The answer is not better coping or just “powering through” them. The answer is finding the driver.

Hot flashes are vasomotor symptoms. That means they involve blood vessel changes, temperature regulation, heart rate, and the nervous system. For many women, the main driver is estrogen deficiency or estrogen instability. For others, the picture includes cortisol, poor sleep, thyroid dysfunction, insulin resistance, alcohol, blood sugar swings, inflammation, medication effects, or chronic viral and inflammatory conditions.

This is why women need practical information, real knowledge and expertise, not vague reassurance. Many women find themselves frustrated by the lack of empathy and understanding from physicians, even friends and family members, who downplay the significance and the impact of the hot flashes or they are simply told their hormones look normal and they’re too young to have menopause or perimenopause.

The simplest solution for hot flashes caused by estrogen deficiency is estrogen therapy.

I would like to take you through the possible scenarios that may apply in the doctor’s office.

• You are told your hormones are normal and strongly reassured that you are not in perimenopause or close to menopause, so you leave the doctor’s office with no answer.

• Your fears and suspicions are confirmed, and the clinician tells you that you are indeed going through perimenopause. You may also be told this is the normal evolution of things, and hopefully you are given possible solutions for managing the hot flashes. Unfortunately, many women are simply told that hot flashes are normal and to come back when they get worse. As if they are not already terrible, because why else would the woman be sitting in the doctor’s office?

• Some women who are confirmed to have estrogen deficiency may be offered estrogen therapy, but they do not feel ready for it yet.

• Many women diagnosed with estrogen deficiency will start estrogen therapy but unfortunately experience only incomplete or partial relief from their hot flashes.

• It is very likely that the great majority of women being evaluated for hot flashes are narrowly tested for estrogen and FSH only, without enough consideration for other tests that may uncover alternative causes or contributing factors.

If you are still having hot flashes after trying hormone therapy, or you were told everything is “normal,” instead of being offered treatment, the next step is to look at the frequently missed details of other causes for hot flashes or contributing factors which will have to be addressed in order for meaningful resolution of the hot flashes.

Hot flashes in perimenopause are different from hot flashes caused by menopause. They respond to different interventions and they have different dynamics.

This guide is designed to help you understand what may be driving the hot flashes, what treatment options make sense, and what to ask your doctor so you can stop guessing. So let’s get started!

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Hot flashes are a real medical condition.

They are not just something annoying that women should tolerate. They are not just an inconvenience. They are not just a “rite of passage” that proves you are going through menopause and should be quiet about it.

That thinking has hurt women for decades. Yes, that long.

A hot flash is a vasomotor symptom. That means your blood vessels, temperature regulation, nervous system, and stress response are involved. This is not simply your body feeling warm for no reason. Your body is reacting to a change, and in midlife that change is very often connected to estrogen instability or estrogen loss.

Vasomotor symptoms, including hot flashes and night sweats, affect as many as 80% of midlife women. Many women are never offered real treatment or a real explanation. They are told to wait it out, sleep with the window open, carry a fan, buy cooling sheets, or dress in layers.

Those things may help you survive the moment.

They are not a cure and they do not explain why your body is generating the hot flash in the first place.

A hot flash can feel like sudden warmth in the face, chest, or body. You may flush. You may sweat. You may wake up drenched, irritated, and unable to fall back asleep. Some women feel their heart racing. Some feel palpitations. Some feel anxious, edgy, or almost panicked.

Some women wake up in the middle of the night with their heart pounding and immediately check their Apple Watch, Fitbit, Oura ring, or blood pressure cuff. And guess what? The device confirms it!

Your heart rate changed.

Your body reacted.

Your sleep was interrupted.

That deserves attention.

I want to be very clear here. I am not saying every woman who has a hot flash needs to panic. I am saying women have been trained to minimize a real physiologic event. If your body wakes you up hot, sweating, anxious, restless, or with your heart pounding, that is critical information. Something abnormal is happening–something that needs attention. Your body is communicating that something changed and is crying for help.

And when the body communicates that loudly, we should listen.

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Fans And Cooling Tricks Do Not Fix The Cause

I have no problem with fans, cooling pajamas, lighter bedding, open windows, cold drinks, or a lower thermostat. Use what helps you function. Use what helps you sleep.

But understand what those tools are doing.

They are cooling your environment but they are not correcting the physiologic disturbance that triggered the hot flash. They are not really cooling YOU down!

There is a big difference between symptom survival and treatment. Cooling your bedroom may make the night easier, but it does not explain why your brain and blood vessels are generating the hot flash.

If your body is repeatedly moving through heat surges, vascular instability, adrenaline, cortisol, broken sleep, and heart-racing episodes, the answer should go deeper than “buy better sheets” or “ it will eventually pass”. In some women, hot flashes last more than a decade! Do not just wait for hot flashes to pass, because while you wait and endure your body is changing! And not in a good way!

Hot flashes are telling you something about your hormone environment, your vascular system, and your stress response.

What Is Actually Happening?

Hot flashes are strongly connected to estrogen loss, estrogen instability, and the way estrogen interacts with the brain’s temperature-control system.

During perimenopause, estrogen may surge and crash. You will still have periods, and in some cases, those periods are normal every month. You may still have a “normal” estrogen level on a blood test, depending on when that test was drawn. But your body may still be reacting to the instability.

One month, your ovary may produce a strong estrogen signal. Another month, the ovary may fail to sustain the same output. Some women may still produce a strong estrogen peak, but the egg recruited in that cycle may not be high enough quality to sustain that peak the way a healthier egg would. As a result, estrogen can drop within the same cycle, often after ovulation or in the days leading up to the period. The body senses the drop.

That drop can trigger hot flashes.

This is why many women have hot flashes before they are officially menopausal. They may notice them right before a period, during the second half of the cycle, during their period or during the months when their cycle is changing. They are not imagining it. Their hot flashes are real. It most likely means the ovarian hormone output is becoming inconsistent, erratic or unpredictable, and your body is reacting to it in many ways and one of those ways is generating vasomotor symptoms.

After menopause, the issue becomes more direct. Estrogen drops and stays low. The body has lost a hormone it relied on for decades.

Estrogen affects the brain, blood vessels, bones, joints, skin, vaginal tissue, bladder, sleep, mood, and metabolism. When estrogen disappears, the body does not simply shrug and moves on. The woman’s body suffers a major loss.

Hot flashes are one loud signal of that loss.

Why Hot Flashes Matter Medically

Hot flashes are often discussed as a quality-of-life problem. They are absolutely that. They can ruin sleep, affect work, interrupt meetings, damage confidence, and make a woman feel like her body is no longer under her control.

But hot flashes may also reflect deeper physiologic stress.

Research has linked vasomotor symptoms with unfavorable cardiovascular risk factors and markers of cardiovascular disease, although the exact cause-and-effect relationship is still being studied. That alone should be enough to stop treating hot flashes like a joke or a minor inconvenience.

Think about what happens during a severe episode.

Your blood vessels are reacting. Your nervous system is activated. Your heart may race. Your sleep may break. Your body may release cortisol and adrenaline as part of a fight-or-flight response.

You cool down, but your heart is still pounding.

You throw off the covers, but your nervous system is still activated.

You try to fall back asleep, but your body is still on alert. The rest of the night is spent doing this a few more times. Imagine how unproductive you are likely going to be at work, how many possible mistakes you could make, and how difficult it will be for you to maintain an optimistic, patient approach to your family life, and relationships in general.

A hot flash can hit in the middle of the day, and suddenly you are trying to return to the task you were doing at work or at home. But your brain is no longer cooperating, and it can take more than a minute to regain focus and get back on track.

Now multiply that by weeks, months, or years.

This is why I take hot flashes seriously.

The part that concerns me is the repeated stress response. Your body heats up, your blood vessels react, your heart rhythm accelerates, and cortisol or adrenaline could enter the picture. Then your sleep is ruined. Then the next day is affected. This can become a loop: hot flash, stress response, poor sleep, more cortisol, worse metabolic stress, foggy brain, irritability, fatigue, cravings, weight gain and more symptoms.

Women are told to tolerate this when they should be evaluated and treated!

Upgraded Supporters: In the full Hot Flash Solution Guide, I go deeper into what should be evaluated when hot flashes come with heart racing, anxiety, blood pressure changes, poor sleep, or a cortisol/adrenaline response. This is where we look beyond “cooling tricks” and start asking what your body is actually reacting to.

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Mild Hot Flashes Still Count

Some women say, “Mine are not that bad.”

Maybe you wake up warm. Maybe you feel flushed around your period. Maybe you sweat a little at night but never soak the sheets. Maybe your heart does not race and your blood pressure does not spike.

That does not mean the symptom is meaningless or something to ignore!

Mild hot flashes can still be a sign that estrogen is fluctuating, estrogen is declining, or the body is entering a different hormone environment. They can also occur alongside sleep disruption, insulin resistance, thyroid stress, cortisol changes, weight gain, anxiety, vaginal dryness, urinary symptoms, and changes in energy.

A mild hot flash can still be a real signal. It is the tip of the menopause iceberg!

The intensity may be small, but the body changes behind it may not be so small!

I was one of the “lucky” 20% or so of women not bothered by their hot flashes.

My hot flashes were mainly in perimenopause, while I was still cycling. My body reacted with vasomotor symptoms to the estrogen dropping more than it reacted to the total and complete loss of my estrogen.

For me personally, the problem was not the tip of the iceberg, but the bulk of it.

The need to go to the bathroom and pee 4 to 5 times a night. The tossing and turning at night. The ruminating and thinking about 1 million things, unable to shut down my brain. The next-day fatigue. The bitchiness and irritability. The feeling of, “I must do it because it’s good for me, but I don’t really want to.” And last, but not least, the weight gain and the way it impacted my body and what I saw in the mirror.

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Hot Flashes Are Not The Whole Menopause Story

Many women judge menopause by hot flashes alone.

If the hot flashes are severe, they know something is happening. If the hot flashes are mild, they assume they are “doing fine.”

That is a mistake.

Hot flashes are often the tip of a much larger iceberg.

Estrogen loss does not just cause hot flashes! It can also affect vaginal health, bladder function, intimacy, mood, muscle, joints, sleep, skin, hair, bone, metabolism, and mental clarity.

Estrogen influences almost every major operating system in a woman’s body. A woman can have very few hot flashes and still have her body, her health, and her quality of life affected by menopause in serious ways.

We need to stop treating menopause like a simple transition. Menopause is the rest of your life after your last period.

For many women, hot flashes are the symptom that eventually improves, sometimes sooner and sometimes after a decade or more. But the deeper body changes can continue. Without estrogen, testosterone, and progesterone support when needed, many women continue to see changes in sleep, metabolism, muscle, bone, skin, mood, sexual health, and overall vitality.

The body does not stop needing hormone support simply because a woman’s ovaries stop producing hormones!

You Should Not Be Told To Endure

Women are strong. That does not mean suffering should be anyone’s treatment plan.

If your hot flashes are frequent, severe, persistent, waking you at night, affecting your work, triggering anxiety, or making you feel physically unstable, you need an immediate solution!

The right clinician is going to ask the right questions.

Why is this happening?

What stage of hormone change are you in?

Is your estrogen fluctuating? Or Is your estrogen deficient?

Is cortisol adding fuel?

Is your thyroid involved?

Do you have insulin resistance?

Is inflammation involved?

Is this truly menopause, or are the hot flashes a symptom of something else pretending to be menopause? For ex EBV flare ups.

The encouraging part is that hot flashes can often improve dramatically when the right driver is identified.

Some women need estrogen. Some need a better estrogen method because the route they are using is not steady enough for their body. Some need progesterone support. Some need cortisol, sleep, thyroid, insulin, or inflammation addressed. Some need a broader workup because their night sweats do not fit the classic menopause pattern.

There are answers.

You do not have to organize your nights, your workday, your clothes, your bedding, your travel, and your confidence around hot flashes.

Your body is giving you a signal, and that signal deserves to be taken seriously.

Once you understand the cause, you can stop guessing and start treating the problem with a plan.

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Disclaimer:

This Substack is here to educate, inform, and advocate. It is not a substitute for individualized medical care. Nothing in this publication should be taken as personal medical advice, diagnosis, or treatment, and reading or subscribing to this content does not create a physician-patient relationship with Dr. Mirela Cernaianu.

Hormone therapy and menopause care should be guided by a qualified clinician who knows your medical history, symptoms, goals, and risk factors. Always speak with your own healthcare professional before starting, stopping, or changing any medication, hormone regimen, supplement, or treatment plan.

Do not use this publication for urgent or emergency medical concerns. If you think you may be having a medical emergency, call 911 or seek immediate care.

Please do not post or send personal health information through comments or messages on this platform.

Sources & Further Reading

The 2022 Hormone Therapy Position Statement of The North American Menopause Society — https://amwa-doc.org/wp-content/uploads/2025/10/2022-Hormone-Therapy-Position-Statement-for-endorsement.pdf

A Review of Hormone and Non-Hormonal Therapy Options for the Treatment of Menopause — https://pmc.ncbi.nlm.nih.gov/articles/PMC9938702/

Vasomotor Menopausal Symptoms and Risk of Cardiovascular Disease — https://pmc.ncbi.nlm.nih.gov/articles/PMC7704910/

FDA Approves Novel Drug to Treat Moderate to Severe Hot Flashes Caused by Menopause — https://www.fda.gov/news-events/press-announcements/fda-approves-novel-drug-treat-moderate-severe-hot-flashes-caused-menopause

Menopause belly can involve hormone changes, insulin resistance, cortisol, inflammation, sleep disruption, muscle loss, and the way the body starts storing fat differently in midlife.

I will break it down clearly and directly and answer your questions.

All subscribers are welcome to join live on Friday, July 10 at 8:00 AM PST/11:00 AM EST.

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If your waist is changing in menopause, do not treat it as a wardrobe problem.

Do not simply buy the larger size, blame aging, and start another round of dieting.

A changing waist can be an early warning sign that something metabolic, hormonal, inflammatory, digestive, or stress-related needs attention.

Start improving your food. Start walking. Start lifting weights. Start paying attention to sleep and alcohol. Those steps matter.

But do not wait months or years for diet and exercise to fail before you make an appointment.

If belly fat is increasing alongside poor sleep, cravings, fatigue, brain fog, low motivation, hot flashes, night sweats, low libido, muscle loss, bloating, constipation, high stress, or a history of PCOS or insulin resistance, it is time for a more complete medical discussion.

This first chapter focuses on one of the most important drivers of stubborn belly fat: insulin resistance.

When I say “the cure for insulin resistance,” I do not mean a magic pill, a crash diet, or a temporary program.

I mean identifying the root cause of your insulin resistance and building a strategy that addresses that specific cause.

Inside this article, we will cover:

• When belly fat should prompt a medical consultation

• What body composition testing can show that a regular scale cannot

• What labs and insulin-resistance markers to discuss with your clinician

• Why a normal glucose or A1c may not tell the full story

• The top root causes of insulin resistance in midlife women

• How menopause, PCOS history, sleep, cortisol, inflammation, medications, diet, and exercise can affect insulin sensitivity

• 10 practical diet strategies that actually matter when insulin resistance is part of the problem

• 10 exercise recommendations designed to improve insulin sensitivity, protect muscle, and help fight belly fat

• How to stop repeating the same plan when the real driver has never been properly evaluated

This is where we move from “why is this happening?” to “what do I need to look at next?”

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Upgraded supporters can continue with The Menopause Belly Solution: Chapter 1, where we start with insulin resistance and the practical steps that may help improve it.

You will learn what to test, what patterns to look for, what root causes may be driving the problem, how to approach food when cravings and blood sugar are involved, and how to exercise in a way that supports insulin sensitivity instead of pushing your body deeper into stress.

If your belly is changing and the usual advice is not working, this is the part you want.

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Instead of asking yourself, “How do I lose the extra weight?...”

You should be asking: what kind of fat is increasing, and why is the body storing it there?

From a medical standpoint, belly fat can include two major types of fat: subcutaneous fat and visceral fat.

Subcutaneous fat is the fat located under the skin. This is the pinchable fat. It may respond more predictably to nutrition changes, exercise, calorie reduction, and improved activity.

Visceral fat is different.

Visceral fat sits deeper inside the abdomen, around the internal organs. This is the fat that can make the belly protrude, and feel thicker or harder. It is also the fat that should concern us more from a medical perspective because visceral fat is metabolically active and inflammatory.

That means belly fat is not only about how your clothes fit.

It can be connected to a variety of serious medical problems, like:

• insulin resistance and blood sugar problems, prediabetes and diabetes

• high blood pressure,

• abnormal cholesterol,

• inflammation,

• cardiovascular disease,

• fatty liver

Visceral belly fat possibly means a higher risk for certain cancers.

So yes, you may care because your waist has changed, and because you don’t recognize your own body when in front of a mirror, or get frustrated when none of your clothes fit anymore.

But medically, the belly fat can reveal something ominous is happening inside your metabolism.

Subcutaneous Fat vs. Visceral Fat

Subcutaneous fat and visceral fat are not the same type of fat.

Subcutaneous fat sits under the skin. It is the pinchable fat, and it often responds more predictably to a variety of diets, including calorie reduction and increased or improved exercise programs.

Visceral fat sits deeper inside the abdomen, around the internal organs. This type of fat accumulates around the internal organs, in the space surrounding all your abdominal organs and also stored in an apron-like flap of tissue which lies over all the abdominal organs, underneath the abdominal wall called omentum. This is the type of fat that can make the belly protrude, and it is more concerning because it releases inflammatory signals that can seriously affect everything in your body, not just blood sugar, blood pressure, cholesterol, liver function, and cardiovascular risk.

As women go through midlife hormonal changes, they tend to accumulate more fat in the upper body: arms, chest, back, and belly. You might not see weight change on the scale, but you might notice a significant change in how your clothes fit: your pants are more difficult to button, and some women notice the bulge over the waistline, or the bikini line, which has gotten names like

• “muffin top,”

• “love handles,”

• “apron belly,” or a

• “fupa” (a soft bulge of fat sitting just above the pubic bone at the bikini line).

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This is also why the regular step-on scale is limited. It does not show how much fat is subcutaneous, how visceral, how much muscle you have, or whether you are losing muscle while gaining fat.

There is one simple reason women may lose fat in the face, arms, or legs before the belly fat actually changes. Diet and exercise may reduce subcutaneous fat first, while visceral fat is often more dependent on other interventions, and tied to hormones, inflammation, poor sleep, and much deeper metabolic dysfunction.

What is a simple way to keep score on your visceral fat?

Waist measurement - a very simple and easy place to start. You do not need a fancy machine to pay attention. Measure your waistline right over the belly button, or keep tabs on how your pants fit at the waist.

In women, a waist measurement over 35 inches is generally associated with increased cardiometabolic risk.

Body composition testing will add significantly more detail by measuring total body fat, lean muscle mass, and overall distribution of your fat over the body - trunk, arms or legs.

Total muscle, in the form of skeletal muscle mass, matters because muscle is a highly metabolically active tissue. It supports glucose control, insulin sensitivity, resting metabolic rate, and the body’s ability to use energy efficiently.

When muscle declines with age, inactivity, low protein intake, low testosterone, poor sleep, or hormone changes, fat loss can become much harder.

Why Menopause Changes Fat Distribution

Perimenopause and menopause change the hormone environment.

Estrogen begins fluctuating, then declining. Progesterone changes, and becomes scarce as the woman stops having ovulatory cycles. Testosterone might decline first. Growth hormone naturally declines with age, and women only have 50% of Growth Hormone compared to what their peak. Insulin sensitivity becomes elusive. Cortisol surges or persistent elevated levels may become more problematic, especially when sleep is broken and stress is constant.

This is why “eat less and exercise more” is an incomplete answer for women going through the midlife hormonal transition.

Food and movement certainly matter a lot.

But if hormones, insulin resistance, cortisol, poor sleep, inflammation, thyroid dysfunction, low testosterone, or muscle loss are part of the problem, a smaller meal and a harder workout will not fix the root cause.

