Difficult Women, Hot Flushes & Perimenopause Around the World

In Episode 12 of On the Mones, Kate explores a word many women recognise instantly: difficult.

Recently Australian activist and former Australian of the Year Grace Tame was described publicly as difficult after speaking out politically. Whether or not you agree with her views, the label landed because women everywhere know that word. The one that appears when women stop being agreeable.

Kate reflects on her own experience navigating leadership, advocacy and midlife reinvention, including the moment she rage-quit a senior hospital pharmacy leadership role at 45. Was she difficult? Or simply done?

Alongside this reflection, Kate answers listener questions from around the world about perimenopause and menopause:

• Anxiety, rage and crying at emails in your 40s: hormones or not coping?
• Painful sex and vaginal dryness: is that perimenopause?
• Why weight gain around the middle happens even when diet and exercise have not changed
• Falling asleep easily but waking at 3am wired

Kate explains the biology of perimenopause, including how fluctuating estrogen affects neurotransmitters like serotonin, dopamine and GABA, and why life in your 40s can suddenly feel harder than it used to.

She also breaks down a new non-hormonal treatment for menopausal hot flushes, Veoza (fezolinetant): how it works in the brain, what the evidence shows, and where it fits alongside hormone therapy.

Because menopause does not care what passport you hold. And sometimes being called difficult simply means you have stopped being convenient.

Whether you are in perimenopause, approaching menopause, or simply trying to understand your hormones, I've got you.

Read more about this episode at Medication Clarity Clinic, Kate's own medication education and telehealth consulting site: https://medicationclarity.com.au

