GLP-1s, the new, “magic” weight loss medications, work by causing food to move through the digestive tract more slowly as well as by interacting with hormones and neurotransmitters such as insulin and dopamine to regulate blood sugar and suppress appetite. Although originally designed to combat Type 2 diabetes, they are being widely used by people trying to lose small amounts of weight or even prevent weight gain due to aging or menopause. Because GLP-1s are so new we do not have a lot of research about them generally, and no information at all about their long-term effects on the body and brain.

An April 7, 2026 Medscape article by Sarah Amandolare enumerates multiple sexual and pelvic floor issues that are being seen in women who are taking GLP-1s. Interestingly, most of these are symptoms of GSM, Genitourinary Symptoms of Menopause:

· Vaginal dryness

· Vulvar changes

· Labial changes

· Itching and dryness in genital area

· Discomfort or pain with sex

Medscape Article

Menopause Matters | GSM

Additionally, some women are experiencing constipation and a lack of libido.

The majority of women taking GLP-1s are between 50 & 64. This is followed by women in the 30-49 age group. Clearly, this is the demographic that is also most likely to be transiting the 7-10+ years of perimenopause and experiencing some percentage of the vast variety of symptoms that go along with that.

At this point, the research cannot draw any conclusions, but while the GLP-1s do not necessarily seem to be causing the symptoms perimenopausal women are experiencing, they are likely to be exacerbating them in various ways:

Labial changes

· When people lose weight, they may be more likely to notice their genitals, especially if abdominal fat had been hiding the genital area previously. If women are unfamiliar with the appearance of their labia, they may not know what is “normal” for them and may worry that what they are seeing is abnormal.

Labia Library

· When women lose weight, this can also lead to fat loss in the labia majora and pubic mons. When the labia lose fat, their appearance will change and the excess tissue that is no longer plump or well-lubricated can rub, leading to itching, irritation, and discomfort during sex. It is possible dry tissue irritated by clothing or rubbing could potentially lead to ulcerations as happened to one woman described in the article.

Dehydration, Malnutrition, Loss of Muscle Mass

· Unsupported rapid weight loss, meaning weight loss that has not been accompanied by specific lifestyle changes, can aggravate menopause symptoms and seriously undermine health for women going through menopause. Both the gastrointestinal side effects of GLP-1 medications and the appetite suppressing effects mean that people are taking in less food. There are at least two challenges with this:

o We do take in some of our water through food. If we are not conscientiously taking in water and salts and minerals, we are going to become dehydrated, and this intensifies the dryness already experienced by women in perimenopause.

o If we are both not eating as much and not eating nutrient dense food, we are likely to become malnourished. Malnourishment contributes to a loss of muscle mass, and both these things contribute to bone density loss.

· Unless we are actively engaging in resistance and strength training exercise when we lose weight, we are likely to lose some percentage of that weight in muscle mass. Women going through menopause are already at risk of losing muscle mass because of hormone and body composition changes. GLP-1 initiated weight loss can make this problem worse.

§ In a recent podcast, Mayim Bialik spoke with Dr. Stacy Sims about GLP-1s and women. Some food for thought:

· For every 10 pounds lost on a GLP-1, up to 4 pounds can be muscle mass.

· Muscle is associated with glucose control, brain development, and cardiovascular health.

· Rather than focusing on what there is to lose, it may be beneficial to consider what we can gain by laying down bone & muscle.

Genitourinary Symptoms of Menopause (GSM) and Pelvic Floor

· While the loss of abdominal fat from GLP-1 use can improve symptoms of stress incontinence or overactive bladder, dehydration contributes to constipation. This, in turn, can increase the risk of pelvic floor dysfunction, pelvic organ prolapse (POP), and incontinence.

Menopause Matters | POP

The Microbiome

• There is evidence that because GLP-1s decrease food intake and slow gut motility, the gut and vaginal microbiomes may be impacted in negative ways. Specifically, there is likely to be a decrease in variety and numbers of beneficial microbes in the digestive tract. This can pave the way for higher systemic inflammation, infection, and compromised immune system health.

Sex

· Although some women taking GLP-1s report feeling more sexually confident, libido can take a hit. One of the primary ways that GLP-1s work is to suppress appetite and compulsive behaviors by downregulating dopamine. However, dopamine is our reward-seeking neurotransmitter and an important part of a healthy libido.

Hormones

· Finally, we know that GLP-1s change how the body processes fats and this can affect sex hormones. As an OB/GYN quoted in the article said, “Our sex steroids are derived from cholesterol, so if you have a real change in your lipid metabolism, it makes sense to me that you could have changes related to your estrogen and testosterone levels.”

We have no idea how GLP-1s are affecting what are already turbulent fluctuations and precipitous drops in critical hormones through the menopause transition.

Considerations for taking GLP-1s

The recommendations in the Medscape article focus on encouraging doctors to ask about sexual or genitourinary concerns and to prescribe physical activity and pelvic floor physical therapy along with any GLP-1. However, while we are waiting for the medical profession to approach health from a more wholistic stance, women interested in taking GLP-1s can be proactive about their well-being in a variety of ways:

· Consider how you will nourish and hydrate yourself with nutrient dense food as you lose weight. Do you know what you need to know about nutrition to lose weight safely?

• Incorporating prebiotic and probiotic foods into your diet and/or taking a probiotic supplement formulated for vaginal health can support the vaginal microbiome.

· How will you incorporate physical activity into your life if you have not already done so? How will you build muscle and bone so that you preferentially lose fat?

· Do you have any sexual concerns about losing weight? How might your sex life change if you lose weight?

· Familiarize yourself with your own genitals and labia generally. Check out the “Labia Library” at the link above or check out

All Vulvas Are Beautiful

· Do you have any pelvic floor vulnerabilities or genitourinary issues that may be complicated by weight loss?

· Where are you in your menopause journey? Do you know what symptoms you are experiencing that seem to be due to menopause? How are you addressing them?

• Using vaginal estrogen in the form of a cream or suppository is a very low risk, low cost way to support vaginal health throughout peri- and post-menopause.

· If you are not yet in menopause, do you know what symptoms might be part of menopause so you can watch out for them?

· Who is part of your health support team? Doctors, personal trainer, nutritionist, family, friend group, etc.

There is so little research available for women about menopause and much less about GLP-1s. We need to be proactive not only about medications and treatments that may enhance our health, but in how we support ourselves in getting healthier and stronger as we use these medications and treatments.

The evidence we do have about GLP-1s is that there is no magic bullet that makes us healthier. These medications do have the capability of helping some people lose weight relatively quickly, but they don’t confer health, and it seems likely they put us at risk of ill health if we don’t take advantage of the opportunities they offer to alter certain habits and make positive changes. Exercise, nutrition, sleep, supportive relationships—these are the things that consistently bolster health and well-being. Right now, GLP-1s are creating an opening for renewing our relationships to these things. And this may be their greatest benefit.

Disclaimer

This blog post is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation.

References

Amandolare, S. (2026, April 7). The Nuanced Sexual and Pelvic Floor Effects of GLP-1s on Women. Medscape. https://www.medscape.com/viewarticle/nuanced-sexual-and-pelvic-floor-effects-glp-1s-women-2026a1000ah4

Kassel, G., & Eisenberg, A. (2026, May 12). Taking Ozempic? Surprising Ways It Can Affect Your Vaginal Health. HealthCentral. https://www.healthcentral.com/condition/obesity/surprising-ways-ozempic-can-affect-your-vaginal-health

Rand. (2025, August 6). Nearly 12 Percent of Americans Have Used GLP-1 Weight Loss Drugs; Medications Are Most Used by Women Aged 50 to 64. https://www.rand.org/news/press/2025/08/nearly-12-percent-of-americans-have-used-glp-1-weight.html

Image References

GLP-1s: https://vitalrecord.tamu.edu/how-glp-1-medications-are-transforming-diabetes-and-weight-loss-treatment/

Vulva/Vagina: https://www.drtahery.com/the-vagina-anatomy-and-how-it-changes-over-time

The Pelvic Floor

The pelvic floor essentially consists of layered muscle and connective tissue that sweeps from left to right and front to back of the pelvis, encircling, supporting, and largely controlling the actions of the three orifices (in women) that emerge at the bottom of the body, the urethra, the vagina, and the anus.

In the front, a set of pelvic floor muscles (PFM) attach to the pubic bone and in the back to the tail bone (coccyx). A second set of muscles stretch from sitting bone to sitting bone (ischial tuberosities) from left to right. All together these muscles are often likened to a hammock or sling.

Most of the time these muscles do their work without us noticing them. They are responsible for:

o Maintaining tone and being able to contract and release so that we have reliable control over processes of elimination and to create some protection about what enters these areas.

o Strong, flexible PFM can contribute to sexual function and pleasure.

o The pelvic diaphragm, another name for this muscle group, are considered one of the breathing diaphragms. It needs to be both toned and flexible for breathing to be full, relaxed, and deep.

o The PFM are also considered part of the “core” of the body. As such, they are implicated in postural integrity, stability and balance, and also essential to

o Creating a stable, strong floor to hold up all the internal organs above them. They literally keep our insides from falling out through our legs.

Except when they don’t…

Pelvic Organ Prolapse (POP)

POP is a condition in which one or more of the structures of the pelvic region either impinges upon another organ (cystocele, rectocele, enterocele) or falls out of place.

This is an excellent video from “Pelvic Empowerment” describing and illustrating what prolapse and cystocele and rectocele are:

(Time stamps in the video notes)

Essentially, prolapse refers to the descent of an organ through its respective tube. So, the bladder falls into the urethra, the uterus into the vagina, and the rectum into the anus.

“-cele” is a medical suffix that means “bulging” or “pouching.” In these cases, an organ or structure impinges on another, for example, the bladder might push into the vaginal wall resulting in pain with sexual intercourse or difficulty emptying the bladder fully.

The POP-Q is the pelvic organ prolapse quantification system and is used to “grade” the severity of a prolapse.

Degrees of uterine prolapse

Uterine prolapse is described in stages, indicating how far the uterus has descended into the vagina. The four categories of uterine prolapse are:

• Stage I – the uterus is in the upper half of the vagina

• Stage II – the uterus has descended nearly to the opening of the vagina

• Stage III – the uterus protrudes out of the vagina

• Stage IV – the uterus is completely out of the vagina.

Prolapsed Uterus | Victoria State Government Department of Health | Australia

Although this example refers to uterine prolapse, it is also possible to have bladder, small bowel, vaginal vault (upper part of the vagina), or rectal prolapse. It is very common for people to have prolapse in more than one “compartment.” In other words, if a person has a uterine prolapse (apical compartment), they are also likely to have prolapse in the bladder area forward of the vagina (anterior compartment), or in the rectal area behind the vagina (posterior compartment).

This makes sense because the most common and important factor contributing to the development of POP is a combination of weakened pelvic floor muscles and overstretched and weakened ligaments.

This is a great image from the “Pelvic Empowerment” video above that simply illustrates what the pelvic floor and ligaments offer the internal organs:

How do the pelvic floor muscles and supporting ligaments of the pelvic organs become compromised?

There are multiple risk factors, and they tend to be common and wide ranging, which is part of why POP is so common.

Giving birth vaginally can be a risk factor. This is especially true if a woman has

o Given birth multiple times

o Given birth to multiples, i.e., twins, triplets

o Has had large babies

o Had a traumatizing birth experience, for example, forceps and/or vacuum extraction were used or she suffered large tears in the perineum that did not heal well.

Anything that increases pressure or strain in the pelvic region. This includes:

Chronic constipation. Pressure builds up in the area so that tissues may become inflamed or overstretched. Additionally, people usually strain and bear down on muscles forcefully to try to eliminate backed up, hardened stool. This can be hard on the pelvic floor muscles (PFM).

Coughing, heavy lifting, and high-impact exercise also put strain on the area.

Pelvic floor injury. This may include accidents that have injured the pelvic floor, surgeries or medical treatments, sexual abuse, or childbirth-related injuries.

Hysterectomy can increase the risk of prolapse in other organs because removing an organ changes the support structure inside. Suddenly an entire organ, perhaps with some of its supporting structures (ligaments) is gone. If the other organs can’t find alternate sources of support, they may start to collapse.

Obesity and overweight can create wear and tear on the pelvic floor as the increase in downward pressure places significant strain on the PFMs and requires them to do more work.

Research is demonstrating that genetics may play a key role in the development of POP. Lince et al. (2012) did a systematic review looking at the research that had been done on hereditary factors in POP. They noted some interesting results:

o One study “found a high rate of concordance between the POP stage of a parous [having given birth] woman and her nulliparous sister, thereby suggesting a familial predisposition toward the development of this disorder.”

o Another study found that POP was transmitted through both male and female relatives

o Ultimately, the writers concluded that women with at least one female family member with POP have a significantly higher risk of developing POP.

Another study by Li et al. (2024) looked in detail at how genetic pathways might account for the research indicating that “sisters of patients with severe POP are five times more likely to develop the condition compared to women without a familial history.”

o It’s possible that genes play a role in how easily connective and muscle tissue sustains injury and/or how well they heal.

o The researchers also found that genetic influence on cellular changes and metabolism could compromise how well PFM function. Unchecked oxidative stress, impaired mitochondrial function, protein homeostasis imbalance, and inflammation could create pathologies in the tissues that contribute to weakness, vulnerabilities to tearing, and impaired healing.

o Interestingly, the authors did consider the questions of environment and epigenetics. In other words, do one’s genes create the conditions for pelvic organ prolapse to happen or do environmental factors “turn on” certain genes that create more overstretching, weakness, and inflammation in the tissues that then contribute to the development of POP? More investigation is needed to understand the complexity of genetics.

Li et al. (2024) also noted that the role of estrogen and progesterone in POP is unclear. Though both hormones contribute to the integrity of connective and muscle tissue, neither is therapeutic for POP and there is no data that either increases the efficacy of POP surgery.

Symptoms

o A feeling of fullness or pressure in the vagina or pelvis

o A sense of something “falling out”

o Pressure or pain during intercourse

o Pain with sex, orgasm, in the hips or back, or in the pelvis generally

o Changes in how one pees or poops

o “splinting” refers to the need to put one’s finger into the vagina in order to fully empty the bladder or rectum

o Stress incontinence

o Constipation or losing control of one’s bowels

Diagnosis

Typically, POP is diagnosed by a pelvic exam. The prolapse may be able to be seen and/or palpated. Muscle testing can also be done to see how well the muscles are contracting or, conversely, how tight they may already be. Ultrasound or MRI can also be used.

Treatments

Pessaries

“Pessaries are devices, often made of medical-grade silicone, that are positioned in the vagina to restore normal pelvic anatomy. They are an option for all stages of prolapse and are useful to prevent the progression of prolapse and can delay the need for surgery. 85% of patients are successfully fit for a pessary” (Aboseif & Liu, 2022).

As noted above pessaries can be extremely helpful for many women, especially if the prolapse is not advanced. Pessaries need to be fitted for each individual by a doctor.

Here is a link to a PDF developed by a Pelvic Obstetric & Gynaecological Physiotherapy group in the UK that describes various types of pessaries and graphical illustrates their placement:

Types of Pessaries

Pelvic Floor Physical Therapy

In more enlightened nations, pelvic floor PT is typically considered an essential part of postpartum care, offered and paid for as a matter of course by national healthcare systems. It is supremely unrealistic to imagine that a woman’s body is going to magically regain its muscle tone and structural integrity without any guided or conscious effort, especially if she has given birth multiple times or endured any birth trauma. When most people think about “getting into shape” after giving birth the focus tends to be on fitting back into pre-pregnancy jeans, not on the pelvic floor and ligaments of the core.

Childbearing could conceivably be thought of as an extreme sport. Muscles in the pelvic region stretch and contract dramatically in unique ways during both pregnancy and childbirth. Relaxin, a hormone produced by the ovaries and placenta during pregnancy, further loosens muscles, ligaments, and joints so that bones can shift easily to make space for a growing fetus as well as to permit passage of the baby through the birth canal. Although relaxin diminishes and production stops after pregnancy, some ligaments may remain in a lax state and joints may not be holding bones in quite the same relationship to each other as before birth.

Although I am emphasizing the changes of pregnancy, pelvic floor health is a concern for all women. Trauma/injury to the area, surgery and medical treatments, or simply the changes inherent in menopause and aging all have an impact on the pelvic floor area. Most women will benefit at some point in their life from learning more about how to care for these tissues.

If one does not have pain or prolapse symptoms, it may be possible to read a book or find a video about pelvic floor exercises to strengthen and tone the PFM. The pelvic floor therapists I have heard and read discourage this approach.

The reason for this is because it can be very difficult for an individual to know if their PFM are too lax/weak or too tight. If the muscles are too tight, doing more Kegels—an instruction women are often given either in magazine articles or by doctors—will make things worse, exacerbating the spasm in the pelvic floor and creating more dysfunction.

Whether lax or tight, the PFM will be weak. And, as you can imagine from looking at all the directions in which the pelvic muscles flow, they each have different ways to contract and release that need to be addressed. There are more varied and important ways to exercise and release these muscles than Kegels alone.

Make sure to seek out a certified pelvic floor physical therapist/specialist for help with POP.

A word on exercise and the “core”

What is the “core”?

I think most people tend to think of the core muscles as the abdominal muscles especially, unconsciously, the superficial ab muscles like the “six-pack” or “obliques.” Some will include the lower back muscles.

But when we think about the “core” of the body it is more accurate to consider the muscles that

o Create and sustain our postural integrity

o Keep our viscera—our organs and guts—protected and contained in the pelvic bowl

o Support balanced, stable, healthy, and powerful movement from the center of our bodies out through the limbs

The deep, core muscles include

o The psoas and iliacus, which support the lumbar spine and connect the spine through the hips to the legs

o Transversus abdominus (our internal corset)

o Quadratus lumborum, which connects the rib cage to the pelvis on each side

o Pelvic floor muscles

Exercise such as abdominal crunches or lifting weights can trigger or exacerbate pelvic floor issues when we hold our breath and bear down while exerting or lifting. It can become a habit for people to hold their breaths when under stress, whether that stress is voluntary or involuntary. When this happens, a person tends to breathe in so that the belly extends and the lungs are full and then holds the breath so that the core muscles stay stretched.

When someone tries to lift or exert effort in this state, the stretched muscles of the abdominal region and pelvic floor are unable to contract to support the effort and protect the internal organs. Additionally, the intra-abdominal pressure is increased and that extends the tissues further, compromising their structural integrity and the well-being of the organs.

Our body is designed so that our core muscles naturally contract to help us exhale. If we inhale a full breath and then exhale, allowing our core muscles to move freely as we exert ourselves and/or lift, our abdominal and pelvic floor muscles will naturally contract, lifting in and up to

o support our spine and upper body

o release air and pressure in the abdominal region

o focus musculoskeletal energy and power up and out in the direction we’re working

Yoga and Pilates are excellent forms of exercise for learning how to connect with, strengthen, and tone the pelvic floor.

Surgery

A look at the back of the uterus and all the ligaments supporting it in its space.

There are basically two categories of surgery used to address/repair POP:

o Obliterative, also called colpocleisis. Appropriately named, this is when the vagina is essentially closed, stitched up so that it acts as a support for a prolapsed uterus.

o Reconstructive. In this type of surgery mesh is used to construct exogenous support for various structures or stitches are used to reconnect and tighten up connections between an organ and endogenous supports like ligaments.