The relationship between fat and hormones is central to understanding menopause belly.

Belly Fat and Cortisol

Cortisol is a stress hormone, and it can strongly affect the waistline. The deep visceral fat has an abundance of cortisol receptors compared to fat tissue anywhere else in the body.

That is maybe why the term cortisol belly is used more and more. It is not an actual diagnosis, it is a clinical problem of belly fat accumulation correlated with persistently high cortisol levels.

When cortisol is chronically elevated or poorly regulated, it will instruct the body to store energy as fat. As the belly fat (internal visceral abdominal fat) is much more sensitive than fat anywhere else to the cortisol, chronically stressed women become more likely to store fat around the abdomen. To add insult to injury, cortisol doesn’t just enlarge and grow the existent visceral fat cells. It actually promotes the formation of new fat cells, which is very different from weight gain happening around the rest of the body, when the existing fat cells are merely hypertrophied and enlarging when you gain weight, and shrinking when you lose weight.

This is exactly why stress driven weight gain will happen around the midsection!

Cortisol can also influence blood sugar, insulin resistance, cravings, blood pressure, inflammation, and lipid patterns.

Chronic stress can raise glucose availability because the body is preparing for survival. That may be useful in an emergency. But, cortisol becomes much less useful when the “emergency” is poor sleep, caregiving, a high-pressure job, running a business, family stress, or years of pushing through exhaustion.

Cortisol excess can contribute to higher blood sugar.

It can worsen insulin resistance.

It can increase appetite and cravings.

It can affect cholesterol and triglycerides.

It can raise blood pressure.

It can make abdominal fat harder to lose.

This is why stress is not just emotional. Stress is biochemical.

If belly fat appeared or worsened during a season of poor sleep, chronic stress, burnout, grief, trauma, overwork, or constant pressure, managing your cortisol should be part of the discussion.

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Belly Fat and Insulin Resistance

Insulin resistance is one of the most important medical issues to consider with the menopause belly.

Insulin is the hormone that helps move glucose from the bloodstream into cells. When the body becomes resistant to insulin, glucose does not move into cells as efficiently. The pancreas may produce more insulin to compensate.

Menopause equals the loss of estrogen. How does the loss of estrogen contribute to insulin resistance?

Estrogen decline during menopause is critical in how women develop insulin resistance because estrogen acts as an insulin facilitator. Estrogen enhances the action insulin has on metabolism in general, within the muscle tissue or the fat tissue.

Chronically high insulin will encourage the body to store excess glucose as fat storage, specifically in the belly.

Insulin resistance can make weight loss harder.

It can increase cravings.

It can contribute to blood sugar swings, fatigue, hunger, and the cycle of eating, crashing, craving, and eating again.

Insulin resistance is closely connected with abdominal fat, prediabetes, diabetes, fatty liver, inflammation, and cardiovascular risk.

This is also where PCOS matters.

PCOS is not just an ovarian problem. It is often connected to insulin resistance, androgen imbalance, metabolic dysfunction, and long-term risk.

The metabolic consequences can follow a woman into menopause. What happened in the 20s, 30s, and 40s may still matter after menopause.

If you have PCOS, irregular cycles, acne, excess hair growth, infertility, blood sugar problems, or a history of insulin resistance, menopause belly deserves a more serious metabolic evaluation.

In the member’s guide, I will review what to ask about when evaluating insulin resistance, including labs and tests to consider.

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Belly Fat and Estrogen

Estrogen influences how the body stores and uses fat.

When a woman loses estrogen at menopause, due to a medical condition, or due to surgery, her tissues stop responding to normal levels of insulin.

Also, the loss of estrogen at menopause (or in any estrogen deficient state) accelerates muscle loss. Less muscle means less capacity to utilize the circulating glucose coming from food intake, which translates into higher levels of glucose and with time will lead to insulin resistance.

Estrogen dictates where your body stores the fat! Estrogen is a master regulator of your metabolism! Estrogen will promote accumulation of fat as subcutaneous fat. This type of fat is actually metabolically protective, and while you have good estrogen, you are guaranteed to not accumulate fat as visceral fat, because estrogen inhibits the storage of fat as visceral belly fat!

Before menopause, many women store more fat in the hips, thighs, and buttocks. As estrogen declines, fat distribution shifts toward the abdomen. This is one reason women may notice a thicker waist, even if their total body weight has not changed dramatically.

Any major decline in your estrogen will change your body composition, a well known fact that seems to be overlooked when women are scared away from estrogen. Even if you do not change the weight on the scale, your body shape will shift to an “android” apple-shape pattern from a “gynoid” pear-shape pattern. And that is what women hate the most - not the number on the scale, but how they fit in their clothes or how they look in the mirror.

Low estrogen impacts not just insulin sensitivity, but also appetite regulation, sleep, mood, inflammation, and metabolic rate. These changes can make it easier to store fat in general and in the belly area in particular, and harder to lose it.

During perimenopause, estrogen may fluctuate dramatically. Some women experience estrogen surges alternating with periods of insufficient estrogen.

Both extremes can affect how the body feels and functions.

Too much estrogen relative to progesterone may contribute to bloating, water retention, breast tenderness, mood changes, and heavier bleeding. Too little estrogen may contribute to hot flashes, sleep disruption, vaginal dryness, mood changes, and changes in fat distribution.

The point is not to blame everything on estrogen.

The point is to recognize that estrogen has an extraordinary metabolic influence.

If the waist changed at the same time sleep changed, cycles changed, hot flashes began, mood changed, or other menopause symptoms appeared, your estrogen should be part of the discussion.

Belly Fat and Progesterone

Progesterone is often discussed only in relation to fertility or uterine protection during estrogen therapy.

That is a very limited view of progesterone and how it impacts a woman’s body.

Progesterone can alter insulin sensitivity in muscles and fat tissue, which can change appetite and can also change how the body uses glucose. A major decrease in progesterone levels, which is what happens during perimenopause, will lead to a hormone imbalance called estrogen dominance, a situation which tells your body to store more fat around the belly.

Progesterone can influence sleep, nervous system calm, mood stability, and the balance of estrogen’s effects in the body.

This matters because poor sleep and stress dysregulation can directly affect weight, cravings, cortisol, insulin sensitivity, and abdominal fat.

Progesterone also matters in perimenopause, when estrogen may surge or fluctuate while progesterone declines. If progesterone is low relative to estrogen, some women may experience heavier bleeding, breast tenderness, mood changes, anxiety, poor sleep, cravings, and a nervous system that is harder to calm, with persistent and chronic activation of the stress response. You know where this road ends: belly fat!

Since sleep, cravings, stress regulation, and estrogen balance are deeply connected to belly fat, progesterone is also indirectly an important player in the larger metabolic picture.

Belly Fat and Testosterone

Testosterone matters for women.

It is not just a libido hormone. Testosterone can influence muscle mass, strength, motivation, vitality, stamina, and body composition.

This matters because muscle is one of the most important tools women have for metabolic health. More muscle generally improves glucose handling, insulin sensitivity, strength, and resting energy use.

When testosterone is low, most women notice not just reduced or absent desire for intimacy , but also reduced motivation, lower stamina and endurance, delayed recovery after strenuous exercise, gradual weakening and loss of muscle, significant fatigue, and difficulty maintaining body composition.

Testosterone is a very important influencer of visceral fat. It is one of the main hormones promoting the breakdown of stored fat to be used as energy, and testosterone helps preserve and build lean muscle, which burns more calories at rest than fat, preserving a healthy metabolic rate.

What makes matters worse is that low testosterone will impact your workouts, and you might struggle at the gym, and not see the results you expect, while your husband does the same workout and drops excess pounds and starts to look defined.

This does not mean testosterone is the answer for every woman accumulating belly fat.

It means testosterone belongs in the discussion when menopause belly appears with low energy, weakening and muscle loss, low motivation, low libido, fatigue, and declining strength.

Belly Fat and Sleep

Sleep is one of the most frequently ignored lifestyle factors affecting the waistline.

Poor sleep can disrupt hunger hormones, increase cravings, worsen insulin sensitivity, raise cortisol, reduce motivation to exercise, impair recovery, and increase the desire for fast energy.

That fast energy is usually sugar, refined carbohydrates, salty snacks, or ultra-processed foods.

This is not because women are weak.

It is because the sleep-deprived brain wants immediate reward and fast fuel.

If hot flashes, night sweats, anxiety, racing thoughts, or 3 a.m. awakenings are destroying sleep, then the next-day cravings and metabolic consequences should not be treated like a discipline problem.

Sleep is medical.

Sleep affects the waist.

And in menopause, sleep disruption often has a hormonal driver.

Belly Fat and Inflammatory Foods

Diet matters, but the issue is not only calories.

Food can affect inflammation, blood sugar, cravings, insulin, digestion, and fat storage.

An inflammatory food pattern usually includes frequent ultra-processed foods, fried foods, refined carbohydrates, excess sugar, poor-quality oils, trans fats, processed snacks, and foods that repeatedly spike blood sugar or irritate the gut.

Restaurant food can also be a problem, even when the order looks “healthy.” A piece of fish may be a good food, but the oils, cooking methods, repeated high-heat exposure, sauces, fried sides, and hidden ingredients can change the metabolic effect of the meal.

This does not mean you can never eat at a restaurant. It means you should understand that food quality matters.

Ultra-processed foods can worsen cravings, inflammation, blood sugar swings, and overeating. They are often designed to be rewarding, easy to overconsume, and difficult to stop eating.

Many “diet-friendly” foods are still processed foods with better branding. They may be low-calorie, low-fat, low-carb, or high-protein, but that does not automatically make them metabolically helpful.

The question should not be only, “How many calories?”

A better question is: what is this food doing inside the body?

Is it stabilizing blood sugar?

Is it supporting muscle?

Is it reducing inflammation?

Is it nourishing the gut?

Is it helping you build a way of eating you can maintain permanently?

Whatever diet changes produce results, they have to be sustainable. This is where many people fail. They follow a plan for a few months, lose some weight, then return to the same habits because the plan was too rigid, too unpleasant, or impossible to live with.

Temporary diet changes create temporary results.

Belly Fat and Digestion

Digestion is another major piece.

You can eat the most perfect diet in the world, but if your body is not breaking down, absorbing, and using the nutrients, the results may not match the effort.

Protein, antioxidants, polyphenols, flavonoids, vitamins, minerals, and healthy fats have to be absorbed and processed. If digestion is weak, the microbiome is disrupted, inflammation is present, or pancreatic enzyme function is low, food quality alone may not be enough.

Digestive symptoms such as bloating, constipation, diarrhea, reflux, food sensitivities, greasy stools, frequent discomfort after eating, or unexplained nutrient deficiencies may suggest the digestive system needs a deeper look.

This matters because gut health can influence inflammation, nutrient absorption, blood sugar regulation, cravings, and immune activity.

A healthy diet is valuable. But the digestive system still has to be capable of using it. Generic weight-loss advice fails because it treats every woman as if she has the same hormones, metabolism, stress load, muscle mass, and root cause.

Inside the full guide, we cover:

• When to make the appointment

• What labs and markers to discuss

• How to evaluate insulin resistance

• Food strategies for cravings, carbs, fiber, and processed foods

• How sleep and cortisol can drive belly fat

• Why thyroid, inflammation, digestion, and hormones deserve attention

• How to approach exercise without overdoing cardio or losing muscle

• What to track before changing your diet again

This is where we stop guessing and start building a plan that matches your actual physiology.

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Disclaimer:

This Substack is here to educate, inform, and advocate. It is not a substitute for individualized medical care. Nothing in this publication should be taken as personal medical advice, diagnosis, or treatment, and reading or subscribing to this content does not create a physician-patient relationship with Dr. Mirela Cernaianu.

Hormone therapy and menopause care should be guided by a qualified clinician who knows your medical history, symptoms, goals, and risk factors. Always speak with your own healthcare professional before starting, stopping, or changing any medication, hormone regimen, supplement, or treatment plan.

Do not use this publication for urgent or emergency medical concerns. If you think you may be having a medical emergency, call 911 or seek immediate care.

Please do not post or send personal health information through comments or messages on this platform.

Sources and Further Reading

Davis SR, Castelo-Branco C, Chedraui P, et al. Understanding Weight Gain at Menopause. Climacteric.

https://pubmed.ncbi.nlm.nih.gov/22978257/

Kapoor E, Collazo-Clavell ML, Faubion SS. Weight Gain in Women at Midlife: A Concise Review of the Pathophysiology and Strategies for Management. Mayo Clinic Proceedings.

https://pubmed.ncbi.nlm.nih.gov/29728289/

Sowers MR, Zheng H, Tomey K, et al. Changes in Body Composition in Women Over Six Years at Midlife: Ovarian and Chronological Aging. Journal of Clinical Endocrinology & Metabolism.

https://pubmed.ncbi.nlm.nih.gov/15292313/

Lovejoy JC, Champagne CM, de Jonge L, Xie H, Smith SR. Increased Visceral Fat and Decreased Energy Expenditure During the Menopausal Transition. International Journal of Obesity.

https://pubmed.ncbi.nlm.nih.gov/18591989/

Kaess BM, Pedley A, Massaro JM, et al. The Ratio of Visceral to Subcutaneous Fat, a Metric of Body Fat Distribution, Is a Unique Correlate of Cardiometabolic Risk. Diabetologia.

https://pmc.ncbi.nlm.nih.gov/articles/PMC3646779/

Nicklas BJ, et al. Menopause Is Associated With a Redistribution of Adipose Tissue Toward Central Adiposity. Scientific Reports.

https://www.nature.com/articles/s41598-021-94189-2

Lankila H, Kekäläinen T, Hietavala EM, et al. A Mediating Role of Visceral Adipose Tissue on the Association of Health Behaviours and Metabolic Inflammation in Menopause. Scientific Reports.

https://www.nature.com/articles/s41598-025-85134-8

National Heart, Lung, and Blood Institute. Aim for a Healthy Weight.

https://www.nhlbi.nih.gov/health/heart-healthy-living/healthy-weight

Centers for Disease Control and Prevention. Healthy Weight.

https://www.cdc.gov/diabetes/living-with/healthy-weight.html

American College of Obstetricians and Gynecologists. Hormone Therapy for Menopause.

https://www.acog.org/womens-health/faqs/hormone-therapy-for-menopause

American College of Obstetricians and Gynecologists. The Menopause Years.

https://www.acog.org/womens-health/faqs/the-menopause-years

The Menopause Society. The 2022 Hormone Therapy Position Statement of The North American Menopause Society.

https://pubmed.ncbi.nlm.nih.gov/35797481/

Harvard Health Publishing. Abdominal Fat and What to Do About It.

https://www.health.harvard.edu/staying-healthy/abdominal-fat-and-what-to-do-about-it

Hall KD, Ayuketah A, Brychta R, et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake. Cell Metabolism.

https://pubmed.ncbi.nlm.nih.gov/31105044/

Poti JM, Braga B, Qin B. Ultra-Processed Food Intake and Obesity: What Really Matters for Health—Processing or Nutrient Content? Current Obesity Reports.

https://pmc.ncbi.nlm.nih.gov/articles/PMC5787353/

Drapeau V, Therrien F, Richard D, Tremblay A. Is Visceral Obesity a Physiological Adaptation to Stress? Panminerva Medica. 2003;45(3):189–195.

https://pubmed.ncbi.nlm.nih.gov/14618117/

Foggy Brain: What Is Happening to Your Memory, Focus, and Mental Clarity?

If you are forgetting words, rereading the same paragraph, losing focus, or feeling like your brain is not as sharp as it used to be, foggy brain may be more than stress or aging.

We looked at how hormones, sleep, B12, thyroid function, gut health, inflammation, long-haul COVID, Epstein-Barr virus, adrenal stress, blood sugar, and mitochondrial dysfunction may all play a role in mental clarity.

Read this if: your brain feels slower, heavier, foggier, or less reliable than it used to.

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Testosterone: You Did Not Lose Your Spark

Testosterone is not just a male hormone, and it is not only about sex drive.

We covered why testosterone matters for women too, including energy, motivation, muscle, stamina, mood, confidence, focus, desire, and that internal sense of drive many women describe as their “spark.”

Read this if: your energy, desire, motivation, strength, or inner fire has changed.

Painful Sex After Menopause: Why “Just Use Lube” Is Not Enough

Painful sex after menopause is common, but common does not mean it should be ignored.

We talked about how estrogen and testosterone loss can affect tissue moisture, lubrication, elasticity, sensitivity, arousal, bladder symptoms, pelvic floor tension, and comfort with intimacy.

This is about more than sex. It can affect confidence, relationships, dating, and quality of life.

Read this if: sex has started to hurt, intimacy feels different, or you have been handed “just use lube” as if that is a complete medical plan.

Crazy Bladder: When Urgency, Leaks, and Bathroom Trips Start Taking Over

Bladder changes can be one of the most frustrating and embarrassing symptoms women deal with in midlife.

Urgency, leaks, frequent bathroom trips, waking up at night to urinate, and feeling like your bladder is suddenly running your schedule may have a hormonal connection.

Read this if: your bladder feels more unpredictable, urgent, or demanding than it used to.

From a medical perspective, brain fog is a form of cognitive decline. That sounds scary, but it is real and serious. The good news is that brain fog is often highly reversible when we identify what is driving it and address it early.

That is why this guide goes deeper than the common advice to sleep more, clean your diet, reduce stress, make lists, or drink less coffee. Those habits may help, but they do not explain why a woman who used to think clearly starts to struggle with memory, attention, word recall, focus, motivation, and mental stamina.

The brain is not separate from the body. It is affected by hormones, sleep quality, inflammation, nutrient status, thyroid function, gut health, blood sugar, chronic infections, post-viral syndromes, adrenal stress, and mitochondrial function.

The multitude of factors involved in suboptimal brain function manifested as brain fog may explain why whatever you’re doing now is not enough. You cannot always fix this by cleaning your diet, exercising more, making lists, or drinking less coffee. When you start experiencing brain fog, it is time to take your brain seriously and seek help.

In this guide, we will look at the top overlooked drivers of brain fog in women: hormone deficiency, vitamin and mineral deficiencies, inflammation, gut dysfunction, mitochondrial dysfunction, post-viral patterns, and thyroid dysfunction.

I will also go over symptoms to monitor, questions to ask your doctor, I will suggest laboratory tests to consider, and discuss available solutions to help optimize your brain function.

Let’s Start by Looking at Hormones

Perimenopause and menopause can absolutely affect the brain. If you have any doubt as to what hormones can do to a woman’s brain, think about what happens to a woman’s body during her cycle and please think about what happens to the brain during pregnancy and postpartum.

Every single one of you has heard of PMS, mood swings during pregnancy, and postpartum depression.

If you ever wonder how estrogen, progesterone, or testosterone fluctuations impact a woman’s brain, all you have to do is think back on how your mood and your mental clarity were impacted by your own cyclic changes of sex hormones, how you felt during your pregnancies, and what happened to your mood and mental clarity during your postpartum recovery.

If you have any doubt as to whether or not estrogen, progesterone, and testosterone are valuable for your brain’s well-being and its capacity to function optimally, then think about what happened to you in perimenopause or after menopause. Maybe you’re not there yet, but maybe you can attest to what happened to older women in your life and how they changed.

There is no point in denying that our sex hormones influence our brain’s optimal function. It is time we face reality: there is a large body of evidence, data, and science backing up the connection between brain fog and hormonal decline. We see it after ovulation as PMS. We see it after pregnancy as postpartum depression. We see it in perimenopause as mood swings. And we see it after menopause as memory issues, too often dismissed as “just aging.”

Estrogen and the Foggy Brain

Did you know that estrogen has a strong relationship with memory, sleep, temperature regulation, attention, mood, and how clearly many women feel they can think? When estrogen fluctuates, some women feel mentally inconsistent. One day they are sharp. The next day they are rereading an email like it was written in ancient Greek by a hostile intern.

Estrogen and Sleep: The Brain Connection Women Are Not Told Enough About

Without sleep, your brain will not function optimally. And when a human being suffers persistent, long-term sleep disruption, the brain will literally be impaired.

