Menopause not taught in medical school
When Dr. Rajita Patil, an obstetrician-gynecologist at UCLA was a resident, she remembers her OB/GYN program offered only one lecture on menopause. “There’s no curriculum,’ she explained. “We don’t get enough training in this field in residency programs.”
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A 2019 Mayo Clinic study found that 20.3% of respondents (doctors) reported not receiving any menopause lectures during their residency and only 6.8% felt prepared to manage women experiencing menopause.
The Mayo Clinic study confirmed what Dr. Patil had observed for years as a practicing OB/GYN. She recognized that leaving menopause out of medical school curriculums and residency programs impacted women’s health because it led to a lack of research and funding for the field. Though inevitable for all women, menopause continues to be understudied, undertreated, and stigmatized.
Menopause is a natural part of aging for all women. More than 1 million women in the United States experience menopause each year reports the NIH, yet the striking reality is that the majority of OB/GYNs receive little to no specialized training in how to properly treat and manage the condition.
Menopause is having a moment
In August 2023, Dr.Patil launched the Comprehensive Menopause Care Center at UCLA to radically change the landscape of how women get the medical support they need during this phase of life. She pointed out that women face additional challenges, apart from a lack of trained caregivers.
From a societal standpoint, “at least in this country – we equate menopause with aging, and there’s like a negative stigma or a shame to it,” said Dr. Patil. Nor do women want to admit their vulnerability to aging because both society and even the medical community have not given them the due care they deserve.
In many other cultures, menopause is a taboo topic because it is a part of reproductive health care, said Dr. Patil. In South Asian cultures, for example, families don’t talk about reproductive health. “The difference in our culture is that.. we didn’t grow up with our parents talking to us about that.”
However, menopause is starting to have a moment. In modern society, especially in the West, women freely discuss hot flashes, night sweats, brain fog, and even heart palpitations- something their mothers never did. But women need help to navigate the menopause years.
“I think that the good thing right now is that we are starting to talk about menopause, ” said Dr. Patil. “That’s a great start. I think that patients are advocating for their care now and demanding care, which is super important.”
What is menopause?
Menopause is the natural biological process marking the end of a woman’s menstrual cycle and fertility. It typically occurs between the ages of 45 and 55, but the exact timing can vary. It can last anywhere from 3 to 10 years and range from mild to extreme symptoms Menopause is officially diagnosed after a woman has gone 12 consecutive months without a period. 50% of all humans experience menopause in their lifetime.
Menopause, a retrospective diagnosis, technically describes just one day – a year after a woman’s final period. After that, she is considered postmenopausal. Perimenopause, on the other hand, is the phase before menopause (which can last anywhere from two to eight years) when the first symptoms appear.
During this time, the ovaries stop producing eggs, and hormone levels decline, especially estrogen and progesterone. This leads to physical and emotional changes, such as hot flashes, night sweats, mood swings, vaginal dryness, and changes in sleep patterns.
Though it marks the end of menstruation, menopause itself is not a medical condition but a natural transition in a woman’s life. While some women experience mild symptoms, others face more severe ones that impact their daily lives and may require treatment to manage effectively.
The physical symptoms
Hot flashes
“The number one that everybody talks about is vasomotor symptoms or hot flashes and 80% of people will experience this in some capacity. The average length of duration that these can be present is normally seven to nine years. And so, it’s a very long time but 10% have lifelong flashing,” said Dr. Patil.
Sleep disturbance
One of the most common symptoms is sleep disturbance, she added. “That can happen a lot of times because of hot flashes. It can also just be the chain that’s happening during perimenopause and early menopause marked by wild fluctuations of hormones. The normal dance that’s happening when you have your period, where you have this very specific rise of levels and ovulation and drop in levels – that’s not happening. It’s all ramped up and that’s what causes the symptoms. You can also have sleep disturbance because of simple hormone changes, but most of the time it’s about staying asleep.”
Aches
Women also experience joint pain and muscle aches and often a 5-to-15-pound weight gain. It’s partly the result of natural metabolic aging, but there is also a sudden sort of loss in muscle, as well as a redistribution of the fat in the body to the middle area, especially in South Asian people, leading to a higher risk for diabetes and heart disease.
Skin & hair changes
There are skin and hair changes as well – more sensitivity of their skin, more eczema, and some women will experience hair loss as well as gut changes. The physical symptoms can also include bladder elasticity changes as well as vaginal dryness.
Mental health impacts
The other symptom that is very common is mood changes. The number one thing to understand is that there are estrogen receptors in the entire body, from your hair, your skin, your vagina, to your heart, everywhere, said Dr. Patil.
The neurotransmitters in the brain are affected by the fluctuations of hormones. “Someone might be riding along, never even having a history of mental health and now the changes are biologically happening and all of a sudden – they’re like – what I normally did when I had to cope with something is not working. I’m very irritable, or I’m very anxious, or I’m feeling sad. And I don’t know why, like there’s nothing changed, but I just don’t know what my problem is.”
That is very normal, said Dr. Patil, but those who have had prior mental health history might see exacerbations during this time.
“You also have to think about what is happening in a person’s life during menopause. They’re usually at the top of their careers, functioning at a high level, raising children but often also taking care of their elderly parents. So, they’re like juggling all this enormous responsibility and doing fine.”
“But then all of a sudden, they’re not able to cope as well. And it’s like a spiral, you know.”