What I have gleaned from my reading is that there are many ways in which a surgeon might approach repairing POP. Generally, repairing POP involves shoring up support from underneath (the pelvic floor) or tightening up the guy wires from above (the ligaments). Sometimes surgeries will incorporate some combination of both and/or hysterectomy and this makes sense when one considers how often multiple compartments are involved in prolapse.

Here are links to a couple of medical sites that describe surgeries for POP:

Royal College of Obstetricians & Gynaecologists

Greater Boston Urology

A few things important to keep in mind:

The doctor you want to see for POP questions and treatment is a urogynecologist! The pelvic floor can be a tricky place to navigate, so if you are considering surgery, you want to find a doctor who does a high-volume of these types of surgery and lots of experience.

“Adequate support of the vaginal apex has been recognized as an essential component of an adequate surgical repair for advanced prolapse” (Aboseif & Liu, 2022). What this means is that even if a surgery is focused on creating support from below in order to lift a prolapsed organ, the surgery is more likely to be successful if the vaginal apex, i.e., the top of the vagina is supported, usually by being stitched up and back to ligaments in the wall of the pelvis or lower back.

Grafts/mesh:

o Native tissue, i.e., one’s own tissue from the pelvic region, can be used to repair tears or shore up weaknesses in the pelvic region in an attempt to relieve prolapse. The downside of this is that often the native tissues are fragile and weakened, which is why the prolapse is occurring in the first place.

o Xenografts are tissue grafts from a non-human species, for example, pig.

o Allografts are from a human donor that is not genetically identical, for example, a cadaver.

o Mesh is a common, but controversial option. Apart from the grafts mentioned above, meshes are made from synthetic materials. Multiple studies have been done, none of which can conclusively say that one kind of mesh is better than another or that mesh should never be used. However, it is advisable for anyone considering the use of mesh in any kind of surgery to do research and ask lots of questions. Things to keep in mind:

o The skill and experience of the surgeon matters. From what I’ve read, a surgeon’s familiarity with the pelvic landscape and skill in placing mesh can make a big difference. “Studies have shown that inexperienced and low-volume surgeons have higher rates of complications that do experienced, high-volume surgeons” (Cardenas-Trowers et al. 2021).

o Transvaginal approaches, while less invasive and involving less recovery time than abdominal approaches, tend to lead to more complications and dissatisfaction post-surgery.

o Apical support is an essential component of adequate POP repair: “It has been established that addressing the vaginal apex at the time of reconstructive POP surgery contributes to a more durable POP repair” (Cardenas-Trowers et al., 2021).

o Quality of the musculature that will hold the mesh. “…the anchoring of mesh to musculature that is already hypertonic [tight] and spastic may perpetuate and exacerbate preoperative dyspareunia” (Gomelsky et al., 2011).

o Properties of the mesh itself. “Several studies suggest that polypropylene mesh may retract or contract after implantation” (Gomelsky et al., 2011).

o Comorbidities: Contraindications to mesh use reported by Gomelsky et al. (2011) include pelvic irradiation, severe urogenital atrophy, immunosuppression, active infection, diabetes, obesity, and heavy smoking.

Women who have had mesh used in various pelvic repairs have been preyed upon by personal injury lawyers whether or not they have experienced complications.

New York Times | April 14, 2018

Here is a link to information about some complications that could arise with mesh:

UAMS Health | Vaginal Mesh Complications

Although the information on the above site is scary and the use of mesh controversial, Dr. Gunter makes a good point when she says, “Lumping all mesh together is like lumping every motor vehicle together, from cars that have passed safety inspections and get high ratings from Consumer Reports to dune buggies with no air bags or seat belts” (Gunter, 2021). The right type of mesh in the hands of an experienced surgeon could greatly improve quality of life for some women.

Knowledge, support from others who have experienced POP and can guide you toward responsible professionals, and self-advocacy are key to maximizing one’s odds of satisfactorily addressing POP.

Recurrence

A meta-analysis of studies conducted by Shi & Guo (2023) found that of 6597 patients in Europe, America, Australia, and Asia, “2419 cases had recurrence after operation for POP, with a recurrence rate of 37.7%” (p.5). The risk of recurrence seems to be dependent on several factors:

o Operation type

o Severity/Grade of the original prolapse

o Number of previous operations (If someone has had a pelvic floor surgery previously, they are more likely to need a second or third.)

o History of hysterectomy

o Obesity/overweight

o Smoking

o Constipation

o Diabetes

o COPD

Prevention of recurrence

Lifestyle changes: weight loss, smoking cessation, dietary changes

Pelvic floor physical therapy ought to be considered an essential adjunct to any kind of POP surgery. Although a surgeon may not believe it to be essential, it seems obvious that anything one can do to strengthen and support the pelvic organs after needed prolapse repairs is likely to help maintain the repairs and prevent recurrence.

Race & Ethnicity

Interestingly, both studies looking at hereditary influences on POP found that race and ethnicity affected both the prevalence (how common it is) of POP and, possibly, the etiology (origin/cause) of POP.

Unsurprisingly, another group found that there are differences in how women of different races are treated for POP. In their 2021 study, Cardenas-Trowers et al. found that:

o “…despite Black women being the youngest racial group…[they] had the longest operating room time and postoperative length of stay of all racial groups” despite having similar surgeries to White and Hispanic women.

o Black women had the highest rates of baseline comorbidities.

o “Hispanic and other minority women had lower odds of undergoing [apical suspension] compared with White women.”

o “Obliterative [as opposed to reconstructive] procedures were more likely to be performed in Black, in Hispanic, and especially in other minority women.”

o “Studies have found that women are generally unknowledgeable about POP, but minority women are significantly less knowledgeable than White women about curative treatment options for POP like surgery.”

Although the scope of the authors’ research did not extend to exploring specific causes of care inequities in POP, they do suggest that social determinants of health play a substantial role.

Polina Kuzovkova | Unsplash

POP does not only happen in aging women!

Clearly experience and research shows that pregnancy and childbearing is a huge risk factor for POP. Aware doctors often encourage women in their “fourth trimester,” the postpartum period, to get checked for or keep an eye out for symptoms of organ prolapse. Pelvic PT started during this period can restore core integrity, potentially protect the body in the event of future pregnancies, and prevent deterioration associated with aging. Carroll et al. (2022) did a qualitative study with fourteen women aged 32-41, half of whom had suffered traumatic births.

It broke my heart to read these women’s words. Many of them were frustrated with what they saw as “the normalisation of pelvic health issues” in women and “that women’s bodily integrity is seen as being secondary to the wellbeing of their babies.” They also felt pressure to prove they were able to cope with being a new mom even as they struggled with pain, exhaustion, and fear about worsening their condition through exertion.

Critically, lack of knowledge on the part of both the women and their doctors, contributed to fear, anxiety, and deterioration of their situation. Most of them had been told by their doctors simply to avoid doing much and accept that the situation would get worse! Because women were afraid to engage in exercise, not only did their physical states decline, but depression, anxiety, tension, and loneliness increased.

However, POP progression is not a foregone conclusion:

According to the authors of the study, “The POP literature has noted a lack of data regarding POP progression and regression, as well as a widespread acceptance that POP is a progressive condition…However, research has demonstrated that POP regression occurs in 19-48% of women with stage 1 or 2 prolapse without intervention over three to eight years, while other research demonstrated 21% regression with the use of vaginal support pessaries” (Carroll et al., 2022).

I’m going to end this post with two things:

A 2025 post on the ACOG (American College of Obstetrics and Gynecologist) site:

"5 Things I Wish All Women Knew About Pelvic Organ Prolapse"

A link to the American Urogynecologic Society’s site where you can find “fact sheets” about a variety of pelvic floor dysfunctions (PFDs):

Voices for PFD

Disclaimer

This blog post is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation.

References

Aboseif, C., & Liu, P. (2020). Pelvic organ prolapse. https://www.ncbi.nlm.nih.gov/books/NBK563229/

Belayneh, T., Gebeyehu, A., Adefris, M., Rortveit, G., Gjerde, J. L., & Ayele, T. A. (2021). Pelvic organ prolapse surgery and health-related quality of life: a follow-up study. BMC Women’s Health, 21, 1-11. https://doi.org/10.1186/s12905-020-01146-8

Cardenas-Trowers, O. O., Gaskins, J. T., & Francis, S. L. (2021). Association of patient race with type of pelvic organ prolapse surgery performed and adverse events. Urogynecology, 27(10), 595-601. DOI: 10.1097/SPV.0000000000001000

Carroll, L., O’Sullivan, C., Doody, C., Perrotta, C., & Fullen, B. (2022). Pelvic organ prolapse: The lived experience. Plos one, 17(11), e0276788. https://doi.org/10.1371/journal.pone.0276788

Cleveland Clinic: https://my.clevelandclinic.org/health/diseases/24046-pelvic-organ-prolapse

Dietz, H. P., Socha, M., Atan, I. K., & Subramaniam, N. (2020). Does estrogen deprivation affect pelvic floor muscle contractility?. International urogynecology journal, 31, 191-196. https://doi.org/10.1007/s00192-019-03909-w

Gomelsky, A., Penson, D. F., & Dmochowski, R. R. (2011). Pelvic organ prolapse (POP) surgery: the evidence for the repairs. BJU international, 107(11), 1704-1719. https://doi.org/10.1111/j.1464-410X.2011.10123.x

Gunter, Jen. (2021). The Menopause Manifesto. Citadel Press.

Li, Y., Li, Z., Li, Y., Gao, X., Wang, T., Huang, Y., & Wu, M. (2024). Genetics of female pelvic organ prolapse: up to date. Biomolecules, 14(9), 1097. doi: 10.3390/biom14091097

Lince, S. L., van Kempen, L. C., Vierhout, M. E., & Kluivers, K. B. (2012). A systematic review of clinical studies on hereditary factors in pelvic organ prolapse. International urogynecology journal, 23, 1327-1336. doi: 10.1007/s00192-012-1704-4

Moon, J. W., & Chae, H. D. (2016). Vaginal approaches using synthetic mesh to treat pelvic organ prolapse. Annals of Coloproctology, 32(1), 7. doi: 10.3393/ac.2016.32.1.7

Shi, W., & Guo, L. (2023). Risk factors for the recurrence of pelvic organ prolapse: a meta-analysis. Journal of Obstetrics and Gynaecology, 43(1), 2160929. https://doi.org/10.1080/01443615.2022.2160929

Image References

Title image: https://www.ladybirdpt.com/post/demystifying-the-pelvic-floor

Types of POP: https://theconversation.com/what-is-pelvic-organ-prolapse-and-how-is-it-treated-239199

Core: https://www.lcocanada.com/why-core-muscles-are-so-important/

“Vaginas are beautiful” | Johannes Steuding | Unsplash

GSM is a collection of symptoms affecting the vagina, vulva, clitoris, urinary tract, and bladder. Although it is typically considered a syndrome concomitant with menopause, some of these symptoms can also affect women who breastfeed for more than six months, those who take oral contraceptives, and even people who take antidepressants (Hudson, 2025). This is because the decline in estrogen levels seems to be primarily responsible for the symptoms of GSM.

Originally, the symptoms of GSM were known as “vulvovaginal atrophy (VVA),” “atrophic vaginitis,” or—worst of all— “senile vagina.” In 2014 the North American Menopause Society (NAMS) and the International Society for the Study of Women’s Sexual Health (ISSWSH) recommended using “genitourinary syndrome of menopause (GSM)” instead. Doust et al. (2023) note three reasons for this change:

· The previous descriptions contained negative connotations with the word “atrophy,” which comes from Latin and Greek roots meaning “wasting away” and “under- or mal-nourished.”

· The older terminology “did not encompass all the genital and urinary symptoms associated with endocrine changes in the perimenopause and postmenopause.”

And my favorite,

· “’the word vagina is not a generally accepted term for public discourse’”

It seems if we’re going to do research and have an open, public discussion about women’s bodies, we’re going to have to neuter them first.

Symptoms and Prevalence

The percentage of women affected by GSM seems to range from 50-60% overall. However, there are a few reasons to be skeptical about these numbers:

1. Vaginal dryness, the most prevalent and widespread symptom of GSM, can affect up to 93% of women and “the most predominant complaints of sexually active women are reduced lubrication and dyspareunia, the prevalence of which has been reported to be 90% and 80% respectively” (Angelou et al., 2020).

2. Vulvovaginal symptoms tend to go underreported and undertreated for a variety of reasons (Nappi & Kokot-Kierepa, 2010):

a. Discomfort and embarrassment discussing vaginal symptoms, even with doctors

b. Not knowing that these symptoms are not simply a sign of “normal” aging and that there are simple, safe, and effective treatments available

c. General lack of knowledge and accessible, evidence-based information about vaginal and pelvic health and issues related to them

d. Acculturation, or as Dr. Jen Gunter puts it, “Women are constantly expected to tolerate the consequences of their biology” (Gunter, p.179).

e. The reluctance of healthcare professionals to address vulvovaginal symptoms (Angelou et al., 2020), as well as the lack of education and awareness among healthcare professionals about these genitourinary issues in women (Hudson, 2025), also contribute to the silence and ongoing absence of information about GSM.

3. There is some evidence that, unlike other symptoms common during perimenopause, GSM symptoms can emerge and intensify in the postmenopausal years, becoming worse and more difficult to reverse if left untreated (Angelou et al., 2020; Hudson, 2025). However, Doust et al. (2023) have stated that “this is not supported by prospective evidence. Whether or not GSM symptoms are progressive without treatment is unknown” (p.7).

In addition to vaginal dryness, symptoms of GSM include the following:

· Itching/burning

· Pain with penetrative sex

· Generalized vaginal, vulval, and/or pelvic pain, especially tenderness at the introitus (entrance to the vagina)

· The labia thin and regress

· Graying and thinning of pubic hair

· Degeneration (atrophy) of smooth muscles in vagina and pelvic floor (which contains both smooth and skeletal muscle)

· Decreased lubrication

· Feeling of tightness in the tissue

· Leukorrhea (thin, white or milky vaginal discharge—not abnormal unless it smells bad, is yellowish or green, or is accompanied by itching/burning)

· Decreased libido

· Decreased strength of and/or longer time in reaching orgasm

· Dysorgasmia (pain with orgasm)

· The clitoris becomes smaller and the amount of erectile tissue decreases, though whether this is related to estrogen decline or simply aging is undetermined

· Vaginal vault prolapse (when the upper part of the vagina descends into the lower part due to pelvic floor muscles weakening)

As estrogen becomes scarcer, collagen and glycogen production are reduced and blood flow in the pelvic and genital region diminishes. This causes the vaginal epithelium (the specialized tissue that lines the vagina and provides a barrier to infection and injury) to thin. It also makes the tissues of the vulva, vagina, urinary tract, and bladder less elastic, more fragile, and therefore more prone to small lacerations or tears that make the area vulnerable to viruses and harmful bacteria.

In addition, changes in the vaginal microbiome tend to involve dramatic reductions in protective, immune-enhancing Lactobacillus microbes, which gives opportunistic, more infectious bacteria a chance to thrive.

This profound anatomical and biochemical remodeling of a woman’s genital region leaves her at increased risk for:

o Urinary urgency, increased frequency, or dysuria (pain with urination)

o Stress incontinence (peeing when coughing, laughing, or with abdominal contraction)

o Urinary tract infections (UTIs) and/or bladder infections

o Sexually transmitted diseases

o Other infections such as bacterial vaginosis

o Autoimmune skin conditions such as lichen sclerosus and lichen planus

(Angelou et al., 2020; Athanasiou et al., 2016; Doust et al., 2023; Gunter, 2021; Mitchell et al. 2023; Muir, 2023)

Diagnosing GSM

It’s important to note that there are objective, anatomical changes that occur in GSM, for example, visible and measurable alterations in the muscles and tissues or the microbiome and pH of the vagina. But there are also subjective, experiential changes—pain with sex, irritation and burning, decreased libido, and urinary/bladder discomfort—and these tend to be the reasons women suffer and why they seek treatment, if they do.

Researchers and healthcare practitioners can look at the size and condition of the vulva, labia, and vagina to see signs of GSM, or they can measure things like severity of pain at the vaginal entrance using cotton swabs (Mitchell et al., 2023), pH levels in the vagina, or use the VMI (the Vaginal Maturation Index) to determine the “maturity” of cells inside the vagina, which gives a glimpse into estrogen levels (Doust et al., 2023).

What is the "Vaginal Maturation Index"?

But the vast majority of healthcare professionals don’t know enough about menopause and GSM to know what to look for or how to diagnose based on anatomical and physiological changes in the genitals. And, as Doust et al. (2023) point out, “Using…’objective’ measures as part of the diagnostic criteria can cause harm, by excluding those who may benefit and including those who will not” (p.9).

Most of the time, doctors cannot even imagine the root causes of the symptoms women are subjectively suffering. In Hudson’s 2025 article in The Guardian, she describes the experiences of women who found wiping after peeing painful, who were too sore to wear underwear, sit, work out, or walk, and even a woman who had to quit multiple jobs, sell her home, and move away from her social network because she’d been told by her GP to “prepare herself for a life of chronic pain.” This was even after she had “paid to see a private vulval pain specialist!” WTF?!

Additionally, it is possible, even likely in some cases, that not all symptoms attributed to GSM actually have to do with the hormonal fluctuations and decline of menopause. Many of the urinary symptoms, particularly urgency, frequency, or incontinence, may be due to a weakened pelvic floor, which can be caused by pregnancy and childbearing, obesity, or simply a chronic lack of muscle tone that has gotten worse with aging.

Angelou et al. (2020) reported “urinary symptoms are considered less frequent” than other symptoms of GSM and mention risk factors apart from menopause and estrogen deprivation, including:

· Absence of vaginal childbirth

· Alcohol abuse

· Decreased frequency of sex and sexual abstinence

· Cancer treatments such as pelvic irradiation, chemotherapy, and endocrine therapy

· Comorbidities involving the urogynecological systems

· Low education levels

This all points to the importance of taking a patient-centered approach to diagnosing and treating symptoms of GSM.

Sincerely Media | Unsplash

Tools for understanding patient experience of GSM

In the process of researching GSM I ran across some interesting tests (like the VMI) and questionnaires I had never heard of. A few instruments have been developed specifically to gauge severity of GSM symptoms.

The “Vulvovaginal Symptoms Questionnaire” asks about physical, emotional, and sexual symptoms of GSM and their social and life impacts.

Information about the "Vulvovaginal Symptoms Questionnaire"

The "Vulvovaginal Symptoms Questionnaire"

This is a link to a “Vaginal Symptoms Questionnaire” from the British Society of Urogynaecology:

"Vaginal Symptoms Questionnaire" from the British Society of Urogynaecology

The “Day-to-Day Impact of Vaginal Aging Questionnaire” asks more about the emotional impacts of GSM symptoms than the “Vulvovaginal Symptoms Questionnaire” and explores how they are affecting one’s relationship with oneself.

