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Chapter 15 of the book

Women's Bodies Across the Life Course

The chapters so far took the body apart signal by signal. Part Six puts it back on a clock, and for women the clock has landmarks of its own: the first period, pregnancy, the long transition out of fertility, and the decades after it. Chapter 16 then follows every body, women's and men's, into the second half of life.

ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.3 things to start with2 popular claims graded102 works cited

How the chapter opens

Every night for two years in the late 1980s, the anthropologist Beverly Strassmann noted which women were sleeping at the two menstrual huts of Sangui, a village of Dogon millet farmers in Mali, where custom sent women during their periods. Nobody in the village used contraception, and women averaged more than eight live births.

The huts turned a private event into a public record. Strassmann read the custom as a way for men to get an honest signal: when a woman went to the hut, her husband's family learned that she was neither pregnant nor nursing without periods, and would soon be able to conceive. Strassmann checked her census against hormones in the women's urine: the women went to the hut for the great majority of their periods, and every birth she monitored came about nine months after the mother's last visit.

What the chapter covers

The argument, the studies and the stories are in the book. Get the book.

  • ·What Your Body Expects
  • ·What It Gets Instead
  • ·Four hundred cycles
  • ·The missing period
  • ·Contraception, in absolute numbers
  • ·Pregnancy and After
  • ·An early stress test
  • ·After the birth
  • ·Two Conditions That Wait Too Long
  • ·PCOS, and a name in transition
  • ·Endometriosis and the long wait
  • ·The Long Transition
  • ·What the big trial showed, and what changed
  • ·Without hormones
  • ·Bone and heart after menopause

Mismatch card

The system

The female reproductive axis across a lifetime, from first period through pregnancy to the transition and the decades after it.

What it expects

A first period in the mid-teens, many pregnancies with long breastfeeding between them and about a hundred periods in a lifetime, food that matches effort, kin nearby, and a working body that carries loads through the transition.

What it gets

Earlier first periods, fewer and later births, short breastfeeding and about four hundred periods; energy deficits in some and surpluses in others; grandmothers far away; and a transition lived mostly sitting down.

What happens in the gap

More hormone-driven cancers and more iron lost; periods that stop from low energy; common conditions such as PCOS and endometriosis diagnosed late; symptoms of the transition endured instead of treated; bone and muscle lost fastest just as loading falls.

The handrail

Track the cycle, take perimenopausal symptoms to a clinician, lift at every stage (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.)

Strength of evidence

ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials. The treatments for flushes, the contraception risks and the pregnancy heart flags rest on trials and large cohorts; the evolutionary accounts of menopause and PCOS, and the timing hypothesis, do not.

What you've heard

Popular claims this chapter tests, each with the book's verdict and grade.

The protocol

Each action carries the book's evidence grade. How the grades work.

Start here

  1. In the reproductive years, track your cycle as a vital sign

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.for spotting problems earlythe wider vital-sign idea is expert opinion

    How: note the first day of each period, how long it lasts and how heavy it is, in any calendar or app, and watch for change from your own pattern. Why: the cycle reports on energy, iron loss, hormones and, later, the start of the transition, for free.

  2. In perimenopause, take your symptoms to a clinician, because effective treatments exist

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.

    How: book an appointment for this alone, with a list: flushes, night sweats, sleep, mood, vaginal or urinary symptoms, and changes in bleeding. Ask about hormone therapy, including a patch or gel, and about the non-hormonal options. Why: hormones treat flushes best, and for healthy women under sixty or within ten years of menopause the balance is favorable.

  3. At every stage, lift

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.for strengthProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.for bone

    How: two strength sessions a week of about thirty minutes. The home session in Chapter 4 needs only a chair, a wall and a loaded bag; add load until the last few repetitions feel hard. After fifty, or with low bone mass, work toward heavier lifts and impact training taught in person. Why: bone loss is fastest around the final period, lean mass falls across the transition, and supervised heavy lifting twice a week built spine bone in women with low bone mass, while walking alone does little.