Everyone knows that hot flashes, night sweats, restlessness, and 3:00 a.m. wake-ups to urinate, or for no obvious reason at all, can wreck the next day.

Without proper sleep, your ability to stay focused will be significantly reduced. You will have more lapses in attention and slower reaction times.

In the absence of deep, restful sleep, you may also struggle to process and hold information in your mind. When you are asked to multitask, solve problems quickly, or respond under pressure, you may be much slower than others. Unfortunately, that can increase the likelihood of struggling at work and possibly being criticized for poor performance.

If your sleep is interrupted and you wake up already tired and exhausted, your ability to form new memories and consolidate newly learned material will be significantly impaired. Without sleep, you will also have lower creativity, less flexible thinking, poor risk assessment, increased chances of risk-taking behavior, and more impulsive choices.

Sleep deprivation will make you irritable, moody, and highly emotionally labile. It will also make you more sensitive to stress and more prone to negatively interpreting the events that happen throughout the day.

Sleep is necessary for your brain to clear waste, consolidate memories, and regulate the balance of your neurotransmitters.

Think about this statistic: 40% of women in perimenopause report sleep disturbance, and 52–64% of women after menopause report problems with sleep.

That means over HALF of all women after menopause are walking around with some degree of sleep-related brain fog!

A woman may think she has brain fog when part of the problem is that her brain never got real sleep. Poor sleep will affect your focus, memory, emotional regulation, cravings, energy, and patience.

Your brain does not work well without sleep.

And sleep disruption when estrogen declines is not simply because of hot flashes or anxiety caused by a decline in estrogen. Research has shown that sleep is directly influenced by estrogen.

Why else would sleep improve so drastically with estrogen therapy?

Many women have already heard about progesterone and sleep. There is widespread knowledge around how progesterone helps sleep. But the truth is that estrogen is also an extraordinarily powerful influencer of your sleep pattern.

Why I Often Start With Progesterone First

I not only see that every day in my practice, but I felt it myself once my hormones rebalanced correctly and I had steady and reliable estradiol levels.

When a woman comes for treatment requesting hormone therapy and she complains of poor quantity and quality sleep, I always ask her to start progesterone first and give it one to two weeks before adding estrogen.

If progesterone makes you sleep like a baby, then you know exactly how much your body needs the progesterone, most likely on a daily basis. If progesterone is only minimally improving your sleep or not at all, and then you add estrogen and your sleep starts to gradually become better and better, with fewer and fewer wake-ups, allowing you to finally wake up in the morning fully refreshed, then you know how valuable estrogen is for your sleep.

It doesn’t work for all women, but it works for the great majority, which means chances are it will work for you too!

Read more

The term fatigue means chronic tiredness, and it has multiple causes. In many circumstances, fatigue is a sign of serious cellular dysfunction, which can also impact the brain. In order to understand whether his fatigue was due to something simple or whether it was actually impacting multiple organs and systems, I asked if he suffered from brain fog.

He responded with, “I don’t think so. Could you tell me what brain fog would feel like?”

So I explained it very simply and listed a few mental clarity manifestations of foggy brain, including poor attention span, difficulty focusing, difficulty obtaining information as quickly as you used to, the need to make lists in order to remember things you need to do, or nowadays, the need to set up multiple reminders on our cell phones.

Foggy brain can also include the need to read a paragraph two or three times either to understand its meaning or to commit the basic information to memory, occasional difficulty recalling names or words, forgetting people’s names, and other similar changes.

He immediately said, “Oh yes, I have all that.”

One of my newly hired medical assistants was listening to the conversation. Later that same day, when I had my first one-on-one with her, she started talking about the importance of writing notes in order to keep things organized and help her remember easily. She admitted that she had absolutely all the symptoms of brain fog I had inquired about during my clinical visit.

She is 35.

From a medical perspective, brain fog is a term used to describe cognitive decline. It is different from dementia, although dementia is also a form of cognitive decline.

Brain fog is most likely highly reversible. Dementia usually signals a more serious underlying brain problem, whether it is vascular, senile, or related to amyloid body deposition, as we see in Alzheimer’s disease.

One of the most commonly ignored, but highly reversible, causes of cognitive dysfunction manifesting as brain fog is hormonal dysfunction and the way imbalanced hormonal change impacts the brain.

Our sex hormones (testosterone for men, and estrogen, testosterone, and progesterone for women), have been labeled and misnamed “sex hormones.” This creates the false impression that they are present in our bodies simply to govern our ability to reproduce and enjoy sexual intimacy.

This is wrong on many levels.

The truth is that our sex hormones have a profound impact on our brain, our cognition, problem solving ability, mental health and emotional stability.

Testosterone has a profound impact on a man’s brain, and not surprisingly the young man I mentioned in the opening had a very low testosterone level (466 ng/dl).

Similarly, estrogen, testosterone, and progesterone have an extraordinary impact on a woman’s brain and her ability to function cognitively and emotionally at the level she desires, or more importantly, at the level she has been used to until the hormonal storm of perimenopause hit, followed by the total devastation and loss of these three hormones: estrogen, testosterone, and progesterone at menopause.

This article’s intention is to raise awareness of the importance our sex hormones have on mental clarity, mental health, and emotional well-being.

Let’s discuss how each hormone individually influences the brain, and their relationship with brain fog.

Share The Hormone Therapy Advocate

Brain Fog Is Not Just a Brain Problem, it is a Body Problem, Too

You’re not imagining it.

A foggy brain can feel like walking through mental humidity, or in some cases, trying to clear a path through a dense Amazonian jungle with a butter knife.

Perimenopause and menopause can absolutely be part of that picture.

Estrogen, Sleep, and the Foggy Brain

Estrogen has a powerful relationship with the brain. It helps influence your sleep, temperature regulation, mood, memory, attention, and how clearly you can think.

When estrogen starts fluctuating in perimenopause, the brain can feel unpredictable. Some days you are sharp. Other days you stare at your laptop like it has personally betrayed you, and you forgot why you opened the search window in your browser….

Then sleep starts getting hit.

Hot flashes. Night sweats. Restlessness. Trips to the bathroom. Waking at 3:00 a.m. hot, cold, irritated, and ready to fight the fitted sheet.

Poor sleep worsens fatigue, cravings, irritability, memory, focus, and mood. Then the next workday arrives, and you still have to answer emails, lead meetings, remember deadlines, regulate your mood and regulate your tone.

That is a lot to ask of any woman’s brain!

For some women, estrogen therapy can be a serious boost in the right direction, especially when fatigue and brain fog are being driven by anxiety, night sweats, hot flashes, and broken sleep from frequent urination. When sleep improves, next-day fog will improve too.

Testosterone and Mental Sharpness

Testosterone’s role in cognitive support and mental clarity for women is a subject of some debate, but what is undisputed is that testosterone matters greatly when it comes to brain health. Not just because most women report better focus and concentration during testosterone therapy, but also because low testosterone is important for a woman’s optimal brain function.

Low testosterone has been associated with fatigue, low motivation, depression, emotional lability, and significantly reduced well-being, which ultimately is felt as mental fatigue and reduced mental sharpness.

Progesterone, GABA, and Sleep Quality

Progesterone and its metabolites impact the brain’s neurotransmitters, especially GABA, the calming neurotransmitter we need to sleep and have a balanced mood. Progesterone has a powerful impact on your sleep, and the deeper and more restful your sleep is, the better your thinking, memory, and focus will be after a good night’s sleep.

Why Brain Resiliency Matters

Obviously, some women will be much more sensitive to hormone fluctuations and imbalances compared to others.

What determines brain resiliency for some women is undoubtedly a variety of key factors like sleep, nutrition and hydration, physical activity, stress management, daily cognitive challenging engagement, socially supportive environments, optimal thyroid function, and probably different genetic and baseline brain reserves.

Upgraded subscribers can access “The Brain Fog Medical Map”, where I dig deeper into the connection between all hormones and brain resiliency and how to maintain a resilient brain meant for longevity, including what to test for when it comes to functional hormones, gut health, inflammation, and mitochondria.

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But hormones are only one part of the picture.

If you have tried improving your nutrition, supplements, sleep routine, hydration, stress management, caffeine habits, and every version of “just push through it,” and your brain still feels unreliable, you may need a deeper medical evaluation.

Hormonal Deficiency Can Change How You Show Up at Work

Hormones influence the brain and body you bring into every meeting, decision, conversation, and deadline.

Estrogen, progesterone, testosterone, thyroid hormone, cortisol, and insulin all affect how steady, focused, energized, and mentally resilient you feel. When they are low, fluctuating, or poorly balanced, you may feel like you are working twice as hard to produce half the output.

You may start questioning your ambition when the real issue is physiology. You may think you are becoming less disciplined when your sleep is broken, your blood sugar is swinging, your thyroid is sluggish, your estrogen is dropping or completely erratic and unpredictable, your testosterone is low, your gut is inflamed, and your mitochondria are limping into the workday with a tiny backpack and no energetic resources.

That is why brain fog deserves more than reassurance and a normal lab printout.

A real in-depth medical evaluation. Not a rushed visit where basic labs are ordered and your hopes to find an answer crash when you are told, “It all looks great,” even though you feel far from great.

A comprehensive evaluation should look at your hormones, sleep, thyroid, B12, gut health, inflammation, blood sugar, adrenal reserve, post-viral history, autoimmune patterns, and mitochondrial health instead of handing you a copy of your normal labs and another reminder to “reduce stress.”

Subscribe to the paid article to get a complete list of recommended labs to test in order to get to the root cause, as well as how to implement a treatment plan.

The Other Usual Suspects Behind Brain Fog

Brain fog can be hormonal, but it can also be inflammatory, nutritional, metabolic, digestive, post-viral, autoimmune, adrenal, mitochondrial, or a messy little combination platter because apparently the body loves a group project.

Your brain needs fuel, nutrients, hormones, oxygen, and working mitochondria to function well.

Your Brain Needs Energy to Think Clearly

Mitochondria are the tiny energy engines inside your cells. When they are stressed, inflamed, or dysfunctional, your brain cells will struggle profoundly to produce the energy needed for focus, memory, motivation, and clear thinking. That is why some women feel technically awake but mentally stuck on under 10% battery.

Mitochondrial dysfunction can show up after inflammatory triggers, long-haul COVID, Epstein-Barr virus reactivation, Lyme disease, autoimmune flares, chronic stress, toxin exposure, or other insults that keep the body inflamed and depleted.

Inflammation Can Make the Brain Feel Heavy and Slow

Inflammation can also make the brain feel heavy and slow. Autoimmune conditions like lupus, rheumatoid arthritis, Hashimoto’s, Crohn’s disease, ulcerative colitis, and many other inflammatory disorders can affect how clearly you think.

And guess who is more prone to developing autoimmune diseases?

Women!

I personally have a whole theory on why women are much more prone to an autoimmune reaction, which is literally a dysfunctional response of a woman’s immune system to an insult that creates inflammation. An article on this topic will be coming soon. And if you are thinking hormones are involved you are right!

Then There Is the Gut

Digestive problems, heartburn, constipation, diarrhea, bloating, food sensitivities, irritable bowel symptoms, inflammatory bowel disease, and leaky gut patterns can affect nutrient absorption and immune system activation and response.

You may be eating well, but if your gut is inflamed or absorption is poor, your brain may still be missing what it needs.

Many women do not know that whatever impairs the absorption of B12 from your intestinal tract will also impair the absorption of any B12 coming in the form of a swallowed pill. B12 should be supplemented as a sublingual lozenge or as an injection until the inflammation of the digestive lining has been resolved.

The same is true for vegetarians who need B12 supplementation.

Why Am I Talking About B12?

Because B12 is essential for the nervous system. Low B12 can contribute to poor concentration, memory issues, low motivation, fatigue, apathy, and low mood.

And because 90% or more of women who I test for B12 levels are deficient. And not just mildly or moderately deficient, but severely deficient.

It is highly gratifying when a woman comes back after a series of B12 injections and sublingual supplementation at home and says:

“Thank you, Dr. C. I feel so much better! My energy is good. My mood has improved, and I feel like a new woman.”

All I did was identify and correct an essential vitamin deficiency.

Subscribe to the paid article to get a full list of all nutrients to consider and test in order to uncover the root cause of brain fog.

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Stress, Cortisol, and Your Brain

Stress and hormonal disruption due to stress will wreak havoc on your brain.

The most important hormone seriously impacted by stress is your stress hormone: cortisol!

Cortisol is produced by your adrenal glands, small walnut-shaped glands located at the top of each kidney, protected by your rib cage and positioned in the center of the body for maximum impact when needed.

Chronic stress and adrenal dysfunction can also make everything worse.

If your nervous system has been running on urgency for years, your body may start living in permanent crisis mode. You wake up tired, push through the morning, crash in the afternoon, crave sweet or salty food, snap at someone you actually like, and then feel guilty because apparently guilt is also on the calendar.

This is the woman who says:

“I can do everything, but it takes everything out of me.”

“I am functioning, but I am not well.”

“I used to be able to handle this. Now one normal workday takes me out.”

That is a body asking for a deeper look.

So Before You Call It Burnout, Get Curious

High-performing women are very good at functioning through dysfunction.

They can keep going for a long time. They can compensate, overprepare, make lists, stay late, double-check everything, and smile through the panic. They can look fine while privately wondering if their brain is betraying them, while slowly their health is changing and not for the better.

But functioning and doing what you must do is not the same as feeling well.

If you used to be sharp and now you are afraid you will blank in a meeting, pay attention. Track when it started. Notice whether it came with sleep changes, cycle changes, hot flashes, anxiety, fatigue, digestive symptoms, illness, COVID, stress, medication changes, or a new sense that your body is not recovering the way it used to.

Your brain fog is a signal. It is pointing to a problem that will likely get worse unless it is discovered and treated.

Your brain fog may be pointing toward hormone deficiency, broken sleep, inflammation, B12 deficiency or other vitamin deficiency, gut dysfunction, adrenal stress, thyroid imbalance, blood sugar instability, long-haul COVID, Epstein-Barr virus reactivation, autoimmune disease, or mitochondria that need support.

Your brain is part of your body. Your body is changing as your hormones change, and those hormonal shifts will change your brain.

Going through menopause after the hormonal wild swings of perimenopause is not easy for most women. Recognizing how hormonal imbalances impact your brain could save your job, your career, your marriage, or your relationship with your children.

Upgraded subscribers can continue with the “The Brain Fog Medical Map: Hormones, Gut, Inflammation, and Your Mitochondria” a comprehensive educational approach, providing suggestions for in-depth testing, and discussing what medical solutions are available.

Subscribe now

Disclaimer:

This Substack is here to educate, inform, and advocate. It is not a substitute for individualized medical care. Nothing in this publication should be taken as personal medical advice, diagnosis, or treatment, and reading or subscribing to this content does not create a physician-patient relationship with Dr. Mirela Cernaianu.

Hormone therapy and menopause care should be guided by a qualified clinician who knows your medical history, symptoms, goals, and risk factors. Always speak with your own healthcare professional before starting, stopping, or changing any medication, hormone regimen, supplement, or treatment plan.

Do not use this publication for urgent or emergency medical concerns. If you think you may be having a medical emergency, call 911 or seek immediate care.

Please do not post or send personal health information through comments or messages on this platform.

Sources & Further Reading

North American Menopause Society. The 2022 Hormone Therapy Position Statement of The North American Menopause Society.
https://www.menopause.org/docs/default-source/professional/nams-2022-hormone-therapy-position-statement.pdf

Greendale GA, Karlamangla AS, Maki PM. The Menopause Transition and Cognition. Obstetrics and Gynecology Clinics of North America.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4235240/

Maki PM, Weber MT. A Research Primer for Studies of Cognitive Changes Across the Menopause Transition. Climacteric.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4851938/

National Institutes of Health. NIH Study Identifies Features of Long COVID Neurological Symptoms.
https://www.nih.gov/news-events/news-releases/nih-study-identifies-features-long-covid-neurological-symptoms

Centers for Disease Control and Prevention. Long COVID Basics.
https://www.cdc.gov/covid/long-term-effects/index.html

National Institutes of Health Office of Dietary Supplements. Vitamin B12 Fact Sheet for Health Professionals.
https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/

Harvard Health Publishing. The Gut-Brain Connection.
https://www.health.harvard.edu/diseases-and-conditions/the-gut-brain-connection

Mayo Clinic. Hashimoto’s Disease.
https://www.mayoclinic.org/diseases-conditions/hashimotos-disease/symptoms-causes/syc-20351855

Johns Hopkins Medicine. Epstein-Barr Virus.
https://www.hopkinsmedicine.org/health/conditions-and-diseases/epstein-barr-virus

Nolan BJ, Liang B, Cheung AS. Efficacy of Micronized Progesterone for Sleep: A Systematic Review and Meta-analysis of Randomized Controlled Trial Data. The Journal of Clinical Endocrinology & Metabolism. 2021;106(4):e942–e951.
https://academic.oup.com/jcem/article/106/4/e942/6007680

International Menopause Society. Brain Fog in Menopause: A Health-Care Professional’s Guide for Decision-Making and Counseling on Cognition. 2022.
https://www.imsociety.org/wp-content/uploads/2022/10/IMS-White-Paper-2022-Brain-fog-in-menopause.pdf

Kullmann S, Heni M, Fritsche A, Preissl H. The Insulin Resistant Brain: Impact on Whole-Body Metabolism and Body Fat Distribution. Diabetologia. 2024.
https://link.springer.com/article/10.1007/s00125-024-06104-9

One of my patients referred at least 10 other women to me, not because I asked her to, but simply because they noticed she became happy, and almost did not recognize her. When they asked what was the secret for her transformation she simply told them to call me. I just changed a testosterone therapy formulation that wasn’t working to one that did. It changed her mood, her energy, her zest for life, it changed her relationships and it gave her back her “spark”.

Naturally, you want to know: could this work for me too?

The easiest answer may be to try the same doctor your friend is using. But what if she lives in another state? What if that clinician has a long waitlist? What if your gynecologist has tested your testosterone, and told you it is normal? What if you find a doctor online who seems promising, but you have no idea what kind of training they actually have?

Welcome to the testosterone maze!

This is where women need information, strategy, and a healthy amount of skepticism, while remaining optimistic and hopeful.

Testosterone can be a remarkable therapy for the right woman, prescribed in the right way and monitored by the right clinician. It can also get confusing fast when you are comparing creams, injections, pellets, online prescribers, cash-pay programs, supplements, insurance coverage, and doctors with very different training.

The Elephant in the Room: Testosterone for Women Is the Wild West

Let’s talk about the elephant in the room: there are currently no FDA-approved testosterone products specifically designed for women in the United States. That one fact changes the entire landscape.

The options women are usually offered fall into three categories:

☐ Compounded bioidentical testosterone creams
☐ Bio-hacked FDA-approved male testosterone products used off-label in much smaller female doses
☐ Pellet hormone therapy

Major organizations have raised concerns about compounded bioidentical hormone therapy because it has not gone through the same FDA approval process for safety, efficacy, purity, dosing consistency, and labeling. They also advise caution with pellets and compounded formulations, especially when FDA-approved options exist.

But here is the absurd part.

When it comes to testosterone, women often do not have an FDA-approved female option to choose from.

Women are told testosterone matters by a large variety of sources, while the conventional health care system has not built any form of training curriculum for med schools or residency, so doctors and mid level providers are clueless about testosterone for women.

The same health care system has not built a clean path for prescribing testosterone, leaving women and clinicians to piece together options in a space that is part science, part skill, part pharmacy access, part office policy, part training, and part cash-pay marketplace.

This is why the prescriber matters as much as the prescription.

Testosterone Therapy Is Where Estrogen Used to Be

Testosterone for women today feels to me like it is positioned just where estrogen sat before its rise to fame.

Estrogen therapy was introduced decades ago and eventually became a massive part of women’s health. Premarin and Prempro became household names before the Women’s Health Initiative study changed the hormone conversation in 2002. Between 1960 and 2000, estrogen therapy rose into blockbuster territory, with Premarin and Prempro sales growing from hundreds of millions in the early 1990s to billions by the early 2000s.