Information about the "Day-to-Day Impact of Vaginal Aging Questionnaire"

The "Day-to-Day Impact of Vaginal Aging Questionnaire:

The “Female Sexual Function Index (FSFI)” asks about sexual functioning, frequency, and satisfaction:

The "Female Sexual Function Index"

The “Menopause-specific Quality of Life (MENQOL) Questionnaire” asks about a range of menopause symptoms, some of which have to do with GSM. This link takes you to the MENQOL and the “Menopause Symptoms Treatment Satisfaction (MS-TSQ) Questionnaire”:

MENQOL & MS-TSQ

You can score some of these questionnaires yourself, however I have included them primarily so that you can

· Learn about the variety of symptoms involved in GSM and see which may be affecting you

· Get a sense of how severely symptoms are impacting your life

· Have a material tool you can take to your provider(s) to help you start a conversation and enable you to point to specific issues that need to be addressed

“Menopause Matters,” a menopause education group in the UK, also has a simple “vaginal symptoms” checklist you can fill out to take to your doctor:

Vaginal Symptoms Checklist | Menopause Matters UK

Treating GSM

Part of what is so frustrating about the ignorance and shame surrounding GSM is that treatments are typically simple, effective, and safe.

Lubricants and moisturizers

Because vaginal dryness is such a common complaint, and because these solutions are somewhat familiar and feel low risk to most practitioners, lubricants and moisturizers tend to be what is recommended first. Indeed, the 2014 NAMS statement “recommends vaginal lubricants and moisturizers as the first line of treatment” (Doust et al., 2023). Unfortunately, doctors and women tend not to be educated about the pros and cons of vaginal lubes and moisturizers.

Dr. Jen Gunter, in her book The Menopause Manifesto, has 4 important pages dedicated to discussing vulvar care, lubricants, and moisturizers. I highly recommend checking out her book.

Lubricants are typically used during sex. There are three types of lubricant: water-based, silicone-based, and oil-based.

Critical things to consider:

· Some women have great success using coconut or olive oil as a lubricant for sex. Howver, oil-based lubricants are not compatible with latex condoms!

· pH or acidity in the lubricant. Healthy vaginal pH is 3.5-4.5, although it tends to increase during menopause, which is part of what creates irritation and increases the risk of infection in GSM. You want to choose a lube that is as close to a healthy vaginal pH as possible. Frustratingly, most lubricants don’t list their pH.

· Osmolality. “When the osmolality [of a product] is higher than that of vaginal secretions the product will draw water out of the vaginal tissues…” This increases the risk of irritation and infection. It’s best to use a lubricant with <380 mOsm/kg and the World Health Organization (WHO) recommends against lubricants with >1,200 mOsm/kg.

· Preservatives: Avoid products with clorhexidene gluconate, polyquaternium, and >8.3% glycerin. They can damage vaginal microbiota.

Stabile et al. (2023) warn that several ingredients in vaginal lubricants, “including glycerin, parabens, sorbic acid and chlorhexidine gluconate…all have been shown to have antimicrobial properties” and inhibit the growth of vaginal Lactobacillus (p.354).

· Warming products or using lubricants with flavoring or fragrances should be avoided.

Hyaluronic acid, a lubricant “with ionic properties that attract water to increase tissue volume and epithelial integrity” was shown in several low to high quality studies to be almost as effective as vaginal estrogen in improving “vaginal pH, subjective symptoms of atrophy, and dyspareunia” (Evans et al., 2023). It is not necessarily used specifically for sex, but may be used to address general symptoms of dryness.

Moisturizers aim to rehydrate vaginal tissues and “are formulated to be bioadhesive, so the product stays on the vaginal tissues and lasts for several days” (p.169). They can be water-, silicone-, oil-, or hyaluronic acid-based.

Moisturizers do need to be used regularly and if one type doesn’t work after a few weeks, trying another one may do the trick.

One systematic review looked at studies using Replens, a ‘polycarbophil-based vaginal moisturizer” that “produces a moist film over the vaginal tissue, which remains attached to the epithelial cell surface.” Evans et al. (2023) found that Replens improved vaginal pH, dryness, and dyspareunia (pain with penetrative sex). It generally performed better than placebo and sometimes equal to estrogen in moderate to high quality studies. There were no adverse effects reported.Vaginal estrogen

The gold standard treatment for GSM symptoms is vaginal estrogen. This is applied locally, directly to the vagina, via cream, suppository, or a ring that can be inserted once every few months. Vaginal estrogen is usually given in low doses, and because its effects are local and it typically does not get absorbed into the bloodstream, it is generally considered safe even for those women who have or have had cancer.

Having said this, it is clear from my research that there is still a lot of confusion and concern about whether or not vaginal estrogen is, in fact, safe for some women, particularly those with hormone receptive cancers. In an attempt to address these concerns, a group of researchers in Spain conducted a study using an “ultra-low-dose 0.005% estriol vaginal gel.” Not only did the dosage offer “a 10-fold reduction in estrogen use compared to other GSM treatments,” but estriol is a weaker form of estrogen than estradiol, which is the form of estrogen typically used in hormone therapy (Fernandez et al., 2024).

Results of this study showed a significant decrease in rate of UTIs, reduction in episodes of asymptomatic bacteriuria, and improved vaginal pH. Authors also noted that the estriol was encased in a highly moisturizing compound that they surmise may have offered additional benefits by moisturizing and lubricating the vulvovaginal area, “reducing the risk of small lesions and micro abrasions that facilitate the entry of infection-causing bacteria” (p.5).

Dr. Rachel Rubin's page on GSM

Vaginal estrogen

The gold standard treatment for GSM symptoms is vaginal estrogen. This is applied locally, directly to the vagina, via cream, suppository, or a ring that can be inserted once every few months. Vaginal estrogen is usually given in low doses, and because its effects are local and it typically does not get absorbed into the bloodstream, it is generally considered safe even for those women who have or have had cancer.

Having said this, it is clear from my research that there is still a lot of confusion and concern about whether or not vaginal estrogen is, in fact, safe for some women, particularly those with hormone receptive cancers. In an attempt to address these concerns, a group of researchers in Spain conducted a study using an “ultra-low-dose 0.005% estriol vaginal gel.” Not only did the dosage offer “a 10-fold reduction in estrogen use compared to other GSM treatments,” but estriol is a weaker form of estrogen than estradiol, which is the form of estrogen typically used in hormone therapy (Fernandez et al., 2024).

Results of this study showed a significant decrease in rate of UTIs, reduction in episodes of asymptomatic bacteriuria, and improved vaginal pH. Authors also noted that the estriol was encased in a highly moisturizing compound that they surmise may have offered additional benefits by moisturizing and lubricating the vulvovaginal area, “reducing the risk of small lesions and micro abrasions that facilitate the entry of infection-causing bacteria” (p.5).

Systemic estrogen

Interestingly, the systemic estrogen (pills, patches, or creams) typically used in menopause hormone therapy (MHT) usually fails to improve GSM symptoms because estrogen levels in the vulvovaginal region do not rise high enough to help (Angelou et al., 2020; Fernandez et al., 2024; Gunter, 2021). In fact, systemic estrogen has been implicated in making the urinary symptoms of GSM worse (Doust et al., 2023)!

Hormonal alternatives to estrogen for GSM

Apart from cancer or other hormone sensitive conditions, some women are simply not comfortable with the idea of using estrogen to treat GSM or menopause symptoms. There are several options that can be effective in lieu of estrogen.

Dehydroepiandrosterone (DHEA) is a precursor to other hormones, specifically estrogen and androgens, including testosterone. Topical DHEA can be used locally in the vagina and has been shown to improve vaginal pH and dryness, dyspareunia, and sexual function over placebo in several moderate to high quality studies (Evans et al., 2023).

Both DHEA and vaginal estrogen can take up to three months to take full effect, though some results can often be felt sooner.

Like estrogen or DHEA, testosterone can be administered topically to the vagina. Testosterone “induces proliferation of the vaginal epithelium,” which can help prevent infection. In moderate to high quality studies, it was found that testosterone “may improve objective signs of atrophy, vaginal dryness, and possibly sexual function” (Evans et al., 2023).

Pharmaceutical options for GSM

Ospemifene is a pill, a selective estrogen receptor modulator (SERM) that acts like an estrogen on some tissues, but not on others. Ospemifene interacts with estrogen receptors in the vaginal wall to increase thickness and reduce pain associated with dyspareunia. It was shown to lower vaginal pH, improve sexual function, and decrease urinary problems. However, it also tends to increase vasomotor symptoms, endometrial thickness, and candidiasis over placebo (Evans et al. 2023).

Endometrial thickening can be an indication of disease and/or a precancerous condition in the tissues of the endometrium. According to Gunter, “ospemifene acts like an estrogen on the uterus” (p.173). Because of this, progesterone may be needed to counteract these effects and protect the lining of the uterus just as in systemic menopause hormone therapy (MHT). However, at this point there is not enough data to draw a conclusion, and Gunter suggests that this decision, like all treatment decisions, should be individualized.

Tibolone is not approved for use in the United States but is used in other countries as hormone replacement therapy and to treat osteoporosis and endometriosis. In low to moderate quality studies, it was found to improve vaginal dryness, atrophy, and dyspareunia, as well as urinary urgency and incontinence (Evans et al., 2023).

Lidocaine can be used before engaging in penetrative sex to help provide pain relief. This has been studied in breast cancer survivors and “90% of patients reported comfortable intercourse” (Angelou et al., 2020). Lidocaine can be purchased over the counter, but if you are going to use it vaginally, please discuss it with your doctor first so that you can get the correct dosage and application type.

Costs of all lubricants, moisturizers, hormones, and pills are likely to vary based on insurance, type of carrier (cream, suppository, ring, etc.), geographic region, dosage, and frequency of use.

Hormone-free, non-pharmaceutical treatments for GSM

Pelvic floor physical therapy is a non-invasive option that can be especially beneficial for any symptoms having to do with urinary urgency or incontinence, prolapse, or atrophy (muscular degeneration). In nations other than the U.S., pelvic floor PT is typically offered to women after giving birth and is viewed as a critical part of healthcare for women’s physical, sexual, and emotional well-being.

Energy-based therapies

There are two types of lasers being used to address symptoms of GSM. Although both are approved for use in certain dermatological applications like skin resurfacing and scar treatment, they are being used off-label to stimulate collagen remodeling, increase blood flow, and stimulate epithelial and microbiota regeneration in the vagina. They do this by using heat and creating small wounds in the tissue to promote the growth of “thickened, glycogen-rich and well-vascularized” vaginal tissue (Evans et al., 2023; Kaunitz et al., 2019).

Microablative fractional CO₂ laser: In moderate quality studies comparing this laser with estrogen, they performed about evenly, with some studies favoring estrogen for improved sexual function, subjective atrophy symptoms, increased vaginal health, and decreased urinary symptoms, and others favoring laser. In studies that compared the CO₂ laser with a sham laser, the CO₂ laser outperformed the sham laser in decreases in dyspareunia and dysuria and was equal to sham in subjective dryness and symptoms of atrophy. In those studies that looked at adverse events and pain associated with the laser procedure, “no significant problems” were found (Evans et al., 2023).

In a study done by Athanasiou et al. (2016) fifty-three postmenopausal women received intravaginal laser therapy once a month for three months. The results of this study were impressive. At the end of the protocol:

· Vaginal pH decreased significantly in 89% of participants, with 32% attaining a pH of <4.5 (normal is 3.5-4.5).

· There was a “significant progressive increase of Lactobacillus morphotypes observed” (p.3). This was especially notable because at baseline, 15% of participants had a “complete absence of any vaginal flora” (p.3, italics mine).

· “Normal vaginal epithelial cells significantly increased after the second and third therapies compared to baseline” (p.3).

· Of 16 participants who were not sexually active at baseline due to GSM symptoms, 15 resumed sexual activity after treatment.

Apart from temporary mild irritation of the vaginal entrance, which spontaneously resolved after a couple of hours, no adverse effects were noted.

Erbium laser

Although in their systematic review of the literature, Evans et al. (2023) found that the erbium laser was effective in improving vaginal pH, dryness, and dyspareunia, the quality of the studies was low. In those studies monitoring for complications, none were reported.

Safety

In July 2018 the FDA release an “FDA Safety Communication” alerting consumers to “serious adverse events” connected to the use of “energy-based devices (radiofrequency or laser) which were approved to treat gynecologic conditions but being used for vaginal procedures such as vaginal ‘rejuvenation,’ vaginal cosmetic procedures, and procedures to treat vaginal conditions and symptoms related to menopause…” The FDA went on to clarify that lasers had not been cleared for use in treating any symptoms related to menopause or GSM (Kaunitz et al., 2019).

This communication was likely in response to an April 2019 article in the journal Menopause, which featured four case studies of women who had experienced vaginal lacerations, post-treatment dyspareunia, stenosis, or scar tissue after laser use (Gordon et al., 2019).

However, in the same journal in October 2020, Guo et al. published the results of a systematic review investigating whether the available evidence about lasers supported the FDA’s safety communiqué. They concluded that “Lacking strong evidence indicating significant patient risk for vaginal laser treatment of GSM, the FDA safety communication appears unsubstantiated and implies gender bias” (Guo et al., 2020).

Because the use of lasers to treat GSM symptoms is off-label at this point, I think it is wise to proceed with caution. While there are reputable medical institutions offering laser for the alleviation of GSM symptoms, there are also likely to be people promoting this service who do not have the medical and technological knowledge to safely use lasers in the vaginal region.

Laser treatment is unlikely to be covered by insurance and can cost from $500 to $1,000 per session. Multiple sessions usually need to be done and then may need to be refreshed each year. Here is a link to the Cleveland Clinic’s page on their laser therapy, MonaLisa Touch:

MonaLisa Touch

Probiotics

The Vaginal Microbiome

I was amazed reading about the importance of the vaginal microbiome and shocked to learn that “In the vaginal microbiota of premenopausal women, Lactobacillus species constituted approximately 71.98%, and pathogenic flora constituted approximately 16.87%. They were 10.08% and 26.78%, respectively, in the vaginal microbiota of postmenopausal women (Yoshikata et al., 2021, italics mine). What I find particularly discouraging is that not only do the numbers of beneficial bacteria decline during menopause, but detrimental bacteria multiply and flourish in the new environment created by estrogen decline (Stabile et al. 2023). Estrogen promotes the production of glycogen, which is a substrate for Lactobacilli. Additionally, as the epithelium (the lining) of the vagina becomes compromised, so does the living space for Lactobacilli.

Although it is not fully known whether Lactobacilli “promote vaginal health or whether they are a marker for vaginal health” (Stabile et al., 2023), what is known is that they are important in defending the vagina against infections of various types and colonization by pathogenic bacteria and “the ideal vaginal environment is maintained by Lactobacillus species” (Yoshikata et al., 2021).

A 2022 study conducted by Yoshikata et al. and described in Stabile et al. (2023) found that using feminine products containing Lactobacillus improved the vaginal ecosystem and urogenital health.

Multiple studies have shown that oral ingestion of probiotics can lead to menopausal symptom relief. In a 12-week, multicenter, randomized controlled trial (RCT) in Korea, it was “reported that oral ingestion of Lactobacilli by postmenopausal women significantly improved symptoms related to menopause” (Stabile et al., 2023). It’s important to note that this article does not describe which specific menopausal symptoms a couple of these studies are targeting, though one was looking particularly at GSM issues.

Yoshikata et al. (2021) found that there does seem to be “crosstalk” between the gut microbiome and vaginal flora. “Therefore, dietary habits and measures to improve the gut environment by increasing the Lactobacillus population in the gut might increase the population of Lactobacillus and reduce that of the bacterial flora in the vagina.”

Oral probiotics geared toward women, and specifically vaginal health, may be helpful in treating GSM symptoms.

Sex

Angelou et al. (2020) note that maintaining regular sexual activity can help maintain vaginal elasticity and lubricative response.

Keep an eye out for an upcoming post on Sexual Health and Menopause.

Last thoughts

If this all seems like an unending parade of possibility and nuisance, I completely understand. Genitourinary symptoms arose for me several months ago, a few years into my perimenopausal symptoms odyssey. First, I used Kindra, a water-based moisturizer with glycerin that was initially effective in alleviating the dryness, although knowing what I know now I will probably seek out a moisturizer with hyaluronic acid and try that. While the moisturizer worked for a while, the symptoms kept piling up, shifting from dryness and irritation to pain with sex, lack of lubrication, and then nocturia (having to pee a lot in the middle of the night).

I started on vaginal estrogen, and it has been extremely beneficial, though a recent Kelly Casperson/Mary Claire Haver discussion on testosterone has made me curious about using DHEA or a testosterone cream in the vulvovaginal area.

It’s a journey.

There’s a lot more to say about the health and welfare of the urinary tract and bladder in postmenopause and as we age, especially because recurrent UTIs have been associated with increased dementia risk, sepsis, and death in older women (Muir, 2023). Pelvic health generally and pelvic floor health specifically are also critical to consider, and I will dedicate future posts to these topics.

For now, let’s pause and pay attention to what is happening in our lady parts so that we can advocate not only for our health, but for our right to be comfortable and happy in our bodies.

Disclaimer

This blog post is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation.

References

Angelou K, Grigoriadis T, Diakosavvas M, et al. (April 08, 2020) The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus 12(4): e7586. DOI 10.7759/cureus.7586

Athanasiou, S., Pitsouni, E., Antonopoulou, S., Zacharakis, D., Salvatore, S., Falagas, M. E., & Grigoriadis, T. (2016). The effect of microablative fractional CO2 laser on vaginal flora of postmenopausal women. Climacteric, 19(5), 512-518. https://doi.org/10.1080/13697137.2016.1212006

Doust, J., Huguenin, A., & Hickey, M. (2024). Genitourinary Syndrome of Menopause: Does Everyone Have It?. Clinical Obstetrics and Gynecology, 67(1), 4-12. DOI: 10.1097/GRF.0000000000000834

Evans, E. A. C., Hobson, D. T., Aschkenazi, S. O., Alas, A. N., Balgobin, S., Balk, E. M., ... & Rahn, D. D. (2023). Nonestrogen therapies for treatment of genitourinary syndrome of menopause: a systematic review. Obstetrics & Gynecology, 142(3), 555-570. DOI: 10.1097/AOG.0000000000005288

Fernández, N. M., Salamanca, J. I. M., de Quevedo, J. I. P. G., Morales, M. P. D., Alameda, L. P., Tello, S. D., ... & Aguilar, E. G. (2024). Efficacy and safety of an ultra-low-dose 0.005% estriol vaginal gel in the prevention of urinary tract infections in postmenopausal women with genitourinary syndrome of menopause: A randomized double-blind placebo-controlled trial. Maturitas, 190, 108128. https://doi.org/10.1016/j.maturitas.2024.108128

Gordon, C., Gonzales, S., & Krychman, M. L. (2019). Rethinking the techno vagina: a case series of patient complications following vaginal laser treatment for atrophy. Menopause, 26(4), 423-427. DOI: 10.1097/GME.0000000000001293

Guo, J. Z., Souders, C., McClelland, L., Anger, J. T., Scott, V. C., Eilber, K. S., & Ackerman, A. L. (2020). Vaginal laser treatment of genitourinary syndrome of menopause: does the evidence support the FDA safety communication?. Menopause, 27(10), 1177-1184. DOI: 10.1097/GME.0000000000001577

Hudson, P. (2025, February 16). The unspoken agony of vaginal dryness: ‘I had to give up four jobs in four years.’ The Guardian. https://www.theguardian.com/society/2025/feb/16/the-unspoken-agony-of-vaginal-dryness-i-had-to-give-up-four-jobs-in-four-years

Kaunitz, A. M., Pinkerton, J. V., & Manson, J. E. (2019). Women harmed by vaginal laser for treatment of GSM—the latest casualties of fear and confusion surrounding hormone therapy. Menopause, 26(4), 338-340. doi:10.1097/GME.0000000000001313.