Transcript

SPEAKER_01 0:00

You're listening to On the Moans, where we have conversations about hormones, midlife, and the moments that make us wonder, is it just me? I'm Kate. I'm a 48-year-old pharmacist and newly minted perimenopausal oversharer. This is where we talk openly about the changes we aren't prepared for, so we never have to feel alone in them again. I acknowledge the Camaragle people of the Iora Nation, the traditional custodians of the land which I am recording today. I pay my respects to elders past and present, and I extend that respect to all Aboriginal and Torres Strait Islander peoples listening. Always was, always will be, Aboriginal land. Hello friends. I want to talk about a word. A small word, a polite word even, a loaded word. Difficult. Recently, Grace Tame was described publicly as difficult after being very vocal about Palestine. For those listening overseas, Grace Tame is an Australian activist and 2021 Australian of the Year. She became nationally known for successfully campaigning to change Tasmania's laws that prevented survivors of child sexual abuse from speaking publicly about their experiences. Since then, she's remained outspoken on a range of social and political issues. Most recently, she was particularly vocal during the visit to Australia by Israeli President Isaac Herzog, where she publicly criticized Australia's stance and encouraged protest action. Women everywhere heard it and flinched. Not because we all agree with her politics, that's not the point. It's because we know that word, difficult. And I've been thinking about it a lot this week because if I'm honest, I suspect I've been described that way too. I worked in management in hospital pharmacy for about ten years, before that, clinical roles, and before that, junior pharmacist trying desperately to be liked and not to kill someone. And for most of my career, I wanted to be pleasant, capable, reliable, reasonable, not emotional, not spiky, not too much. I worked for a benevolent Christian organization. The executive table was, for the most part, unsurprisingly, middle-aged white Christian men. Good men, smart men, but a very particular culture. And somewhere in my early 40s, something shifted. My tolerance for waffle decreased. My appetite for politics shrank. My willingness to prioritize being palatable over being correct evaporated. And I don't think it was just hormones, although let's not pretend Eastrogen doesn't have opinions. It was something deeper. I started caring less about whether they liked me and more about whether my team felt protected. I cared less about being agreeable and more about whether patient's safety was being upheld. And if that meant I pushed harder in meetings, if that meant I didn't soften my tone, then so be it. But I've been thinking, was I effective or was I just frustrated? There is a difference. Advocacy feels deliciously righteous. I love to get on a high horse as much as the next person, but effectiveness is tactical. One person's difficult is another person's refusing to dilute for sure. But the harder question for me is, was my delivery maximizing impact or maximizing friction? Because friction feels powerful in the moment, you feel alive, you feel morally clear, you feel like you're standing up for something. You're advocating for whatever or whomever it is you're advocating for, but friction also exhausts people. It closes doors and it hardens rooms, and eventually it isolates. And me, well, I rage quit. And I say that lightly, but it was a moment. Push came to shove, a line was crossed, and I resigned on the spot at 45, which depending on how you look at it, is either brave or reckless. Look, if I'm honest, towards the end I was bored, I was stale, I wasn't doing my best work. And sometimes what masquerades as moral righteousness is actually intellectual restlessness. That's not easy to admit, but it's true. I had outgrown the role, and instead of evolving it so that it became what I needed it to be, I pushed against it. And here's the thing, there was a time in my career when I wasn't difficult at all, and this still stings. There was a moment early in my time at this benevolent Christian organization when Australia was leading up to the marriage equality vote, and I was in a room with senior leadership. The conversation turned to the vote, and one by one, almost casually, confidently, people around that table were talking about how they would be voting against it. It wasn't hostile, it wasn't aggressive, it was just assumed. Of course we're all voting no. And I remember sitting there thinking, how is this even up for debate? Why on earth would I have an opinion over who someone else loves? Why would I vote on whether someone else gets to marry the person they choose? I was baffled. I still am if I'm honest. And yet I said nothing. I was the only person in that room who would have voted yes, and I remained silent. Not because I didn't believe in it, not because I was unsure, but because I didn't want to rock the boat, I didn't want to be the lone voice, I didn't want to be, there's that word again, difficult. So I sat there, polite, professional, quiet, and in that silence I let myself be represented by something that wasn't true. My silence implied agreement, and that moment still sits with me. Because that wasn't strategy, that was fear, that wasn't modulation, that was self-protection. And I looked back on that younger version of myself with compassion, but also with a little bit of shame. Because I didn't have the courage of my convictions. Now here's the counterfactual. If I had been more palatable, more strategic, less spiky, would I still be there? Probably. I might have negotiated part-time, I might have found side projects or secondments or promotion within the organization. I might have stayed safe in the environment I knew well. I would likely still be in a senior, secure position, respectable, comfortable. But I wouldn't be here. I wouldn't be doing this podcast, I wouldn't be on social media, and I wouldn't be reinventing myself in my late forties like a slightly unhinged teenager with a Canva login. And reinvention matters especially as we age, because when you stop stretching, you calcify, you get stuck in your lines of thought, you start mistaking familiarity for correctness. And then you risk becoming intolerant. Not because you're bad, but because you're no longer challenged. I didn't rage quit because I wanted chaos. I think I rage quit because I knew I desperately needed growth and I didn't like the version of me that I was every time I entered that building. The friction was the symptom, not the cause. So was I difficult? Maybe. But I was also done. Done shrinking, done modulating myself for comfort, done prioritizing, being liked over, being right. I don't think we should aim to be difficult for sport. There's a narrative emerging online that says if being assertive makes me difficult, then good. I understand that energy, but I also know something else. Strategy is not submission, and modulation is not weakness. Sometimes the smartest woman in the room is the one who knows exactly how much edge to show and exactly when to sheath it. Was I playing chess or was I flipping the board? I'm still not entirely sure, and maybe that's the point. Midlife isn't about becoming louder, it's about becoming clearer. Clearer on what matters, clearer on when to push, and clearer when to pivot. And sometimes clarity looks like confrontation, and sometimes clarity looks like leaving. What I know is this. In my thirties being called difficult would have devastated me. In my forties, it almost feels like a promotion. Because difficult often just means she won't comply quietly, she won't smile through it, she won't prioritize comfort over truth. But effectiveness still matters. If the goal is to win the outcome, not just the point, then we owe it to ourselves to ask, Am I being authentic