle of My Life?

Mrs. Malaprop:a character in Richard Brinsley Sheridan's 1775 playThe Rivals."A...woman ofalmost fifty[emphasis added] who...is famous for misusing...long words that sound similar to the correct words."

-- Larousse Dictionary of Literary Characters

Malapropisms:the type of verbal errors made by the character Mrs. Malaprop.

There are some topics almost no one talks about till you do first. The stampede for the male impotence drug Viagra unveiled one such topic. This book is about another one: the previously unrecognized cognitive symptoms that are caused by the effects of perimenopause and menopause on the mind.

Sometimes it begins out of the blue with occasional slips of the tongue, meaning to say one word and unexpectedly hearing another pop out. Or when you realize that you, once a champion speller, aren't so sure anymore how to spell "potato" or "forty." Sometimes it begins with uncharacteristically forgetting important appointments or drawing unexpected momentary blanks -- total blanks -- when it comes to remembering your only child's or best friend's name, or how to turn on the computer you've been using for years. Sometimes with feeling mentally "hazy" "foggy," or "spacey" and not being able to clear things up though you need to be "sharp" at that moment. "What's happening to me" you wonder. "Could this be early, early, early Alzheimer's disease or a brain tumor?"

But it is usually not early Alzheimer's disease or a brain tumor. It is something else, a particular set of symptoms -- a syndrome -- that can occur in women beginning in their mid to late thirties or in their forties or fifties that more than likely can be halted and even largely reversed according to the best evidence available today. It is a syndrome associated with estrogen loss that is mainly experienced from within, and that until now, amazingly, no one has recognized as common among women or has linked to the wealth of post-1990s research evidence revealing the many important newly discovered roles estrogen plays in the remembering, naming, and attending parts of the brain. This is research that helps explain why the symptoms occur and why they can often be reversed.

"I'm losing it," women say. "I'm going out of my mind," "I'm falling apart at the seams." "I'm flipping out." "I'm cracking up." "I'm having a nervous breakdown," "I'm just not myself." "I don't know what's wrong with me." "I do the strangest things." "I think I'm getting early Alzheimer's."

These arenotthe hysterical rantings of women with vague psychosomatic complaints but rather the blanket descriptions frequently used by perimenopausal (women experiencing or undergoing changes associated with the shifting hormonal functioning of the ovaries that precedes the last period. Symptoms can begin four to fifteen years before menopause.) and menopausal (women who have had their last period twelve months ago) women to describe the dislocating experience of confronting an assortment of unpredictable mind, speech, and behavioral "flash" symptoms. These are surprising symptoms no one has ever prepared them for. Physicians hearing these dramatic statements over the years have simply had no basis in training for understanding what they were hearing and as a result have been able to offer no, or minimally constructive, help to women who dared to mention them.

THE SYMPTOMS OF PERIMENOPAUSE AND MENOPAUSE CAN BE VERY STRANGE BUT NORMAL

Before describing the specific symptoms I am referring to it makes sense first to agree about certain realities of a perimenopausal/menopausal symptom you alreadydoknow something about. Hot flashes. Consider this: If we on earth had never heard of hot flashes as a "normal" midlife symptom associated with ovarian and hormonal changes, and a returning astronaut-discoverer of a twin planet to ours reported drenching, unpredictable, overheating episodes as normal in otherwise healthy midlife-and-older women, we would likely say in quick dismissal, "Go away! You must have gotten something wrong there. The women were probably fooling with you in some way. You couldn't be right. That symptom is just too weird to be true of normal people."

And yet the reality is hot flashes are definitely normal but strange symptoms for healthy women to have. The fact that they are so common makes them seem normal to us. What makes them believable apart from their strangeness is the fact that they are also sometimes observable to others, leaving "tracks" of the internal experience visible to those who don't have them and who might otherwise be inclined to dismiss them as "too crazy" to credit as real.

PERIMENOPAUSAL AND MENOPAUSAL SYMPTOMS CAN OFTEN BE CURED EVEN WHEN NOT FULLY UNDERSTOOD

It's also useful to point out that though science does not yet have a clear consensus on what specific sequence of events produces hot flashes in women -- beyond the bigger picture of changing ovary and estrogen function during perimenopause and menopause -- nevertheless medicine has developed at least one quite effective empirical treatment for hot flashes based on trial-and-error experience, even in the absence of a clear scientific understanding of their basis. Namely, estrogen replacement. (Other remedies that apparently work for some proportion of women have been considerably less tested and proven.) Successful treatment therefore of a symptom associated with ovarian/hormonal changes can precede biological understanding of the full complexity of the symptom.