Testosterone is now having its own moment (finally!)

The interest is rising. Patient demand is rising. The online conversation is exploding. Women are realizing testosterone belongs to them too.

I predict testosterone for women will become a major topic in medicine over the next few decades. Patient demand is rising faster than the system is building a safe and responsible path. So proceed with caution, please!

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She still gets up. She still works. She still takes care of everyone. She still shows up for the people who need her.

But something inside her feels dimmed.

Her energy is lower. Her body feels heavier. Her patience is thinner. Her desire is gone or unreliable. Her workouts feel harder. Her recovery takes longer. Her motivation feels like it packed a suitcase and left town. She may look in the mirror and think, “What happened to me?”

Then she goes to the doctor. The labs come back. And she is told everything is “normal.”

The word “normal” can be one of the most frustrating words in women’s health, when it comes to hormones.

Normal according to whom? Normal compared to what? Normal even though the woman no longer feels vibrant, strong, sexual, clear, motivated, and alive? Or normal because the number landed inside a laboratory reference range that may have very little to do with optimal levels, or how she actually feels inside her body?

This is where many women get stuck!

They are told their symptoms are caused by stress, age, depression, relationship issues, lack of discipline, lack of sleep, poor diet, or the natural cost of getting older. And of course, all of those things can matter.

But so do hormones. And one of the hormones women are least knowledgeable and taught to ask about is testosterone.

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Whenever I explain to one of my patients that their testosterone levels are low I immediately get asked what does low testosterone feel like, and when I describe the possible symptoms almost all women exclaim: “OMG that’s me! That is how I have been feeling!”

Testosterone Is Not a Male Hormone

For far too long, testosterone has been treated like it belongs to men only, and women are simply borrowing it in tiny, irrelevant amounts.

That is just flat wrong.

Yes! Women make testosterone. Women use testosterone. Women have testosterone receptors. Women can become deficient in testosterone. And when that happens, the symptoms may show up in far more places than just the bedroom, as many are led to believe.

Testosterone is one of the most powerful anabolic hormones in the human body. “Anabolic” means it helps build, restore, repair, and maintain tissue. This matters for muscle, bone, strength, stamina, endurance, metabolism, sexual function, and the ability to feel physically capable as we age, it matters for pretty much anything that happens in your body!

And yes, testosterone matters for libido.

But sexual desire is simply the tip of the iceberg of what testosterone can do for a woman!

The mistake is reducing testosterone to just regulating sex drive, as if a woman only needs testosterone to want intimacy.

Testosterone is capable of influencing mood, energy, motivation, mental clarity, focus, muscle mass, metabolic rate, body composition, stamina, sexual response, and that deep inner sense of drive women often describe as their “spark” or their “mojo”.

So when a woman says, “I do not feel like myself,” and no one checks testosterone, she is likely missing a major part of the picture.

The Lab Said Normal. Your Body Said Otherwise.

Here is where the problem gets interesting.

A woman can have a testosterone level that falls inside the lab’s “normal” range and still feel awful.

Why?

Because normal and optimal are not the same thing.

Normal usually means the lab did not flag the result. It means your number landed somewhere inside the reference range printed on the report.

But the “normal range” for testosterone is not necessarily built around women who are thriving.

A woman may have a testosterone level that is technically “in range,” while her body is running on fumes. She may be losing muscle. She may be gaining fat around the middle. She may feel flat, irritable, foggy, unmotivated, tired, weak, and disconnected from desire.

Then she sees the word “normal” and assumes testosterone could not possibly be involved.

That is the trap.

A low-end normal result can still be a low-functioning result. A number can be accepted by the lab while rejected by the body.

The Trap of the Normal Lab Range

The question we need to ask is how Quest Diagnostics, Labcorp or other labs came up with their so-called “normal range.” The bottom number for testosterone is actually 2 for Quest Diagnostics, so according to their range a testosterone level of under 10, which is really just a smidge of testosterone, is considered “normal” because it is in range!

How did Quest diagnostics become the authority on determining “normal”? Because the great majority of physicians have no idea what to look for, or how to interpret the so-called normal and they base their assessments purely on the lab results. Anything that’s out of range is abnormal but anything that’s within the lab range is OK.

At this point, if all the physician does is interpret the hormone results based on whether the lab says it’s in range or not in range, then the physician is no better than a robot, which could simply tell the patient: “Everything is normal. Go home. There’s nothing wrong with your hormones and you certainly have normal testosterone”.

What is an optimal testosterone level? That is likely to vary from woman to woman, just like estrogen! There are women who thrive on estrogen of 100, and at this same level others are experiencing signs of deficiency. Similarly, a woman can feel great with a testosterone of 40, but another functions better when therapeutic testosterone levels are over 100!

What “Optimal” Actually Means

Optimal levels take into account how your body functions at that level.

Can you build muscle? Can you recover from exercise? Can you think clearly? Can you feel motivated? Can you tolerate stress without feeling like you are going to snap? Can you access desire? Can you feel connected to your body? Can you feel strong enough to live the life you are trying to live?

A lab range tells you where your number sits on paper.

Your symptoms tell you whether or not your body is thriving with that number.

Ideally, every woman would know what her testosterone level was when she felt her best, perhaps in her 20s or 30s, before symptoms began, when she was off birth control, off any drugs, before long-term hormonal suppression, before perimenopause, before menopause, before the slow disappearance of muscle, stamina, drive, and desire.

As women come to the realization of how important their hormones are, maybe with time the medical community will implement a new standard of care which I personally believe is a necessity: check your hormone levels when you feel your best in order to determine your baseline. But no one does that. I advocate for it. Strongly and loudly.

Most women who are being tested for testosterone levels are already experiencing symptoms of testosterone deficiency. Therefore, it is obvious that a statistical analysis by Quest Diagnostics, to use this major widely know lab as an example, what is considered a normal range for women will often show a maximum of 45, probably because that may be the maximum level seen in 99.99% of the women being tested.

But the women getting tested are the women who already have low testosterone!

All women only test hormones after something has already changed. When they know something is wrong, and suspect hormone problems are to blame. Unfortunately by then, we have no personal baseline. We are trying to reconstruct the scene after the spark has already gone missing. All an untrained physician has is a number on a lab test.

That is why a properly trained and skilled clinician should look at the whole picture: symptoms, age, cycle status, menopause status, birth control history, estrogen, progesterone, thyroid, insulin, metabolic health, muscle mass, mood, sexual function, and the actual testosterone level.

The testosterone number matters. But the woman and how she feels also matter.

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Testosterone Is About More Than Wanting Sex

Women have been told testosterone is about libido.

That is like saying a car battery is only about turning on the radio.

Yes, testosterone can influence sexual desire. It can affect interest in intimacy, arousal, sexual response, and the sense that your body is available for pleasure.

But testosterone also has a much broader role.

Low testosterone may show up not only as lower desire for intimacy, but also as fatigue, loss of stamina, lower endurance, slower recovery, loss of muscle mass, more body fat, reduced motivation, mood changes, brain fog, poor focus, irritability, reduced resilience under stress, and the uncomfortable feeling that you are simply less like yourself.

This is why the “just libido” framing fails women.

A woman may walk into a doctor’s office saying she is tired, gaining weight, foggy, emotionally flat, unmotivated, and no longer interested in sex, and instead of anyone asking about testosterone, she may be offered an antidepressant, told to exercise more, told to lose weight, told to sleep better, told to reduce stress, or told this is aging.

Those things may be a good part of the treatment plan.

But they should not be the entire answer when no one has looked at all the hormones connected to muscle, metabolism, mood, stamina, and desire.

I honestly wish women knew the extraordinary value of testosterone for their bodies and how important it is for a woman’s mental health! Women with good optimal testosterone levels are able to tolerate stress without getting overwhelmed, they have stable mood and zero mood swings, they have a positive outlook on life, they are confident, ambitious, and driven. Women with good testosterone are more motivated to exercise, they build new muscle and maintain muscle mass effortlessly, their stamina and endurance is very good and they recover quickly and promptly even after very strenuous exercise.

I wish women knew what a hidden gem testosterone is. Testosterone is not a male hormone. We need to shatter that dogma.

Testosterone is the yang to a woman’s yin. There has to be a balance between the masculine and the feminine energy. Chinese medicine knows that. Conventional medicine has ignored and continues to ignore testosterone, focusing exclusively on estrogen.

The Hormone I Underestimated Until My Body Proved Me Wrong

I have a personal story to share with you. Once I balanced my hormones post menopause by choosing the right therapy for me, I immediately and without any effort, lost the stubborn 15 pounds that had been plaguing me for the past 10 years, which seemed to accumulate slowly and inexorably, in spite of all my diet and exercise efforts.

I was able to maintain my weight for five years easily, and I stopped dieting and enjoyed food again. In 2024 I noticed that my estrogen lasted longer than my testosterone. I did not feel any different, so I decided to space out my therapy to allow time for my body to clear the estrogen. I did not believe that testosterone was that important for me. I felt absolutely fine until December 2024 when I went on vacation. I gained 10 pounds which was double the normal weight I would usually gain on a two week vacation. I never had a problem losing weight. It would easily come off in the next two months. In 2025 I was unable to lose the extra vacation weight. By summer of 2025 I realized what was wrong. My testosterone was too low. My number was 24. I immediately changed the frequency of my testosterone therapy, but it took six months for my body to regulate and be able to come back to normal.

For those of you who are fighting and losing the battle of the bulge I have news for you: testosterone could be your best ally and your best solution!

You Are Not Lazy. You May Be Underpowered.

There is a lot of quiet shame many women carry in midlife. They blame themselves for many things.

They think they are lazy because they cannot push through workouts the way they used to.

They think they lack discipline because their body composition is changing.

They think they are failing their partner because desire does not come as easily.

They think they are moody because they cannot tolerate stress the same way.

They worry they are terrible mothers because they start yelling at their children, when they suddenly get angry and can no longer reign it in!

But a woman’s body does not run on willpower alone.

Your muscles need hormonal support. Your brain needs hormonal support. Your emotions and mood need hormonal support. Your sexual tissues need hormonal support. Your metabolism needs hormonal support.

Your ability to recover, rebuild, and feel alive in your body is not a personality trait.

If testosterone becomes low, or too low for you, even putting more effort into anything you do will stop producing the same result.

You can eat the protein. You can go to the gym. You can walk. You can sleep. You can try to be positive. But if one of the major anabolic hormones in your body is missing from the plan, you may feel like you are climbing a hill with weights tied to your ankles.

That does not mean testosterone is the answer for every woman. It means testosterone should be part of the evaluation when the symptoms fit.

Why Birth Control Can Complicate the Picture

This topic is not only for women in menopause.

Younger women can also have low testosterone, especially if they are using hormonal birth control that suppresses ovarian hormone production. When the ovaries are quieted by synthetic hormones, natural testosterone production may also be affected.

This does not mean every woman should stop birth control or panic about it. Birth control can be necessary, useful, and protective depending on a woman’s goals and circumstances.

But women should understand what is happening.

If you are using a medication that changes your natural hormone production, and then you develop low desire, mood changes, poor focus, fatigue, or a sense that your body feels muted, it is reasonable to ask whether testosterone is part of the story.

Women should not have to wait until midlife to learn that they are losing their testosterone.

Menopause and Testosterone

Some women continue making meaningful testosterone after menopause. They are the lucky exceptions.

The great majority of women do not.

And most have already been losing testosterone long before their final period.

This matters because midlife is the stage when the body becomes less forgiving. In your 20s and 30s, youth can cover a lot. You may be able to stay up too late, skip recovery, push through stress, under-sleep, and still feel fairly functional.

Then the 40s arrive, and the same habits start charging interest.

By the 50s and 60s, when estrogen has declined and testosterone has been low for decades, the female body may struggle more and more with muscle loss, belly fat and overall fat gain, significant fatigue, low desire, mood changes, and reduced resilience.

We should not treat testosterone like a side note.

It may be one of the missing links in how a woman ages, builds strength, preserves muscle, maintains sexual wellness, and keeps enough energy to participate fully in her own life.

The “Testosterone is Too High” Panic

There is another side to this issue.

Sometimes a woman starts testosterone therapy, feels better, and then another clinician sees her lab result and panics because the number is above the lab’s reference range.

This is where interpretation is so important and where a trained hormone expert would be key.

A woman using testosterone therapy may have levels that look “high” compared with a standard lab range. That does not automatically mean something is wrong. It means the result must be interpreted in context: the dose, delivery method, timing of the blood draw, symptoms, side effects, cardiovascular risk, metabolic markers, blood pressure, lipids, glucose, insulin, liver enzymes, and the woman’s actual clinical response.

Testosterone therapy should be monitored carefully. Side effects matter. Safety matters. Long-term risk matters. More is not automatically better.

But fear and panic do not belong when data is interpreted by another physician, who is not trained and who does not have experience with testosterone therapy in women!

A woman should not have to experience unnecessary anxiety because a number looks high to a clinician who may not understand testosterone therapy in women. She needs someone trained enough to explain the result, adjust the dose if needed, monitor the right markers, and look at her entire health picture.

Paid members get access to the most important facts about testosterone therapy, what formulations are available, how to choose and how to monitor.

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Delivery Method Matters

Testosterone can be delivered in different ways, including topical creams, injections, or pellets. Each method behaves differently in the body.

A cream may create a rise after application and then decline over the day.

An injection may have its own peak and decline pattern usually over the time span of 1 week.

A pellet is designed to release more steadily over time.

Because of different bioavailability and peak and trough levels, which are different with each therapy, it does matter when testosterone levels are tested.

Testing one or two hours after a cream application can show a very different result than testing many hours later, or in the morning before you apply the next dose.

Testing after an injection depends on whether you are looking for the peak, the midpoint, or the trough before the next dose.

Testing after pellet therapy also has its own timing considerations.

This is why a single number without context can be misleading.

If a woman is using testosterone and the blood draw is timed poorly, the result may create confusion, anxiety, or an unnecessary dose change. Good hormone management requires knowing what form of testosterone is being used, when it was taken, when the blood was drawn, how the woman feels, and whether any side effects are showing up.

That is not something a lab range, or an untrained physician, should decide by itself.

Side Effects Should Be Managed, Not Ignored

Testosterone therapy is not a magic cure.

It is a powerful hormone therapy, and like any powerful therapy, it needs skill, monitoring, follow-up, and honest communication between a woman and her clinician.

Testosterone therapy should bring a woman closer to herself: stronger, clearer, more energized, more connected, and more alive in her body. That requires careful dosing, proper testing, and a clinician who knows how to monitor the full picture.

Some women do beautifully on testosterone therapy, while others may need a lower dose, a different delivery method, closer monitoring, or a pause while symptoms are sorted out.

Possible side effects can include acne, oily skin, facial hair growth, hair shedding, irritability, anxiety, possible aggression, feeling overstimulated, water retention, bloating, sleep disruption, palpitations, changes in blood pressure or metabolic markers.

These symptoms do not mean testosterone is “bad for you.” They mean the dose, delivery method, your unique metabolism, or overall hormone picture may need to be reassessed.

Please call your doctor early if you notice more hair shedding than usual, more than a couple of new chin hairs, more than a few acne spots, swelling, bloating, anxiety, new irritability, feeling argumentative, trouble sleeping, or palpitations you did not used to have.

Do not wait until the next visit while silently loving but also hating the therapy. It helps no one.

Adjustments can often be made, but your clinician needs to know what is happening. Sometimes the answer is lowering the dose. Sometimes it is changing the delivery method. Sometimes it is checking levels and interpreting them in context. Sometimes testosterone is not the right fit, or not the right fit yet.

And yes, there are women who notice they need more laser hair removal sessions and would rather do that than give up testosterone therapy because they love how they feel. That is a valid conversation too, but it should still involve testing, monitoring, and a clinician who understands how to interpret the whole picture.

What to Ask Your Clinician

If you feel like your spark is missing and testosterone has never been discussed, start with better questions.

Ask what your total and free testosterone levels are.

Ask whether your result is simply in range or whether it looks optimal for your age, symptoms, and goals.

Ask whether low testosterone could be connected to low desire, fatigue, muscle loss, mood changes, or reduced stamina.

Ask whether estrogen, progesterone, thyroid, insulin, glucose, and metabolic markers are also being evaluated.

If you are on birth control, ask how it may affect natural testosterone production.

If testosterone therapy is being considered, ask which delivery methods are used, how therapy is monitored, what side effects to watch for, and when labs should be checked based on the method used.

These questions matter because a woman should not have to accept “your labs are normal” as the end of her story, when her body is clearly telling her something is wrong.

The Version of You That You Remember Is Still There

There is a version of a woman that she remembers.

The version who had energy. The version who wanted to be touched. The version who recovered faster. The version who could build muscle. The version who felt sharper, steadier, stronger, and more alive.

That version may not be gone.

She may be under-supported.

Testosterone is not the whole story, but for many women, it may be one of the most overlooked chapters. It is not just a male hormone. It is a woman’s hormone too, and it influences and controls much more than sexual desire.

So if you have been told everything is normal while your body feels anything but normal, ask a better question.

Ask whether your testosterone was checked.

Ask whether the number was interpreted by someone who understands hormone therapy in women.

Ask whether “normal” is actually enough for the life you are trying to live.

Because you did not lose your spark overnight.

And maybe no one ever checked the hormone that helps keep it lit.

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Disclaimer:

This Substack is here to educate, inform, and advocate. It is not a substitute for individualized medical care. Nothing in this publication should be taken as personal medical advice, diagnosis, or treatment, and reading or subscribing to this content does not create a physician-patient relationship with Dr. Mirela Cernaianu.

Hormone therapy and menopause care should be guided by a qualified clinician who knows your medical history, symptoms, goals, and risk factors. Always speak with your own healthcare professional before starting, stopping, or changing any medication, hormone regimen, supplement, or treatment plan.

Do not use this publication for urgent or emergency medical concerns. If you think you may be having a medical emergency, call 911 or seek immediate care.

Please do not post or send personal health information through comments or messages on this platform.

Sources & Further Reading

Global Consensus Position Statement on the Use of Testosterone Therapy for Women.

https://academic.oup.com/jcem/article/104/10/4660/5556103

International Society for the Study of Women’s Sexual Health. Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women.

https://www.isswsh.org/images/PDF/jsm_18_5_849.pdf

Endocrine Society. Androgen Therapy in Women: A Reappraisal.

https://www.endocrine.org/clinical-practice-guidelines/androgen-therapy-in-women

Cleveland Clinic Journal of Medicine. Prescribing testosterone and DHEA: The role of androgens in women.

https://www.ccjm.org/content/88/1/35

The Lancet Diabetes & Endocrinology. Testosterone in women — the clinical significance.

https://www.thelancet.com/journals/landia/article/PIIS2213-8587%2815%2900284-3/fulltext

Testosterone: Vital to female physiology.

https://pmc.ncbi.nlm.nih.gov/articles/PMC13180063/

Global Consensus Position Statement on the Use of Testosterone Therapy for Women.
https://academic.oup.com/jcem/article/104/10/4660/5556103

International Society for the Study of Women’s Sexual Health. Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women.
https://www.isswsh.org/images/PDF/jsm_18_5_849.pdf

Endocrine Society. Androgen Therapy in Women: A Reappraisal.
https://www.endocrine.org/clinical-practice-guidelines/androgen-therapy-in-women

Cleveland Clinic Journal of Medicine. Prescribing testosterone and DHEA: The role of androgens in women.
https://www.ccjm.org/content/88/1/35

The Lancet Diabetes & Endocrinology. Testosterone in women — the clinical significance.
https://www.thelancet.com/journals/landia/article/PIIS2213-8587%2815%2900284-3/fulltext

Testosterone: Vital to female physiology.
https://pmc.ncbi.nlm.nih.gov/articles/PMC13180063/

Quest Diagnostics. Testosterone, Total, MS.
https://testdirectory.questdiagnostics.com/test/test-detail/15983/testosterone-total-ms

Labcorp. Testosterone, Total, Women, Children, and Hypogonadal Males, LC/MS-MS.
https://www.labcorp.com/tests/070001/testosterone-total-women-children-and-hypogonadal-males-lc-ms-ms

Zimmerman Y, Eijkemans MJC, Coelingh Bennink HJT, Blankenstein MA, Fauser BCJM. The effect of combined oral contraception on testosterone levels in healthy women: a systematic review and meta-analysis. Human Reproduction Update.
https://academic.oup.com/humupd/article/20/1/76/887764

Painful sex is not a medical condition. Painful sex is a clear alarm signal that you have a medical condition which requires prompt attention and appropriate treatment for an immediate and permanent resolution.