or am I being strategic? And do those two have to be opposites? I don't think they do. I think the most powerful midlife woman is not the loudest one. She's the one who understands her leverage, she knows when to push, when to reframe, she knows when to exit. And she doesn't confuse burning a bridge with lighting a path. So when I hear that word now, difficult, I don't immediately flinch, I pause, and I ask Difficult to whom? In service of what? And at what cost? Maybe being difficult was my incubation period, maybe the friction cracked something open. Maybe the rage quit was less an explosion and more of a shedding. And maybe reinvention requires a little abrasion. So I'll leave you with this. Have you ever been called difficult? And if you have, were you wrong or were you just no longer convenient? And the harder question, were you effective or were you done? Voice notes are welcome because I suspect there are lots of us recalibrating. And maybe that's not difficult, maybe that's evolution. I don't want to be the woman who stays silent when it matters, and I don't want to be the woman who mistakes volume for impact. Somewhere between those two versions of me is the one I'm still becoming. There is a newish medication for menopausal hot flushes that has generated quite a lot of interest. It's called VIOSA, and the drug name is physalinitant. It is TGA registered, but it is not on the PBS, so it is a private prescription from your doctor. The reason people are excited about this medication is that it is not a hormone. For decades, the most effective treatment for menopausal hot flushes has been menopausal hormone therapy, estrogen plus or minus progesterone. And for many women, that works beautifully. But for many women who either cannot take estrogen or prefer having a non-hormonal option that actually works, this is a big deal. I'm going to tell you what this drug is, how it works, and where it might fit in. But first, what actually causes hot flushes? Because they're not just random overheating, they are caused by a misfiring temperature control system in the brain. Deep inside the brain there's a region called the hypothalamus. You can think of it as your body's thermostat. When estrogen levels fluctuate during menopause, something interesting happens. A group of nerve cells in the hypothalamus called Kindi, KNDY neurons, become overactive. These neurons release a chemical messenger called neurokinin B. And that neurokinin B signal basically tells the brain, we're too hot, even when you're not. So the brain activates its cooling system and you get sudden heat, flushing, sweating, sometimes palpitations, and often that lovely wave of anxiety that comes with it. So the hot flush is really the brain misreading the temperature. Enter phessalinitant. Pheasalinitant works by blocking the neurokinin 3 receptor. That's the receptor that neurokinin B binds to. So instead of changing hormones, this medication calms down the temperature signaling pathway in the brain. It essentially tells those overexcited neurons, relax, everything's fine, you're okay. And when that pathway settles down, the frequency and intensity of hot flushes drop. So it's targeting the brain's mechanism for hot flushes directly rather than replacing estrogen. What does the evidence say? The main clinical trials were called the Skylight Studies. These looked at women with moderate to severe vasomotor symptoms, meaning hot flushes. Participants were having at least seven to eight hot flushes per day, and the results were pretty encouraging. Women taking phesolinatent had about a 50 to 60% reduction in hot flush frequency. And many saw improvement within a few weeks. Now that's not quite as powerful as estrogen therapy, which can reduce hot flushes by around 80 to 90%, but for a non-hormonal medication, that is actually quite impressive. It also improved sleep disturbance, which makes sense because night sweats are one of the things that keep women awake. This medication is aimed at women who cannot take estrogen or choose not to. Examples might include women with a history of estrogen-sensitive breast cancer, those who have medical contraindications to hormone therapy, women who simply don't want to take hormones, or women who have tried hormonal therapy and didn't tolerate it. Another group might be women who are very early in menopause and want symptom relief without committing to hormone therapy. Vesalinitant is a once-a-day tablet, which is quite convenient. Unlike hormone therapy, there is no need for progesterone protection of the uterus because it doesn't stimulate the endometrium. So from a prescribing and compliance perspective, it's relatively simple. Side effects and safety. So the current guidance in many places is that women should have liver function tests before starting the medication and then periodically during treatment. This is not unusual, we do this with many medications, but it is something that doctors will be monitoring. How does it compare to other non-hormonal treatments? Before Fissolinitant, our non-hormonal options for hot flushes were a bit uh repurposed. We've used medications like SSRIs and SNRIs, gabapentin and clonidine. And while these can help, they weren't originally designed for hot flushes. They tend to reduce symptoms by about 30 to 50%. And some of them have side effects like sedation, dizziness, dry mouth, sexual dysfunction, and difficulty tapering or coming off them. So phesalinotent is interesting because it's the first medication designed specifically for the hot flush pathway. Important point, it doesn't treat menopause itself. One thing that is important to understand is that phesolinitant does not replace estrogen, so it will not help with vaginal dryness, bone density loss, cardiovascular protection, skin changes, or the broader health effects of declining estrogen. It is really a targeted treatment for hot flushes and night sweats. Which means for many women, hormonal therapy will still be the more comprehensive treatment. So where does it fit? I suspect this medication will sit in a middle ground. Something like first line for women who cannot take estrogen, an option for women who prefer non-hormonal treatment, possibly a bridge treatment for women deciding what to do next. But it's probably not going to replace hormone therapy as the gold standard. Estrogen still works extremely well for vasomotor symptoms and has all the additional health benefits like cardiovascular protection and reducing dementia risk. What I actually love about this development is that it reflects something really important. For a long time, women's health research lagged behind, is still lagging behind. Hot flushes were sometimes treated as a bit of a joke, you know, the fan in the handbag era. But they can be seriously disruptive. Sleep disturbance alone can affect work performance, mood, cognition, relationships. So seeing a medication that specifically targets the biology of hot flushes shows that research is finally catching up. So to summarize, VIOSA or phessalinitant is a non-hormonal medication for menopausal hot flushes. It works by blocking neurokinin 3 receptors in the hypothalamus, calming the temperature control system in the brain. Clinical trials show it can reduce hot flush frequency by around 50 to 60%. It is taken orally once a day, and doctors will usually monitor liver function while you're on it. It's particularly useful for women who cannot take or prefer not to take hormone therapy. But it doesn't replace estrogen's broader benefits, so hormone therapy will still remain an important option for many women. If you're experiencing severe hot flushes, the key message is this you don't have to put up with it. There are now multiple treatment options, both hormonal and non-hormonal. And the best approach is always a conversation with a clinician who understands menopause care and can tailor treatment to your situation.