The broad array of symptoms I have named the WHM Syndrome -- for Warga's Hormonal Misconnection Syndrome -- may at first, I suspect, appear as strange and bizarre as hot flashes do to those unfamiliar with them. But in the years to come, I believe, it will seem one of the great mysteries of our time that such a common, unusual, but apparently typical set of biologically based symptoms could have been overlooked for so long. Cultural and medical historians of the future, I predict, will long ponder the great divide of female patient/doctor non-communication that is implicit in physicians not having "heard" and detected this set of symptoms and its cause in women for so many years.

What WHMS Is Like

The list of possible symptoms I am specifically referring to is presented in Table 1 to help you better understand the cases you will shortly be reading about. (A fuller description of possible WHMS symptoms with examples of how they actually occur in women's lives follows in chapter 7.) In Table 1, however, I list only the mind/speech/attention/ behavioral symptoms to which I have given the name "WHM Syndrome," or "WHMS." This table does not include any of themoodorphysicalsymptoms that are also frequently but not inevitably associated with menopause and the years preceding menopause. (These are more fully described in Appendix I.)

TABLE 1

The WHM Syndrome: Warga's Hormonal Misconnection Syndrome

As you examine the following chart keep in mind that the symptoms below typically occur as brief come-and-go episodes within the context of a functional ongoing nondisabled life, not unlike the manner of hot flashes. Women who experiencesomeof the symptoms need not experienceallof the symptoms or evenmanyof the symptoms. Some symptoms may appear similar but are experienced by women as different from each other and are thus listed as distinct, pending additional research. Implied in each symptom is the sense that it occurs with a greater frequency than it did in the past. The symptoms most typically do not occur continuously but in erratic on-and-off intermittent episodes, in the pattern of occurrence of "hot flashes," so each symptom should be read preceded by the phrase "Flash episodes of." The headings over the symptoms are provisional pending further research, i.e., whether a specific symptom belongs under a speech, memory, or attention category may ultimately change as more is discovered about the symptom's biological basis.

Symptoms of Warga's Hormonal Misconnection Syndrome

THINKING CHANGES

* Losing your train of thought more often than in the past

* Forgetting what you came into a room to get more than in the past

* Not being able to concentrate as well upon demand

* Feeling foggy, hazy, and cotton-headed and not being able to clear it up at will

* Experiencing a thought blockade: an inability to pull ideas out at will

* Fluctuating agility in prioritizing as well as in the past

SPEECH CHANGES

* Naming difficulties for long-known names: children, best friends, things, places

* Finding yourself at a loss for words in how to express something while speaking

* Experiencing "It's on the tip of my tongue but I can't get it out" sensation

* Making malapropisms: saying wrong words that are related some how to the intended one

* Reversing whole words while speaking

* Reversing the first letters of words while speaking

* Experiencing "echo" words as unintentional intrusions into present speech

* Relying on "filler" words more often: "whatchamacallit," "that thing," "you know what I mean"

* Organizing sentences and ideas less efficiently while speaking

CHANGES IN THE "BEAM" OF ATTENTION

* Blinking social attention when interested and interacting: listening but not always attending

* Blanking-out amnesia for what you just did

* Experiencing increased distractability

MEMORY CHANGES: SHORT- AND LONG-TERM

* Forgetting what you just did, or past occurrences, with no threads of association to getting back to what's missing: missing links

* Changing certainty in how words should be spelled in once good or great spellers

* Fluctuating agility in calculating and in "counting with a quick scanning look"

* Experiencing changes in the speed and accuracy of memory retrieval

* Forgetting thecontentof a movie right after seeing it but remembering youremotionalreaction to it

BEHAVIORAL CHANGES

* Making behavioral "malapropisms": unintended slips in behavior that are related to the intended behavior somehow, such as putting shampoo in the refrigerator

* Forgetting briefly how to do things long known, such as where to turn on the computer

