New treatments, renewed focus galvanize menopause care

Every year, 1.3 million American women reach menopause, many having experienced years of bewildering symptoms that mark the end of their reproductive lives. Yet less than half of women ages 50 to 64 report that a health provider told them what to expect during the menopause transition - much less how to manage disruptive and sometimes debilitating symptoms such as hot flashes, brain fog, and sleep disturbances.

Fortunately, the outlook for women at this critical life stage is improving. A growing number of academic medical centers have launched centers dedicated to women's midlife and menopause health, including the Women's Health Specialty Clinic at Mayo Clinic in Jacksonville, Florida; the Center for Midlife Health and Menopause at NYU Langone Health; the UCLA Comprehensive Menopause Program; the Women's Wellness and Healthy Aging Program at multiple Johns Hopkins Medicine locations; and the Midlife Women's Health and Menopause Program at the University of Utah Health.

At the same time, more doctors and other health care practitioners are joining the leading professional organization in the field, the Menopause Society (formerly the North American Menopause Society), and seeking certification to demonstrate their expertise in providing women with needed care. According to Stephanie Faubion, MD, MBA, director of the Mayo Clinic Center for Women's Health and the society's medical director, the ranks of the society have exploded from 2,000 to nearly 12,000 in the past five years. There are currently some 4,100 Menopause Society-certified menopause practitioners, up from about 1,000 a decade ago, all searchable by geographic location on the society's website.

"Effective treatment affects the ability for someone to function, to do their job, to maintain a relationship - the list goes on and on," says Lauren Streicher, MD, clinical professor of obstetrics and gynecology at Northwestern University's Feinberg School of Medicine and the founding medical director of the Northwestern Medicine Center for Sexual Medicine and Menopause. "You're not only helping women through this midlife transition, but you're also setting the stage for the second half of their lives, as the decisions made during this time have a huge impact later on with things like bone health and fracture risk."

Menopause and its impacts

The average age of menopause - the cessation of menstrual periods for a year - is 52. Most women experience a transition period, known as perimenopause, that typically lasts four to eight years, as their estrogen levels seesaw and then fall. This can trigger vasomotor symptoms (hot flashes and night sweats), vaginal and vulvar issues, painful sex, urinary tract infections, incontinence, mood changes, and insomnia, as well as less familiar symptoms, such as fatigue, dizziness, anxiety, panic attacks, pelvic pain, migraines, memory lapses, and even joint pain.

Menopause is a challenge not just because it can be hard to navigate the symptoms, but because of its lasting impacts, experts say. As estrogen declines, so does its healthful effects on the entire body - from the cardiovascular system to sexual functioning, brain health, and bone density. Research shows that declining hormone levels leave menopausal women at an increased risk for heart disease and stroke, and data suggest it's important to understand the interplay between menopause and Alzheimer's disease to determine the best therapies for women.

The most effective treatment for many menopause symptoms is hormone therapy (HT), say experts. "Menopause hormone therapy provides relief from hot flashes and night sweats 85% of the time," says Samantha Dunham, MD, clinical associate professor of obstetrics and gynecology at NYU Grossman School of Medicine and codirector of the Center for Midlife Health and Menopause.

Until 2002, HT was the standard therapy of choice for millions of women suffering from menopausal symptoms. However, that year a large study, from the Women's Health Initiative (WHI), found links to heart disease and breast cancer, and overnight, the use of hormone therapy dropped by almost 50%.

Subsequent analyses largely rebutted the study's conclusions that the risks of HT outweighed the benefits, many experts say. The breast cancer risk associated with the use of hormones amounted to less than a 10th of 1% per year, noted the WHI's former acting director, Jacques Rossouw, MD, The New York Times has reported. At the same time, news of the study played down the therapy's clear benefits, including drops in the risk for colon cancer and osteoporosis. In addition, the study evaluated only one type of hormone therapy and focused on women who were 12 to 15 years past the onset of menopause - only 30% of the participants were younger than 60, according to a 2023 report.

Many experts now believe that there is an optimal window of time for hormone use. The treatment is generally considered appropriate for women under age 60 or within 10 years of menopause, with bothersome symptoms, and at low risk for heart disease, breast cancer, and venous thromboembolism.

"Overall, for the majority of people, this is a low-risk medication to use at the time of perimenopause and menopause," says Rajita Patil, MD, director of the UCLA Comprehensive Menopause Program and assistant clinical professor of obstetrics and gynecology at the UCLA School of Medicine.

Yet, Faubion points out, only 1.7% of women are on systemic hormone regimens. "It was well over a quarter of women using systemic hormone therapy [in 2002], so we are still at an all-time low," she says. "We're probably underutilizing this effective therapy."

In addition to oral tablets and capsules, HT is delivered in transdermal products such as estrogen patches, gels, and vaginal rings. With these modes of delivery, the hormone may more naturally mimic the hormones in the body, says James Simon, MD, a clinical professor of obstetrics and gynecology at the George Washington University School of Medicine and a leading menopause researcher and clinician. Also, patches, gels, and vaginal rings bypass the liver, allowing estrogen to be absorbed directly into the bloodstream; thus, these products pose a lower risk for blood clots, Streicher says. Vaginal hormones that work locally to combat genital and urinary symptoms (known as the genitourinary syndrome of menopause) are considered to be safe for almost everyone.