Then, pick from this menu

  • **Know your heart numbers in midlife (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).** Have blood pressure, cholesterol and glucose checked at regular checkups, and tell your clinician about an early menopause or a pregnancy complication; both raise later heart risk.

  • **Ask about iron if you menstruate and feel tired, or bleed heavily (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).** Ask for a ferritin test and for the number itself, not just "normal". The 2026 guideline counts 30 or lower as iron deficiency, or 50 or lower with heavy periods. Do not take iron supplements long-term without testing.

  • **Eat to cover your training (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).** If your periods thin out or stop while you train hard or diet, eat more before you cut training, and see a clinician. It can happen without any weight loss.

  • **Choose contraception on absolute numbers, with a clinician (StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.).** Implants and IUDs fail least in real life. Among combined pills, those with levonorgestrel, norethisterone or norgestimate carry the lowest known clot risk. Watch your mood in the first months, and if it changes, switch with a plan for the next method instead of simply stopping.

  • **Keep moving through pregnancy (StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.).** About 150 minutes a week of moderate activity, such as brisk walking, swimming or a stationary bike. Keep up training you already did unless your clinician says otherwise, and avoid lying flat on your back after the first trimester. Stop and call your clinician if anything feels wrong.

  • **Train your pelvic floor during pregnancy (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).** Ask your midwife or a physical therapist to show you the exercises. It probably prevents leaking late in pregnancy and helps a little after the birth.

  • **Carry a pregnancy complication forward (StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism. for the risk, ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials. for the follow-up).** After gestational diabetes, get the glucose test your clinician offers after the birth and keep up regular diabetes screening. After preeclampsia or high blood pressure in pregnancy, tell every future clinician and have blood pressure, cholesterol and glucose checked.

  • **Arrange help for after the birth before it arrives (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).** Named people for named jobs: meals, nights, an adult to talk to (Chapter 11). If you have had depression before, ask about counseling during pregnancy.

If this is you

Irregular cycles or possible PCOS

ask for the diagnosis to be settled against the two-of-three criteria, and for glucose and mood screening. Activity and preventing weight gain help at any weight. You do not need an insulin test (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).

Painful periods

pain that stops you working, studying or sleeping deserves assessment; ask about imaging and a trial of hormonal treatment; you do not need surgery first (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).

Trying to conceive, or pregnant

if you are at high risk of preeclampsia, ask about low-dose aspirin from twelve weeks. With PCOS, ask about a glucose tolerance test before or early in pregnancy (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials. to StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.).

Perimenopause and after

expect flushes to last years, and treat them if they bother you. For dryness, pain with sex or repeated urinary infections, ask about low-dose vaginal estrogen. Broken sleep and new low mood in these years have a physical basis and deserve treatment (Chapters 8 and 13).

A history of breast cancer, blood clots or stroke

hormone therapy needs specialist advice. CBT for flushes was tested in women after breast cancer, and for vaginal symptoms, involve your oncologist.

Migraine with aura, or a smoker aged thirty-five or older

combined contraceptive pills, patches and rings (the ones containing estrogen) are ruled out with migraine with aura at any age, and for smokers of fifteen or more cigarettes a day from thirty-five. Progestogen-only methods and IUDs remain options. This rule is about contraception; menopause treatment is weighed separately. Stopping smoking helps everything else (Chapter 1).

Over 50, or stiff joints

start with chair-height and wall versions of the strength moves and add load slowly (Chapter 4).

Tight budget

cycle tracking, home strength work and pelvic floor exercises cost nothing once someone has shown you them, and self-help CBT for flushes worked about as well as group sessions. In the US, a progestin-only pill is sold without a prescription.

Short on time

keep the cycle log and make one appointment with one list. Two thirty-minute strength sessions a week, working toward heavy loads, were enough to raise spine density in a trial; shorter sessions still help muscle.