* Feeling that automatic skills such as driving for a few moments are not "automatic" in the same way as usual

* Dropping things more often that require fine finger/hand coordination

* Absentmindedly, leaving out or reversing letters in words while writing

* Forgetting how to write a word in the middle of writing and having to leave blanks

* Experiencing "translating" hesitations in converting what's heard into writing

* Not handling the same amount of stress in the same way

SPATIAL SKILLS CHANGES

* Changing skill in remembering and/or recognizing faces(notwell-known faces)

* "Looking at but not seeing" what you are looking for when it's right there ultimately, more than in the past

* Changing reading skill in visually "seeing" and comprehending reading material

* Spending less time reading, without difficulties above (for formerly heavy-duty readers)

* Forgetting briefly how to get to long-known landmarks in your life

* Experiencing familiar locales in one's experience as momentarily unfamiliar

ALTERED SENSE OF TIME

* Forgetting appointments more or not anticipating events of personal importance with the same accuracy as in the past

* Forgetting important events in your personal history timeline, i.e., which breast you had biopsied

* "Living more in the moment" out of necessity: a "spliced-film-frames" sense of personal time

WHY IT'S CALLED THE WHM SYNDROME

I have named this set of symptoms the WHM Syndrome, or WHMS, because women who experience the symptoms often feel subjectively as if they are observing their own "bad show," watching their mind behaving whimsically, unexpectedly taking off on a whim with seeming intentions of its own while violatingtheirintent.

In my mind WHM originally stood for the Women's Hormonal Misconnection Syndrome. I felt the acronym in good measure characterized the subjective experience of women who had the symptoms without stigmatizing them. And the words behind the letters described what I believe is going on at the neurophysiological level -- namely, cognitive/behavioral/speech episodes that are mis-hits. Episodes that are off the mark misconnections, in which the mind's intentions are not producing the right physiological connections that they used to in the preexisting circuitry and/or chemical flow patterns of the brain. The reason for the misconnections? A body/brain retooling or "retuning" brought on by the effects of declining ovarian function and declining estrogen hormone supplies on a thinking, remembering, attention-creating brain that science has recently learned (see chapter 4) depends heavily on estrogen as a brain "transmission" fluid of sorts, as a fortifying performance-enhancing steroid or multivitamin. (Estrogen is after all a steroid hormone even though it isn't the kind typically used by athletes. I'll explain this more later in chapter 4.)

However, as I continued interviewing women and experts and reviewing the research literature in this area over the span of several years, I came to the conclusion that calling this theWomen'sHormonal Misconnection Syndrome would not be prudent. (You'll have to read chapter 14 to find out exactly why.) But for the moment suffice it to say that I learned that science had very recently discovered that male thinking/remembering brains and sex organsalsodepend on estrogen supplies for their normal function. So for reasons of faltering estrogen hormonal levels in their brains I began to suspect that at least some men too may have similar WHM symptoms at possibly similar ages. What to do?

To preserve the acronym WHM and prevent the syndrome from being called the rather farcical HM(mmm) Syndrome, I have renamed the set of symptoms Warga's Hormonal Misconnection Syndrome. It turns out that naming new medical syndromes and hormonal/behavioral phenomena after their discoverer has a long history, respectively, in both medicine and behavioral neuroendocrinology (the hormones and behavior branch of science), according to the eminent sociobiologist Edward O. Wilson. Describing a series of known behavior-and-hormones effects in the animal kingdom -- i.e., the Bruce Effect, the Lee-Boot Effect, the Ropartz Effect, and the Whitten Effect -- Wilson in his landmark 1975 bookSociobiology,writes: "In the manner of the medical sciences, the different kinds of physiological change are often called after their discoverers."

Why have I called this set of symptoms asyndrome?Because the set of symptoms occur frequently in association with each other, as a constellation, or sets of subconstellations. Certainly not all women who have some of the symptoms have all of the symptoms, but sufficient cumulative experience interviewing women has persuaded me that the symptoms represent a possible set that are part of the same causative agent.