Mitchell, C. M., Larson, J. C., Reed, S. D., & Guthrie, K. A. (2023). The complexity of genitourinary syndrome of menopause: number, severity, and frequency of vulvovaginal discomfort symptoms in women enrolled in a randomized trial evaluating treatment for genitourinary syndrome of menopause. Menopause, 30(8), 791-797. DOI: 10.1097/GME.0000000000002212

Muir, K. (2023, December 17). ‘Millions of women are suffering who don’t have to’: Why it’s time to end the misery of UTIs. The Guardian. https://www.theguardian.com/society/2023/dec/17/millions-of-women-are-suffering-who-dont-have-to-why-its-time-to-end-the-misery-of-utis

Nappi, R. E., & Kokot-Kierepa, M. (2010). Women’s voices in the menopause: results from an international survey on vaginal atrophy. Maturitas, 67(3), 233-238. https://doi.org/10.1016/j.maturitas.2010.08.001

Stabile, G., Topouzova, G. A., & De Seta, F. (2023). The role of microbiota in the management of genitourinary syndrome of menopause. Climacteric, 26(4), 353-360. https://doi.org/10.1080/13697137.2023.2223923

Yoshikata, R., Yamaguchi, M., Mase, Y., Tatsuzuki, A., Myint, K. Z. Y., & Ohta, H. (2022). Age-related changes, influencing factors, and crosstalk between vaginal and gut microbiota: a cross-sectional comparative study of pre-and postmenopausal women. Journal of Women’s Health, 31(12), 1763-1772. https://doi.org/10.1089/jwh.2022.0114

Yoshikata, R., Yamaguchi, M., Mase, Y., Tatsuyuki, A., Myint, K. Z. Y., & Ohta, H. (2022). Evaluation of the efficacy of Lactobacillus-containing feminine hygiene products on vaginal microbiome and genitourinary symptoms in pre-and postmenopausal women: A pilot randomized controlled trial. PLoS One, 17(12), e0270242. https://doi.org/10.1371/journal.pone.0270242

Image References

GSM symptoms: https://www.everydayhealth.com/womens-health/genitourinary-syndrome-of-menopause/

Sexual lubricants: https://sexualhealthalliance.com/nymphomedia-blog/sexual-lubricants-materials-and-best-uses

Signs of needing a pelvic floor PT: https://pelvicpainrehab.com/blog/how-pelvic-floor-physical-therapy-helps-female-pelvic-pain/

Vaginal microbiome: https://medical-technology.nridigital.com/medical_technology_sep23/the_vaginal_microbiome_in_women_s_health

Spiritual Chakra Painting | Ƴєɱαγά ღ αηα| Debs Stott

It has recently occurred to me that part of what has made the menopause transition hard for me is the loss of my cycle. It’s not so much the loss of the period in itself, though that did offer a tension-relieving valve for me, but the erratic decline of the regular rhythm I have lived by—without fully realizing or appreciating it—for the last forty years.

My period and the days leading up to it were not generally problematic or painful enough for me to pay a lot of attention to it. I never took time off work or school to attend to myself during my premenstrual or menstrual time. (I have heard from many other women about their experiences of menstruation, and I know I was fortunate in this.)

However, I did experience enough mood shifting, heaviness, fatigue, and low energy in the days prior to and in the first part of my period that I often naturally slowed down, bowed out of things with less agonizing and guilt, took more baths, and offered myself more restorative activities.

Toward the later days of my period and directly after, I would feel a surge of energy and lightness, when it seemed much more effortless for me to accomplish things, my mood was brighter, and my activity naturally and easily increased.

Additionally, I remember feeling all the signs and symptoms of my cycle as it unfolded each month. As I moved into the second week of my cycle, I could feel my body revving up for ovulation. There would be an increase in slippery mucus and moisture (such a contrast to the vaginal dryness I feel now!), often a lift in libido, and occasionally even the sensation of the egg being released from its follicle. This is a phenomenon known as mittelschmerz, from the German words meaning “middle” and “pain.” I felt it as a sharp pain on one or both sides of my abdomen that would typically arise at some point during the day, hurt until I went to sleep that night, and be better by morning.

After ovulation I would feel the slow, consistent descent into the more sluggish, yet irritable moods and sensations that would intensify in the 2-3 days before my period and then slowly taper off, relieved by the release of the blood flowing and the innate, unconscious but regular surrender to a process over which I had no control.

In our lives now we do, of course, have some control over our periods. We can use contraceptive methods that prevent periods all together. We may choose—by medical necessity or not—to have a hysterectomy, removing our uterus and any possibility of a period. If we are transgender men, we may use hormones to suppress our cycles and periods, and if we are transgender women, the hormones we use may create cycles that effect moods and visceral sensations in the body akin to premenstrual tension or stress even though there is no period.

Additionally, it’s important to acknowledge that the things we take in—food, alcohol, drugs, etc.—and the things we do—exercise, sleep, socialize—all have an impact on our cycles and how we feel throughout.

However, even though our cycles may be impacted through nutrition, exercise, hormonal therapies, medical treatments, etc., the fact of our menstrual cycles—or the absence of them—is something we have little control over. As girls we don’t know when we will get our first period (menarche), as adults we don’t know which one will be our last (menopause).

In between we find ourselves working to figure out

· If we are late this month due to stress, travel, illness, or pregnancy

· If we feel more cramps or have a heavier flow this cycle because we haven’t been exercising or there is something more going on like fibroids or endometriosis

· If we are truly in menopause, because we’ve been on birth control and haven’t had a period in over a year, but we don’t know if that’s just because of the contraceptives or if we have truly made it through the menopause transition

Our cycle is a constant companion, even when it’s not. Because when it doesn’t show up, or doesn’t show up as usual, that is a sign to us that something is off.

Lisa Hendrickson-Jack has written an excellent book entitled The Fifth Vital Sign that discusses the importance of menstruation to women’s health and argues for considering it the fifth vital sign of well-being. (I highly recommend this book for anyone still menstruating or if you have a daughter, niece, or friend who is menstruating.)

The first four vital signs include body temperature, pulse rate, respiration rate, and blood pressure, all of which are routinely checked at doctors’ appointments. Most of us can appreciate how important these indicators are because of what they may reveal about our immediate state of well-being and how they point to possible underlying conditions or disease processes.

Rarely is the status and experience of the menstrual cycle asked about or discussed. However, what is happening or not happening in a person’s cycle may point toward serious underlying health concerns or to chronic or severe stressors that may, if unchecked, continue to undermine health and well-being.

The National Institutes of Health have written,

The menstrual cycle—a complex process orchestrated by interactions between many of the body’s tissues, cells, and hormones—reflects a person’s overall health status and can be thought of as a “fifth vital sign,” along with blood pressure, body temperature, heart rate, and respiratory rate. Menstrual irregularities can indicate hormonal imbalances, gynecological diseases, or infections. Stress, changes in weight or diet, certain medications, and other lifestyle factors can cause temporary changes in the menstrual cycle. (National Institute of Child Health & Human Development (NICHD), 2021).

For the last 12-16 months my period has been increasingly irregular. There were months when I had two or three brief periods and months when I had none. Sometimes the bleeding was more like spotting and sometimes the flow seemed normal for me. In some cycles I had more cramping than usual, as if my uterus was trying to wring itself out.

The irregularity of my cycle stressed me out. Perhaps if I was better able to accept the total experience of this transition it wouldn’t have stressed me so much. But I’m not sure about that.

When the cycle becomes irregular it’s because the hormones involved in menstruation—estrogen, follicular stimulating hormone (which stimulates the ovaries to ripen eggs, creating follicles), luteinzing hormone (which triggers ovulation each month), and progesterone—are fluctuating wildly. As a result, the brain tries to figure out why the ovaries aren’t producing as much estrogen as it’s used to and attempts to get them to form follicles and release eggs as usual.

So, my hormones were going up and down, rising and falling in tighter and then longer cycles that made me feel off balance, anxious, and uncertain. Intellectually I knew what was happening, but viscerally and emotionally it didn’t feel that way. It felt mysterious and out of control.

It also felt like loss. It feels like loss. As I write this, I have now gone 132 days without a period. At this point, the regularity of the non-cycle feels calmer than the chaos of irregularity, and I am hoping that I am heading toward menopause, though I have heard of women going four or six months and then having their period again.

But even in this calmer state, where it feels as if the bottom has dropped out of something (my estrogen levels?), I miss my cycle. I feel a bit unmoored without it, and unsure—of myself and my future—in a way that feels different. When I have felt unsure before, I also felt more connected to the hope and the possibility of growing into more fullness and more of life to be lived. Now, the uncertainty I feel is tinged with a new and potent awareness of mortality—intensified by the loss of my father in 2023—and vulnerability, exacerbated by the multiple symptoms of menopause.

I did not realize how much I relied on the steady signs and symptoms of my menstrual cycle to anchor me mentally and physically. I did not understand how the regular ticking over of the days and weeks each month, along a set rhythm established in my genes by some evolutionary intelligence, directly connected me to a much larger lineage and sense of place in the scheme of things. I’m not sure if this makes sense to you. The loss that I feel is somewhat ineffable, difficult to describe.

Blaine Duggan | Unsplash

In my mind and spirit the prevailing sense is one of being unrooted, floating around trying to make sense of this experience and figure out how to ground myself again. In my body there is a sense of waiting to see what comes out of all the chaos I’ve been experiencing. There is a vigilance to this waiting that stems in part from all the sympathetic nervous system activation that has been intrinsic to this transition, but also to a new hopefulness that what emerges will be truly strengthening and amazing.

In the Menopause Yoga training I recently completed, the instructor Petra Coveney suggests a very positive way of viewing the loss of our cycles.

She says, “The cessation of our periods is generally perceived as the natural advancement of aging, when it is in fact our bodies’ natural effort to slow down this [aging] process and bring new balance to our advancing years.”

If we continued to menstruate throughout our lifetime, the wear and tear of potential pregnancies and constant cycling would likely cause accelerated aging, even with the salutary presence of estrogen and progesterone at premenopausal levels. Additionally, our energy would be consumed by procreation and the risk of procreation as it is for many of us in our 20s, 30s, and even into our 40s.

With the ending of our menstrual cycles, that energy is freed for creative, rather than procreative, pursuits. Women and people are released from cyclic highs and lows, the loss of vital fluids (literally, life blood), and the fear of becoming pregnant when they don’t want to be. This resurgence of energy has the potential to fuel extraordinary vision, creativity, wisdom, community building, teaching, and transformation by those who emerge rested and renewed on the far side of the menopause transition.

To be sure, menopause is a precarious time for many people—and it often feels this way. I will never forget listening to Stacey Sims, an exercise physiologist who specializes in women’s health, speaking on Andrew Huberman’s podcast. She was talking about menopause, and she said that men tend to age linearly, gradually declining over many years. For women, she said, aging is and feels like a precipitous drop off in strength, cognitive and physical functioning, and well-being. Many women are left reeling, struggling to cope with what feels like an abrupt freefall into deterioration.

On top of this we are told by healthcare professionals and scientific research that menopause leaves us vulnerable to increased risks for cardiovascular disease, osteoporosis, diabetes, dementia, and more of the ailments of aging. In fact, our risks for these ailments can increase over men’s risk, where previously we had had the advantage in heart, brain, and metabolic health.

These risks may be reduced if we have enough money, time, education, and privilege to negotiate this transition with awareness; applied coping techniques such as yoga classes, bodywork, strength training; and access to medical and well-being resources.

Thousands of women—even millions around the world—do not have access to these options.

The ending of my cycle does feel like loss to me, for many good reasons. But having the option to view this ending as the beginning of a “Second Spring,” as menopause is known in Traditional Chinese Medicine, feels like a gift to me.

Perhaps being released from what seemed to be the endless wheel of highs and lows, potential pregnancy, and bleeding will free me going forward. On the other side of this transition, I can see a calmer, more stable emotional life; increased faith and self-esteem grounded in greater confidence in my intuition and knowledge; wisdom that offers easier access to equanimity and compassion; focused, channeled creativity that finally allows me to offer the world what I have to give; and power rooted in my pride and belief in the unique authority and creativity of women.

Saiya Maeda | Unsplash

Disclaimer

This blog post is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation.

References

NICHD, 2021. https://www.nichd.nih.gov/about/org/od/directors_corner/prev_updates/menstrual-cycles

Image References

Title Image:

Spiritual Chakra Painting | Ƴєɱαγά ღ αηα| Debs Stott

Blaine Duggan: Upside Down Woman https://unsplash.com/photos/a-woman-in-a-white-dress-flying-through-the-air-qnTBjeeEA6g

Woman crossing bridge: https://unsplash.com/photos/a-person-with-a-backpack-walking-across-a-bridge-iXvjsYG2dnQ

Photo Credit: Marek Studzinski | Unsplash

Although most of what we hear about perimenopause and postmenopausal health seems to be unremittingly negative, the truth is that

1. While the physiological changes of and emotional responses to perimenopause can be risk factors for future serious and chronic disease,

2. perimenopause is also “an inflection point,” “a critical window,” “a multidimensional transition,” and crucial to understanding a woman’s long-term health. (Atlas, 2026; Khoudary et al, 2020; Yousefzai et al, 2025)

Perimenopause is a time of profound vulnerability in health and well-being. However, if we are able to slow down and pay attention to what we are experiencing and accept the opportunity for change we are being offered, we may end up stronger, healthier, calmer, and happier as we age into our postmenopause.

Statistics about women and cardiovascular disease (CVD)

Contrary to popular belief, breast cancer is not the primary cause of death for women.

Some facts about heart health and women:

· Heart disease is the number one cause of death for women in the U.S. (1 in 3 women die each year in the U.S. due to heart disease.)

· Prior to menopause, a woman’s risk of heart disease is less than ½ that of a man; after menopause her risk equals his, and once she is in her 70s, her risk is higher than his.

· Women under 55 are seven times more likely than a man to be sent home from the ER while having a heart attack.

· Women are more likely to die after a first heart attack than men.

· They are more likely to develop heart failure after a heart attack.

· Women are more likely to be disabled by a stroke than men.

· Only 44% of women currently recognize that heart disease is the #1 killer of women; this statistic is down from 65% in 2009.

(Haver, 2025; Khoudary et al, 2020)

AHA: Facts about women and heart disease

There are a few reasons for the severity of cardiac consequences for women. These issues interact in ways that exacerbate risk and create exponentially more harmful outcomes.

Atypical symptoms

The very fact that women’s symptoms are classified as “a-typical” is an indication of another huge red flag for women’s heart health, namely the lack of research into cardiovascular health in women. What this terminology means is that women do not present in the same way men do; this does not mean we are “atypical,” it means that we are different from men, who have been presented as the norm.

Typically, rather than the “elephant on the chest” sensation, acute chest and left arm pain, and difficulty breathing that men tend to show up in the ER with, women have symptoms such as:

· Feeling tired and rundown

· Flu-like achiness and fatigue

· GI symptoms and nausea

· Jaw pain

According to Dr. Jayne Morgan, a cardiologist, the reason women have such different symptoms of heart disease and attack compared with men is because of a difference in how cardiovascular disease manifests. Men usually end up with a large or complete blockage in one of the main arteries that lead directly to the heart. Because of this their heart symptoms tend to be dramatic and unmistakable leading to rapid diagnosis and treatment once they present themselves to first responders.

In contrast, cardiovascular disease in women tends to manifest as a “studded pattern of plaques,” not only in the main arteries, but in smaller vessels throughout the body. In this situation, blood flow to the heart is impeded slowly, starving multiple parts of the heart of oxygen over time. As a result,

· Symptoms manifest in myriad places throughout the body, such as the jaw, the gut, or the back

· Women may feel okay or just tired most of the time, but when the body is under more acute stress, for example, after eating or under time pressure, symptoms may flare, becoming more acute and difficult to ignore

· The heart is subjected to chronic oxygen deprivation over a longer period of time, and this can put women at increased risk of heart failure and less optimal recovery

In addition to the fact that most health professionals are unable to recognize symptoms of cardiac distress in women, there are not adequate tests for detecting a scattershot pattern of blockages throughout numerous smaller vessels in the cardiovascular system. Women are often sent home from the ER or a doctor’s office with serious cardiovascular disease or a heart attack in progress.

As Dr. Morgan points out in her interview with Dr. Mary Claire Haver, if a woman goes into the ER with fatigue and flu-like symptoms, she is probably going to wait for hours to see a doctor and then is likely to be sent home, while a man who arrives complaining of shortness of breath and chest pain is almost certainly going to be whisked directly back to the cardiac lab for testing and immediate, life-saving treatment. This delay increases the risk that women will die. If they do survive, they are less likely to recover full cardiac function and quality of life than a man who has been treated quickly.

Perhaps most maddeningly, a large percentage of women who present to health professionals with “atypical” cardiac symptoms are referred for psychiatric consults or “rule out panic disorder” is written in their charts. Dr. Morgan herself discussed how often she saw and did this herself when seeing female patients earlier in her career. Unsurprisingly, “rule out panic disorder” was almost never written into a male patient’s chart. (Haver, 2025)

Where is the research on women? Where are women in the research?

Sexism undermines women’s health, and sexism sometimes disguises itself as concern for women.

From 1977 to 1993 women were barred from participation in clinical research studies in the U.S. The reasons given:

· Concern about potential pregnancies and repercussions of research on possible fetuses

· Women’s hormonal cycles were so complex they “messed up” the data (M2)

The blindingly obvious problem with neglecting to research women’s health because their bodies are “too complicated” and skew the data is that when we try to extrapolate from research done on men and apply those medications, procedures, and understanding to the complexity of women’s bodies, it tends to cost women heavily—in time, money, health, and sometimes our lives. (This tendency to extrapolate also happens across race and gender expression, because non-White, non-cisgender people are also seriously underrepresented in research.)

A recent example of this was described by Dr. Morgan. At a European cardiology conference she attended in 2025 a paper on beta blockers was presented. Although administering beta blockers after a heart attack has been the standard of care based on extensive research with men over the last few decades, the study presented uncovered disturbing data. Giving beta blockers to women after a heart attack:

· Increased the risk of a second attack

· Made it more likely that a woman would be admitted to the hospital for heart failure

· Increased the risk of death by 3 times (Haver, 2025)

Although more recent research has included clinical trials using women as subjects, there is still a dearth of research about women and cardiovascular health generally and about menopausal women and heart health specifically. In fact, according to the American Heart Association’s (AHA) 2020 Scientific Statement, “US Food and Drug Administration guidance on clinical trial design for new products to be approved for treating vasomotor symptoms recommends including only postmenopausal women…” (Khoudary et al, 2020). While postmenopausal women do deal with vasomotor symptoms, the perimenopausal women are typically the ones more regularly being clobbered by these symptoms. But because perimenopause is a time of so much extreme fluctuation and unpredictability (even wackier than just typical menstrual cycles!!) researchers and medical professionals continue to try to avoid dealing with it. As a result, women continue to deal with the consequences of this systemic avoidance of the reality of their lives.