Not enough people talk about painful sex. Maybe it is still taboo, but painful sex has impacted, at some point, the intimate life of billions of women worldwide.

How do you treat painful sex before painful sex could become the end of your sex life?

How do you stop painful sex before it damages your ability to be intimate with your partner?

First you take it seriously! You prioritize an evaluation and once the diagnosis is made you ask for a cure.

“Try more lubricant” is such an incomplete and inadequate answer.

Lubricants can help. We will talk about it. Keep it in the toolbox. But if painful sex is being caused by fragile tissue, estrogen loss, pelvic floor guarding, lichen sclerosus, vulvar skin changes, recurrent infections, bladder irritation, scarring, fibrosis, endometriosis, fibroids, cervicitis, nerve pain, or deeper pelvic conditions, another bottle of lubricant is not a treatment plan.

This article is designed to help you understand the treatment categories, the questions to ask, the options that may be worth discussing, and the difference between choosing a therapy because it is right for your body versus choosing it because it happens to be what a practice sells.

I want you to achieve comfort, function, confidence, pleasure, intimacy, and a body that does not feel like it is fighting you!

Treat Painful Sex Like It Matters Because Early Action is the Absolute KEY to a Cure!

If you had chest pain in the middle of the night, you would not say, “Maybe this is just aging.”

You would not wait months or years and hope it works itself out, right? You’d call someone immediately, maybe an ambulance.

Painful sex deserves that same seriousness. Not panic. Not shame. Not delays. Not denial. It deserves seriousness.

If sex suddenly becomes painful, or if it happens more than a few times and the pain keeps returning, please call the doctor’s office without delay and ask for an evaluation.

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It is rarely just the physical discomfort.

Painful sex can slowly take away intimacy, sexual confidence, ease with a partner, and eventually vaginal intercourse altogether. That is the part women are rarely warned about.

It often starts quietly. A woman feels drier than before. Penetration feels scratchy. Then it burns afterward. Then she needs more lubricant. Then she starts bracing before intimacy because her body already knows what is coming.

Over time, she may stop initiating. She may pull away before her partner reaches for her. She may feel guilty, embarrassed, frustrated, or confused because she still loves her partner, still wants closeness, and still remembers what sex used to feel like before her body started responding with pain.

This is where painful sex becomes much more than a symptom. It can become avoidance, anxiety, resentment, emotional distance, and the quiet fear that something important has changed.

So when women are told to simply “use more lube,” I have a problem with that.

Lubricants can help reduce friction when dryness is mild or occasional. But when sex keeps hurting, the real question is no longer which bottle to buy next.

The real question is: what changed in the tissue, hormones, muscles, nerves, bladder, skin, or pelvic floor that made sex painful in the first place?

Sex When Aging Can Be Better Than Ever Until Pain Takes Over

Women are often given the cultural message that sex after midlife naturally fades into the background. I do not agree.

For many women, sex after menopause can become more confident, intimate, and enjoyable. There is no fear of an undesired pregnancy. Children may be older or out of the house. A woman may have more privacy, more maturity, and more clarity about what she likes and what she prefers to avoid.

In a stable relationship, a partner may know her body well. She may know her own body better than she ever has. Orgasms may be more reliable because she understands what works. Many women admit that sex as they age becomes better.

Then unexpectedly discomfort and then pain enters the picture.

When intercourse starts to burn, when your skin starts to tear, when you feel tight, raw, when sex will trigger bladder symptoms, or cause days of irritation, the whole emotional landscape changes. A woman may still want intimacy, but her body begins to associate sex with discomfort.

Desire changes. Anticipation changes. The sense of safety changes.

Her partner may feel rejected. She may feel pressured or guilty. He may become distant, insecure, short-tempered, or confused. She may become avoidant, sad, resentful, or ashamed. Neither person may know how to talk about it without turning the conversation into blame, defensiveness, or silence.

Some relationships survive long seasons without sexual intimacy. Others become strained, lonely, or vulnerable to distance that neither partner intended.

This is why painful sex deserves urgency.

We must act before pain starts writing the story of the relationship!

What Painful Sex Means And Why It Happens

Painful sex is also called dyspareunia. It can feel like burning, tearing, rawness, tightness, deep pressure, bladder pain, sharp pain, or discomfort that lingers after intimacy.

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After 40, one of the most common reasons this begins is hormone-related tissue change. As estrogen and testosterone decline, the vaginal and vulvar tissues can become thinner, drier, more fragile, less elastic, and less able to tolerate friction.

The pelvic floor can also begin guarding against pain. The bladder and urethra can become more irritated. Recurrent infections can enter the picture. Nerves, vulvar skin, scar tissue, endometriosis, bladder pain, and deeper pelvic conditions like fibroids or tumors of the ovaries, may also be involved.

That is why painful sex is rarely solved by one generic answer.

One woman may need local vaginal estrogen. Another may need pelvic floor physical therapy. Another may need evaluation for vulvodynia, lichen sclerosus, recurrent infections, bladder pain, endometriosis, or a deeper pelvic issue.

Some women may need a broader conversation about whether their hormone therapy is actually optimized for sexual function, or is simply targeting hot flashes and their consequences.

For in depth discussion on hormone optimization and hormone impact on painful sex please enroll in our paid tier and also get access to more tools and paid member benefits.

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Painful sex requires a real history, a real exam, and a clinician willing to ask serious questions about intimacy, including uncomfortable and possibly triggering questions.

It takes courage for a physician to ask a woman about intimacy, especially when sex has become painful, uncomfortable, or emotionally complicated. The woman may feel embarrassed, guarded, ashamed, or simply not ready to open that door.

And it takes just as much courage for a woman to face the fear that something may be wrong, put words to what she has been silently carrying, and ask for help.

Vaginal Atrophy Is More Serious Than Women Are Told

One of the most common reasons sex becomes painful after 40 is estrogen decline.

Estrogen is what I love to call the “Goddess Hormone” because its influence on female tissue is profound. Estrogen supports vaginal tissue thickness, natural moisture, blood flow, elasticity, sensitivity, lubrication, and resilience during penetration.

When estrogen declines in perimenopause, menopause, and postmenopause, the vaginal tissues can become thinner, drier, more fragile, less elastic, and less able to tolerate friction. The medical term many women hear is vaginal atrophy. A newer and broader term is Genitourinary Syndrome of Menopause, or GSM, because the vagina, vulva, urethra, bladder, and pelvic floor can all be affected.

Vaginal atrophy sounds clinical and boring. Its consequences can be deeply personal.

The tissue that once tolerated intercourse comfortably may begin to react with burning, tearing, irritation, bleeding, or pain. Touch that once created pleasure may feel less sensitive or downright uncomfortable. The vaginal opening may become less flexible. The vagina may feel shorter, tighter, drier, or more easily irritated.

Some women lose their ability to enjoy sexual intimacy and orgasm because the local receptors and tissue response have changed.

This is why I do not want women hearing “vaginal atrophy” and thinking it only means “a little dryness.”

The implications are much bigger.

Hot flashes often improve with time. Vaginal atrophy tends to progress as a woman gets further from menopause when tissue health, estrogen support, and sexual function are ignored for years.

That is why waiting can be costly.

When Women Ask for Answers and Still Get Dismissed

From my experience, many women do try to get an answer.

They courageously overcome embarrassment, fear, and confusion about what is happening to their bodies. They finally bring up painful sex, vaginal dryness, burning, recurrent infections, bladder symptoms, or the slow disappearance of intimacy. They ask for a solution.

Too often, they receive incomplete answers.

They are told to use a different lubricant. They may be offered vaginal estrogen without a full explanation of what is happening, how it works, what it can improve, what else may be involved, or what to do if it does not work well enough.

Many women leave with the feeling that the visit ended before the real conversation even started.

So they give up.

They adapt to intimacy without vaginal intercourse. They avoid sex because they are afraid of pain. Some stop having sex completely.

This is where painful sex becomes much bigger than a bedroom problem. It becomes grief. It becomes distance. It becomes a woman quietly mourning a part of herself while wondering why no one seems to understand how much she has lost.

When “It’s Probably Nothing” Becomes Years of Pain

Many women do not walk into an appointment and announce, “I have painful sex.”

They say sex feels different.

They say they feel dry.

They say they need more time.

They say they burn afterward.

They say they feel irritated for days.

They say they keep getting yeast infections or bacterial vaginosis.

They say they have low desire, but when you ask more carefully, desire may not be the original problem. Pain became the problem. Fear became the problem. Recurrent infections became the problem. The loss of trust in their body became the problem.

Women have been trained to minimize discomfort, especially when the discomfort involves sex, the vagina, the bladder, or anything that feels embarrassing to say out loud.

So they start negotiating with pain.

Maybe I need more lubricant.

Maybe we need a different position.

Maybe I am tired.

Maybe it is my relationship.

Maybe this is what happens now.

Maybe we should just stop vaginal sex and do other things.

Every couple can define intimacy for themselves. There is no single version of intimacy that every woman must choose. But no woman should be pushed into giving up comfortable and enjoyable vaginal intercourse because no one explained what was happening or offered a serious treatment plan.

If sex hurts after 40, the next step is very clear: figure out what changed.

Recurrent Infections May Be Part Of The Hormone Story

Painful sex is often discussed as a dryness problem, but many women experience a more complicated pattern.

They have recurrent yeast infections. Recurrent bacterial vaginosis. A change in vaginal odor. Burning after sex. Irritation that lasts for days. Bladder symptoms that appear after intimacy. A cycle of antibiotics, antifungals, temporary relief, and then the symptoms return.

This pattern can be connected to estrogen decline.

The vaginal microbiome depends heavily on a healthy, estrogen-supported environment. Beneficial bacteria called lactobacilli help protect the vagina. Lactobacilli thrive when vaginal cells produce glycogen, and that process is closely tied to estrogen levels.

When estrogen declines, the vaginal environment can become more vulnerable to irritation, imbalance, odor changes, candida, bacterial vaginosis, tampons, tight underwear or pants. urinary symptoms, and post-sex discomfort.

This is why a woman can be treated again and again for an infection while the deeper hormone-related tissue change remains unaddressed.

The infection may be real. The missing explanation is the reason why the infection returns. Women deserve a full hormone evaluation as soon as painful sex or vaginal wellness issues become a problem, even if the woman is younger. Young women have low estrogen too!

A woman deserves treatment for the immediate problem, but she also deserves an explanation for why the pattern keeps returning.

I recently had a conversation with a woman in her late 40s who had been dealing with recurrent candida or bacterial vaginosis symptoms for more than a year. She had seen other physicians and had been treated with antibiotics or antifungals, but no one had explained the possible connection between declining estrogen, changes in the vaginal microbiome, recurrent infections, and discomfort with intimacy.

When the conversation opened up, she admitted that sexual activity often led to days or weeks of discomfort, and that this was affecting her desire and her relationship.

That is the moment a woman needs more than a prescription.

She needs an explanation. She needs tools. She needs a plan. She needs to stop being afraid of intimacy because she finally understands what may be happening and what can be done next.

If you want the practical next step

If you are already thinking, “Okay, but what do I actually ask for?” that is exactly what the paid companion covers. The companion guide walks through what to track, what to say at the appointment, which treatment categories to discuss, and how to know when lubricant, moisturizer, or vaginal estrogen may be only part of the answer.

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Pain Can Train The Body To Protect Itself

When sex hurts once, the body remembers.

When sex hurts repeatedly, the body starts preparing for pain before penetration even happens. The pelvic floor muscles may tighten. The vaginal opening may feel smaller or blocked. A woman may want intimacy emotionally while her muscles behave as if they are protecting her from injury.

This can become vaginismus, which involves involuntary contraction of the pelvic floor muscles around the vaginal opening. Penetration can become extremely painful or sometimes impossible.

This is physiology. It is not a lack of love, effort, attraction, or relaxation.

Telling a woman to “just relax” when her pelvic floor is guarding against pain is lazy medicine. The muscles may need pelvic floor therapy, retraining, patience, and a clinician who understands how painful sex becomes a loop.

The earlier this is addressed, the better.

When painful sex continues for years, the original problem may become layered with tissue loss, fear, guarding, avoidance, relationship stress, narrowing of the vaginal opening, and loss of confidence. The solution can still exist, but it may require more time, more commitment, more money, and more emotional patience.

Weeks and months matter.

Years can make the path harder.

Why Doctors Fail Women on Painful Sex

Many clinicians lack training in menopause-related sexual pain, and even well-meaning providers may not have enough time to take a detailed sexual history, ask about relationship impact, evaluate bladder symptoms, review recurrent infections, examine the vulvar skin carefully, assess the pelvic floor, or consider whether hormone levels and hormone therapy optimization are part of the picture.

Access to meaningful solutions can also be limited. A clinician may recognize vaginal atrophy or GSM but still feel unprepared to manage pelvic floor dysfunction, vulvodynia, recurrent infections, bladder pain, vaginismus, or sexual pain that has become layered over time.

And then there is the discomfort around the subject itself. If a physician asks, “Are you having pain with sex?” and the answer is yes, that question suddenly requires time, skill, comfort, and a treatment plan. Too often, the question is avoided because the system is not prepared for the answer. Many medical providers were trained on the definition and the medical implications and causes of painful sex, but not trained on how to manage any real life intimacy problems sitting in front of them.

So the woman gets brushed off.

Use lubricant. Try vaginal estrogen. Relax more. Give it time and try more foreplay.

And most likely the physician will rush off to the next patient.

But painful sex deserves more than a rushed answer, especially when intimacy, desire, confidence, and a relationship may already be suffering.

Ask yourself the blunt question

“Have you decided that you never want to be intimate again for the rest of your life?”

Most women immediately say no.

They have not decided that. They are not ready for that. They simply adapted to pain, avoided the conversation, lost hope, or assumed this was the unavoidable ending of womanhood.

That question matters because painful sex can make a woman surrender without realizing she surrendered.

She may stop initiating. Then she may stop expecting comfort. Then she may stop expecting pleasure. Then she may stop believing solutions exist.

I want women to pause before they accept that.

If you are no longer sexually active because of divorce, widowhood, loss of a partner, or a season of life without intimacy, this still matters. Many women believe that if a new partner appears, sexual intimacy will resume the way it used to. After menopause, and as a woman ages, that assumption can turn out to be painful and embarrassing.

When Intimacy Hurts, Relationships Can Suffer

I’ve encountered quite a few women in their 60s and beyond who tried to be intimate with a new partner, only to find the pain unbearable. In some cases, the relationship ended before it ever had the chance to become something meaningful. The men disappeared, not necessarily because they did not care, but because they did not want to be the person causing pain.

The partner became afraid and literally “ran for the hills,” as one woman jokingly told me. The men will disappear, never to be seen or heard from again, not necessarily because they do not care, but because they do not want to be the person causing pain.

No man wants to intentionally hurt a woman he is attracted to. So the embarrassment, sadness, and disappointment often exist on both sides. The woman may feel brave enough to keep trying, even through pain, but many men do not want intimacy to feel like they are injuring someone they care about.

That is why painful sex after menopause is not a small quality-of-life issue. It can affect confidence, connection, dating, relationships, and the possibility of love later in life.

Normal vaginal function benefits from regular use, adequate blood flow, tissue stimulation, and optimal hormonal support. The old saying “use it or lose it” is unfortunately relevant when it comes to vaginal function and aging.

This does not mean every woman must be sexually active. It means every woman deserves to preserve her choice.

If you want the option of comfortable intimacy in the future, talk to a clinician about maintaining vaginal tissue health NOW. Depending on your body, that conversation may include vaginal estrogen, systemic hormone support, moisturizers, pelvic floor therapy, dilators, laser therapy or regular use of a vaginal device at home.

The purpose is preservation of YOUR choice!

Do you want to know everything you need about real therapeutic solutions, including laser therapies? Please subscribe for the paid version of this article and get more member benefits like access to our other in-depth guides on women’s health.

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Solutions Exist, But the Right Plan Depends on the Cause

Painful sex is rarely one simple condition with one universal treatment. Lubricants, moisturizers, vaginal estrogen, pelvic floor therapy, infection treatment, vulvar skin care, bladder evaluation, hormone support, or newer technologies may all belong in the conversation depending on what is actually causing the pain.

That is why the first step is not another guess. It is a better evaluation.

If sex still hurts after basic solutions, ask whether the tissue, hormones, pelvic floor, vulvar skin, bladder symptoms, infection history, nerves, or deeper pelvic structures have been fully considered.

The right clinician may take effort to find, but painful sex deserves someone who knows how to look beyond using a lubricant or vaginal estrogen or both and offer a plan that matches the real cause, and is a real long term solution restoring baseline or better intimacy!

Please Address Painful Sex Early And Promptly

Painful sex after 40 deserves attention within weeks or months, rather than years.

The longer a woman waits, the more complicated the problem can become. Tissue changes may progress. The vaginal opening may narrow. Recurrent infections may continue. Pelvic floor guarding may become stronger. Desire may fade. Avoidance may become routine. A relationship may absorb pain that could have been addressed sooner.

This is about refusing to normalize the slow loss of intimacy when solutions exist.

If sex hurts, your body is giving you information.

Listen early, ask better questions and find someone who knows how to help!

For Paid Subscribers: A Real Action Plan

The companion guide helps you walk in prepared with the symptoms to track, the questions to ask, and the treatment options to discuss when painful sex needs much more, including valuable information about new advanced vaginal laser technology applicable for sexual wellbeing problems.

Disclaimer:

This Substack is here to educate, inform, and advocate. It is not a substitute for individualized medical care. Nothing in this publication should be taken as personal medical advice, diagnosis, or treatment, and reading or subscribing to this content does not create a physician-patient relationship with Dr. Mirela Cernaianu.

Hormone therapy and menopause care should be guided by a qualified clinician who knows your medical history, symptoms, goals, and risk factors. Always speak with your own healthcare professional before starting, stopping, or changing any medication, hormone regimen, supplement, or treatment plan.

Do not use this publication for urgent or emergency medical concerns. If you think you may be having a medical emergency, call 911 or seek immediate care.

Please do not post or send personal health information through comments or messages on this platform.

Sources & Further Reading

JAMA. Dyspareunia in Women.
https://jamanetwork.com/journals/jama/fullarticle/2791520

The Menopause Society / North American Menopause Society. The 2020 Genitourinary Syndrome of Menopause Position Statement.
https://www.isswsh.org/images/content/2020-NAMS-GSM-Paper.pdf

American Urological Association, SUFU, and AUGS. Genitourinary Syndrome of Menopause Guideline, 2025.
https://www.auanet.org/guidelines-and-quality/guidelines/genitourinary-syndrome-of-menopause

Johns Hopkins Medicine. Genitourinary Syndrome of Menopause.
https://www.hopkinsmedicine.org/health/expert-qa/genitourinary-syndrome-of-menopause

Mayo Clinic. Vaginal Dryness After Menopause: How to Treat It.
https://www.mayoclinic.org/diseases-conditions/menopause/expert-answers/vaginal-dryness/faq-20115086

American College of Obstetricians and Gynecologists. Vulvodynia.
https://www.acog.org/womens-health/faqs/vulvodynia

American College of Obstetricians and Gynecologists. Persistent Vulvar Pain.
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/09/persistent-vulvar-pain

MSD Manual Professional Edition. Genito-Pelvic Pain/Penetration Disorder.
https://www.msdmanuals.com/professional/gynecology-and-obstetrics/female-sexual-function-and-dysfunction/genito-pelvic-pain-penetration-disorder

MSD Manual Professional Edition. Menopause.
https://www.msdmanuals.com/professional/gynecology-and-obstetrics/menopause/menopause

BMJ Best Practice. Evaluation of Dyspareunia.
https://bestpractice.bmj.com/topics/en-us/661

World Health Organization. Endometriosis.
https://www.who.int/news-room/fact-sheets/detail/endometriosis

National Institutes of Health / PubMed Central. Updated Cross-Sectional Prevalence Data for Lichen Sclerosus in the All of Us Database.
https://pmc.ncbi.nlm.nih.gov/articles/PMC12227238/

National Institutes of Health / PubMed Central. The Relationship Between Interstitial Cystitis and Endometriosis in Patients With Chronic Pelvic Pain.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015716/

It calls meetings at 2 a.m., makes you locate the bathroom before you even sit down, and interrupts your laugh, your cough, your walk, your sleep, and your confidence.