When to see a clinician

  • Your periods stop for three months or more and you are not pregnant, or they become very irregular.
  • Bleeding is very heavy (for example, soaking through a pad or tampon every hour or two) or lasts more than a week.
  • Period or pelvic pain stops you working, studying or sleeping.
  • Any bleeding after twelve months without a period.
  • Low mood that lasts more than two weeks after a birth, or any thoughts of harming yourself (in the US, call or text 988).
  • Hot flushes, night sweats, sleep or mood changes in your forties or fifties that bother you.
  • New snoring, morning headaches, unrefreshing sleep or new insomnia after menopause (Chapter 8).
  • Chest pain, pressure or tightness, especially with jaw, neck, arm or back pain: call emergency services and say you are worried it is your heart.

Safety

This chapter is not a substitute for a clinician who knows your history. Never stop a prescribed contraceptive, antidepressant or hormone without a plan agreed with your prescriber. Hormone therapy is for symptoms, not for preventing heart disease or dementia. With osteoporosis or a past fracture from a minor fall, start heavy or impact training only under supervision. On fezolinetant, stop and call your prescriber at once with tiredness, nausea, itching, yellow eyes or skin, pale stools or dark urine. On elinzanetant, do not drive if drowsy, and have the liver tests. On zuranolone, do not drive for twelve hours after a dose. Take low-dose aspirin in pregnancy only on a clinician's advice.

The skeptic's box

What could overturn this chapter, from the chapter itself.

The chapter's frame rests on one village: Strassmann's lifetime counts are extrapolated from two years of hut records, and "cycles" stand in for hormone exposure. No one can rerun human evolution to test the grandmother hypothesis, and the Ngogo chimpanzees may be a well-fed exception. The timing hypothesis for hormone therapy could fall to a large trial that started women at fifty and counted heart attacks and deaths. The pooled breast cancer figures assume causation, and for estrogen alone they conflict with the trial. The FDA's relabeling reads old evidence differently; it adds none. The pill's link to mood is observational, the adult cycle as a vital sign is expert opinion, and the evolutionary account of PCOS is a hypothesis. The firm core is this: effective treatments for flushes exist, contraception's absolute risks are small, pregnancy complications flag later heart risk, and loaded exercise builds bone.

Go deeper in the reference library

The research this chapter was built from, as longer reference entries: each with its own mismatch card, graded recommendations and the case against it.

See also in the book

Sources behind this page

  1. 9.McNulty, K.L., Elliott-Sale, K.J., Dolan, E., Swinton, P.A., et al. (2020). "The effects of menstrual cycle phase on exercise performance in eumenorrheic women: a systematic review and meta-analysis." Sports Medicine, 50(10), 1813-1827. https://doi.org/10.1007/s40279-020-01319-3 ; Colenso-Semple, L.M., D'Souza, A.C., Elliott-Sale, K.J., and Phillips, S.M. (2023). "Current evidence shows no influence of women's menstrual cycle phase on acute strength performance or adaptations to resistance exercise training." Frontiers in Sports and Active Living, 5, 1054542. https://doi.org/10.3389/fspor.2023.1054542 ; Colenso-Semple, L.M., McKendry, J., Lim, C., Atherton, P.J., et al. (2025). "Menstrual cycle phase does not influence muscle protein synthesis or whole-body myofibrillar proteolysis in response to resistance exercise." Journal of Physiology, 603(5), 1109-1121. https://doi.org/10.1113/JP287342 (The 2025 crossover trial enrolled 12 women.; McNulty et al. pooled 78 studies)
  2. 35.Chlebowski, R.T., Anderson, G.L., Aragaki, A.K., Manson, J.E., et al. (2020). "Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the Women's Health Initiative randomized clinical trials." JAMA, 324(4), 369-380. https://doi.org/10.1001/jama.2020.9482 ; Collaborative Group on Hormonal Factors in Breast Cancer (2019). "Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence." The Lancet, 394(10204), 1159-1168. https://doi.org/10.1016/S0140-6736(19)31709-X ; Manson et al. (2017), as above, for cancer mortality. (WHI combined therapy: about 0.45% vs 0.36% a year; the per-1,000 conversion is this book's arithmetic, and the pooled figures assume the association is causal, as the authors state.)

Every work this chapter cites

The chapter's 39 notes cite 102 works, listed by note number. Each is also in the full source register.

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