With the shadow cast on HT, there's been a focus on alternatives to estrogen. Nonhormonal agents to treat hot flashes are being developed, and older drugs are being recruited for symptom relief. For instance, some antidepressants have been shown to quell vasomotor symptoms as well as stabilize mood.

Plus, lifestyle measures play important roles. "[Women's] sleep habits, nutrition, and exercise habits impact how they do," says Dunham.

New products, investigational medications, and even new indications for older drugs may add more tools to the menopause toolkit. An older drug, Duavee, which is a combination of estrogen and the drug bazedoxifene (a selective estrogen receptor modulator, or SERM), may actually help to reduce the risk of breast cancer, a recent Northwestern University study suggests. Women with ductal carcinoma in situ (DCIS) taking Duavee had lower levels of a key marker of cell growth in the breast tissue, compared with women on a placebo. Cancer patients are typically advised against taking standard hormone therapies.

A nonhormonal hot flash drug, fezolinetant, was approved in 2023. And a new one called elinzanetant, currently under investigation, has been shown to significantly reduce the frequency and severity of vasomotor symptoms.

"It affects one of the neurons that talks to the temperature control center in the brain and reduces vasomotor symptoms," says Dunham. "It looks like it's beneficial for sleep disorders as well."

Renewed focus on menopause spurs big changes

The actress Halle Berry has said that it took years for her to realize that her bewildering symptoms were related to menopause. In 2024, she took her frustration to Congress to lobby for research funds. At a press conference outside the U.S. Capitol, she declared, "I'm in menopause!"

"Midlife women are not ashamed of the fact that they are now midlife and are recognizing that the symptoms they've been told are just a natural part of aging are really ones that should be addressed, whether it's sexual concerns, cardiac issues, which get ignored in that age group, or weight gain," says Sheryl A. Kingsberg, PhD, professor of reproductive biology and psychiatry at the Case Western Reserve University School of Medicine and chief of OB-GYN behavioral medicine at University Hospitals Cleveland Medical Center.

The hospital-based menopause programs that are popping up around the country tend to rely on networks of specialists for hard-to-treat symptoms. The multidisciplinary Northwestern Medicine Center for Sexual Medicine and Menopause includes specialists in reproductive endocrinology, musculoskeletal pelvic pain, and vulvovaginal disease, many of them certified through the Menopause Society. The same is true at UCLA, where patients may be referred to the program's menopause neurologist to address cognitive concerns or to a sleep medicine specialist to rule out a sleep disorder. First, patients new to the program fill out a detailed online questionnaire. Then, with the help of organ-specific algorithms the program has developed, providers prioritize and guide treatment recommendations, based on contraindications to treatments and patient preferences, says Patil. Behavioral health is also a key component of treatment.

A wide scope is necessary, says Faubion. "I see women in my internal medicine practice that have no idea that the conglomeration of symptoms they're experiencing relates to menopause," she says.

An unmet need

Faubion, along with other physician experts, would like to see more training for all physicians about menopausal symptoms and treatments. A 2019 Mayo Clinic study found that just 6.8% of obstetrics and gynecology, family medicine, and internal medicine residents felt adequately prepared to manage the health care needs of women experiencing menopause. According to a 2023 report, less than a third of OB-GYN residency programs offer training in menopause. One reason: "After the WHI study, hormones were a complete no-no, so there was little or no education around them," says Simon.

The Menopause Society recently launched the NextGen Now initiative, a $10 million training program to equip 25,000 health care professionals (physicians, nurse practitioners, physician assistants, and trainees) with training experiences, study materials, scholarships, and consensus recommendations for treating women effectively during and after the menopause transition. Patil has also developed a continuing education course for primary care physicians and ob-gyns at UCLA, with the goal of expanding the network of menopause providers to meet the rising demand for treatment. She eventually hopes to extend the model of integrated menopause care to all University of California-affiliated medical centers.

Such efforts would not only help get physicians up to speed on menopause but also combat the misinformation many women receive from dubious online platforms peddling medications or supplements, part of a burgeoning $18 billion menopause market.

"Business interests jumped on the need for information to fill the void," says Simon. "Although well-meaning and educated practitioners are in that space, there are also deceptive charlatans."

There are many routes to becoming a menopause practitioner. Although some come to the field by way of obstetrics and gynecology, others are in internal medicine, urogynecology, reproductive endocrinology, or even psychiatry. "Internal and family medicine doctors are the ideal people to deal with hormones and menopause, because they know about brain, bone, and heart health," says Faubion.

She adds that the rewards of the specialty can be profound.

"It's one of the fields in medicine where it's easy to help people who are really struggling," Faubion says. "Women come back and tell me that I saved their lives, all the time. I recently stopped someone from quitting her job because of menopause symptoms. Another woman who got relief from horrible mood symptoms, along with her hot flashes and night sweats, told me that I literally saved her from being suicidal. It's a very rewarding field, because you can make a huge difference for people."