And somehow, women are expected to accept this like it is a normal promotion package for aging.

Use a panty liner. Cross your legs. Drink less water. Avoid the trampoline. Hope intimacy does not trigger another UTI. Pretend waking up all night is normal.

No.

Maybe your bladder has become unpredictable. Maybe intimacy has become uncomfortable. Maybe you are waking up at night, dealing with recurrent UTIs, or feeling dry, irritated, fragile, tight, and quietly embarrassed by symptoms no one properly prepared you for.

You are not falling apart. You may simply be living in a body no one bothered to explain.

Maybe the problem is not that you are weak, dramatic, or aging badly. Maybe the problem is that estrogen loss can affect your body in ways no one prepared you for, and then you are expected to just handle it: the hot flashes, the sleep disruption, the bladder changes, the painful intimacy, the recurrent UTIs, and the discomfort.

Estrogen loss can affect the vagina, vulva, urethra, bladder, anal sphincter, vaginal and urinary microbiome, and far more than most women are ever taught.

This guide is about what you can actually do next: what to track, what to ask, how to know when estrogen loss may be part of the problem, when pelvic floor therapy or devices may help, and when it is time to ask for a deeper evaluation.

You are not trying to diagnose yourself. You are trying to not present with symptoms that sound “vague” when they are actually connected. Clear language helps your clinician see the pattern, and a better pattern leads to better care.

Start Here: Name What Is Happening

Before the best solution is offered to you and chosen, you have to admit and recognize that the symptoms are impacting your quality of life and you would like help.

For paid subscribers, the rest of this guide gets into the real plan: what to track, what to ask, where estrogen fits, when pelvic floor therapy matters, what non-device strategies may help, and which bladder-control technologies are worth knowing about.

Because your bladder does not get to hijack your sleep, boss around your workouts, interrupt your intimacy, or steal your confidence without a fight.

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Read more

And sadly, most women are still quietly managing urinary leakage instead of openly treating it.

They buy pads or carry extra underwear. They avoid jumping, laughing too hard, long car rides, certain workouts, certain outfits, and sometimes even intimacy. They learn where the bathrooms are before they ever relax in a room.

And then there is the nighttime version.

You wake up at 2:13 in the morning because your bladder has decided, once again, that this is an emergency. You stumble to the bathroom half-asleep, crawl back into bed annoyed but hopeful, and then lie there wide awake calculating how many hours you have left before the alarm goes off.

Maybe you finally fall asleep, only to wake up again an hour later with the same urge.

I know this feeling. It happened to me, and the next day I felt awful, like a hangover without the fun of the party.

At some point, it can feel like your bladder has become an attention-seeking, soul-sucking part of your body that only wants something from you in the middle of the night. Conveniently quiet during the day. Fully dramatic at 2 a.m.

The problem is that women are so used to adapting that even a bladder running a nightly hostage situation can start to feel “normal.”

Even if crazy bladder syndrome is common it does not mean it is inevitable. Common does not mean harmless. And common definitely does not mean you should be handed a panty liner instead of an explanation, and a solution!

Urinary leakage, urgency, nighttime bathroom trips, and recurrent UTIs after menopause deserve a better answer than “just live with it” or “it’s normal after having children” or “most women develop urinary problems as a consequence of aging.”

One of the biggest missing pieces in this discussion is estrogen.

Most women are taught to connect estrogen with periods, fertility, hot flashes, or maybe breast cancer fear. Very few are taught that estrogen also rules and controls their bladder, urethra, vaginal tissues, pelvic floor support, and ultimately determines the quality of urinary health and comfort.

So if your bladder has started running your life after menopause, please DON’T resort to asking yourself:

“What pad should I buy?”

You SHOULD be asking yourself: “What changed in my body, and what can I do about it?”

Nocturia Is Not Just “Getting Older”

Let’s pause on the nighttime bathroom trips for a moment, because waking up to urinate has been normalized to the point that many women barely mention it.

The medical term is nocturia, which means waking up at night because you need to urinate.

One trip may be annoying, especially if it interrupts your sleep. Two, three, four, or five trips can wreck your sleep, your mood, your patience, your energy, your focus, and your ability to function the next day.

And yet women will say it like it is nothing:

“Oh, I just wake up to pee a few times.”

A few times?

That is not a cute little aging quirk! That is your bladder interrupting your sleep architecture and stealing tomorrow’s energy before the day even begins.

If your bladder is waking you up repeatedly, please stop treating that as normal background noise. It is information and it deserves attention.

Statistics Are Impressive, and They Do Not Lie!

Urinary incontinence is not rare.

Almost half of women experience it at some point in life, and research commonly reports that anywhere from about 25% to 45% of women experience some form of urinary incontinence, depending on age, definition, and study population.

This is also a problem that is hugely underreported.

Women rationalize it. They minimize it. They tell themselves it only happens with physical exertion, only when they are very sick and coughing or sneezing, when they are laughing too hard, jumping, or waiting too long.

Women tell themselves they accidentally leak urine and lose control because they had children. They tell themselves it is because they are aging. They tell themselves a little story about how their mother had it, their grandmother had it, and maybe this is simply what happens to women.

No.

That kind of thinking is exactly how women end up adapting their entire lives around a symptom that deserves prompt attention and a viable solution.

Leaking urine and wearing a pad to avoid needing to change your clothes after an accident can leave women feeling embarrassed, ashamed, and quietly defeated.

There is a stigma attached to urinary leakage, and many women have probably heard some version of this from their mothers, grandmothers, friends, or even clinicians:

You are a woman.

You had children.

You are aging.

This is what happens.

Just handle it.

And women do handle it.

The evidence is in the number of pads and adult diapers being sold as women age and quietly suffer.

Pads Are Not the Same as Solutions

Pads and protective underwear can be helpful. A woman should never feel ashamed for using what she needs to get through the day.

But let us be honest about what is happening.

A pad may protect your clothes. It does not explain why you are leaking. A diaper may help you leave the house. It does not restore your bladder control.

According to Yahoo Finance, the global adult diaper market was projected at $20.9 billion in 2025 and is expected to reach $41.4 billion by 2035. The explanation is not mysterious: an aging postmenopausal population, increasing mobility impairment due to osteoarthritis and other chronic medical conditions due to aging and on top of that there is a growing acceptance of adult hygiene products among healthcare professionals, home caregivers and ultimately the women themselves.

In other words, the world is becoming very good at helping women contain the problem, and women are okay with simply using diapers.

This article has no intention of shaming any woman for using a pad, a liner, or for using protective underwear.

I would like my readers to start asking why so many women are offered containment before they are offered a real explanation and an effective therapeutic cure.

And for those of you who are not quite ready to embrace diapers as the grand finale of womanhood, please keep reading.

There are solutions. Do they require commitment, time, effort, and sometimes money? Yes. Are they still worth knowing about? Absolutely.

Do all women know about them?

No.

And that is the problem.

In the paid companion: I show you how to stop guessing and start tracking the actual pattern: urgency, frequency, nighttime urination, leakage triggers, recurrent UTIs, and whether vaginal dryness or painful intimacy is happening at the same time. Because “my bladder is annoying” is easy to dismiss, but a clear pattern is much harder to ignore.

Paid subscribers also get access to detailed information on some of the best devices and technologies currently available to help treat urinary symptoms related to aging, menopause, pelvic floor weakness, and bladder changes, including what they are designed to do and what to ask before trying them.

First, Know What Kind of Leakage You Have

Knowing exactly what type of incontinence you may have matters because the treatment solution may need to be different.

If you leak urine when you cough, sneeze, laugh, run, jump, lift, exercise, get out of the car, bend down, or move a certain way, that is usually called stress urinary incontinence. It is not limited to intense workouts. It can happen during ordinary daily activities.

If you leak because you suddenly feel an intense, almost impossible-to-control urge to urinate and cannot make it to the bathroom in time, that is usually called urge incontinence.

If you have both, that is often called mixed incontinence.

And if you always need to know where the bathroom is, wake up one or multiple times at night, urinate more than eight times a day, or feel like your bladder is sending urgent signals too often, you may be dealing with symptoms of overactive bladder.

Overactive bladder is the polite medical phrase for what I call “crazy bladder” syndrome.

Because the truth is that your bladder has gone absolutely crazy, and it does that because of aging without estrogen!

If you are under 40, have regular predictable periods, and started leaking after pregnancy or childbirth, then pelvic floor weakness, muscle tears, or nerve injury may be the obvious place to look.

But if you are in perimenopause, menopause, or postmenopause, estrogen deficiency is the key player in this situation. Your bladder, urethra, vagina, and pelvic floor support system are not separate departments. They are connected, and they change as hormones change.

So no, the answer is not always “you had kids” or “you are aging.”

The better question is: “What changed, when did it change, and what needs support now?”

Overactive bladder describes uncontrolled, involuntary bladder contractions that can create a sudden, intense, and sometimes impossible-to-control urge to use the bathroom. The pressure can rise quickly, and sometimes the urethral sphincter simply cannot hold it in. It happens whether your bladder is almost empty, partially or totally full.

That is why urine can rush out with no warning.

That is why you may leak on the way to the bathroom.

That is why a bladder that used to mind its business, and was under your control, can suddenly feel like it is actually running the show and controlling your entire schedule.

Stress Leakage Is Not the Same as Urgency

Stress leakage, urge leakage, mixed incontinence, recurrent UTIs, overactive bladder, pelvic floor weakness, and estrogen deficiency are not all the same problem.

And they should not all be treated with the same treatment solution, but what women should understand clearly is that estrogen impacts pelvic floor strength, bladder wall health, vaginal and urinary microbiome and acts like a common denominator.

That is why estrogen therapy could help spectacularly alleviate all types of incontinence!

Yes it is true that stress incontinence is often connected to weakness or poor support in the pelvic floor, which is the group of muscles and connective tissues that support the bladder, urethra, vagina, uterus, and rectum.

It is also true that pregnancy and childbirth can affect these muscles. Aging can affect them. Menopause can affect them. Trauma, tearing, nerve injury, and muscle damage can affect them too.

This is why “just do Kegels” is often incomplete advice and likely not going to be effective.

Some women do not know how to identify the right muscles. Some are doing the exercises incorrectly. Some have muscles that are weak. Some have muscles that are too tight. Some have nerve or tissue damage that makes it hard to activate the pelvic floor properly.

So yes, pelvic floor strengthening can be extremely helpful.

But the real question is not simply:

“Are you doing Kegels?”

The better question is:

Do you know what type of urinary problem you have, and are you treating the actual cause?

Because if the cause is estrogen deficiency, pelvic floor weakness, overactive bladder, recurrent UTIs, medication effects, neurological disease, bladder irritation, or a combination, the solution may need to be more thoughtful than a liner and a shrug.

In the paid companion: I go deeper into pelvic floor therapy, why Kegels are not always enough, and when guided tools, electrical stimulation, or device-based technology may be worth discussing. Because if your pelvic floor muscles are weak, injured, poorly coordinated, or impossible to identify, “just squeeze” is not a serious plan.

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The Missing Piece: Estrogen and the Bladder

Now let us talk about the elephant in the room.

Estrogen.

Most women are told about estrogen only in the context of hot flashes, periods, fertility, menopause symptoms, or fear. They are not taught nearly enough about what estrogen does for the urinary tract.

I want to talk about estrogen because when it comes to uncontrolled urgency, frequency, nighttime urination, recurrent UTIs, and the bladder going completely bonkers after menopause, estrogen deficiency should not be treated like an irrelevant side note.

It may be one of the most important solutions.

Your bladder is not just a storage tank.

It is living tissue.

In order for your bladder to work well and not go crazy on you, it needs two things:

1. Flexibility

2. A healthy lining

Your bladder works like a balloon, except it does not fill with air. It fills with urine coming from the kidneys, and it stores that urine until you are ready to empty it on your terms.

The Bladder Lining Matters Too

Estrogen also helps maintain the integrity of the bladder lining, called the urothelium.

That lining matters because urine is not just water. It contains waste products your body is trying to eliminate. The bladder lining is supposed to protect the deeper bladder wall and nerve endings from irritation.

How important is it that your bladder lining does a good job protecting the bladder wall from irritating waste products? VERY!

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When estrogen declines, the bladder lining may become thinner and more vulnerable. If that protective lining becomes compromised, the bladder wall and nerve endings may become more irritated, more reactive, and more unpredictable.

You guessed it!

More urgency.

More frequency.

More random contractions.

More leakage.

We talk about leaky gut all the time.

Some people talk about leaky blood vessels.

But almost nobody talks about what happens when the bladder lining becomes more vulnerable after estrogen loss, nobody talks about leaky bladder syndrome.

That needs to change.

I am not saying estrogen is the only factor. There are other possible causes of overactive bladder and urinary leakage, including urinary tract infections, diabetes, kidney stones, neurological conditions, bladder irritants like caffeine or alcohol, certain medications, weakened pelvic floor muscles, aging, cognitive decline, and sometimes causes we do not fully identify.

But when bladder symptoms appear or worsen around perimenopause or after menopause, estrogen deserves to be part of the conversation!

Not ignored.

Not dismissed.

Not treated like some dangerous word women are supposed to be afraid to say.

Timing Matters

The longer you live without estrogen support, the more significant tissue changes may become. That does not mean every woman has the same symptoms, needs the same treatment, or has one magic solution waiting on the shelf.

But it does mean timing matters.

If the bladder wall has been losing flexibility for years, the lining has been thinning, and the nerve endings have been repeatedly irritated, the bladder can begin to develop a life of its own.

That is when the “crazy bladder” starts acting like it owns you.

This is why I do not want women waiting until urinary symptoms are severe before asking for help. You do not have to tolerate a bladder gone bananas any more than you have to tolerate hot flashes without asking what can be done.

Hot flashes are common. Leaking urine is common. Waking up at night to urinate is common.

But common does not mean inevitable, harmless, or untreatable.

What Can You Ask Your Clinician?

The first step is to name the pattern clearly.

Are you leaking with coughing, sneezing, laughing, exercise, or movement?

Are you leaking because the urge hits suddenly and you cannot make it in time?

Are you waking up at night?

Are you getting recurrent UTIs?

Are symptoms worse after intimacy?

Are you also dealing with vaginal dryness, irritation, painful sex, or discomfort?

These details matter because they help your clinician understand whether this may involve stress incontinence, urge incontinence, overactive bladder, pelvic floor dysfunction, estrogen deficiency, recurrent infections, GSM, or a combination.

You can also ask:

“Do I have stress incontinence, urge incontinence, mixed incontinence, or overactive bladder?”

“Could estrogen loss be contributing to my bladder symptoms?”

“Should I be evaluated for GSM?”

“Would vaginal estrogen, systemic estrogen, or both be appropriate for my symptoms and medical history?”

“Do I need a pelvic floor evaluation?”

“Should I see a gynecologist, urogynecologist, menopause-trained clinician, or pelvic floor physical therapist?”

These are not embarrassing questions.

They are quality-of-life questions.

In the paid companion: I walk through the questions women should be asking about vaginal estrogen, systemic estrogen, pelvic floor evaluation, non-device urinary support, recurrent UTI prevention, and device-based technologies. In other words, the part where we stop whispering, stop guessing, and start building an actual plan.

The Healthcare System Is Not Always Built for This

Here is another frustrating truth: your doctor cannot help if you never ask, but even when you do, not every clinician is adequately trained in urinary incontinence, menopause-related bladder changes, or the connection between estrogen, the urethra, the bladder, and the pelvic floor.

That does not make them bad doctors. It means this issue has been under-discussed, under-taught, and under-prioritized for far too long.

Many women bring up leakage and are told to wear a pad, lose weight, do Kegels, drink less water, or consider surgery. Sometimes those suggestions are appropriate. Sometimes they are incomplete. And sometimes they skip the most important question:

Why is this happening to this woman, in this body, at this stage of life?

That is the question that leads to an actual solution. That is the question leading to a cure.

This is also why women may need to ask for the right referral. A gynecologist, urogynecologist, menopause-trained clinician, or pelvic floor physical therapist may be better equipped to evaluate the full picture, especially when urinary symptoms are happening alongside vaginal dryness, painful intimacy, recurrent UTIs, pelvic floor weakness, or other menopause-related changes.

Surgery may be necessary for some women, and there are absolutely situations where it is appropriate.

But surgery should not be the first solution or the only solution offered without understanding the type of incontinence a woman has, the actual strength of her pelvic floor, the role of estrogen deficiency plays in her case and whether urge symptoms or overactive bladder are part of the picture.

If urge incontinence or overactive bladder is driving symptoms, surgery for stress incontinence will not address the whole problem.

This is why an accurate diagnosis matters.

This is why the type of leakage matters.

This is why women need more than a five-minute dismissal and a pad recommendation, or referral for surgery!

We Need to Stop the Shame Stigma

Many women stay silent because they have been trained to believe urinary leakage is the price of having children, aging, or being female.

I disagree.

A bladder that controls your sleep, exercise, confidence, intimacy, clothing choices, travel plans, and daily schedule deserves attention before it becomes the boss of your life.

The answer is not always one thing. Sometimes it is estrogen support, pelvic floor strengthening, bladder training, recurrent UTI prevention, technology, or a thoughtful combination.

If anyone ever told you leaking urine is just part of being a woman, please say “no it isn’t, not for me” and say NO to normalizing urinary incontinence.

Leaking urine may be common. Hot flashes are common too. That does not mean women should be expected to tolerate either one without answers.

Share this with a woman who may need to hear this today:

“It is happening because you are a woman” is not an explanation or a reason to accept what is happening as “normal.”

Disclaimer:

This Substack is here to educate, inform, and advocate. It is not a substitute for individualized medical care. Nothing in this publication should be taken as personal medical advice, diagnosis, or treatment, and reading or subscribing to this content does not create a physician-patient relationship with Dr. Mirela Cernaianu.

Hormone therapy and menopause care should be guided by a qualified clinician who knows your medical history, symptoms, goals, and risk factors. Always speak with your own healthcare professional before starting, stopping, or changing any medication, hormone regimen, supplement, or treatment plan.

Do not use this publication for urgent or emergency medical concerns. If you think you may be having a medical emergency, call 911 or seek immediate care.

Please do not post or send personal health information through comments or messages on this platform.