Current JAMA Cardiology study

Although it was already known that there was a short-term risk of future CVD risk in women who had a premature menopause, the current study by Freaney et al (2026) wanted to know if there was a longer-term CVD risk for women. What they found:

· Both Black and White women with premature menopause (defined as menopause prior to age 40) had a 40% lifetime risk of coronary heart disease

· Black women with premature menopause were more likely to have a history of diabetes; White women with premature menopause were more likely to be current smokers

· Black women were three times more likely than White women to experience premature menopause

Although the study excluded women who had a premature menopause that was surgically or medically induced, the AHA scientific statement makes it clear that women who have experienced premature surgical menopause are also subject to an increased risk of coronary events and disease. The issue seems to be the prematurity of the menopause rather than how the menopause is triggered. (Khoudary et al, 2020)

The authors of the JAMA study point out several limitations that provide potentially fruitful directions for future research:

· They only looked at women over 55 years of age. Might younger women who have a premature menopause be at risk of dying earlier from CVD or other conditions correlated with premature menopause?

· Information on PCOS, other sex-specific risk factors, or heart-related pregnancy disorders were not adjusted for and could be included in future studies.

· Adjustment for HRT was not possible in this analysis. Future studies should look at timing of HRT initiation, route, dose, and duration of use.

· The reproductive duration—i.e., time from menarche to menopause—was not assessed. It would be good to know if and how the number of reproductive years, as well as number of pregnancies, impacts a woman’s lifetime risk of CVD.

The good news is that, while women are still underrepresented in the medical field generally and in specialty fields particularly, the numbers are improving. As women gain access to the power and money that fuels research, the gender gap will continue to close. This holds true for race, sexual orientation, gender expression, and more.

Other issues in women’s health

Apart from research, there are other systemic issues in the medical and healthcare field that contribute to the ignorance surrounding women and heart health:

· As Dr. Morgan said, “menopause is a word that has no context for a cardiologist.” Medical specialties tend to be siloed from each other, each taking a different body “part” and becoming expert in the functioning of that part in separation from the whole. Women’s bodies are constantly defying this approach. In menopause, a woman is likely to experience symptoms that cause her concern for her brain, her nervous system and mental health, her reproductive organs, metabolism, digestion, heart, and more. She may be referred to or see multiple specialists, none of whom have the education or awareness to understand that there is an underlying root cause in the form of a natural life transition that needs to be supported and understood. (Haver, 2025)

o Women are also put at risk because there is no menopause education in dental school and very little awareness among dental professionals about how menopause may be impacting women’s oral or systemic health. Women experiencing jaw pain may decide to see a dentist and most dentists, upon discovering no dental issues, will not have the education or awareness to send that woman directly to the ER to have her heart checked. (Haver, 2025)

· Only 31% of medical schools have a menopause curriculum (Atlas, 2026). Even these curricula tend to be brief and, due to the lack of research, incomplete. Because of this, not only do women not recognize their perimenopausal or cardiovascular symptoms, but health professionals and systems fail to recognize them as well.

· Women’s health has tended to be synonymous with reproductive health. There has been an overemphasis on women seeing an OB/GYN annually for pap smears and breast exams and a neglect about encouraging women to see a primary care physician for annual bloodwork that includes cardiovascular, metabolic, and inflammatory markers, for example, lipids numbers, blood glucose, and High sensitivity C-reactive protein.

· Implicit bias in doctor’s offices coupled with gaps in and misunderstandings about research can lead to the under prescribing of medications that could be protective for women’s health generally and heart health specifically, for example, hormone replacement or statins. The AHA has pointed out a need for research on the use of statins to reduce the risk of elevated lipids in women. Dr. Jayne Morgan said that from her perspective statins are underdiscussed, under prescribed, and underutilized for women.

o Additionally, in spite of the setbacks of the Women’s Health Initiative (WHI) research debacle in the 1990s, hormone replacement therapy (HRT) shows a lot of promise in being protective for cardiovascular health if given to women prior to CVD development and within a certain time frame (see more below). Many doctors—even OB/GYNs—are still not caught up on the latest data regarding HRT safety and efficacy.

Estrogen

It is not clear at this point where the risk of cardiovascular disease originates in women. It is known that estrogen provides a protective, anti-inflammatory effect for women throughout their lives, supporting their bones, healing and immune processes, brains, hearts and vascular system, skin, and gut.

Research has shown that when estrogen declines in menopause:

· Cholesterol tends to increase, though it’s actually more complex than this. There is evidence that not only does LDL, the “bad” cholesterol, increase, but HDL, the “good” cholesterol begins to behave in ways that not only cease to provide cardiovascular protection but actually contribute to greater atherosclerosis.

· Estrogen is a hormone that helps to maintain flexibility and responsiveness in the walls of the blood vessels. When estrogen declines, arteries and veins tend to stiffen. This can interfere with optimal blood pressure regulation and foster hypertension.

· When estrogen declines, the way that fat is deposited around the body shifts. Instead of being primarily subcutaneous (under the skin), fat begins to build up inside the visceral cavity and around the organs. This type of fat is highly inflammatory and contributes to the development of chronic disease.

· The hypothalamus in the brain is our temperature regulator, and its cells have estrogen receptors. As estrogen fluctuates during perimenopause and declines in postmenopause women often experience hot flashes, sweating episodes, and periods of intense cold; essentially, our temperature gauge becomes dysregulated. Hot flashes are recognized as indicators of future CVD risk. The more severe or frequent hot flashes are for a woman, the greater her risk of developing CVD or heart attack.

(Derby et al, n.d.; Haver, 2025; Khoudary et al, 2020)

Although there is plenty of evidence for the protective effects of estrogen, it is still not clear that the reduction or lack of estrogen alone is the primary driver of CVD risk in menopausal women. Indeed, the current study (Freaney et al, 2026) and others, raise the possibility that other factors apart from estrogen decline could be major contributing factors not only to CVD risk, but also to more severe perimenopausal symptoms in those women with greater risk. (Cooney, 2026; Derby et al, n.d.)

As Conway-O’Donnell and Chesler (2022) write, “the protective and detrimental roles of estrogen in the cardiovascular health of premenopausal women, postmenopausal women, and men remain poorly understood.” And the AHA recommends “facilitating research to disentangle the health effects of ovarian and chronological aging” in order to better understand how much our risk of ill health is due to hormonal changes and decline and how much is contributed by changes in our DNA due to time, stressors, and the weathering that creates “aging.”

Risk Factors contributing to the development of cardiovascular disease

The role estrogen plays in the body is intertwined with most of these risk factors. However, there are other physiological and environmental elements at play as well.

· Frequency and severity of hot flashes

· Hypertension

· Increases in dangerous lipids (cholesterol)

· Changes in bodyfat distribution that promotes increased visceral fat

· Sleep disturbances/not enough sleep

· Smoking

· Low BMI/high BMI

· Metabolic syndrome/diabetes

· Early menarche/short menstrual cycles

· Low parity

· Heart issues in pregnancy/preeclampsia/gestational diabetes

· Early and premature menopause

· Smoking

· Psychological stress & depression

· Trauma, including early childhood trauma and intimate partner violence (IPV)

· PCOS

· Weathering, i.e., the process of accelerated cellular aging due to chronic stress and the coping it requires (Geronimus, 1992)

· If part of an immigrant family, it has been shown to be a risk factor to become increasingly culturally assimilated and affluent

· Lifestyle factors: diet, exercise, stress levels, work habits, alcohol and drug use, etc.

· Social Determinants of Health (SDoH): access to nutritious food and outdoor spaces; access to healthcare; educational level; economic status, etc.

(Atlas, 2026; Cooney, 2026; Derby et al, n.d.; Freaney et al, 2026; Haver, 2025; Yousefzai et al, 2025)

Although there are many factors that interact in complex ways to increase the risk of contracting cardiovascular disease, the number and complexity of factors can also work in our favor. According to Dr. Morgan, “80% of heart disease is preventable” (Haver, 2025).

What can we do to prevent heart disease?

Lifestyle factors: We have heard it before many times in multiple ways, but the choices we make about how we live our lives has the single biggest impact on our health and well-being.

· What we eat

· How much we move

· Where we live

· How we handle stress

· What our sleep is like

· If we smoke or drink alcohol and how much

· How much social connection we have

· The work we do and how we balance work with the rest of our life

Hormone Replacement Therapy: While we do not have adequate research about how estrogen supplementation in peri- or postmenopause may provide protection against CVD specifically, there is quite a bit of evidence that hormone replacement of estrogen, as well as progesterone and testosterone, can be beneficial for many of the symptoms that erode women’s health and quality of life during the menopause transition. Using HRT can help with sleep disturbances, mood swings and depression, weight gain and metabolic issues, collagen elasticity and cognition. In other words, many of the symptoms of menopause that are known to contribute to the development of heart disease are attenuated by estrogen supplementation. As Dr. Kelly Casperson pointed out in “The (M) Factor 2,” “We have to use the data that we have…We know that transdermal estradiol decreases your risk of diabetes, decreases your risk of depression, helps you sleep better, can lower your cholesterol, lowers blood pressure in some people, and those are all risk factors for heart disease…It’s not making your heart disease worse, and it will help all these parameters [to] decrease your risk of heart disease” (Atlas, 2026).

Some doctors and women are still wary of the interplay between estrogen and heart disease. This is due in large part to the Women’s Health Initiative study in the 1990s, which was halted because researchers found links between increased risks of breast cancer and CVD and the hormone replacement being used in the study.

These results were premature and were based on data that had not been completely or clearly analyzed. Additionally, the hormones being used in the trial were synthetic, not bio-identical.

As scientists have continued to analyze the data, more nuanced conclusions have been drawn, many of which are simultaneously positive and reassuring for the use of HRT and also point to the urgent need for more research regarding dosage, route of delivery, and timing.

Timing

Currently, there is a “timing hypothesis” that surmises a “window of opportunity” that is ideal for starting HRT. Generally speaking, the ideal time for starting HRT is while one is still in perimenopause and prior to the development of symptoms of chronic illness. However, HRT is increasingly being used with women who are in postmenopause.

What we know:

· Estrogen started early, within 10 years of menopause and prior to any development of CVD, is protective against CVD

· Estrogen started within 10 years of menopause with women who show some signs of CVD can slow or halt the progress of CVD

· For women more than 10 years out of menopause, there is an increased risk of heart attack within the first 4-12 months of starting estrogen. This risk then declines.

••• Should women over 60 or women who have some heart disease be started on estrogen?

••• Once plaques have calcified in the vessels, will estrogen be helpful?

Dr. Jayne Morgan pointed out that we simply do not know enough about estrogen and its impact on women at different phases of menopause and various stages of CVD to answer these questions one way or the other. (Haver, 2025)

Overall, there are strong, evidence-based reasons to consider HRT if one is preparing for or currently in perimenopause. However, due to the current lack of research in this area, it is likely that the generation of women now going through the menopause transition, primarily Generation X and the Millennials, will be providing the population-scale data for the use of HRT over time and in interaction with various conditions, genetics, and situations.

A note on non-hormonal therapies: There are some non-hormonal treatments such as gapabentin, fezolinetant, and oxybutynin that can be used by women who cannot tolerate hormone replacement to address perimenopausal symptoms. However, while these can potentially mediate risk factors that may contribute to CVD risk, for example, sleep disturbances and vasomotor symptoms, they do not replace the protective effects of estrogen.

GLP-1s: According to Dr. Morgan, because GLP-1s often alleviate a variety of factors that contribute to CVD—high BMI, poor dietary choices, low exercise tolerance, metabolic disease, sleep disturbances, etc.—they can decrease the risk of heart disease. There are a couple of issues with relying on GLP-1s:

· Because they are a relatively new drug, we do not have data on the long-term use of them, so we don’t yet know what effects they might be having on the body and mind over time.

· Currently, there seems to be no way to come off them without regaining weight, so people need to understand that they may be on a long-term or lifetime dose.

Social Determinants of Health: SDoH are primarily systemic in nature; what any one individual can do about them is limited. However, I wanted to bring them up because being mindful of how SDoH impact our personal health and the health of our larger human community is something we can all contribute to changing collectively in more positive ways.

(Atlas, 2026; Haver, 2025, Khoudary et al, 2020; Yousefzai, 2025)

AHA: Menopause & Heart Health Infographic

Testing

In her interview with Dr. Jayne Morgan, Dr. Mary Claire Haver asked about what tests might be most beneficial for women in preventing or diagnosing heart disease.

Bloodwork

Dr. Morgan encouraged women to start getting annual blood work that includes lipids and blood glucose levels, starting in their 20s if possible. LP(a) is considered a cholesterol marker that can point to a greater or lesser genetic risk of heart disease. Although current conventional wisdom says that nothing can be done about this number, Dr. Morgan noted two things:

· First, there is no conclusive evidence at this point that the number won’t shift one way or the other (indicating increasing or decreasing heart risk) around menopause. The research simply hasn’t been done.

· Second, knowing one’s risk empowers proactive decision-making. Just as PCOS is a factor that simply exists that increases one’s risk of future heart disease. Knowing one has that risk factor means that an individual can make educated, positive decisions about diet, exercise, stress management and other risk factors that can be modified.

Dr. Morgan seemed to feel that inflammatory marker tests might not be as helpful as simply asking a woman about her current symptoms and stress levels. However, inflammatory markers on a blood test might help get a conversation started with one’s doctor.

Stress tests are appropriate and can help women get a sense of their current cardiac health. If a woman is suspected of having had a heart attack, getting a cardiac enzyme test to confirm the magnitude and length of the attack is critical. (Haver, 2025)

A note on brain health

It is critical to understand that heart health is intimately connected to brain health. (Atlas, 2026; Haver, 2025)

In 2024 a paper was presented at the American Conference of Cardiology showing that, in a study of women with 1-6 hot flashes a week, women with the most hot flashes had a greater narrowing of the carotid arteries, increasing their risk of stroke. (Haver, 2025)

And Dr. Lisa Mosconi, Director of the Weill Cornell Women’s Brain Initiative and author of The Menopause Brain, says that Alzheimer’s is a disease of mid-life with symptoms that start in old age. (Atlas, 2026) The transitional period of perimenopause has a profound impact on the brain. In many ways, this is positive, as pathways and connections that are outdated and no longer needed for a woman’s life going forward are being pruned and new connections begin to be constructed. However, while the brain is undergoing construction, brain fog, forgetfulness, lapses in concentration, and a general feeling of cognitive impairment can be among our most distressing symptoms. The vulnerability is real. We need to be aware that what is happening can send us down a path toward more serious illness and debility, but it does not mean that it will. All of the information, while occasionally overwhelming, can be integrated to empower positive action and outcomes.

Dr. Louise Newsom

Proactivity

Overall, in both the “The (M) Factor 2” documentary and her interview with Dr. Haver, Dr. Morgan stressed the importance of proactivity. She encourages women to

· consider how women in their family have aged and become ill

and

· think about how they want their health and lives to look twenty years down the line.

What do we do with this information?

· Know that there may be an underlying common cause of your multiple or most distressing symptoms.

o Many women, because of age, lack of knowledge, distraction, or denial simply do not have perimenopause on their minds as a possible reason for what they are experiencing. However, if you are a woman in her 30s-50s who is suddenly “NFLM: not feeling like myself” (Atlas, 2026) or for whom doing all the right things is no longer “working,” then the menopause transition is likely to be the reason. Perimenopause does not mean there is no underlying heart, metabolic, or brain vulnerability, but it does offer us a unique window of time in which some symptoms may point us toward our specific vulnerabilities and in which proactive, positive change can be enacted for greater future health and well-being.

· Take your knowledge to your health care professionals

o Ask your doctor to be aware of your reproductive history and how it may impact more than your reproductive capability and health. What the JAMA study offers is a waving flag to healthcare professionals that they need to be aware of how a woman’s menstrual cycles, pregnancy history, and menopause experience is impacting her whole health and life expectancy.

o Ask your doctor for the blood tests that you want. You may need to be proactive in terms of doing research about what tests will offer you the information you want and how to read the results you get. Information about testing would be a series of posts in itself; it can be a frustrating journey. I have found that functional and naturopathic medicine have offered me the most fruitful paths to testing and interpretation, however, most primary care physicians within conventional medicine that I have met can be convinced to add certain tests to standard panels. Then you want to seek out “optimal” ranges from Functional Medicine, which has stricter standards than mainstream allopathic medicine.

o Advocate for yourself and ask others to support you. If you are experiencing symptoms of what you suspect is a heart attack, tell the personnel in the ER what you know about symptoms, risk factors, and your family and individual history. I know it’s difficult when we are consistently encouraged to doubt the evidence of our own senses but believe what you know about yourself.

Conclusion

When we are in the throes of perimenopausal fatigue, overwhelm, fury, and grief it can feel as if the odds are stacked against us. However, nothing is written in stone nor woven into the DNA that cannot be mitigated if we have the information, access to resources, and social and medical support that we need. These sometimes seem like big “ifs” in the current milieu, but the more we know and the more we connect with each other, the more power we have.

Disclaimer

This blog post is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation.

References

Atlas, J. (Director). (2026). The (M) Factor 2: Before the Pause [Documentary]. https://www.pbs.org/video/the-m-factor-2-before-the-pause-qsyotj/

Conway-O’Donnell, C. K., & Chesler, N. C. (2022). The stronger sex, until menopause: understanding the impact of estrogen loss on heart function. American Journal of Physiology-Heart and Circulatory Physiology, 323(1), H128-H129. https://doi.org/10.1152/ajpheart.00270.202

Cooney, E. (2026, March 18). Premature menopause is linked to 40% increase in heart disease risk. STAT News. https://www.statnews.com/2026/03/18/premature-menopause-heart-disease-risk-jama-cardiology-study/

Derby, C., Thurston, R.C., & Santoro, N. (n.d.). Unraveling how the menopause is related to cardiovascular risk & heart health in women during and after menopause. Study of Women’s Health Across the Nation (SWAN). https://www.swanstudy.org/womens-health-info/cardiovascular-risk-and-heart-health-in-women-during-and-after-menopause/

Freaney PM, Ning H, Carnethon M, et al. Premature Menopause and Lifetime Risk of Coronary Heart Disease. JAMA Cardiol. Published online March 18, 2026. doi:10.1001/jamacardio.2026.0212

Geronimus, A. T. (1992). The weathering hypothesis and the health of African-American women and infants: evidence and speculations. Ethnicity & disease, 207-221. https://www.jstor.org/stable/45403051

Haver, M.C. (Host). (2025, October 28). Menopause and Heart Disease: What Every Woman Needs to Know with Dr. Jayne Morgan. [Video podcast episode]. In The UnPAUSED Podcast. YouTube.