Women start to feel like they can’t recall words. The processing speed and their attention are affected. “And it’s a real thing. It’s because again, the neural connections are lost,” says Dr. Patil.
The good news is that new connections are built over a longer period to make up for that, but it can take time. For most people, it’s a temporary fog.
But Dr. Patil cautioned that there is missing science in this area “We don’t know for which people. There’s going to be lingering issues that lead them to a little higher risk for cognitive impairment and dementia in the future.”
The Comprehensive Menopause Care Center at UCLA
The only one of its kind on the West Coast, Dr. Patil’s Comprehensive Menopause Care Center has six providers working in collaboration with more than 30 UCLA Health specialists in bone health, sleep, cognition, integrative medicine, genitourinary health, and other areas affected by the menopause transition. The Center has treated more than 1000 patients so far and will double that number in 2025, says Dr. Patil.
Recognizing that menopause is the least-funded area of women’s health research, Dr. Patil and her team developed a proprietary UCLA-developed clinical support tool that takes into account the diverse physical, hormonal, and psychological aspects of menopause.
This tool assesses bone health, breast health, cardiovascular health, cognition, mental health, sleep, genitourinary health, gut health, hot flashes, and lifestyle practices.
Responses are processed through a series of organ-specific algorithms that assign a stoplight-style color code to each area. Green indicates few symptoms and risks, yellow signals that the area needs attention, and red highlights areas of potential concern and high risk, likely requiring referrals.
This rigorous intake form allows the medical provider to get a comprehensive snapshot of a patient before they even walk in the door. So when the patient is seen, it’s a much more productive conversation allowing Dr. Patil and her team to focus on shared decision-making and form and plan an individualized treatment that considers each patient’s unique genetic profile, health history, and personal preferences.
This innovative solution meets a demand that’s going to grow in this country. “And that’s really hard to do and so I think that we’ve kind of figured that part out,” said Dr. Patil.
History of Menopause Treatment
Hormone Replacement Therapy (HRT) started in the 1960’s and grew in popularity for women suffering many of the menopausal symptoms. In 2002, the first results of the Women’s Health Initiative (WHI) were published. The negative findings of the study were widely publicized, causing panic among some users and prompting new guidelines for doctors on prescribing HRT. The media’s message was clear: HRT posed more risks than benefits for all women.
In the years that followed, a reanalysis of the WHI trial was conducted, and new studies revealed that HRT use in younger women or those in the early postmenopausal phase had a positive effect on the cardiovascular system, reducing coronary disease and overall mortality.
But the damage was done, leading to significant negative consequences for women’s health and overall quality of life during menopause. Residency programs, already intent on cutting back hours, stopped investing time teaching menopause, while practicing doctors became much more hesitant to prescribe HRT. Menopause stopped being talked about by patients and doctors alike.
Gen X women, now in menopause, are enraged. High-functioning women are struggling to sleep, get to work, sweat through their clothes, and keep their lives in check. And they are not getting medical help from doctors who are downplaying their symptoms.
What the future holds
Women need to talk with their healthcare provider to determine the best treatment options based on their symptoms, health history, and personal preferences. There are several solutions to help manage menopause symptoms, depending on the severity.
They include Hormone Replacement Therapy (HRT), one of the most effective treatments for relieving hot flashes, night sweats, and other vasomotor symptoms. It involves supplementing the body with hormones such as estrogen and progesterone to balance hormone levels.
There are Non-Hormonal Medications for women who cannot or prefer not to take HRT for example, those with a history of blood clots.
Cognitive Behavioral Therapy (CBT) is a very structured psychotherapy that helps to change behaviors. It’s been very much shown to help for insomnia or mood for vasomotor or hot flashes, says Dr. Patil.
Simple lifestyle changes such as regular exercise, a balanced diet, stress management, and good sleep hygiene can help alleviate some symptoms. “From a lifestyle standpoint, there’s so much to talk about in terms of the proper diet and exercise, and the bone strengthening that we need to be kind of focusing on to live our best lives going forward,” she suggests.
Alternative therapies like yoga, ayurveda, and acupuncture also have a role to play and Dr. Patil and her team at UCLA have put a special focus on learning more about these other solutions to help their patients.
Who pays for treatment?
Most insurance companies create a burden for most patients because they do not approve most therapies, explains Dr. Patil. The danger is that women are struggling without medical solutions, leaving them vulnerable to unsafe practices that are not scientifically proven. A simple online search reveals a vast array of so-called solutions, many of which are promoted by social media influencers.
In response, Dr. Patil and a team of doctors went to Sacramento to advocate for patients in the California Senate and push for the approval of Assembly Bill 2467.
This bill will require a health care service plan contract or health insurance policy to include coverage for evaluation and treatment options for perimenopause and menopause. This will include hormone replacement therapy, prescription medications, and alternative therapies.
“The goal of it is really to make insurance companies cover basically the different classes of drugs that are approved and regulated and scientifically proven to be safe and effective,” explains Dr. Patil.
Young women are taught about puberty, contraception, and pregnancy, but many have never been taught about menopause or even know what the word means, according to Dr. Patil.
That needs to change. It’s time to normalize talking about menopause and help women live their best lives, at any age.
This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations and The NIHCM Foundation.
This is the first article in a series about menopause.
Read the second article here: What Every Woman Should Know About Menopause & Hormone Therapy
Lead image artwork by Tanya Momi.