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It all comes down to access
“Every single day, I would have a hot flash, maybe two times a day. I was walking around with paper towels under my underarms.”
Fifty-year-old Nehal, who lives in Pasadena and runs an online business, is in the throes of perimenopause. Her symptoms started about six years ago with night sweats. In the beginning, says Nehal, “I didn’t notice it as much because it wasn’t really messing with my life or routine.” But that changed once severe hot flashes, brain fog, mood swings, and heavy bleeding became more frequent.
“I have been suffering a lot for the last two years. And when I say suffer, I actually do suffer.”
Nehal’s journey through menopause reflects the common struggles many women face during this life stage. Some struggle to function competently at a point when they need both mind and body at peak fitness to balance life’s responsibilities, including career and family life. And some suffer in silence, even in well-resourced regions like the Bay Area or Los Angeles, where access to top-tier medical care is readily available, but not to physicians trained in treating menopause symptoms.
Unlike the doctors interviewed for this article, a 2019 Mayo Clinic study found that nationwide, 20.3% of physician respondents (OBGYNs) had received no menopause education during residency, and only 6.8% felt adequately prepared to care for women going through menopause.
“The problem is access,” says Dr. Karen Adams, Director of the Stanford Program in Menopause & Healthy Aging in the OB/GYN department. “Literally, people have to wait eight months to see me. I mean, there’s just not enough of me to go around.”
What is perimenopause?
The Cleveland Clinic defines Perimenopause as the stage leading up to menopause when the body gradually shifts from its reproductive years toward the end of menstruation. This transition can begin several years before menopause, typically in a woman’s forties, but sometimes starts earlier.
In perimenopause, the hormonal rhythm is disrupted as estrogen levels become erratic. These fluctuations can cause symptoms like hot flashes, mood swings, and breast tenderness. Progesterone levels decline, especially as ovulation becomes less frequent. This drop can lead to heavier or irregular periods, anxiety, and sleep disturbances. As ovulation becomes irregular or stops altogether, it further disrupts the balance between estrogen and progesterone.
Over time, this hormonal instability gives way to a more consistent decline in estrogen and progesterone, leading to the end of menstruation and the start of menopause. Menopause is officially diagnosed after 12 consecutive months without a menstrual period.
Nehal describes the symptoms she experienced as menopause kicked in. She had trouble sleeping, random headaches, pimples, shooting pain in her breast and pelvis, water retention, and, of course, hot flashes.
“Brain Fog. Oh, my God, yes. Fog was the biggest thing that annoyed me, because I’m a very task-oriented person. I am pretty good at remembering things, but it was really just going downhill.”
“Mood swings. I was getting very angry, very easily.”
And for someone who describes herself as a ‘very happy person,’ Nehal says, “I had mild depression. I enjoy a lot of things, but I wasn’t on some days of the month”. She stopped enjoying normal things – movies, her favorite food, or just talking to a good friend.
The final straw came late in 2023. Nehal was still experiencing symptoms, but noticed that her periods were becoming shorter with lighter bleeding. She guessed that maybe things were slowly improving or going away on their own. Instead, after December, her periods started every 10 to 12 days, becoming more irregular and unpredictable.
“That’s what really got to me, because I felt like – I can’t get through this,” she recalls. She shares a traumatic incident that happened to her. “I was meeting a friend for lunch, and just in the car, I started bleeding. I had my pants all red, and I was like – What the hell is happening? It wasn’t my normal day, and I think I probably had a period a week ago. So I’m like, what – this is happening again already?”
The birth control pill & perimenopause
Trying to find answers, Nehal booked an appointment with Dr. Rajita Patil, an OBGYN and the Director of the Comprehensive Menopause Center at UCLA. From the moment she walked into the office, says Nehal, she felt like she was heard and that she could find a solution to her symptoms. Dr. Patil did a thorough consultation and got Nehal to complete an in-depth clinical support tool developed by UCLA to capture the full picture of her symptoms and health history.
The result after the review, says Nehal, was that Dr. Patil recommended a birth control pill to help regulate her hormones. Within a month, Nehal noticed a dramatic difference. For the first time in a long while, she felt herself again.
“I’m 80% better now,” says Nehal, listing her improvements after going on birth control.
“I have no headaches, I’m sleeping.
My mood has improved.
The shooting pains have gone away.
I’m not bloated.
My memory is so much better. Fogginess is almost gone.
I’m feeling better and my periods are now every month.”
How did a birth control pill work its magic?
Birth control pills are designed to mimic ovulation, explains Dr. Manjita Bhaumik, an OBGYN at Kaiser Permanente in Redwood City.
In perimenopause, hot flashes can occur for two weeks in a row, go away for months, and then come back; women can feel completely debilitated as hormone levels fluctuate and periods become irregular. “I will put somebody in perimenopause on birth control pills instead of hormone therapy,” says Dr. Bhaumik, “because it keeps the hormones more cyclical, more at levels that are more common in ovulating women.”