Khoudary, S.R.E., Aggarwal, B., Beckie, T.M., Hodis, H.N., Johnson, A.E., Langer, R.D., Limacher, M.C., Manson, J.E., Stefanick, M.L., & Allison, M.A. (2020, December 22). Menopause transition and cardiovascular disease risk: Implications for timing of early prevention: A scientific statement from the American Heart Association. Circulation, 142(25), e506-e532. https://doi.org/10.1161/CIR.0000000000000912

Yousefzai, S., Amin, Z., Faizan, H., Ali, M., Soni, S., Friedman, M., Kazmi, A., Metlock, F.E., Sharma, G., & Javed, Z. (2025, August 12). Cardiovascular health during menopause transition: The role of traditional and nontraditional risk factors. Methodist DeBakey Cardiovascular Journal, 21(4), 121-128. 10.14797/mdcvj.1619

Image References

Title image (Studzinski): https://unsplash.com/s/photos/women-heart

Symptoms chart: https://www.nhlbi.nih.gov/health-topics/education-and-awareness/heart-truth/heart-truth-for-women-social-media-resources

Premature Menopause: https://www.shecares.com/menopause/premature-menopause

Estrogen: https://responsumhealth.com/conditions/menopause/benefits-of-estrogen/

Take Menopause to Heart:

Menopause is a Neurological Event: https://www.femgevityhealth.com/blog/menopause-and-the-brain-why-its-more-than-just-hormones

Menopause as opportunity: https://www.linkedin.com/posts/drlouisenewson_theres-no-denying-that-the-symptoms-women-activity-7295868974288850944-eFoV/

We know that each individual will experience their own distinctive menopause transition rooted in what might be called the causes and conditions of their unique history and context. It is also true that various groups of people tend to have experiences of menopause that have certain characteristics in common, for example:

· Earlier onset of perimenopausal symptoms and of menopause itself

· A longer perimenopausal transition

· Increased number, frequency, and severity of symptoms

· Greater difficulty accessing effective care and treatment for symptoms

The economic and social systems in our culture have developed within a milieu of racism, misogyny, and discrimination and are in large part fueled by the exploitation of certain groups of people, beings, and Earth itself. Groups who do not fit the attributes associated with the dominant group—White, cisgender male, heterosexual, wealthy, educated, having access to traditional routes of material and social power, and sympathetic to theocratic aims—tend to be actively excluded or routinely neglected by the systems that are meant to serve and support health and well-being. These systems include healthcare; education; social safety nets that address special health and life needs, both temporary and permanent; public health projects that ensure access to clean air, water, and soil; security such as emergency healthcare and first responders, etc.

We know that the hormonal cycle of menstruation confers protective benefits on the human body. The rise and fall of estrogen, progesterone, and testosterone circulating through a woman’s body powers her brain; helps to build bone; calms the nervous system; supports arterial and venous elasticity; moderates the highs and lows of blood sugar; aids in the repair and suppleness of skin, ligamentous tissues, and hair; facilitates the building and maintenance of muscle, and more.

According to Cortés and Marginean (2022), “women of color tend to enter the MT [menopause transition] at earlier ages than non-Latina White women and may have a longer transition” (p.1). When women enter the menopause transition earlier, they may have to wrestle with symptoms longer and they are more likely to cross the threshold into postmenopause earlier. This gives them fewer years with access to the protective hormonal benefits of menopause.

The status of minority groups in this culture (some of whom will soon no longer be in the minority), tends to undermine the state of their health and well-being on a comprehensive level. These inequities only become exacerbated during menopause.

Weathering

In a 1992 paper published in the journal Ethnicity & Disease, public health researcher Arline Geronimus introduced the concept of “weathering.” At that time in the U.S., it was thought that the “excessive infant mortality rate” in the African-American community might be linked to the relatively high rate of adolescent childbearing in that group. As Geronimus points out, the logic behind this was based “on a common presumption that maternal age variables measure a universal developmental process—biologic or psychosocial” (p.208). In other words, it was assumed that women in their 20s would be at the ideal childbearing age physically and psychologically, while women on either side of that range would experience a higher rate of complications, including infant morbidity and mortality. In fact, statistical data from women in this presumptive “prime” childbearing period is often used as the reference group against which other age groups are compared.

However, what Geronimus discovered is that Black women in their teens actually had a lower infant mortality rate than those in their 20s. As she wrote, “This variation suggests that different ‘aging’ processes may be occurring among women from different populations who become mothers” (p.208).

The weathering hypothesis suggests that “maternal age variables…be seen as reflections, on a population level, of the ways in which socioeconomic inequality, racial discrimination, or race bias in exposures to environmental hazards may affect differentially the health of women who will become mothers, not only in absolute terms, but also interactively with each other and increasingly as women age” (p.210, bold mine).

So, there are a few things to pull out of this:

· Social determinants of health (SDOH, pictured in a graphic below), profoundly and—in an inequitable environment—preferentially impact each person’s health and well-being.

· These SDOH interact with each other over time in a compounding effect that serves to physiologically age people more quickly than they would otherwise age. This can be measured at the genetic level. According to multiple sources, including a post from the Yale School of Medicine, “weathering has been tied to telomere shortening” (Cortés & Marginean, 2022; Yup, 2022). Telomere length is associated with signs of chronological aging because telomeres protect chromosomal stability and tend to shorten with age, increasing the risk of disease and deterioration.

· Just as with the intersection of multiple identities described in the previous post, SDOH intersect in a way that is not merely additive but is multiplicative. In other words, poverty + racial discrimination + toxic exposure ≠ cancer. It’s less like an equation and more like a meteorological riddle: How will the winds from the four corners meet? At what velocity will they spin? Will they coalesce into a storm, and if so, which direction will they go?

· Chronic and/or repeated exposure to stress is called allostatic load and it creates physiological changes that have long-term consequences for a person’s health. These consequences can remain in a person’s genes and physiological functioning long after the stressors have been alleviated. So, for example, a girl that was raised in poverty, suffering malnutrition and hypervigilance due to reduced safety in her environment, is at greater risk of having difficulties with bearing healthy, full-term infants later in life (Geronimus, 1992).

· In a 2023 NPR interview on “Fresh Air,” Geronimus says, “the work you’ve done to survive the storm is also the storm itself.” Coping mechanisms such as smoking and poor nutrition can influence the age at which a woman goes into menopause, plunging her into the aging process earlier and increasing her risks of long-term health problems.

o Coping mechanisms learned within an inequitable milieu, such as eating processed foods, engaging in addictive behaviors, neglecting or avoiding healthcare visits, or relying on relative strangers for childcare, might be viewed from the outside as unhealthy individual choices a person is making. However, it’s important to understand that these “choices” might be the only options economically or geographically available and/or they serve a need for alleviating the perception of stress or how stress is experienced in that moment.

In the same NPR interview Geronimus shares why she chose the term “weathering” to describe the process of accelerated cellular aging due to chronic stress and the coping it requires. She says she wanted to describe not just the erosion and cost to one’s being, but also to the survival orientation of those who are subjected to weathering. “Weathering” is a term chose to connote “withstanding the storm as well as being beaten down by it” (NPR, 2023).

NPR Interview | Arline Geronimus

Race and Menopause

According to statistics from the Study of Women’s Health Across the Nation (SWAN), a longitudinal study launched in 1994, the average time span of menopause symptoms is different for different groups of American women:

· 4.8 years for Japanese-American women

· 6.5 years for White women

· 8.9 years for Latina women

· 10.1 years for Black women

(Quoted in “The M Factor,” a film premiered on PBS November 2024)

Obviously, there are many groups missing from these statistics, Indigenous and mixed-race women as well as gender non-conforming women, to name a few. However, the statistics are so widely diverse that an investigation of underlying causes and conditions of women’s lives within this culture are clearly merited.

SDOH and the effects of weathering can account for much of this variation. What researchers have been discovering over the last several decades is that the American way of life is essentially unhealthy for most people. Just as the theory of weathering accounts for why some people become unhealthier as they age at a much quicker pace than is typical, it has been shown that immigrants to the United States suffer more stress-related damage the longer they’ve been in this country. In fact, the more upwardly mobile they are and the further they shift from their own cultural milieu into mainstream, traditionally “White” spheres of influence, the unhealthier they become (NPR, 2023).

Complexity

Interestingly, in the “Fresh Air” interview Geronimus says that in the research on weathering so far, the group that suffers the most stress-related damage in terms of weathering are poor Whites. None of this is simple cause-and-effect, it’s more chaos theory, in accord with the meteorological metaphor I offered above.

In one study I read, Kochersberger et al. (2024) reported on the severity of menopausal symptoms of close to 69,000 women in the U.S. and how these symptoms were associated with race, ethnicity, and socioeconomic status (SES).

I found it interesting that each group of women had different symptoms of menopause that were more severe or prevalent:

· Black women reported more severe vasomotor symptoms such as hot flashes and night sweats, sleep issues, painful sex, and unusual periods.

· Asian women had more mood swings, an increase in acne or facial hair, and heart discomfort.

· Indigenous women had more sleep disturbances, skin/hair changes, and joint/muscular discomfort, and the most severe anxiety/depression.

· Middle Eastern and Indigenous women had the highest severity of brain fog.

· South Asian women had a lower prevalence of symptoms generally, but the highest severity for weight changes among all races/ethnicities

· All races/ethnicities, including mixed-race women and Latinas, reported greater severity in menopausal symptoms than White women.

Although “across all symptoms, higher affluence score[s] corresponded to lower symptoms severity,” researchers ultimately found that differences in SES alone could not account for disparities in the severity of symptoms between women of different race/ethnicities. This sound confusing, but what it means is that a woman’s economic status alone could not account for the severity of symptoms. When SES was statistically controlled for, women of non-White groups still had greater severity of symptoms.

This points to race itself being a significant enough factor in itself to account for health inequities regardless of a woman’s economic standing.

The variety in symptoms and symptom severity according to race/ethnicity reveal some of the complexity in attempting to address root causes of both ill health and systemic health inequities.

Areas of Inequity

There is a large and growing body of research in the field of health disparities and health equity. Multiple studies I consulted spoke to myriad contributing factors in the perpetuation of health inequities:

Geographic access to clinics, practitioners, pharmacies

Economic access to healthcare generally

Education level, which contributes to comfort seeking healthcare, knowing how to access it, and understanding what is being said to you by providers

Health Literacy:

This includes culturally relevant, linguistically congruent educational materials and medication/treatment instructions.

It also means making sure that instructions and educational information is written at a reading level that can be understood by someone at a 3^rd-6^th grade reading level.

Race and culture concordant healthcare practitioners: People of diverse races, languages, and genders are woefully underrepresented in the healthcare professions. Yet people tend to be more comfortable with providers with whom they feel some cultural affinity. Zahn et al. (2024) found that “Some…black women…felt more comfortable and respected in race-concordant care” (p.3).

Even if we do not currently have enough healthcare practitioners to attain racial/cultural congruence with the general population, it is possible for current and future practitioners to become more culturally competent, inclusive, and humble. We can incorporate cultural competency curricula into health education across the board so that even when practitioners are confronted with someone whose culture and community they are not familiar with, they understand their own limitations and know how to educate themselves to provide sensitive and effective care.

Women of other races are underrepresented in research: Just as all women have been excluded from medical research for generations, essentially because their hormonal complexity “messed up the results,” the same thing continues to be true for women of non-White races.

Reeves et al. (2023) found that there was “systematic exclusion” of Black women from the SWAN study from the beginning due to selection bias, i.e., how participants in the study were chosen. They offer evidence that the effects of “weathering” led to the exclusion of thousands of participants and ultimately, “Failure to account for multiple forms of selection bias masked racial/ethnic disparities in the timing of menopause in SWAN” (abstract).

In their article on menopause hormone therapy (MHT) prescribing Conklin et al. (2024) wrote “physicians’ recommendations may be influenced by studies including mainly non-Hispanic (NH) White women and…physicians may be less likely to recommend MHT to Black women due to the lack of evidence for MHT use among minorities” (p.18).

As alluded to above in the research looking at menopause symptoms at the intersection of socioeconomic status and race/ethnicity, “limited research exists on the hierarchy and weight of attribution of…factors [contributing] to women’s experiences [of menopause symptoms and treatment utilization]” (Peate et al., 2024, p.2). In other words, we need to do more research on how to do the research that can tell us more about how women’s life circumstances are affecting their health.

Another issue that can arise in research is “addressing the discrepancy between what researchers choose to study and what patients and healthcare providers want to know” (Peate et al., 2024, p.4). In recent years translational research, which seeks to move evidence-based knowledge into practical application and test it there, has been in the ascendence, especially in public health.

Discrepancies in treatment regimens, including menopause hormone therapy prescribing. In their research looking at health disparities and hormone therapy prescribing, Conklin et al. (2024) found a variety of results, including:

· Black women “used medications other than hormones to treat menopause symptoms more often compared with NH White women.”

· “Non-White women had had less anti-osteoporosis medications prescription claims than NH White women.”

· “Asian women used non-prescription therapies more compared with all other ethnicities.”

· There were discrepancies in prescribing according to age, with some studies showing older women getting more MHT and others showing younger women getting more prescriptions.

What the authors did find is that “the most frequent disparity in MHT prescribing was found between ethnic groups” (p.17). Factors that had a significant impact on MHT prescribing and patient adherence:

· Income

· Geographic location

· Insurance coverage

· BMI, alcohol use, and smoking

· Practitioner bias

· Trust

Dismissal of symptoms

This is something that tends to happen of women of all races across time. Dismissal happens because of sexism, racism, and paternalism, but also because of time crunches for health providers, impatience with communication difficulties, lack of cultural awareness and sensitivity, and deficiencies in education about women and menopause generally and how race/ethnicity affects health specifically. Dismissal of symptoms profoundly impacts women’s trust/distrust of healthcare and its providers.

History

Photo: Anarcha, Lucy & Betsey

The issue of trust is one rooted not only in the lack of education and health literacy on the part of individuals or in language barriers, cultural insensitivity, patient-provider incongruency, and lack of inclusivity in health care generally. It is also based on a grim history of how people of different races have been exploited by the medical field.

I will not go into a lot of detail here, but will mention a few key instances of exploitation, some of which have been present into the 21^st century.

The Tuskegee Syphilis Study:

Started in 1932, this study was instituted to follow a few hundred African-American men with the aim of observing and charting the normal course of syphilis. However, these men were not ever offered treatment for their disease, even after penicillin was readily available. The study was ended in 1972, after being exposed by the media.

Tuskegee Syphilis Study

Anarcha, Lucy, and Betsey:

These women were slaves who were repeatedly experimented on by the self-styled “father of gynecology,” James Marion Sims. He was approached by slavers who were interested in resolving the problem of vesicovaginal fistulas, a complication of childbirth that leads to chronic incontinence as well as vaginal scarring and dysfunction. These men could not get the work they wanted out of women who were suffering with post-childbearing complications and wanted Sims to come up with a solution. Over the course of five years Anarcha alone underwent 30 operations without the benefit of anesthesia. Betsey and Lucy also endured multiple surgeries. In the end, with the assistance of Anarcha, Betsey, and Lucy after his male assistants deserted him, Sims discovered a way to repair the fistulas. The three women were sent back to their owners and Sims went on to fame and fortune.

Anarcha, Lucy, and Betsey

Sterilization

According to Ko (2016), “federally-funded sterilization programs took place in 32 states throughout the 20th century.” These were associated with various eugenics movements and were considered “a cost-effective way of relieving society of the burden of providing for the social welfare of the unfit and socially inadequate” (Bold, 2015).

The Supreme Court put its imprimatur on these strategies in Buck v. Bell (1927) when “the court held 8 to 1 that the state, under its police powers, had the constitutional authority to segregate and systematically sterilize people to reduce the economic and societal burden they inflicted on the nation” (Bold, 2015).

Although he considered America’s forays into eugenics “weak beginnings,” Adolf Hitler wrote admiringly of these attempts in Mein Kampf (Bold, 2015).

Referred to as “Mississippi appendectomies” because these procedures often happened without prior discussion, understanding, or consent while women were receiving appendectomies, California prisons were still authorized to do sterilizations up until 2010 (Ko, 2016).

And in a 2011 post in Ms. magazine, Lisa Wade writes that “Puerto Rican women in both Puerto Rico and the U.S. have ‘one of the highest documented rates of sterilization in the world.’ Two-thirds are sterilized before the age of 30, many of them choosing this route because of economic conditions that prevent them from choosing to have more children.

All of this is to say that while health literacy, economics, patient-provider connection, and research are all factors affecting women’s menopausal transitions, different people groups have different histories with medicine and research.

All of these factors tend to contribute to the following:

· Suspicion and lack of understanding about what providers are offering

· Unwillingness or inability to pick up prescriptions or take medicines as prescribed

· Wariness about participating in research

· Suffering side effects and not being willing to or knowing how to follow up with providers

Resources that may be helpful for people of non-dominant race/ethnicity

The Pause Life

Black Girls Guide to Surviving Menopause

Gender Diversity and Menopause

There is not a lot of research available on how menopause affects gender non-binary and trans people. However, what is known is that menopause “affects anyone who has periods” (Queen Mary UofL). The menopause transition does happen to people who are not cisgender and the symptoms and risks they may experience are not well understood.

Trans women, those who were assigned male at birth (AMAB), are likely to undertake hormone therapy for life, but they may experience symptoms of menopause, such as hot flashes, body aches, depression/anxiety, etc., if that therapy is unstable or interrupted. They are also likely to experience some of the psychological/emotional impacts of how menopause and aging women are perceived socioculturally.

Trans men, those assigned female at birth (AFAB), will experience a menopause if they do not undertake hormone therapy and retain their ovaries. If they do have a full hysterectomy, they will go into a premature menopause, just as any woman would do. Experiencing menopause earlier is likely to put them at risk for things like lower bone density, but this risk may be offset by masculinizing hormone therapy that facilitates the development of muscle mass. This is not well understood at this point.

Non-binary and intersex people may experience menopause or not. It depends on anatomical factors and any medical/hormonal therapies they may be using.

This is a two-minute video from Menopause Alliance Australia narrated by Dr. Michelle Yong that describes how menopause may manifest in gender diverse individuals:

https://menopausealliance.au/talk/trans-and-non-binary/

Barriers to care

Gender diverse individuals and groups in this culture experience the same barriers to healthcare and risks of poor health as those who have a different race/ethnicity from the dominant group.

They are subject to provider bias and lack of education, a paucity of research about their unique experiences, hesitancy to engage with the healthcare system because of systemic discrimination and past experience, and a history of violence against them in the culture that may make them reluctant to draw attention to themselves. As with any other person, they are subject to the social determinants of health, and because of systemic discrimination gender diverse individuals may find it more difficult to remain at home through adolescence, find housing, stay the course in higher education, find well-paying jobs, afford basic or complex medical care, etc. “Weathering” is a phenomenon that affects this group as much as any other person subject to the chronic stresses of living in a culture that insists on gender duality and the erasure of diverse experience.

More than a body

We know that the experience of menopause is more than a simple physiological transition. If menopause was simply the cessation of menstruation this blog would not exist. Menopause itself is a rather meteorological manifestation with myriad systems within and without the body interacting in new ways to produce effects that are physical, psychological, emotional, mental, relational, and spiritual.

Toze and Westwood (2024) note that “Biomedical definitions of menopause are…closely entangled with normative social expectations of gendered discourses” (p.2). These discourses tend to be “deficit focused…[and with] close interrelations between menopause and gendered ageism” (p.1-2).

Interestingly, the experiences of gender diverse individuals going through menopause can shed light on personal and social constructions of biological processes such as menopause. For example, in a qualitative study asking gender diverse individuals about their experience of menopause Toze and Westwood (2024) noted the following:

· Some people felt more settled in their chosen identity, but others found the transition sparking more questions about their identity and how much hormonal effects define identity.

· One person felt more female, but then also noted, “it has made me focus on my female body in a way that I am not totally comfortable with” (p.5)

· A man who identified as both “non-binary” and “trans man,” and who still had a female anatomy, found that menopause was “pushing [him] into an externally female gendered experience and category” (p.5).

· A non-binary person who had found no dissonance with experiencing periods and pregnancy/childbirth found menopause “much more conceptually difficult. I think in large part because the social narrative is so much about ‘menopausal women’ and also often denigratory or shame-laden” (p.6).

Social narratives and the struggle to find relevant healthcare support were key factors in how difficult the menopause transition was perceived to be.