WHMS SYMPTOMS HAVE TYPICALLY BEEN IGNORED OR WALLPAPERED OVER

Till now in the relatively few instances when popular writers have referred to the above symptoms they have usually used seemingly mild, and nonspecific terms such as "concentration problems," or "forgetfulness," or "memory problems" to refer to women's experiences during these years, without an appreciation of the range of possible "glitches" in speech, behavior, and cognition that women in actuality have been experiencing. Broad-spectrum terms such as "forgetfulness" or "concentration problems," in effect, "wallpapered" or plastered over the variety and the bizarreness of the symptoms women have encountered. The casual, familiar terms masked or obscured the specific reasons why otherwise seemingly normal and healthy women might be inclined to say such phrases as "I think I'm losing it" or "I think I'm flipping out" or "I think I'm cracking up."

If you had occasion to go into major bookstores at the time I am writing this to look in the indexes of the many books now on the shelves currently addressing menopause or perimenopause for such terms as "memory" or "concentration" or "forgetfulness," you would find that in the vast majority there is either no mention of even these broad-spectrum terms or at most a one- or two-line reference to their possibility at this time of life but without much in the way of elaboration. There is virtually no reference in most of these books to the unusual behavioral symptoms listed in Table 1.

HOW DO WHMS SYMPTOMS PLAY OUT IN WOMEN'S LIVES

But how do these symptoms actually play out in the lives of real women? Let's look at three very different women:

Case 1: Katherine Kennedy

Katherine Kennedy (alias) is a thirty-eight-year-old professor of English at an Eastern university who also hosts a weekly talk-radio show. She is married to a scholar, has no children yet, but hopes to have them in the future.

Reproductive state: still gets her period regularly appears to be perimenopausal, though she does not yet realize it.

When I was younger I had the most retentive memory for everything, especially names and faces. Friends in college would say, "Your mind is like a Rolodex." When I entered my thirties I started having these strange symptoms. I would meet people and the next day felt as though I had never seen them before. They'd know me but I had no due as to who they were. Their faces were just not registering. It so happens that I had begun to menstruate copiously around that time, more than before but I did nothing about it. Not recognizing faces still happens. I find that slightly scary because my grandmother was demented; and I sometimes wonder if it's hitting me very early.

What drives me mad is that I now forget the precise names of things, objects, and will end up saying "that thing" instead of "diploma" for example. It's the same with verbs. I will use the word "doing" instead of the verb I actually want to use. I also have the sense that sometimes I'm grasping for a word and I can't get to it. It feels like mental clutter, like I'm shuffling around inside not finding what I want. I find it hard to retrieve things. I'll have a sense of what I want -- it's not even the sense of being on the tip of my tongue but rather I can't get it to my tongue. I'll want to say "chair" and will think "something about sitting" but can't fill in what I want. It's like mental miasma. This happens not all the time but intermittently enough so that it concerns me.

I find it [these symptoms] enormously frustrating. One of the ways it affects me is when I'm having a disagreement with my husband. I'll know there's a point I want to make but I can't make my point. Either that or I lose it midstream.

The difficulty in retrieving, to some degree, also overlaps with what I call fog or haziness. My mind sometimes feels foggy, hazy, or cloudy. If it's fog I'm feeling it's more confused, more grasping than when I'm trying to retrieve something. With fog I don't know what I'm looking for -- that's the worst -- being lost in the fog. When this happens I think I'll end up like my grandmother, not knowing the names of my family and having lost decades. Or like my friend who got ECT [electroconvulsive therapy] and lost decades of her life, big chunks of her brain. At times like this I feel like I'm losing it. And I'll think to myself "I didn't even drink or take drugs and I'm losing it."

In the classroom and when I'm on radio I want to be sharp and alert, and it hasn't happened terribly much, these blunders, when I'm working. In fact when I'm in front of a class or microphone I'm somehow sharper. I have to be really alert and thinking and focused. And when I'm working I'm better than in my private life.

I find now that often when I walk into a room and want to get something, I'm apt not to recall what I went to find. I think it's a little early for this to be happening to me. My mom and grandmother do this. I never did this as much as now.

In my late twenties if I was writing fast I noticed that I started to reverse letters on words. I also used to be a great speller. Now if I see something that's wrong I won't realize what the correct thing should be. Strangely though, I started doing crossword puzzles only recently as a way to reassure myself of my verbal skills, and I can finishThe New York Timescrossword puzzle pretty easily writing in ink. But at the same time I just feet really stupid. I used to be and probably still am pretty smart. I always did very well in school. Verbal things were very easy for me. Now I'm still strong verbally but I hate any slippage. It might be analogous to being really gorgeous when you're young and now not feeling as radiant.