SPEAKER_05 17:55

I am flat and anxious and crying for no reason. Could this be premonopause? I feel like I'm not coping.

SPEAKER_01 18:06

First of all, if you're 44 and suddenly crying at emails, you are not weak and you are not failing. The average age of menopause in Australia is 50, and the average age of menopause in Nigeria is about 48 to 50. Menopause is defined as one day in your life, the day 12 months after your last period. And perimenopausal symptoms on average can start 10 years before menopause, so statistically you are well within the age range to be experiencing perimenopausal symptoms. Perimenopause is a hormonal transition and it's not a slow, graceful taper. It's chaotic. Estrogen doesn't decline gently, it fluctuates wildly. One month it's high, the next it drops sharply. And those fluctuations affect neurotransmitters in the brain, particularly serotonin, dopamine, and GABA. Estrogen enhances serotonin signaling, so when it drops, serotonin signaling drops too. That can feel like anxiety, low mood, irritability, even panic. And if you've never had anxiety before, when it shows up it feels frightening and unfamiliar, which is totally understandable, right? Now, is everything hormones? No. Life at 44 is often peak responsibility. Work, aging parents, teenagers, mortgages, the invisible labor of being a woman. Hormones lower the buffer. They don't create your lifestyle stress, they just reduce your resilience to it. So the question isn't, is this hormones or am I not coping? The question is, is there a biological shift that's making this harder than it used to be? And often the answer is yes. If symptoms are intrusive, persistent, or affecting work or relationships, that's worth seeing your GP about. Sometimes therapy helps, sometimes SSRIs help, sometimes HRT helps, sometimes it's a combination. Many women from cultures where emotional distress isn't openly discussed can feel confused by these changes because it doesn't fit their idea of who they are. And I'm speaking from personal experience here. The seemingly random waves of anxiety in no way fit with my personal belief about who I am. But please, don't default to self-blame. Perimenopause doesn't care what kind of passport you carry, and biologically, women around the world are far more similar than we are different. Thank you for listening from Nigeria. I'm so pleased you're here.

SPEAKER_04 20:32

Hello, my name is Mr. In my culture, we do not talk about vaginal dryness. But many women in 40s feel pain during sex. Can anything help?