· “It’s very hard for anyone who doesn’t identify as cis female to overcome barriers to treatment, and infuriating” (p.6).

· “GP’s…have very little knowledge of female menopause never mind anyone who doesn’t identify as female” (p.6).

· “…GP at time hadn’t made the link between changing hormones, and vaginal atrophy leaving me vulnerable to UTI” (p.6).

· “I saw a GP about menopause symptoms later at around usual age, I think I was not offered anything, and came away feeling like I was expected to just ‘ride it out’” (p.6).

That last sentiment in particular may be familiar to anyone going through menopause regardless of gender identity. However, these words describe the lived experiences of a particular group of people, a group that demonstrates in its intra-group diversity the reality of how much range exists within any particular category of being we construct socially.

Just as this diversity creates friction, it also holds out to all of us the possibility of a radical kind of freedom involving self-definition and identity as our bodies and minds evolve within the constraints of systems based on ideas that increasingly no longer serve us.

This is part of why it is essential that we hear more about their life experiences directly from people who are different from us. But the more critical and immediate need to know more is so that all people will be able to survive and thrive. We all deserve not only to get our needs met, but to be fully supported in making the greatest contribution each of us can to the community we are—no matter how divided we currently feel.

Menopause across cultures

People from different cultures across the world, as well as diverse people groups within the United States, view menopause, its symptoms, and its solutions from unique perspectives. A tiny bit of this has been alluded to above. Discrepancies in treatment regimens does not occur only because of bias and lack of research. There is some evidence that Asian-American women tend to use non-prescription treatments to alleviate symptoms because that route of care is more culturally familiar or congruent for them. And, as Conklin et al., (2024) noted, Black women tended to use non-hormonal medications as well as compounded hormone therapy more than non-Hispanic White women. The reasons for this are not known, but there may be cultural perceptions or preferences that lead to these choices.

In a future post I will explore how menopause is perceived and addressed across cultures and nations.

Disclaimer

This newsletter is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation.

References

Bold, M.G. (2015, March 5). Op-Ed: It’s time for California to compensate its forced-sterilization victims. Los Angeles Times. https://www.latimes.com/opinion/op-ed/la-oe-0306-bold-forced-sterilization-compensation-20150306-story.html

Cheung, A. S., Nolan, B. J., & Zwickl, S. (2023). Transgender health and the impact of aging and menopause. Climacteric, 26(3), 256-262. https://doi.org/10.1080/13697137.2023.2176217

Conklin, D., Ramakrishnan, A., Yu, L., Varghese, S., Sajatovic, M., Loue, S., & MacPhedran, S. (2024). Health Disparities and Hormone Therapy Prescribing for Early, Peri-, and Postmenopausal Women: A Scoping Review. Journal of Racial and Ethnic Health Disparities, 1-22. https://doi.org/10.1007/s40615-024-02209-4

Cortés, Y.I., & Marginean, V. (2022, October). Key factors in menopause health disparities and inequities: Beyond race and ethnicity. Current Opinion in Endocrine and Metabolic Research, 26. https://doi.org/10.1016/j.coemr.2022.100389

Davies, D. (Host).(2023, March 28). How poverty and racism ‘weather’ the body, accelerating aging and disease [Audio interview]. NPR. https://www.npr.org/sections/health-shots/2023/03/28/1166404485/weathering-arline-geronimus-poverty-racism-stress-health

Geronimus, A. T. (1992). The weathering hypothesis and the health of African-American women and infants: evidence and speculations. Ethnicity & disease, 207-221. https://www.jstor.org/stable/45403051

Ko, L. (2016, January 29). Unwanted sterilization and eugenics programs in the United States. PBS: Independent Lens. https://www.pbs.org/independentlens/blog/unwanted-sterilization-and-eugenics-programs-in-the-united-states/

Kochersberger, A., Coakley, A., Millheiser, L., Morris, J. R., Manneh, C., Jackson, A., ... & Hariton, E. (2023). The association of race, ethnicity, and socioeconomic status on the severity of menopause symptoms: a study of 68,864 women. Menopause, 10-1097. DOI: 10.1097/GME.0000000000002349

Namazi, M., Sadeghi, R., & Behboodi Moghadam, Z. (2019). Social determinants of health in menopause: an integrative review. International journal of women’s health, 637-647. https://doi.org/10.2147/IJWH.S228594

Peate, M., Johnson, T. L., Avis, N. E., & Hickey, M. (2024). Addressing sociodemographic, socioeconomic, and gendered disparities for equity in menopause care. Cell Reports Medicine, 5(6).

https://doi.org/10.1016/j.xcrm.2024.101616

Printz, C. (2019). Black women less likely to adhere to hormone therapy for breast cancer. Cancer, 125(3), 331-331. https://doi.org/10.1002/cncr.31970

Queen Mary University of London. Who can experience menopause? https://www.qmul.ac.uk/human-resources/equality/menopause/who-can-experience-the-menopause/

Reeves, A., Elliott, M. R., Karvonen-Gutierrez, C. A., & Harlow, S. D. (2023). Systematic exclusion at study commencement masks earlier menopause for Black women in the Study of Women’s Health Across the Nation (SWAN). International Journal of Epidemiology, 52(5), 1612-1623. DOI: 10.1093/ije/dyad085

Toze, M., & Westwood, S. (2024). Experiences of menopause among non-binary and trans people. International Journal of Transgender Health, 1-12.

https://doi.org/10.1080/26895269.2024.2389924

US Preventive Services Task Force (USPSTF). Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. 2025;333(6):498–508. doi:10.1001/jama.2024.27154

Vedantam, S., Penman, M., Schmidt, J., Boyle, T., Cohen, R., & Connelly, C. (Hosts). (2017, February 7). Remembering Anarcha, Lucy, and Betsey: The mothers of modern gynecology. [Audio podcast]. NPR. https://www.npr.org/2017/02/07/513764158/remembering-anarcha-lucy-and-betsey-the-mothers-of-modern-gynecology

Wade, L. (2011, July 21). Sterilization of women of color: Does ‘unforced mean “freely chosen?” Ms. https://msmagazine.com/2011/07/21/sterilization-of-women-of-color-does-unforced-mean-freely-chosen/

Wikipedia. (2025, April 3). Tuskegee syphilis study. https://en.wikipedia.org/wiki/Tuskegee_Syphilis_Study

Yup, K. (2022, November 30). Black women excluded from critical studies due to ‘weathering.’ Yale School of Medicine. https://medicine.yale.edu/news-article/black-women-excluded-from-critical-studies-due-to-weathering/

Zahn, K., Pittman, A., Conklin, J., Knittel, A., & Neal-Perry, G. (2024). Disparities in menopausal care in the United States: A systematic review. Maturitas, 108021. https://doi.org/10.1016/j.maturitas.2024.108021

Image References

Human rights: https://www.facebook.com/UNFPA/photos/providing-support-for-menopause-is-not-just-a-matter-of-equityits-necessary-for-/1003116955180271/

SDOH: https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health#:~:text=Determinants%20of%20Health-,Social%20Determinants%20of%20Health,Social%20and%20Community%20Context

Race: https://www.medpagetoday.com/resource-centers/advances-in-menopause/severe-menopause-symptoms-do-race-ethnicity-and-socioeconomic-status-fit-in/5219

Anarcha, Lucy, & Betsey: https://www.smithsonianmag.com/smart-news/mothers-of-gynecology-monument-honors-enslaved-women-180980064/

Queer Menopause: https://www.queermenopause.com/

Menopause in different cultures: https://www.thewomensjournal.co.uk/health/menopause-in-different-cultures-around-the-world/

What is intersectionality?

Much of how we interpret any life event—including the menopause transition—has to do with

· our unique perspective on that event

AND

· how we contextualize it and ourselves in relationship with what is happening to us or what we are causing to happen

We each exist at the intersection of multiple identities, and this makes our individual experiences of life more or less complex depending on how many overlapping identities we have and how many characteristics we share with the dominant group. Most of us have a range of groups we belong to that contribute to the make-up of our individual identity. These groups can include race, ethnicity, and religion, but may also include things like zip code, volunteer at Planned Parenthood, or vegan activist. The physical and mental characteristics we have, as well as the relationships, activities, and groups that we invest in and identify strongly with all contribute to how we vote, behave, spend our money and time, and also how we are perceived and what others believe about us and how they treat us.

In American culture, from its inception to the present day, the power dominant group is the White, cisgender, heterosexual, able-bodied male who was born with access to wealth, higher education, and the echelons of power and who is sympathetic to Christian theocratic aims.

In her 1989 paper, Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics, judicial scholar Kimberlé Crenshaw coined the term intersectionality to describe the unique status and forces of oppression experienced by Black women in the United States.

Kimberlé Crenshaw

There are (at least) four critical points to understand about intersectionality:

Power & Disadvantage

First, where we sit within the overlapping of our identities shows us both what kinds of power and privilege we have as well as where we are disempowered and vulnerable culturally/socially/politically.

For example, three characteristics of my identity are White, college-educated and female. I am privileged and able to wield power because of my race and educational status and at the same time I am systemically oppressed and made uniquely vulnerable because of my gender. A further refinement of this intersection would be to acknowledge that I am cisgender and heterosexual, so theoretically and at times materially, I wield more power as a female than lesbian or queer women or those females who do not identify as women.

Invisibilization (Is that a word?)

Second—and this is a point that Crenshaw focused on in her paper—the intersection at which a person stands makes that person more or less visible in the eyes of the law, society, and culture. Crenshaw used three Title VII (antidiscrimination) legal cases to describe intersectionality and how it works practically.

In one case, a black woman filed a sex discrimination suit “on behalf of all women” at a helicopter company. Ultimately, a circuit court found that since she had claimed to be discriminated against “only as a Black female…[T]his raised serious doubts as to Moore’s ability to adequately represent white female employees” (p.144). Basically, the court thought a Black woman incapable of representing the category “female.”

In another case Black women sought to bring a racial discrimination suit against a company. However, “The court refused…to allow the plaintiffs to represent Black males…” (p.147). In this case the women were permitted to represent the class “Black women,” but were not allowed to represent men of the same race.

Finally, and most damningly, a suit was brought against General Motors by a Black woman alleging sex discrimination because of the system of promotion that was used. Ultimately, the court found that because the woman was a Black woman, she was not due protection from either discrimination based on gender, or on discrimination based on race. She was something “other” that was “neither” and ended up being essentially “nothing” in the eyes of the law.

What the court said was “The legislative history surrounding Title VII does not indicate that the goal of the statute was to create a new classification of ‘black women’ who would have greater standing than, for example, a black male. The prospect of the creation of new classes of protected minorities, governed only by the mathematical principles of permutation and combination, clearly raises the prospect of opening the hackneyed Pandora’s box” (p.142).

In other words, this court could not risk seeing or recognizing a legal class of “Black women” because it was concerned it would then have to legally recognize the experiences of groups and individuals with multiple intersecting identities, hearing and ruling on cases having to do with the specific and unique ways these groups and individuals are discriminated against.

And so, the term invisibilize comes into vogue to describe the ways in which entire groups of people become legally invisible and, in the process of erasure, become increasingly marginalized and vulnerable to abuse.

Interestingly, there is a group that profits by a type of invisibility with the resulting profit also often rendered invisible. This would be those in the dominant group. As Crenshaw points out, “because the privileging of whiteness or maleness is implicit, it is generally not perceived at all” (151). We are so accustomed to viewing whiteness, maleness, genderedness as the “norms,” that we tend not to see them or the benefits that accrue to them; we see only what contrasts with them.

Seeing and being seen

The third thing to keep in mind about intersectionality is that identification goes both ways: We are always seeing others and being seen by others. Others are making assumptions and asking themselves questions about us, just as we are with them.

Greater than the sum

A fourth thing to appreciate about intersectionality is that any point on the diagram is greater than the sum of its parts. Crenshaw writes, “Black women’s experiences are much broader than the general categories that discrimination discourse provides…the continued insistence that Black women’s demands and needs be filtered through categorical analyses that completely obscure their experiences guarantees that their needs will seldom be addressed” (p.149-150).

The life of a poor White male miner will never be described by the simple arithmetic of adding up poor + White + male + miner. The overlapping of all those characteristics, plus religion, geography, education, birth order, etc. all comprise a unique life experience within this particular culture that cannot be easily summed up by piling stereotypes on top of each other.

What the court was afraid of

If every individual has their own unique experience of discrimination and/or if individuals are willing to band together into groups that acknowledge a shared discrimination, where will it end?

After all, many characteristics such as race, gender, sexual orientation, or physical ability may appear to be definitive, distinctive, unalterable, and easily categorized. However, as we have witnessed in just the last few decades, these categories are blurring more and more.

· According to Wikipedia, as of 2019 19% of new marriages in the U.S. are interracial, up from 3% in 1967. Any offspring from these relationships are going to be multiracial, defying easy categorization. (Wikipedia, n.d.)

· The vocal emergence of trans and genderfluid groups and people into the mainstream culture have made it impossible to adhere to a simple binary understanding of gender identity or sexual expression.

· Attributes such as physical ability, intelligence, and health are no longer considered intractable harbingers of destiny. Those who understand the impact of systems on individual lives also understand that how a blind person or a person who doesn’t do well on standardized tests is treated and educated has an impact on that person’s access to economic power, meaningful work, and sense of belonging in the community and culture.

· Further, how any person’s health is valued and supported, or not, will create variation across any category labeled “healthy” or “diseased.”

The vast majority of us do differ in multiple ways from the small subset of the dominant group that seeks to reify and wield its abnormal levels of power and access to resources. The last several decades have been a time of intensifying vocalization and self-description by people who are demanding

· that their differences from the dominant group be seen and acknowledged

AND

· the oppressions they have suffered and do endure because of those differences stopped

Although this process has been characterized and presented to us as an ivory tower academic’s “woke” fever dream, the truth is that this recognition and acknowledgment of what has been perpetrated by a small powerful clique on all those who are not part of this select “in-group,” is happening at a grassroots level as people live their lives.

It feels like a hot mess at times, sort of like menopause.

What else does this have to do with menopause?

As I said at the beginning of this post, how we understand ourselves and how we are perceived within our cultural, social, political, and familial contexts, affects how we approach and integrate our life experiences. In the next post I will be considering how race and gender identity may impact the experience of menopause.

An understanding of intersectionality grounds this information in an appreciation of how complex individual experience may be and helps us avoid a reductionistic view of ourselves and others. Having a more nuanced appreciation for how individuals and groups can be both exaggerated and eclipsed by stereotypes and systems may give us more compassion as we look at statistics, as well as a greater ability to understand the implications and shortcomings of research findings for all of us.

Reference

Crenshaw, K. (2022). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics [1989]. Contemporary sociological theory, 1(354), 0.

Wikipedia. (n.d.) Interracial marriage in the United States. https://en.wikipedia.org/wiki/Interracial_marriage_in_the_United_States

Image Reference

Headline image: https://soundwriting.pugetsound.edu/universal/intersectionality.html

Venn diagram: https://www.vecteezy.com/vector-art/92614-complex-venn-diagrams

Disclaimer

This newsletter is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation.

Zoe is a health science company in the UK that offers personalized nutrition programs based on extensive functional medicine testing. They have a cohort of over 70,000 women (50% peri- and 50% post-menopausal) from which they are gathering data in order to fill some of the gaps in menopause research.

According to a recent Zoe podcast, 99.8% of perimenopausal women in their cohort experience at least 1 of the 20 symptoms they ask about; 66% say they experience 12 or more of these symptoms

Greater than 80% of perimenopausal women report experiencing EACH of the following symptoms:

· Sleep disturbances

· Memory loss/brain fog

· Irritability

· Anxiety

· Depression

· Low libido

· Weight gain

· Slow metabolism

And 50-60% of postmenopausal women say they still experience some symptoms 10+ years after reaching menopause. Interestingly, hot flashes are one of the least common symptoms, experienced by only about 45% of the population.

Currently, there are 34 “official” menopause symptoms acknowledged by medical authorities, however, lists that comprise between fifty and one hundred different symptoms have been compiled by researchers speaking to women about their experiences.

Data coming out of the National Institute for Clinical Excellence (NICE) in the UK says that 75-80% of women will experience menopause symptoms. At least 25% will have severe symptoms that profoundly affect their health, their well-being (quality of life), their work and relationships. One-third will experience long-term symptoms lasting 7+ years.

According to a survey conducted by the University College London (UCL) in 2023, “90% of postmenopausal women were never taught about the menopause at school and over 60% only started looking for information about it once their symptoms had started.” (UCL, 2023).

The vast majority of women do not realize that the disorienting, often painful or uncomfortable, symptoms they are experiencing are the harbingers of menopause. Many believe they are getting dementia, have cancer, are going crazy, or simply being overtaken by a degenerative and inevitable aging process that is taking a steep toll on their bodies and minds.

And because menopause is barely mentioned in mainstream medical education, most healthcare professionals are ill equipped to recognize the symptoms of menopause, much less be helpful to women in treating and managing them. In a New York Times article from October 30, 2024, Dr. Mary Claire Haver, author of The New Menopause, said that when she was in medical school she received “about an hour of instruction on menopause” and during her OB-GYN residency “she got about six [hours]” (Friedman, 2024).

A woman can spend thousands of dollars, multiple years, and a tremendous amount of energy she doesn’t have to spare going from PCP to neurologist to gynecologist to dermatologist to oncologist attempting to figure out what is wrong with her.

Photo Credit: Alfred Schrock | Unsplash

There is NOTHING wrong with her. Nothing wrong with you. We are only changing.

Petra Coveney, Menopause Yoga™ teacher and author of Menopause Yoga: A Holistic Guide to Supporting Women on Their Menopause Journey, quite correctly points out that when people go through puberty or pregnancy, each constituting huge hormonal shifts and rearrangements in one’s physiology and psyche, we naturally understand that their needs and behaviors may be different:

· They need more rest

· Their appetites may change, and they have different nutritional requirements

· There may be differences in their cognitive function as their brains come under the influence of hormonal fluctuations and do a certain amount of rewiring

· Physical exertion, exercise, and participation in sports, social gatherings, and the workplace may necessarily fluctuate as physical and emotional energy shifts over the course of each day, week, or month

· Mood swings may be extreme, daily events

· They may experience disorientation and sometimes extreme physical discomfort as their bodies shift and change, becoming strange to them and requiring an adjustment in self-perception

· They may lose confidence or have their self-esteem shaken as they adjust to new bodies, points of view, and ways of being in the world

· They need more physical and emotional support from family members, friends, teachers, colleagues, and employers

· Ways of being that were comfortable and familiar are shaken up and changed inexorably and forever

Why do we imagine that perimenopause and the entire menopause transition into postmenopause would be any different?

Yet it does feel different somehow and there are at least three reasons for this that I can see. (I’m sure you can probably come up with more.):

1. Until the last few years there has been a shameful paucity of medical and scientific research on menopause. Generally speaking, women, non-binary people, and transgender men are woefully misinformed, uneducated, or unable to locate consistent, evidence-based information about a major life transition all of them will undergo.

2. It is clear from the historic lack of research into menopause and healthy aging in women that women have been primarily thought of and valued for their role as reproductive beings. Hence puberty, menstruation, and pregnancy have been studied and taught in medical schools. With the menopause, women cease to be reproductive beings, and it is not clear—from a cultural perspective—what they then are or are for.