I don't think others have noticed the verbal changes because I'm still better than most at noticing names. I'm always the first person who knows the name of a writer or actor. At the same time though I will mispronounce words and can't get back to recalling the correct word. Recently, for example, I was trying to say the plural of roof and couldn't recall if it was "roofs" or "rooves." Both sounded wrong. It's this confusion over basics that I find scary. In the past once I learned something I would have remembered it always. I seem to need a lot more reinforcement than I used to, to learn new commands on the computer.

In the last couple of months I've also begun to lose things and I never ever did that before. My wallet, for example. I lost it and I couldn't think at all where I might have lost it. I had absolutely no associations the way I normally would as to where it might have happened. Fortunately a Good Samaritan returned it, I have a special telephone message pad that's been by the phone forever that's got important numbers on it. I just couldn't remember what happened to it in my home office. It's the lack of associative threads that seems so strange.

I'm the treasurer in my family who does all the practical things. My husband is incredibly brilliant but doesn't really live on this planet. He always loses things and people return them. Recently, I thought I had cash in the bank and when I looked I had appreciably less than I recalled. I couldn't think at all where I spent it. Nothing came to mind in the way of any associations. It's as though I had no links to the past when this happens.

I think I tend to compensate for all of this fairly well. I keep lists and write things down and use the mnemonic devices from childhood that I was always great at. But at the same time all these things affect my whole identity. I've always thought of myself as verbally skilled and these episodes affect my sense of self. I met a woman at the radio station a few weeks ago. Then I met her again two nights later and didn't recall her at all.

Another night I asked the same couple twice if I gave them passes to something and they got annoyed with me. I had already given them the passes.

The ironic part is that as a teenager I had unbearable contempt because my mother couldn't recall the names of people. But she could recall other things really well -- what she paid for something.

All this makes me feel diminished. I now feel not as sharp as I used to be. I'm not depressed but feel like I'm getting dim, with the foggy, hazy, cloudy episodes.

At the same time I'm probably happier in my life than I've ever been. I'm in a great marriage that's working well. My husband and I have a wonderful relationship. Over the years I have had depressions on and off but things are going well now both in my private and professional life. I love the work I do.

I don't go to doctors unless I'm dying and I wouldn't know who to go to with these symptoms anyway. I just keep hoping they'll go away on their own.

Katherine Kennedy's case is an example of pure WHM cognitive/speech/behavioral symptoms occurring at a rather early age -- what I think of as a "one-ring circus" of symptoms -- with no body symptoms (i.e., hot flashes or vaginal dryness) or associated mood/emotional symptoms except for her diminished sense of self in reaction to having the symptoms. Her symptoms can't be said to be occurring in reaction to sleeplessness, or hot flash disruptions, or depression because she does not report these. Like many women her age she isn't thinking about hormone changes in relation to these symptoms, but her mention of greater bleeding in her early thirties when her WHM symptoms appeared to her to begin, likely reflects the increased variability of periods (more, less, longer, shorter) that typically characterizes perimenopause. I view her case as being linked to hormone changes because, as you will see with later cases, it echoes in its pattern of specific symptoms so many of the other women whose symptomsdidbegin in association with hot flashes or vaginal dryness -- indicators of hormonal changes. Like many women Katherine Kennedy has not seen a doctor about these symptoms. She has been coping with them in multiple ways. As with many women the symptoms are occurring within the context of a fully lived functional life. They are mainly invisible to others though very noticeable to her.

Case 2: Sherry Strumph

Sherry Strumph (actual name) is the forty-nine-year-old president of a highly successful major office-services company in New York City that now employs over thirty-five people. She has built this company from a one-person venture over a twenty-year period through great initiative, ability, creativity, and sustained directed effort. She owns another unrelated business as well. Sherry is married and the mother of a grown daughter.

Reproductive state: "I'm perimenopausal now. I'm still regular but my periods come for ten minutes. The last one was over before I knew it."