Dr. Bhaumik clarifies that birth control pills are hormone therapy as well – they are estrogen and progesterone working together to regulate the menstrual cycle for women.
Estrogen thickens the lining of the womb in the normal menstrual cycle because it prepares the womb. “It has to get nice and thick to receive the fertilized egg and the embryo. And if the fertilization doesn’t take place and pregnancy doesn’t occur, then the progesterone thins the lining of the womb, then you have a period,” explains Dr. Azmy Birdi, an Obstetrics & Gynaecology (OBGYN) physician who is an accredited Menopause Specialist in the United Kingdom.
As with any prescription, dosages can vary, so each patient must work with their doctor to find the right dosage for them. Nehal had to tweak her dosage several times in consultation with Dr. Patil to alleviate her symptoms.
Using Hormones to Ease Menopause Symptoms
However, the vernacular is changing, says Dr. Bhaumik. “We don’t like calling it hormone replacement therapy anymore; rather, (we call) it hormone therapy (HT). And the rationale behind that is that it is intended to be a treatment of symptoms, not necessarily replacing something that’s lost.”
That’s important, Dr. Bhaumik explains, because not all women struggle with menopausal symptoms. “Everybody is very different in how they experience menopausal symptoms, and some women don’t need to take hormones and do okay going through the transition of menopause, whereas other women really struggle.”
She sees a trend emerging in women among the perimenopausal or menopausal age group of an increased interest in seeking hormone therapy and talking about menopause, after it fell out of favor. However, in all her years of practice, says Dr. Bhaumik, working with women in menopause, she always advocated for HT, even when it was not in vogue.
In the early 2000s, following the release of the Women’s Health Initiative (WHI) study, hormone replacement therapy (HRT) faced a major setback. The findings raised alarms by suggesting a link between HRT and increased risks of breast cancer, cardiovascular disease, and stroke. The impact was immediate and far-reaching—prescriptions plummeted. In 2000, about 1 in 5 women over 50 were on HRT; by 2008, that number had dropped to fewer than 1 in 20.
“And so we went from giving everybody HRT to nobody getting HRT,” says Dr. Deepika Reddy, an endocrinologist in Salt Lake City, Utah.
However, in the years that followed, a reanalysis of the WHI trial 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.
The Science behind Hormone Therapy
Hormone Therapy is prescribed based on a woman’s symptoms, medical history, age, and whether she’s had a hysterectomy (removal of the uterus), notes Dr. Bhaumik, adding that a doctor will tailor the type, dose, and delivery method to her needs.
Estrogen and progesterone are prescribed for women who still have a uterus, but if they’ve had a hysterectomy, estrogen alone is usually enough; they don’t need progesterone, explains Dr. Birdi.
She goes on to explain that if a woman is given estrogen after menopause without progesterone, it could thicken the lining of the womb, leading to a condition called endometrial hyperplasia, which could turn cancerous.
Dr. Bhaumik has a standard dosage she starts with, but tweaks after an individualized conversation with her patients. “I usually recommend using it for at least one to two months to see how it works before deciding to change.” Her priority is informed, patient-centered care, and she is committed to supporting women in making their own decisions.
A doctor might prescribe hormones in the form of pills, patches, gels/sprays or vaginal treatments depending on a woman’s preference, lifestyle and medical needs.
“You can do oral estrogen with oral progesterone. You can do an estrogen patch with oral progesterone. Or you can do a patch with both,” Dr. Reddy clarifies.
Dr. Karen Adams explains that taking an estrogen pill increases the risk of blood clots once it goes into the liver. “Now it’s not a huge risk – it’s about 18 extra cases per 10,000 women,” she adds, but one that’s avoidable by taking the risk down to baseline with something other than a pill. “They do a skin patch, or we do gel on your arm, or gel on your leg, or we do a ring in the vagina.” She recommends the progesterone pill at night because the side effect is drowsiness. It helps people sleep.
The patches come in five dosage strengths, explains Dr. Adams, and the middle dose has been shown in trials to protect people’s bones. Without adequate data about lower doses, doctors will typically start people on the middle dose of the patch. “It manages their symptoms, and it will protect their bones later on in life. But then we can adjust if we need to.”
Not a Candidate for Hormone Therapy
There’s a small group of people who are not good candidates for hormone therapy, says Dr. Adams. They include women who have a personal history – not a family history – of breast cancer, or women who have had a blood clot in their leg or their lung, or their brain. Generally, hormone therapy is not recommended for people who have had a heart attack or a stroke, gallbladder or active liver disease, pregnancy, or people who have undiagnosed vaginal bleeding.