Sources & Further Reading

The Menopause Society. Genitourinary Syndrome of Menopause.
https://menopause.org/patient-education/menonotes

The Menopause Society / North American Menopause Society. The 2020 Genitourinary Syndrome of Menopause Position Statement.
https://www.isswsh.org/images/content/2020-NAMS-GSM-Paper.pdf

American Urological Association, SUFU, and AUGS. Genitourinary Syndrome of Menopause Guideline, 2025.
https://www.auanet.org/guidelines-and-quality/guidelines/genitourinary-syndrome-of-menopause

American College of Obstetricians and Gynecologists. UTIs After Menopause: Why They’re Common and What to Do About Them.
https://www.acog.org/womens-health/experts-and-stories/the-latest/utis-after-menopause-why-theyre-common-and-what-to-do-about-them

American College of Obstetricians and Gynecologists. Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-Dependent Breast Cancer.
https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2021/12/treatment-of-urogenital-symptoms-in-individuals-with-a-history-of-estrogen-dependent-breast-cancer

Johns Hopkins Medicine. Genitourinary Syndrome of Menopause.
https://www.hopkinsmedicine.org/health/expert-qa/genitourinary-syndrome-of-menopause

NCBI Bookshelf / StatPearls. Genitourinary Syndrome of Menopause.
https://www.ncbi.nlm.nih.gov/books/NBK559297/

Centers for Disease Control and Prevention. Sepsis.
https://www.cdc.gov/sepsis/index.html

Merck Manual Professional Version. Introduction to Urinary Tract Infections.
https://www.merckmanuals.com/professional/infectious-diseases/urinary-tract-infections/introduction-to-urinary-tract-infections

Cleveland Clinic. Urosepsis: Causes, Symptoms, Diagnosis & Treatment.
https://my.clevelandclinic.org/health/diseases/25008-urosepsis

Scotland KB, Lo J, Grgic T, Lange D. Urosepsis and Urinary Tract Infections. Current Urology Reports. 2019.
https://pubmed.ncbi.nlm.nih.gov/30868426/

Tandogdu Z, Wagenlehner FME. Global Epidemiology of Urinary Tract Infections. Current Opinion in Infectious Diseases. 2016.
https://pubmed.ncbi.nlm.nih.gov/26694621/

National Institute of Diabetes and Digestive and Kidney Diseases. Definition & Facts for Bladder Control Problems (Urinary Incontinence).
https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems/definition-facts

JAMA Internal Medicine. Urinary Incontinence in US Women.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/486453

Milsom I, Gyhagen M. The Prevalence of Urinary Incontinence. Climacteric. 2019.
https://www.tandfonline.com/doi/pdf/10.1080/13697137.2018.1543263

Yahoo Finance / PRNewswire. Adult Diapers Market to Reach USD 41.4 Billion by 2035.
https://finance.yahoo.com/news/adult-diapers-market-reach-usd-162800437.html

Mayo Clinic. Overactive Bladder: Symptoms and Causes.
https://www.mayoclinic.org/diseases-conditions/overactive-bladder/symptoms-causes/syc-20355715

Cleveland Clinic. Nocturia: Causes, Symptoms, Diagnosis & Treatment.
https://my.clevelandclinic.org/health/diseases/14510-nocturia

As a physician who treats women almost every day, I hear the same fear repeated in different ways: fear of estrogen, fear of breast cancer, fear of hormone therapy, fear of aging badly, and fear of making the wrong decision.

Sometimes I am honestly flabbergasted by what women have been told, what they were not told, and how much context was left out before they were expected to make serious decisions about their health. Some of this comes from doctors who simply do not have enough time. Some of it comes from lack of menopause training. Some of it comes from outdated information, bad information, or limiting beliefs created by years of WHI indoctrination. And some of it comes from clinicians who are excellent in their own specialty, but were never trained to understand menopause as a whole-body biological event.

This is why The Hormone Therapy Advocate exists. Women do not need more fear. They need the whole story.

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What Women Were Never Told About Estrogen

Estrogen did not suddenly appear when a woman wanted to have a baby, and it does not become irrelevant when reproduction is over. From early development through adulthood, estrogen has been influencing the brain, bones, blood vessels, skin, urinary and vaginal tissues, joints, muscles, mood, sleep, cognition, and cardiovascular system for decades.

So when estrogen declines during menopause, it should not surprise anyone that a woman may feel the change broadly, not in one isolated symptom.

And yet, many women were never taught what estrogen was doing for their bodies all along.

They heard about fear. They heard about risk. They heard about breast cancer. But they heard much less about what happens when estrogen disappears.

That missing information matters.

Because women are often expected to make major decisions about hormone therapy without first understanding what estrogen has been contributing to and controlling for decades.

A Mammogram Is Not a Breast Health Plan

We also talked about breast cancer screening and why women deserve more than a reminder postcard.

A mammogram can be a valuable tool. It can detect breast cancer early, and early detection matters. But a mammogram should never be mistaken for the whole breast health plan.

Women deserve to understand their personal risk, breast density, family history, hormone history, symptoms, screening options, callbacks, false positives, overdiagnosis, and what happens next if something is found.

They deserve facts, options, and a plan. Not panic, avoidance or blind obedience.

A thoughtful breast surveillance plan.

Because women deserve more than a mammogram order and a “see you next year.”

The Breast Screening Questions Women Should Have Been Given Years Ago

For paid subscribers, we created a practical breast screening guide with questions women can bring to their annual exam, mammogram appointment, callback, or hormone therapy follow-up.

The guide was designed to help women think through dense breasts, mammogram callbacks, BI-RADS categories, screening tools, hormone therapy questions, overdiagnosis, breast cancer risk factors, and the Top 10 Protectors to Decrease Breast Cancer Risk.

The goal was not to make women afraid of screening.

The goal was to help women walk into the appointment informed.

Because “just get your mammogram” is not enough of a plan.

Your Heart Is More Than a Cholesterol Number

Then we turned to heart health, because this is where the fear imbalance becomes impossible to ignore.

Heart disease kills far more women than breast cancer, yet the public health panic around estrogen and breast cancer is much louder than the discussion about menopause, estrogen loss, hot flashes, inflammation, sleep disruption, blood pressure, plaque, and cardiovascular risk.

Too often, a woman’s heart health is reduced to cholesterol.

Your cholesterol is high.

Take this medication.

See you next year!

Cholesterol matters, but it is not the whole cardiovascular picture. Women need to understand what is damaging the blood vessel wall, whether plaque is already present, whether inflammation is involved, whether hot flashes and poor sleep are affecting blood pressure and stress hormones, and whether estrogen deficiency is being considered at all.

Menopause is not a side note in a woman’s heart-health history.

It is a major biological turning point.

The Common Thread: Stop Practicing Shortcut Medicine on Women

The common thread this month is simple: women deserve the full picture before they are told what to fear, what to tolerate, what to screen, or what medication to take.

They deserve to understand estrogen before being told only to fear it, breast screening before being handed a mammogram order, heart disease risk before being reduced to a cholesterol number, and menopause before being told their symptoms are just part of aging.

If the system does not always make time for that level of explanation, then women need to become better informed before they walk into the room.

That is not rebellion. That is self-preservation.

Looking Ahead

In June, we will continue this work with topics that affect women’s lives in very real ways, including vaginal health in menopause and why it matters far beyond intimacy. We will talk about how vaginal and urinary changes can affect daily comfort, confidence, sleep, relationships, and quality of life. We will also begin looking at how menopause and hormone changes affect women professionally, from energy and focus to confidence, leadership, irritability, burnout, and career longevity.

If one of this month’s articles helped you see your body differently, please share it with a woman who may need it.

She may be tired, scared, blaming herself, or being told everything is “normal” while her body is clearly asking for help. Women deserve better than dismissal. They deserve information, context, and clarity. Please share and let’s build a movement together!

Share The Hormone Therapy Advocate

If you do not have the full picture, how can you make a truly informed decision?

This is how women get limited medicine. They are handed a lab result, given a prescription, and sent home believing they had a complete cardiovascular evaluation when, in reality, menopause was barely mentioned, estrogen deficiency was ignored, hot flashes were dismissed, inflammation was not investigated, and no one asked whether plaque is already present.

That is not comprehensive heart-health care. That is a shortcut.

Your cholesterol is high. Your blood pressure is high. Take this. Come back next year.

But what if heart disease risk after menopause is much bigger than cholesterol? What if estrogen deficiency matters? What if hot flashes matter? What if inflammation matters? What if sleep matters? What if body fat percentage, insulin resistance, family history, and actual plaque matter just as much as the lipid panel?

And what if the real issue is not simply, “How low can we get your cholesterol?” but rather, “What is actually happening inside your blood vessels?”

Start With the Real Risk

Heart disease is the number one killer of women. That should be said clearly and often.

Women are trained to fear breast cancer, and breast cancer is serious. But heart disease kills far more women every year, and the risk increases as women age and move through menopause into the decades beyond.

That means cardiovascular surveillance should not simply begin and end with cholesterol. A woman deserves to know her real risk, not a rushed interpretation of one number.

Start by asking your clinician:

Read more

Last week, I talked about breast cancer screening and why women deserve a better health recommendation than “just get your mammogram.”

This week, I want to continue from a different angle.

If women are being taught to fear breast cancer, hormone therapy, and estrogen, then we need to ask something very important:

Why are we not equally afraid of heart disease?

Heart disease is the number one killer of women in the United States. According to the CDC, heart disease was responsible for 304,970 deaths among women in 2023. Breast cancer, by comparison, caused 42,213 deaths among females in 2023.

Please think about that.

We are talking about more than seven times as many women dying from heart disease as from breast cancer.

And yet, what gets the fear, the pink ribbons, the campaigns, the panic, the emotional messaging, and the repeated “be careful with estrogen” warning?

Breast cancer.

But where is the same level of urgency around heart disease after menopause? Where is the public focus on estrogen loss and the heart? Where is the discussion of hot flashes, blood pressure, sleep disruption, inflammation, vascular aging, and what happens to a woman’s cardiovascular system when she loses her estrogen?

Too often, a woman’s heart health is reduced to cholesterol.

Your cholesterol is high. Take this medication. See you next year!

Don’t you think women deserve more than that? I certainly do.

The Heart Scare Around Hormone Therapy

In 2002, women and doctors all over the world were told that hormone therapy after menopause increased the risk of cardiovascular events, including heart attack and stroke.

And here is what I want women to understand.

The study was not completely wrong about that specific hormone therapy.

The hormone therapy used in the Women’s Health Initiative study was Prempro, a pill that combined conjugated equine estrogens derived from pregnant mare urine with a synthetic progestin called medroxyprogesterone acetate.

That specific combination, in that specific oral form, was not good for the heart.

That is what we should have learned.

Instead, the entire world was told that estrogen is bad. Doctors and women were told that all hormone therapy for menopause is dangerous.

Obviously, that wasn’t true because it only applied to one type of hormone therapy: oral synthetic estrogen progestin combination or oral equine estrogen alone.

And that is where the truth stopped.

That is not a small distinction. That is the whole point.

The problem is that hormone therapy was treated as if it were one single thing, when the truth is much more specific. The WHI studied a particular oral combination, in a particular form, in a particular population of women. That should have led to a more intelligent conversation about the type of hormone therapy, the route, the dose, the age of the woman, her medical history, and her personal risk. Instead, women were handed one frightening conclusion: estrogen is bad and they were left with one oversimplified message:

“Estrogen hormone therapy for menopause is dangerous. Be afraid!”

Why the Route of Estrogen Matters

Here is another truth women deserve to know.

Any oral estrogen can increase the risk of thrombotic complications because it goes through the liver first. This is called the first-pass liver effect.

When estrogen goes through the liver, it can stimulate the production of clotting factors. That is one reason oral estrogen can increase the risk of blood clots, stroke, or other cardiovascular complications in certain women.

But transdermal estrogen is different.

Estrogen delivered through the skin, or vaginal such as a patch, cream, gel, pellet, or vaginal cream and inserts , bypasses the first-pass liver effect. It does not interact with the liver in the same way.

This is not a tiny detail.

This is one of the most important differences in the entire hormone therapy conversation.

And yet, how many women are told this clearly?

How many women are told, “Let’s talk about the route, the dose, the timing, the form, and your personal risk”?

Instead, many women are simply told:

No estrogen for you!. Too dangerous. That is not informed consent. That is fear-based poor quality medicine!

The Biggest Risk Factor No One Wants to Name

When a woman enters menopause and spends the rest of her life in post-menopause, one of the biggest changes in her body is the loss of estrogen.

Not a tiny dip.

Not a minor inconvenience.

A massive biological change.

Estrogen affects blood vessels. It affects inflammation. It affects blood pressure. It affects metabolic health. It affects insulin sensitivity. It affects fat distribution. It affects sleep. It affects the brain, the bones, the skin, the urinary tract, and the heart.

So why is estrogen so often ignored in the cardiovascular conversation?

How many cardiologists ask women:

Have you gone through menopause?

When did your periods stop?

Are you having hot flashes?

Are you sleeping?

Have you had your estrogen checked?

What is your FSH?

Are you using hormone therapy?

If so, what kind?

What route?

What dose?

How are you being monitored?

The answer, for many women, is probably almost none.

What is worse, many cardiologists are of the old school and part of the generation indoctrinated by the WHI findings, and they firmly believe that all hormone therapy for menopause is dangerous for the heart and increases cardiovascular risk. The same cardiologists ignore recent evidence of how damaging hot flashes can be for a woman’s heart, health, and cardiovascular risk. They ignore the extraordinary beneficial impact estrogen has on a woman’s lipid profile, and they don’t take into consideration the terrible consequences of menopause stress on a woman’s cardiac and vascular well-being.

And yet, stress is the top leading cause of cardiac disease and vascular dysfunction leading to plaque. Is menopause a stressor? Yes! A huge one.

When a woman goes through menopause, her entire biological profile will be altered by the loss of estrogen.

The hot flashes, the sleepless nights, the anxiety, depression, and irritability, the bad behavioral habits around food cravings, alcohol use, a much more sedentary lifestyle, and the fatigue are all factors that greatly impact a woman’s heart and vascular health.

All these things matter, and they matter to a great extent, but your cardiologist, your primary care doctor, family doctor, or internal medicine doctor will all ignore menopause. Through no fault of their own, because they have not received any training in menopause.

Hot Flashes Are Not Just Annoying

Women are often told to power through hot flashes because they are “natural” and will eventually go away.

But high blood pressure also becomes more common as we age, and no serious doctor would say, “Just ignore it. It is part of aging.” A racing heart, repeated sleep disruption, night sweats, anxiety surges, and blood vessel changes deserve more than a dismissive shrug.

I strongly disagree with the idea that women should simply suffer through hot flashes, and more and more research supports how dangerous hot flashes are for a woman’s heart and vascular health.

A hot flash is a loud signal of estrogen deficiency. When it happens repeatedly, night after night, it can affect cardiovascular health through surges in heart rate, blood pressure changes, blood vessel expansion and constriction, anxiety, poor sleep, inflammation, and the lifestyle choices that follow exhaustion.

A woman who cannot sleep is not going to exercise well. She is more likely to crave sugar, processed foods, alcohol, or whatever gives her temporary relief.

Waking up drenched night after night is not “just menopause, or part of the aging natural process!”

It is the body asking for help.

In the paid companion, I explain why hot flashes, night sweats, poor sleep, anxiety surges, and blood pressure changes should be part of a woman’s heart-health evaluation after menopause, along with the questions women can bring to their clinician.

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Cholesterol Is Not the Whole Story

I am not saying cholesterol does not matter.

It matters.

But cholesterol is not the whole cardiovascular picture.

Cholesterol is a life-giving molecule. Without cholesterol, your body cannot make estrogen, progesterone, testosterone, cortisol, vitamin D, or bile acids. Your nervous system depends on cholesterol. Your cell membranes depend on cholesterol.

So when the entire appointment becomes focused on “lower the cholesterol,” women need to pause and ask what else is being missed.

Do I have plaque?

Do I have inflammation?

What is damaging my blood vessels?

What is my blood pressure doing?

What is my fasting insulin?

What is my body fat percentage?

Am I sleeping?

Am I in menopause?

Am I estrogen deficient?

Are hot flashes affecting my cardiovascular system?

Do I have a family history?

Is my doctor looking at me as a whole woman, or just at one number on a lab report?

Lowering cholesterol may be appropriate and life-saving for some people. I have prescribed cholesterol-lowering medication when it made sense.

But the decision should not be based on fear, bullying, or one isolated number.

It should be based on the full picture.

Your Heart Is More Than a Cholesterol Number

Cholesterol belongs in a cardiovascular evaluation after menopause, but it should never crowd out everything else that matters.

To understand why, women need to understand how plaque actually starts.

Plaque does not begin simply because cholesterol exists in the bloodstream. Cholesterol is part of the process, but the process usually begins with damage to the lining of the blood vessels.

In a simplified way, plaque formation happens in five stages:

1. The inner lining of the blood vessel becomes damaged by factors such as inflammation, high blood pressure, smoking, diabetes, stress, toxins, or metabolic dysfunction.

2. The blood vessel wall becomes more permeable, allowing LDL particles to enter the vessel wall.

3. Inflammation oxidizes LDL, turning it into a more damaging form of cholesterol.

4. The immune system responds, and immune cells consume the oxidized LDL, becoming foam cells that create early fatty streaks.

5. Over time, more cells and proteins accumulate, forming plaque that can narrow the artery, stiffen the blood vessel, or eventually rupture and trigger a clot.

So when the entire appointment becomes about lowering cholesterol, we may be skipping over the real root issue: what is damaging the blood vessel wall in the first place?

A woman’s actual cardiovascular risk includes much more than cholesterol. It includes estrogen deficiency, hot flashes, sleep disruption, blood pressure, inflammation, insulin resistance, body composition, stress, family history, smoking, alcohol, exercise, and whether plaque is already present and how much plaque a woman already has.

Women are much more than cholesterol numbers to be lowered with medication, mammograms to be ordered annually, or hot flashes to be tolerated.

Women are whole human beings whose bodies change dramatically after menopause. And if heart disease kills far more women than breast cancer, then it is time we start making a much bigger fuss about heart health.

In the paid companion, I walk through this plaque process in more detail, including the advanced cholesterol markers, inflammatory markers, calcium score discussion, and questions women can bring to their doctor before accepting a heart-health plan based on cholesterol alone.

Subscribe now

Before You Let Fear Decide for You

If you are afraid of hormone therapy because you were told it causes heart attacks and strokes, please do not stop at that headline. Ask what kind of hormone therapy we are talking about: oral or transdermal, synthetic progestin or bioidentical progesterone, started at what age, in what dose, with what medical history, and with what monitoring.

If you do not have the full picture, how can you make a truly informed decision?

The same is true for heart disease risk. If your doctor is only discussing cholesterol, blood pressure, weight, and medication, but not menopause, estrogen deficiency, hot flashes, sleep, inflammation, metabolic health, or plaque, then you are being asked to make decisions with partial information.

In the paid companion to this article, I created a menopause heart health guide with questions to ask your clinician about estrogen, FSH, hot flashes, cholesterol, inflammation, blood pressure, calcium score, plaque, and what should actually be part of cardiovascular surveillance after menopause.

Subscribe now

Disclaimer:

This Substack is here to educate, inform, and advocate. It is not a substitute for individualized medical care. Nothing in this publication should be taken as personal medical advice, diagnosis, or treatment, and reading or subscribing to this content does not create a physician-patient relationship with Dr. Mirela Cernaianu.

Hormone therapy and menopause care should be guided by a qualified clinician who knows your medical history, symptoms, goals, and risk factors. Always speak with your own healthcare professional before starting, stopping, or changing any medication, hormone regimen, supplement, or treatment plan.

Do not use this publication for urgent or emergency medical concerns. If you think you may be having a medical emergency, call 911 or seek immediate care.

Please do not post or send personal health information through comments or messages on this platform.

Sources and Further Reading

Centers for Disease Control and Prevention. About Women and Heart Disease.
https://www.cdc.gov/heart-disease/about/women-and-heart-disease.html

Centers for Disease Control and Prevention. Female Breast Cancer Mortality by State. https://www.cdc.gov/united-states-cancer-statistics/publications/female-breast-cancer-mortality.html

American Heart Association. Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000912

American Heart Association. The Connection Between Menopause and Cardiovascular Disease Risks.
https://www.heart.org/en/news/2023/02/20/the-connection-between-menopause-and-cardiovascular-disease-risks

Zhu D, Chung HF, Dobson AJ, et al. Menopausal Vasomotor Symptoms and Risk of Incident Cardiovascular Disease Events in SWAN. Journal of the American Heart Association.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955448/

National Heart, Lung, and Blood Institute. Hot Flashes Plus Migraines Ups Risk of Heart Disease and Stroke After Menopause.
https://www.nhlbi.nih.gov/news/2024/hot-flashes-plus-migraines-ups-risk-heart-disease-and-stroke-after-menopause

The Menopause Society. The Combination of Migraine and Persistent Hot Flashes Could Prove Deadly.
https://menopause.org/press-releases/the-combination-of-migraine-and-persistent-hot-flashes-could-prove-deadly

Thurston RC, et al. Vasomotor Symptoms and Their Links to Cardiovascular Disease Risk.
https://www.sciencedirect.com/science/article/pii/S2451965023000157

This guide is for women who want to approach breast cancer screening with more common sense, more logic, and less fear.