I remember this beginning about two to three years ago when I caught myself saying something wrong to myself. I said to myself, "You used to have a 'photogenic' memory" and then said, "You fool, you mean 'photographic' and now you can't even remember what your husband told you ten minutes ago." This was in response to my husband reminding me that he would be out that evening and my not remembering it at all. He said we spoke about it several times. For me it was the first time. I laughed it off thinking "OK here comes old age." I thought memory problems began around age seventy-five, not in your forties. Another time a friend asked me something and I said I didn't remember; and she said, "But you always remember everything. I can't accept that you say you can't remember." She was so taken aback because my memory had always been phenomenal -- everybody relied on it. My husband started saying things like "You used to be so reliable and I used to be able to count on you. Now I never know when you'll do whatever you say you'll do." I realized myself that I wasn't the same as before but I said to myself, "It's the way I am now." I was very accepting. Maybe because I had been so responsible all these years. I used to be so driven to be right. It's kind of refreshing for me not to have to do that.

When this began I had been away from the office for two years. I had excellent management there. I was free as a bird so it wasn't job burnout or stress. My memory lapses created havoc for some of the people around me, but not me. I just accepted it. But then too I didn't know what to do about it and it's not my style to complain to people.

Before I started using estrogen cream nine months ago, I'd say that my worst memory issues were one to two years ago [ages forty-seven to forty-eight]. When I'd forget something I would joke with people and say "Mind-like-a-sieve strikes again."

When this began I had no idea this could even be related to hormonal changes. I learned this from the experience of my friends. I thought menopause was about going through hot flashes. I didn't associate hormonal changes with what I was experiencing. I didn't have any mood swings during this time the way some women do. In fact I was the calmest, most unflappable I'd ever been. Things I had feared doing before I could do now, like driving at night. But my memory was a mess. I'd write things down and forget where I'd put the list.

I thought about going to a doctor but I'm not one to go running to them very readily. I thought maybe I was pre-Alzheimer's but then I said to myself, "No one in my family has ever had it." I did stop using my deodorant, however, because I had read that something in deodorant -- aluminum -- caused Alzheimer's. I also stopped using aluminum foil and switched to shrink-wrap for that reason.

My concentration also changed. I would start to read a book and pick it up two weeks later and have absolutely no memory of any of it. As though not a trace had stayed with me. However, when I tested myself, by pulling cards from a deck and reading them to myself, to see how many I could remember, I could do it if I tried. This forgetting happens more when I'm on automatic pilot. I need to really pay attention to "get" some things now, more than I used to. And I can but I need to make a conscious effort to do so.

I finally broke down and bought a date book and I'm pretty religious about writing in it but not at all religious about looking at it.

I started to make the connection that the things happening to me were related to hormones when friends started telling me what they were going through. My friend A. said to me one day that she was much more forgetful than I was. She was diagnosed as needing estrogen for her bones and started being treated with it, and she said it was working forallher symptoms. Then another friend said that she'd been put on estrogen and could think like a young girl, meaning that things came easily again. I was percolating on this information and then my friend A. said she was switching to an estrogen cream. She used to be a chemist. After she went on the hormone cream she said she stopped being hot all the time (the way I am too all day without any hot flashes), her memory got better, and amazingly she was able to successfully lose weight.

I started using the [estrogen] cream in August (nine months ago) and they say to give it three months. I've noticed a difference in some things but not a great difference in everything. But I also haven't used it consistently -- probably about 50 percent of the time. I forget to. But I'm also afraid of hormones because of my family history. I'm the only one in my family who hasn't had cancer. So I've got a love/hate relationship to taking estrogen. Now at least I know I have a choice in whether I want to stay this way if it lasts.

After I went on estrogen my attention got better. I'm more focused. It might also be because I'm back at work full-time. It kind of forces me to be focused. The result is I appear more focused than I am in my personal life. Besides my husband and good friend, I don't think others noticed any difference in me. The changes weren't blatantly observable.

Did I go to a doctor about this? Yes and no. At regular intervals I would go to my internist and when I told her what I was experiencing she said, "Well, welcome to the club honey."

Excerpted from Menopause and the Mind: The Complete Guide to Coping with the Cognitive Effects of Perimenopause and Menopause - Including Memory Loss, Foggy Thinking and Verbal Slips by Simon and Schuster Staff, Claire Warga
All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.