Sheila (name changed to protect her medical privacy), like many women going through perimenopause, is constantly on the go. She’s a mom, a wife, a daughter, and holds a high-pressure corporate job. About a year ago, she began waking up several times a night, drenched in sweat from hot flashes. Her sleep patterns became fragmented, and she never felt rested. Lying in the dark, she’d glance at the clock, stressed about her day, “Oh God, I have to be up for a seven o’clock meeting.” Exhaustion crept into her days, though like many women, she kept pushing through.
After sleepless nights and relentless hot flashes, Sheila scheduled an appointment with her gynecologist. She also talked to friends and started researching books and articles to better understand what was happening to her body. After a detailed consultation and routine tests—including a mammogram—Sheila was cleared for hormone replacement therapy (HRT).
Before her treatment began, Sheila experienced an unnerving incident. While watching TV, she noticed that the straight lines on the screen appeared crooked. Instantly, Sheila knew something was wrong, and a trip to the optometrist confirmed her fears. She was immediately referred to an ophthalmologist, who diagnosed her with Branch Retinal Vein Occlusion (BRVO), a condition where a small vein in the retina becomes blocked, potentially affecting vision.
Sheila now receives treatment for her BRVO, but that diagnosis came with an unexpected setback – she is no longer a candidate for hormone replacement therapy because HRT can potentially worsen vascular issues or increase the risk of complications. Sheila is grateful this was caught in time, before it led to more serious health consequences.
The hidden economic cost of menopause
More than 1 million women in the United States go into menopause each year. A national survey by AARP reveals that 90% of women over the age of 35 experience one or more menopause symptoms. With nearly 50 million women in the U.S. workforce falling within the menopausal age range—and symptoms that can last a decade or more—menopause isn’t just a personal health issue. It carries serious economic implications for employers, working women, and ultimately, the broader U.S. economy.
The Mayo Clinic estimates that the U.S lost $1.8 billion in work time per year and $26.6 billion annually after medical expenses were added.
Making a more direct economic case – a study in the UK shows that an additional £1 invested in obstetrics and gynaecology services per woman in England could generate an estimated £319 million return to the economy.
This is because about 60,000 women in the UK are unable to work because of the impact of menopause symptoms on their overall physical and mental health. This report also laid bare the stark health inequalities women face nationwide in the UK.
“Women are taking their place outside (the home) because of the economic structure or the needs of families. And if you’re suddenly getting mood swings, you’re getting hot flushes, nights you have other symptoms – then you know it is a huge problem for your work. You need help,” adds Dr. Azmy Birdi.
Navigating early menopause
A media professional, whose name has been withheld to protect her medical privacy, was diagnosed with early menopause at the age of 39 in 2015. The diagnosis was confirmed by an FSH (follicle-stimulating hormone) test, which showed postmenopausal levels. Being diagnosed as menopausal at age 39 was hugely unsettling, but she wasn’t surprised – her mother had also experienced early menopause.
Unexpectedly, to her amazement, she became pregnant in 2016, a pregnancy that boosted her mental health. “My second pregnancy was a very happy pregnancy.”
“When I heard that I might be going (through) menopause at that age, I didn’t feel sad, but the pregnancy, you know, back to those hormones – happy hormones – I think it was good.”
A few years later, her OB/GYN reconfirmed the diagnosis of early menopause, and both her OB/GYN and primary care physician recommended she begin hormone therapy. “Since 2020, I’ve been on HRT,” she says — and she feels good. No more night sweats, no roller coaster emotions, and no unexplained weight gain.
She credits her mother as her greatest advocate, recalling her advice to see a doctor and get treatment.
A Right Time to Begin HT?
Initiating hormone therapy depends on several factors. “If you start under age 60 or less than 10 years from your last menstrual period,” says Dr. Adams, “then you have this window of opportunity where you start and you just stay on.”
Her approach is to review her patient’s health history and new diagnoses every year to make sure there are no new contraindications. “Then we decide whether to continue or not. But we don’t automatically stop at any time.”
Personally, Dr. Adams says, “I’m 66 and they’re going to get my hormones when they pry them from my cold, dead hands. I’m not giving them up.”
Educating patient and provider
At the Stanford menopause program, advocacy and research are also a big part of their charter at the local, state, and national levels for menopause friendly workplaces and increased funding for both research and care.
Dr. Adams puts it in perspective – “women’s health is the most over-legislated and under-researched area of health care.”
At her clinic, in addition to patient care, Dr. Adams offers education for both patient and provider. “I’m really, really passionate about training every provider,” she says, and wants to increase access to trained specialists. Her program recently hosted a menopause conference that was attended by 1100 people from 47 states and 16 countries around the world.
“That’s a big part of what I was brought in to do because I can’t see all the people who need to be seen. I’m really trying in our program to train other providers so that there’s more access for patients.”
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 second article in a series about menopause.
Read the first article here: Beyond The Hot Flash: Unveiling Menopause
Photo by OG Productionz: https://www.pexels.com/photo/a-woman-in-a-sweater-is-holding-her-head-16249348/