It is not meant to replace a medical consultation. It is meant to help you have a better one before your annual exam, before your next mammogram, or after an abnormal result when you feel scared and need to organize your thoughts.

Because the conversation should not end with, “Here is your mammogram order. See you next year!”

Women deserve to know what they are doing, why they are doing it, what the test can find, what it cannot find, what happens if the result is abnormal, and what other questions should be asked based on age, breast density, personal history, hormone therapy use, and overall health.

Breast cancer risk is a reality all women have to face as they enter menopause. I think of it in terms similar to the risk of a car accident when driving. You learned the rules for driving safely, you follow them, you pay attention to the road and other drivers, and you keep driving.

No woman dwells on the risk of a car accident the moment she gets behind the wheel to start her daily life.

But women have been told, encouraged, and conditioned to fear breast cancer as they age. Our bodies are changing once we enter menopause and lose estrogen. Our bodies change as we age.

Our risk for breast cancer goes up as we age to reach 12% or more by age 80. Our risk for breast cancer increases with hormone therapy for menopause, but using hormone therapy could also reduce the risk.

I believe the conversation about breast cancer should not end with the discussion around a mammogram. It should start there, with a breast cancer screening consultation dedicated in its entirety to assessing risk factors, and discussing daily strategies to mitigate or neutralize identified risks.

Read more

Last week, I talked about the fear surrounding estrogen and breast cancer.

This week, I want to continue that conversation by talking about breast cancer screening, because this topic becomes very important for any woman considering hormone therapy for menopause, already using hormone therapy, or simply trying to age with common sense, logic, and peace of mind.

Breast cancer screening is often reduced to one sentence:

“Just get your mammogram every year!”

“An annual mammogram could save your life!“

That sentence may sound responsible, but it is incomplete.

A mammogram can detect breast cancer early. That is valuable, and I am not telling women to ignore breast cancer screening. I am also not targeting mammograms as the enemy.

What I am saying is that there is much more to breast health surveillance than just doing a mammogram.

You might say, “Wait a minute. I thought doing an annual mammogram is all that is needed. What in God’s name is there to talk about?”

Well, there is a lot to talk about.

Breast Cancer Screening Is More Than a Mammogram

We should talk about the possible dangers of having an annual mammogram: cumulative radiation, overdiagnosis, abnormal findings, repeated follow-up testing, anxiety, fear, and the emotional trauma that creates a bad experience for many women who then become afraid of mammograms.

We should talk about alternative screening methods outside of mammograms, because this diagnostic tool has been around since the 1980s, and cancer detection has come a long way with viable alternative possibilities.

We should talk about how often women need a mammogram. Do women really need an annual mammogram from age 40 until 79? A totality of 40 mammograms?

And last, but not least, we should talk about true breast cancer screening because mammograms are not a screening tool!

Mammograms are an early, valuable diagnostic tool meant to catch breast cancer early, when it’s 99% curable. However, a screening test ideally would identify women at risk for breast cancer and women with breast pre-cancer lesions, none of which is accomplished by having an annual mammogram.

That is why, when we talk about breast cancer screening, we need to have a full conversation and not simply write an order for a mammogram and rest easy when the findings come back reassuring. Mammograms do not detect which women are truly at risk, and more so, will not detect 10% of breast cancers, perhaps even more, in women with dense breasts.

Share The Hormone Therapy Advocate

A Mammogram Is a Tool, Not the Whole Plan

A mammogram is designed to detect breast cancer once cancer is already present.

Hopefully, it detects it early. That matters. Early detection can save lives.

But a mammogram does not tell you why your breast tissue may be at risk. It does not tell you whether your hormones are balanced or not. It does not tell you whether inflammation, alcohol, poor sleep, metabolic dysfunction, endocrine disruptors, stress, or other exposures are contributing to your long-term breast cancer risk.

That is one of the biggest misunderstandings I see in women’s health! Many women have been conditioned to believe that if they get their mammogram every year, they have done what they need to do for breast cancer prevention.

But screening for early cancer is not the same thing as preventing cancer!

Screening looks for early disease or early tissue changes that are a prelude for serious disease, including cancer.

Prevention asks why disease develops, what may be increasing risk, and what can be changed before a diagnosis appears.

Women need to understand the difference between an actual medical consultation, where breast cancer risk will be assessed with a thorough, in-depth evaluation of risk factors, which requires time, versus your well-woman exam covered by your health insurance, where you simply get a breast exam and a mammogram order.

Even the Guidelines Are Not One Simple Sentence

Even inside conventional medicine, breast cancer screening recommendations are not as simple as “every woman, every year, forever.”

The U.S. Preventive Services Task Force recommends that women at average risk get screened with mammography every other year from ages 40 to 74. The American Cancer Society gives different guidance: women ages 40 to 44 should have the choice to begin annual mammograms, women ages 45 to 54 should get mammograms every year, and women 55 and older can switch to every two years or continue yearly screening.

So even respected medical organizations do not all say the exact same thing.

That should tell us something.

Women are different so risk is different. Breast tissue is different. A woman with dense breasts is not in the same situation as a woman without dense breasts. A woman with a strong family history is not in the same situation as a woman at average risk. A woman who uses hormone therapy for decades after menopause will be in a different risk category than a woman who chooses not to use any hormone therapy after menopause.

The better question is, “What is the right breast surveillance plan for you?”

Dense Breasts Matter for Two Reasons

Dense breast tissue is common, but many women do not understand what it means until they see it written on a mammogram report.

This does not mean women with dense breasts should panic. It means they should ask better questions.

Do I have dense breasts?

Does my breast density make my mammogram less sensitive?

Would ultrasound add useful information for me?

Would 3D mammography or MRI ever be appropriate based on my risk?

Should I have a thermogram instead?

These are good and valid questions. They are informed questions.

And women deserve clinicians who can answer them.

Want the practical question list?
In the paid companion to this article, I created a more detailed breast screening conversation guide with questions to ask or consider during a breast cancer screening consultation.

These questions can help you talk with your clinician about dense breasts, mammograms, ultrasound, MRI, callbacks, hormone therapy, family history, personal risk, and what kind of breast surveillance plan actually makes sense for you.

Subscribe now

Mammogram, Ultrasound, MRI, or Thermography?

Women often ask, “If not a mammogram, what else is there?”

There are other imaging techniques, but each has advantages and limitations.

Mammogram

A mammogram uses low-dose X-ray imaging to look for abnormalities in the breast.

It is the standard screening tool. It can detect breast cancer early, but it can be less sensitive in dense breasts and may lead to callbacks, false positives, overdiagnosis, and cumulative radiation exposure over decades.

Mammograms are painful and invasive. The woman has to undress and her breast is handled by a technician, who pulls on it to make it fit between 2 cold metal plates, and then presses on the top one to squeeze the breast tissue as much as possible for best viewing.

No matter how nice and apologetic the lady is, you probably still hate her for doing it. You are happy when done, and out of there!

Ultrasound

Breast ultrasound imaging uses sound waves.

A 2D ultrasound provides a flat, two-dimensional view of a slice of tissue and is often used to help determine whether an abnormality is solid or cystic.

A 3D ultrasound captures multiple two-dimensional images from different angles and reconstructs them into a more comprehensive view.

A 4D ultrasound adds real-time movement and can evaluate changing tissue, blood flow, and dynamic features over time.

A viable tool, and maybe a viable alternative in some specific circumstances, I believe women should at least know that ultrasound technology has advanced, especially when dense breasts make mammogram interpretation more challenging.

I believe breast ultrasound is definitely to be preferred over a mammogram in younger women with dense breasts, between the ages of 40 and 50.

MRI

Breast MRI does not use ionizing radiation and can be very sensitive.

But it is expensive, not always covered by insurance, can also be uncomfortable, and can lead to false positives. It is usually reserved for higher-risk women or specific diagnostic situations.

Thermography

Thermography appeals to many women because there is no radiation, no compression, and no one has to squeeze their breasts. I understand why women ask about it.

But I want to be clear: thermography should not be presented as a simple replacement for mammography. The FDA states that thermography should not be used in place of mammography for breast cancer screening or diagnosis.

But because thermography uses infrared to detect changes in blood flow and metabolic abnormalities in the breast tissues, it may provide useful information before a structural tumor is visible.

It is non-invasive and there is no risk of radiation. It is suitable for dense breasts, and the lack of standardization can be improved by dedicating funds to studying it and standardizing it.

At the same time, I believe we should pay attention to why women are asking for other options. They are asking because they are uncomfortable, concerned about radiation, frustrated by callbacks, dealing with dense breasts, or simply wanting a more complete conversation.

Rather than dismissing these concerns, we should discuss them.

That is how we build trust and understanding. This is how we improve the breast cancer screening process and maybe even breast cancer prevention.

What About Blood Testing?

There are many advances in this field, including tests that look at inherited breast cancer risk, cancer recurrence, or early cancer signals.

• Tumor markers like CEA, CA 15-3, or CA 27.29 - not used for early screening, more for monitoring of cancer recurrence once diagnosis is confirmed and the woman enters surveillance. It is simple, rather inexpensive testing that can be discussed with your doctor.

• The multi-cancer screening tests like the Galleri test are able to detect cell-free DNA and proteins circulating in the blood, identifying molecular signatures associated with a variety of cancers. It has some limitations for breast cancer, but this is the future - a simple blood test!

• For women with a history of breast cancer Signatera is a personalized circulating tumor DNA test specifically designed for monitoring patients who have already been diagnosed with cancer. It can detect if microscopic traces of cancer remain in the body after surgery or treatment, and can catch cancer relapse months before it shows up on traditional imaging like mammograms or MRIs. Because Signatera is custom-built based on the unique genetic mutations of a patient’s existing cancer, it does not work as a general population screening tool, but this kind of specific testing it at the forefront of early diagnosis, way before the cancer can solidify into a tumor.

• BRCA gene testing analyzes the BRCA1 and BRCA2 genes to identify genetic mutations which greatly increase the risk of developing breast, ovarian, and other cancers. It is recommended for individuals with a personal history of cancer or a strong family history.

Please Do Not Forget the Breast Exam

Somewhere along the way, many women started believing that if they get a mammogram, they no longer need a breast exam.

I strongly disagree.

A self-breast exam and an annual clinical breast exam are still valuable.

Many women say, “I don’t know what I’m looking for.” You are looking for anything outside your own normal.

If you examine your breasts regularly, you get used to what your breasts feel like. Then, if there is a new lump, new thickening, new painful area, skin change, nipple change, discharge, or new asymmetry, you are more likely to notice it. And if you notice something different, you come in. You get examined. You get diagnostic imaging if needed.

This is simple, but it has been minimized. I think that is a mistake.

Keep in mind that approximately 30-40% of breast cancers are self detected, and only 40-50% are diagnosed by a mammogram or other imaging.

Monthly Self-Breast Exam Checklist

Self-breast exams are not about becoming your own radiologist.

They are about knowing your own body.

If you still have periods, do your exam in the first week after your period. If you are menopausal or postmenopausal, choose a consistent time each month, such as the first week of the month.

Look and feel for:

• A new lump

• A new thickened area

• A hard area

• New asymmetry

• Skin dimpling

• Skin redness

• Skin texture change

• Nipple inversion

• Nipple discharge

• Persistent pain in one area

• Swelling

• Anything that feels different from your usual pattern

If something is new, persistent, or concerning, call your clinician.

Do not panic. Do not ignore it. Have it evaluated.

And please remember, many women find their own breast cancers. This is why knowing your normal matters.

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Mammogram False Positives Are Not to Be Discounted

Another problem we do not discuss enough is the false positive result.

A false positive means something looks concerning on imaging, and after additional testing, the woman is eventually told there is no cancer.

That may sound like good news, and of course it is good news. But the process can still be deeply stressful.

A woman gets the call. She is told her mammogram is abnormal. She needs more images. Maybe she needs a diagnostic mammogram. Maybe a targeted ultrasound. Maybe a biopsy.

And while this is happening, she is living with fear.

The psychological damage done to a woman’s psyche and emotional well-being due to a false alarm is not to be discounted.

I have met women who refused to have another mammogram because of a previous traumatic experience caused by a false positive finding. They were not being careless. They were reacting to a process that frightened them, overwhelmed them, and made them feel trapped inside a medical system they no longer trusted.

The Emotional Cost of Repeated Follow-Up Testing: My Story

Like a good and compliant patient, I got my first mammogram at age 40. I am in a high-risk category, as I have never had children.

I was told I have dense breasts and the mammogram was picking up some architectural distortion, and they needed to follow up with more diagnostic mammograms every six months for two years. I complied, even though I hated the process. It was painful and emotionally distressing.

After my fourth mammogram in a row, I asked if I’m in the clear, and I was told, “Maybe we should do one or two more every six months just to be safe.”

I said, OK, fine. I walked away and did not come back for five years. I was done with the process. I was done with the fear, but first and foremost, I was done with what I thought was unnecessary testing.

Many women mirror that experience when they come and talk to me about skipping breast imaging testing, or opting for a breast ultrasound instead of a mammogram, or asking if a thermogram is a safer, better alternative. Many women ask about something better!

Mammography Overdiagnosis Dangers, Especially After 70

Overdiagnosis is different from a false positive.

A false positive means cancer was suspected but later ruled out.

Overdiagnosis means a real cancer was found, but it may have been so slow-growing that it would never have caused harm during the woman’s lifetime, but the treatment for the cancer diagnosed can and will cause harm.

This is especially important in older women. The National Cancer Institute summarized a 2023 study showing that the risk of overdiagnosis with routine screening mammography becomes substantial for women in their 70s and older, and that risk increases with age and other health problems.

Mammography can detect cancers that will likely never endanger a woman’s life, or threaten her for the remainder of her lifespan. But medical science cannot differentiate between these cancers and the more aggressive ones, therefore an older woman can be subjected to serious harmful cancer therapy for a cancer that would have not impacted her until her death came from other causes.

This does not mean women over 70 should never screen.

It means they deserve a more thoughtful conversation.

Ask:

• What is my realistic benefit from continued mammography?

• What is my risk of overdiagnosis?

• If cancer is found, would I want surgery, radiation, chemotherapy, or hormone-blocking medication?

• Would treatment improve my quality of life or harm it?

• Should my screening plan change based on my age, health, and personal priorities?

This is not an easy conversation, but it is a necessary one.

Your Annual Exam Is Not Just a Pap Smear

Many women have confused the Pap smear schedule with the annual exam.

They are told they do not need a Pap smear every year, and somehow that becomes, “I do not need to see my doctor every year.”

Please do not make that mistake.

Do not associate the need for a Pap smear with the need for an annual exam. They are not the same.

Even if you do not need a Pap smear this year, you may still need a breast exam, a pelvic exam, a menopause conversation, a hormone discussion, a bone health screening conversation, colon cancer screening, urinary symptom evaluation, sexual health discussion, metabolic labs, or simply a careful clinical exam by someone who is paying attention.

We need to change the narrative of the well-woman exam. It should not be all about the Pap smear and the mammogram.

It should be about what matters most for your health and cancer prevention. Which is different based on age, and where you are in your reproductive cycle.

A Better Breast Surveillance Plan

A better breast surveillance plan should include more than one automatic annual order.

It should consider your age, risk, breast density, imaging options, self-breast exams, annual clinical breast exams, and what happens if you are called back.

It should also include a conversation about overdiagnosis as women age, because more screening is not always the same thing as better care.

Most importantly, it should include a clinician willing to look at the whole woman, not just the mammogram order.

Before You Schedule Your Next Mammogram, Know What to Ask

If this conversation made you realize you have more questions than answers, that is exactly the point.

In the paid companion, I go deeper into the questions women should ask during a breast cancer screening consultation, including what to ask about dense breasts, callbacks, hormone therapy, age, imaging options, genetic testing, personal risk, and your actual breast surveillance plan.

I also include my Top 10 Protectors to Decrease Breast Cancer Risk — the lifestyle, hormone, metabolic, and environmental factors I believe women should be thinking about if they want to take a more active role in protecting their breast health.

The goal is not to make women afraid of screening.

The goal is to help women walk into the conversation informed.

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The Next Step Is Not Fear

The next step is a better question.

Ask what your personal risk is. Ask whether you have dense breasts. Ask what screening interval makes sense for your age, history, and breast tissue. Ask whether ultrasound, MRI, thermography, or genetic testing should be part of the conversation.

Do your own breast exams. Pay attention to your body. And please remember: a mammogram can be a very useful tool, but it should never be mistaken for the whole plan.

Disclaimer:

This Substack is here to educate, inform, and advocate. It is not a substitute for individualized medical care. Nothing in this publication should be taken as personal medical advice, diagnosis, or treatment, and reading or subscribing to this content does not create a physician-patient relationship with Dr. Mirela Cernaianu.

Hormone therapy and menopause care should be guided by a qualified clinician who knows your medical history, symptoms, goals, and risk factors. Always speak with your own healthcare professional before starting, stopping, or changing any medication, hormone regimen, supplement, or treatment plan.

Do not use this publication for urgent or emergency medical concerns. If you think you may be having a medical emergency, call 911 or seek immediate care.

Please do not post or send personal health information through comments or messages on this platform.

Sources and Further Reading

U.S. Preventive Services Task Force. Breast Cancer: Screening.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening

American Cancer Society. American Cancer Society Recommendations for the Early Detection of Breast Cancer.
https://www.cancer.org/cancer/screening/american-cancer-society-guidelines-for-the-early-detection-of-cancer.html

National Cancer Institute. Dense Breasts: Answers to Commonly Asked Questions.
https://www.cancer.gov/types/breast/screening/dense-breasts

National Cancer Institute. Mammogram False Positives May Affect Whether Women Return for Screening.
https://www.cancer.gov/news-events/cancer-currents-blog/2024/mammogram-false-positives-affect-future-screening

U.S. Food & Drug Administration. Breast Cancer Screening: Thermogram No Substitute for Mammogram.
https://www.fda.gov/consumers/consumer-updates/breast-cancer-screening-thermogram-no-substitute-mammogram

National Cancer Institute. Tumor Markers.
https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis/tumor-markers-fact-sheet

Centers for Medicare & Medicaid Services. Tumor Antigen by Immunoassay - CA 15-3/CA 27.29.
https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=134

Medscape. CA 15-3: Reference Range, Interpretation, Collection and Panels.
https://emedicine.medscape.com/article/2087491-overview

National Cancer Institute. BRCA Gene Changes: Cancer Risk and Genetic Testing.
https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet

Centers for Disease Control and Prevention. Genetic Testing for Hereditary Breast and Ovarian Cancer.
https://www.cdc.gov/breast-ovarian-cancer-hereditary/testing/index.html

Mayo Clinic. BRCA Gene Test for Breast and Ovarian Cancer Risk.
https://www.mayoclinic.org/tests-procedures/brca-gene-test/about/pac-20384815

GRAIL. The Galleri Test.
https://www.galleri.com/hcp/the-galleri-test-2

Chen X, Dong Z, Hubbell E, et al. Real-world data and clinical experience from over 100,000 multi-cancer early detection blood tests. Nature Communications.
https://www.nature.com/articles/s41467-025-64094-7

Natera. Signatera for Breast Cancer.
https://www.natera.com/oncology/signatera-advanced-cancer-detection/clinicians/signatera-for-breast-cancer/

PubMed. Circulating Tumor DNA Detection of Local Recurrence in a Patient With Triple-Negative Breast Cancer.
https://pubmed.ncbi.nlm.nih.gov/40690158/