SPEAKER_01 20:44

Yes, and I'm really glad you asked this because in many parts of the world, including India, we don't openly talk about pain during sex. It's often endured quietly. But pain is information. It's not something you're meant to tolerate. It's rare that someone would actively seek out an experience that is painful. During perimenopause and menopause, estrogen levels fluctuate and then decline. Estrogen keeps the vaginal and vulval tissues thick, elastic, well lubricated, and well supplied with blood. When estrogen drops, those tissues become thinner, drier, and more fragile. That can lead to pain with penetration, burning or irritation, microtears, recurrent urinary tract infections. This is called genitourinary syndrome of menopause. It sounds dramatic, but it's simply tissue biology responding to lower estrogen. Now here's the important part this is treatable. Local vaginal estrogen in creams, tablets, or rings acts directly on the tissue with minimal systemic absorption. It is one of the safest and most effective therapies we have. Lubricants can help in the moment, and the silica based ones are usually better, although be careful if using condoms. Vaginal moisturisers can help if used regularly, for example, hyaluronic acid vaginal moisturisers, but if pain persists, medical treatment is appropriate. Painful sex is not something you have to endure to be a good partner. It's not disinterest, it's not psychological weakness, it's hormonal tissue change. To our dear friend in Delhi, thank you for asking something that many women are thinking about but not saying. Firstly, it's not laziness. In perimenopause, body composition changes even if behavior doesn't. There are several mechanisms at play. 1. Estrogen influences where we store fat. When levels fluctuate and decline, fat distribution shifts from hips and thighs towards the abdomen. More visceral storage. 2. Insulin sensitivity can change. You may process glucose slightly less efficiently than you did when you were 30. 3. Sleep disruption. Melatonin production decreases with age. Poor sleep alters ghrelin and leptin, the hunger and satiety hormones, and increases cravings. 4. Muscle mass naturally declines from our 30s onwards unless we actively resistance train. Less muscle means lower resting metabolic rate. So no, it's not simply calories in versus calories out. It's hormonal signaling plus aging physiology. Now, lifestyle still matters. Protein intake, strength training, sleep hygiene, alcohol reduction, all important. The goal in midlife isn't to look 25. It's metabolic health, strength, bone density, and function. Your body is adapting. It's not betraying you. Even though it might feel like it is. First, progesterone. Progesterone has a calming, GABA-enhancing effect. In perimenopause, ovulation becomes irregular. And when you don't ovulate, you don't produce much progesterone. Less progesterone means lighter, more fragile sleep. Second, temperature regulation. Estrogen plays a role in stabilizing the brain's thermoregulatory centre. When estrogen fluctuates, the threshold for heat dissipation narrows. That can mean night sweats, even subtle ones that wake you. Add to that, cortisol rhythms, decreased production of melatonin, alcohol which fragments sleep, life stress, screen exposure, and 3 a.m. suddenly becomes very popular. What helps? Reducing evening alcohol, strength training earlier in the day, cooling the bedroom, managing the caffeine, in some cases HRT, occasionally micronized progesterone specifically for sleep, sometimes a course of slow release melatonin to reset the sleep cycle if appropriate. But most importantly, if this is new in your 40s and it wasn't your baseline before, hormones are very likely a part of the picture. It's not just stress, it's a physiological transition, and a good chat with your GP will be able to get you on the right path to getting a good night's sleep. Because no one is their best when they haven't slept well. So where does that leave us? We started with a word difficult. A word that was recently used to describe a woman who has built a public life on refusing to be quiet. And whether you agree with her politics or not, the word landed because women know that word. Some of us have swallowed our opinions to avoid it. Some of us have worn it like armour. I've done both. I have sat silent in a room while people confidently declared they would vote against marriage equality and said nothing. And I have stood in boardrooms in my forties, sharper, less filtered, less willing to smooth the edges. Silence spike two versions of the same woman. And neither one feels entirely comfortable when I look back. But maybe that's because growth is uncomfortable. Maybe midlife isn't about becoming louder. Maybe it's about becoming calibrated enough to know. When is silence integrity and when is it fear? When is sharpness courage and when is it ego? When does pushing serve the outcome? And when does it just release the pressure inside you? Is being difficult sometimes just advocacy? Yes. Can tone change the outcome? Also yes. Is there a smarter way to hold conviction without burning the room down? Almost certainly. And here's the part I'm still learning. The younger version of me stayed quiet because she wanted safety. The midlife version of me pushed because she wanted integrity. The woman I'm trying to become is learning leverage. Because winning the point is satisfying. Winning the outcome is powerful. And leaving entirely, sometimes that's evolution. Some of the questions that came through for this episode were brilliant. Thank you for sending them to me. I love hearing your voices from around the world. It reminds us that 50% of the population will go through menopause, and that we are more alike than we are different, and the more we talk about it, the more powerful we become. I'll look forward to your company next time we get on the moans. And you can follow me on TikTok, Facebook, and Instagram at prescribe or pass, or on LinkedIn, Kate Thomas, Medgov by Thomas Dowling Consulting. Bye bye. But it's probably not gonna replace hormonal tri hm. But it's probably not going to replace hormone therap. But it's probably not going to replace hormone trim oh wow.