3. American and Westernized culture generally views aging negatively and we are now routinely being bombarded by health professionals and entrepreneurs offering us innumerable bio-hacks and work arounds to ward off aging and mortality if we can afford the money and time to implement them. Aging women in particular have historically been viewed as haggard, undesirable, useless, and burdensome in spite of the fact that women in postmenopause tend to have an extraordinary amount of wisdom, expertise, energy, and emotional maturity to expend in creative pursuits, advocacy, and networking.

I have had a terrible time negotiating this transition. It has felt overwhelming much of the time, and I have felt angry, frustrated, fearful, and generally graceless through most of it. I do think that my active avoidance of thinking or reading about it in the years leading up to my menopause transition has contributed to my difficulties.

Why did I avoid it? There are likely many reasons, but briefly, it took me a long time to come to terms with menstruating. I had never looked forward to getting my period and once I got it, it took a while to adjust. However, I did adjust and even came to look forward to getting my period each month. I was lucky in not having bad cramps, nausea, headaches, or heavy flows, and it felt like my period was a built-in pressure valve for tension release that got opened on a regular basis, relieving stress naturally. I was not looking forward to relinquishing my cycle, along with the many fortuitous benefits of estrogen, progesterone, and testosterone, of which I had then only the barest inkling.

I think I also believed—myopically, naively—that because my periods had been relatively easy, I would weather the menopause fairly smoothly.

Not. At. All.

According to current medical authorities, there are 34 “official” symptoms of menopause (though women often experience symptoms not on the list). According to the newsletter, “Medical News Today” out of the UK, these include:

· Hot flashes & night sweats

· Irregular periods & breast tenderness

· Vaginal dryness & recurring UTIs

· Burning mouth & changes in taste

· Fatigue & sleep “disturbance” (a description of what happens to your sleep so mild as to be laughable. Or do I mean infuriating?)

· Electric shock sensations (WTF?)

· Muscle & joint pain

· Brain fog & forgetfulness

· Brittle nails & thinning hair

· Stress incontinence

· Tinnitus & heart palpitations

· Depression, anxiety, panic attacks (Todd, 2025)

These are just a few of the 34 symptoms recognized by the medical field and do not catalogue the entire list that are experienced by women. (In the Zoe podcast referenced above Dr. Sarah Berry mentions 50.)

My own list stands at 24 symptoms and counting (November 2024):

· Grinding fatigue pursuant to insomnia

· Overheating at night, sometimes hot flashes, though they don’t exactly flash. Instead, I tend to heat up in the core of my body and stay hot for a while; I feel like a glowing ember.

· Occasional night sweats

· Depression, crying jags, despair, hopelessness

· Anxiety, fear, some panic attacks at night

· Tinnitus—the harbinger of menopause for me

· I am more prone to injury, shoulder discomfort, more aches and pains generally

· Irregular periods with some cramping associated with them

· Intense nausea a couple of times

· Increased tension generally throughout body and mind

· Difficulty focusing—mild forgetfulness, more frequently a sense of being scattered so it seems to take a lot of effort to pull myself together to concentrate

· Vaginal dryness, which can lead to itching/irritation

· Strange sense of having to pee more often during the night

· Some discomfort with sexual penetration

· Drier, more brittle nails

· Occasional bouts of hair loss; hair has lost some luster

· Takes longer to heal—injury, wounds—perhaps due to chronic sleep deprivation, perhaps due to estrogen deprivation

• A couple of days of intense uptick in libido that totally bowled me over and was accompanied by painful orgasm. This has only happened once.

· Appetite has changed; it’s taking me a while to figure out how much and when I need to eat to keep my blood sugar stable; I have much less tolerance for sugar and alcohol and don’t digest or recover from dietary indulgences as efficiently as I used to

· Weight gain—mostly in the form of belly fat--that has been difficult to budge even with testosterone on board

· Loss of confidence & self esteem

· Dehydration, feeling of being dried out

· Strange staining on teeth that we finally discovered was due to hormonal fluctuations coupled with taking an iron supplement. I stopped the supplement and staining has stopped (after being polished up at dentist’s).

· Increased rage and intolerance for all things patriarchal/male/asinine and re: the status of women generally all over the world and throughout time

Each year since January of 2022 new symptoms have arrived, sometimes replacing old ones, most often just piling on.

I am sharing this list with you for the same reason I started writing this blog. In Autumn 2024 I hit a real nadir in my physical, mental, and emotional experience of perimenopause. I decided that I needed a way to deal with this process more constructively and creatively if I did not want to continue to deteriorate. To that end I joined a Menopause Yoga™ training, started a women’s health coaching program, and began researching and writing these articles.

I thought that if I reached out to others, worked to support others going through this transition, and dug intensively into reading the research and stories shared formally by pioneering health professionals and informally by people moving through this transition, I would feel better—less alone, less helpless, more empowered, confident, and happier. I hope what I am offering here can do the same for you.

Photo Credit: Sara Ferreira | Unsplash

The good news is that as I sit here now in March of 2026, updating this post before putting it on Substack, my symptoms have alleviated dramatically. It has been a rough road, but as of January of this year I am officially in menopause and—although I still heat up a bit too much at night (even with HRT on board)—things have calmed quite a bit in the last few months.

Having said that, I have also come to the inexorable realization that I am a different being in a different body on this side of the menopause transition. It sounds so mild to say it that way, but it’s not mild at all. To me it is very much akin to the journey a girl takes over many years in becoming a woman. It takes a long time to adjust to the profundity of the transformation and all the physiological, psychospiritual, and sociocultural implications of the changes that have taken place. Now begins the process of getting to know myself anew and fully embodying my power, energy, and possibilities in this (re)new(ed) form.

Ultimately, this is where we are all headed.

Tools

If you would like to track your own symptoms, here are two resources that may be helpful:

Menopause Support

You can visit menopausesupport.co.uk to find a link to their “Menopause Symptom Checker” and “GSM Symptom Checker:”

Menopause Support

GSM stands for Genitourinary Syndrome of Menopause and refers to symptoms such as vaginal dryness and irritation, incontinence, painful intercourse, needing to pee a lot, etc. These can be difficult symptoms to confront, much less discuss openly. However, treating these symptoms with vaginal estradiol (a topical cream or suppository) can be relatively simple and safe and can also prevent future illness and pain. (See my post about GSM, which will be up soon.)

A doctor in the UK recommends using these checklists to prepare for doctor’s appointments, so that we can show up to these meetings with a clearer picture of what we are experiencing and more accurately assess the doctor’s ability to help us.

Greene’s Climacteric Scale

This scale helps to determine both the number of symptoms a person has and how severe they seem to be. It was developed in 1976 by Dr. J.G. Greene and, according to My Menopause Centre in the UK, it is “used by practitioners worldwide and is a really reliable scale because so many women are measured against it.”

What is Greene's Climacteric Scale?

Here is a link to the scale that you can fill in online:

Greene's Climacteric Scale

Zoe Menoscale:

Zoe Menoscale

Disclaimer

This newsletter is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation.

References

Friedman, D. (2024, October 30). The menopause queen’s gambit. New York Times. https://www.nytimes.com/2024/10/30/well/dr-mary-claire-haver-menopause.html?campaign_id=61&emc=edit_ts_20241030&instance_id=138207&nl=the-great-read&regi_id=52710249&segment_id=181769&user_id=de265e4c917e125aae8981e7c166ee57

Todd, L. (2025, December 17). What are the 34 symptoms of menopause, and what helps? Medical News Today. https://www.medicalnewstoday.com/articles/what-are-the-34-symptoms-of-menopause#managing-symptoms

University College London. (2023, April 26). Nine in ten women were never educated about the menopause. https://www.ucl.ac.uk/news/2023/apr/nine-ten-women-were-never-educated-about-menopause

Image References

Butterfly: https://unsplash.com/@puregeorgia

Absence of women in history: https://feministtrash.com/products/the-absence-of-women-in-history-is-man-made-unisex-t-shirt?srsltid=AfmBOoq78c4_ZdRg-F8xchf7L2I1S3GNXPTx08_Uo_kQ7hx0H7-0LHMP

Surprising Symptoms: https://www.joinmidi.com/post/22-surprising-symptoms-of-menopause

Light at the end of the tunnel: https://unsplash.com/@ferreirasara?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

Image: om/blogs/learn/symptoms-perimenopause-menopause

Menopause Symptoms

Menopause is a highly individual experience. Each person going through menopause will have a unique constellation of symptoms, as well as ideas and meanings that they attach to the experience. Having said this, it is important to recognize that no one goes through the menopause transition in a vacuum.

In addition to a person’s current physical & mental health, genetics, lifestyle, and trauma history, every person’s menopause is impacted to a greater or lesser degree by myriad factors, including, but not limited to:

· race, educational, and socioeconomic status

· gender expression & sexual orientation

· ability status

· levels of social and financial support

· access to healthcare

· attitudes and environment of their workplace

· religious mores

· cultural and biomedical perspectives and opinions regarding menopause and those who experience it

The major categories of menopause symptoms include:

· Vasomotor symptoms, such as hot flashes, sweating episodes, freezing episodes, etc.

· Mood changes

· Cognitive difficulties, such as forgetting things, brain fog, grappling for words, etc.

· Sleep “disturbances,” which can range from full-on insomnia to chronically disrupted sleep

I have written an entire post about menopause symptoms in themselves so I will not go into a lot of detail here. However, I do want to point out that there are 34 “official” menopause symptoms currently acknowledged by medical authorities and lists that comprise between 50 & 100 different symptoms that have been compiled by researchers speaking to women about their experiences.

Symptom Stats

Data coming out of the National Institute for Clinical Excellence (NICE) in the UK says that 75-80% of women will experience menopause symptoms. Zoe, a health sciences company in the UK that is conducting research into menopause, puts the statistic at closer to 100% of women who will experiences at least one menopause symptom.

The Health and Employment after Fifty (HEAF) study was run from 2013-2019 in the UK. It followed 608 women and found that the most commonly reported symptoms were:

· Vasomotor symptoms (92%)

· Sleep difficulties (68%)

· Psychological symptoms (64%)

Significantly, a full 27% of these women reported “moderate/major difficulties coping at work with their menopausal symptoms” (Walker-Bone & Davis, 2025). This tracks with the data from NICE that showed that at least 25% of women will have severe symptoms that profoundly affect their health, their well-being (quality of life), their work and relationships.

While symptoms such as hot flashes and mood shifts may arise initially from the physiological changes induced by fluctuating hormone levels, it’s important to understand that, as Daly et al (2024) point out, symptoms “are not always a direct consequence of hormone changes, instead being seen as the result of a ‘domino effect,’ with one symptom leading to another.” Hot flashes at night disrupt sleep, which can lead to cognitive impairment and mood disruption, especially over time. Likewise, heavy and/or unpredictable bleeding can contribute to anxiety, low energy, chronic discomfort, and other health issues that affect mood, sleep, concentration, and relational ease.

Image: https://www.citation.co.uk/news/hr-and-employment-law/the-reality-of-menopause-in-the-workplace/

Menopause Symptoms at Work

The limited research available has shown that when women are coping with difficult menopause symptoms it can have an adverse effect on their work in the following ways:

· Presenteeism (showing up for work, but accomplishing less)

· Absenteeism (lost days of work and/or time spent on outpatient medical visits)

· Reduced work hours (having to cut back to cope with symptoms)

· Lower work satisfaction

· Job loss (retiring early or changing jobs in an attempt to balance health and well-being with work) (Faubion et al, 2023)

A Mayo Clinic study published in 2023 detailed the results of a survey tracking self-reported adverse work outcomes related to menopause symptoms. Essentially, what researchers found is that women who experienced more symptoms and greater symptom severity had more adverse work outcomes and were more at risk of leaving work altogether (Faubion et al, 2023).

Other studies discussed in the Mayo paper:

In Japan, a study found that more menopause symptoms were linked with lower work performance.

In the UK, those with severe menopause symptoms were 1.43 times more likely to leave employment rather than reduce work hours and 1.23 times more likely to reduce work hours rather than continuing as usual.

The Fawcett Society report (2022) out of the UK found that 77% of women surveyed said they had one or more menopause symptoms that were difficult to cope with, and “44% expressed that it affected their ability to work.” What is perhaps the most shocking statistic from this report: “one in ten respondents…reported having left work because the symptoms were too difficult to cope with” (Dalingwater & Winett, 2025).

According to Aggarwal (2025), in the U.S. Study of Women’s Health Across the Nation (SWAN), “large-scale observations of women aged 42-64… identified onset of sleep problems later in midlife to be associated with increased unemployment risk (31% increase) and a yearly productivity loss of USD 2.2 billion because of reduced working hours.”

Why is the workplace difficult for perimenopausal women?

Stigma and Fear

At the head of the list of why the workplace can be so challenging for women coping with the menopause transition is stigmatization and shame. Women’s physical experiences, whether menstruating, childbearing, or moving into menopause, have historically been considered—throughout most current cultures on Earth—dirty, shameful, sinful, and something to be kept hidden and quiet, well out of the public sphere and polite conversation.

Study after study has revealed that women fear disclosing their struggles with menopause symptoms in the workplace for several reasons having purely to do with sociocultural stigmas around menopause and aging:

· they are embarrassed by what they are experiencing

· they believe they will be perceived negatively by colleagues and bosses

· they are afraid that their symptoms will harm their status and potential at work, and they will be viewed as weak, incapable, aging into decrepitude (Angco, 2025; Daly et al, 2024; Faubion et al, 2023)

In the West, the conflation of menopause with aging and aging with inevitable decline—of beauty, strength, power, and capacity—terrifies many women, and they seek to hide any evidence that they may be changing in ways that reveal or signify the natural process of getting older. Daly et al (2025) refer to “ageing as an aspect of gendering processes within the work context,” which means that as a woman ages, she somehow becomes more of a stereotypical woman in the eyes of those around her at work—weaker, less visible, less capable and consequential, less desirable to have around.

The stereotypical image of “The Older Woman” in Western culture is the witch with the wart on her nose—withered, ugly, undesirable, physically used up. In the limited imagination of the West, if a woman is unavailable for reproduction, her productive capabilities seem to have come to an end (Quental et al, 2023).

Women also feel the additional burden of not letting other women down by making their struggles with menopause known. There is an implicit pressure felt that one is responsible for not contributing to the negative narrative around menopause, and by extension womanhood, that could implicate other women and make work harder for them (Daly et al, 2024).

Additionally, in one interesting qualitative study conducted by Daly et al (2024), one of the themes revealed was that “negative menopausal symptoms were perceived as a burden for everyone in the workplace.” Participants were uncomfortable hearing about menopause, knowing about a woman’s health struggles, and also were concerned about having to take up the slack if she is not well enough to do her job as usual.

A second theme in the same study was that menopause does not “belong in the workplace;” as a “woman’s issue” it belongs at home, or at least not talked about. This is heartbreaking. Women are half the population. We “belong” everywhere men belong. Our reproductive capacities, of which menopause is a natural phase, is what makes human life possible. Yet, as Daly et al (2025) point out, and as I can attest to from all the research I have done, “Discourses of fear and loss are interwoven through much of the menopause literature.” Some of this fear and loss are an integral and natural part of the process of change and transformation. However, so much of it is unnecessary, piled on by social and belief systems mired in misogyny and existential fear.

Challenges of the workplace

Different job types and workspaces offer unique challenges for women experiencing menopausal symptoms. Generally speaking, there are three areas menopause advocates point to as needing reform:

· Workspace organization

o The physical layout of the space: How easy is it to access restroom? Are restrooms stocked with menstrual supplies? Are there cooling rooms or fans available? How well-ventilated is the area? Is there access to cool drinks?

o How flexible are dress codes? Is layering of clothing possible? What kind of fabrics are uniforms made of?

· Workplace attitudes and norms

o Are managers and staff trained in how to recognize signs and symptoms of menopause? Do people in the organization know what menopause is and feel comfortable discussing it? Is there sensitivity to health and well-being generally and to menstruation, pregnancy, and menopause specifically within the organization?

o How easy is it to get flexible working hours? Is there flexibility regarding working from home?

o Is there a strong cultural push within the business to keep personal issues private, quiet, to be dealt with on one’s own?

· Institutional benefits

o Is it considered reasonable or allowed to take sick leave for menopause-related symptoms? Do people have access to paid leave to take care of themselves when coping with menopause symptoms?

o Does the employer offer access to menopause specialists and treatments through apps, benefits, in-company trainings, HR, or an on-site health clinic?

o Do insurance benefits cover the expense of menopause hormone therapy? (Aggarwal, 2025; Dalingwater & Winett, 2025)

A couple of the articles I read also brought up the issue of how traditional evaluation procedures tend to penalize women dealing with menopause symptoms. Because of the unpredictable nature of menopause symptoms, women may end up taking multiple, unscheduled days off work. This absenteeism tends to count against them in performance reviews and may result in disciplinary action, lost promotion opportunities, or even dismissal. (Dalingwater & Winett, 2025; Daly et al, 2024). The fact that many women do not feel comfortable being honest about why they are needing time off, added to the reality that menopause often is not considered a good reason for taking time off, exacerbates this problem.

In her article on “The Estimated Cost of Menopause-related Productivity Loss,” Aggarwal (2025) investigated how menopause symptoms interact with four different spheres of work:

· “Knowledge-Intensive”: In corporations or academia, cognitive issues, sleepiness, and brain fog can be particularly damaging to a woman’s work life. There tends to be a high degree of presenteeism, as women show up, but have difficulty focusing, being present, and producing their best work.

· “Service and Care Work”: These are customer-facing jobs that require continuous interpersonal engagement and a lot of emotional labor. Anxiety, mood swings, and hot flashes can be particularly triggering and are also likely to be triggered in these types of situations. Again, presenteeism is the norm as women tend to experience fear around “discovery” of their symptoms and resist disclosing what they’re experiencing for fear of being stigmatized by coworkers, managers, or customers/clients.

· “Manufacturing and Manual Labor”: In these environments, the physical demands of the work--coupled with set shifts, round the clock shifts, hot, poorly ventilated workspaces, rigid break schedules, and distant restrooms—tend to exacerbate vasomotor symptoms, injury risk, and fatigue. Women in these jobs tend to have less education and fewer financial resources, both of which are risk factors for more severe menopausal symptoms in themselves (Faubion et al, 2023; Walker-Bone & Davis, 2025).

· “Professional/Corporate”: Like the knowledge-intensive sphere, cognitive issues tend to be highlighted, though this does depend on the person. In these work environments, personal disclosures of any type are uniformly discouraged and competition is rampant. Presenteeism, without complaint or obvious discomfort, is expected and rewarded.

Image: https://www.facebook.com/photo/?fbid=1325529242952723&set=pcb.1325529296286051

The issue for society

A September 2024 “Issue Brief” from the Women’s Bureau at the U.S. Department of Labor says that “one in 10 workers is a woman aged 55 or older.” According to Angco (2025) in the “International Journal of Public Health Research,” “approximately 45% of the over-50-year-old workforce in nearly all forms of employment are women.” And in a 2018 debate in the UK Parliament, MP Martin Whitfield “underline[d] that women may spend a third of their working lives living through perimenopausal or postmenopausal conditions” (Dalingwater & Winett, 2025).

There are many who still want to consider menopause a “woman’s issue” and who desire to keep “women’s issues” out of the workplace and public conversation. However, it is clear that with women comprising slightly more than half the human population and women in mid-life expanding in the workforce, the time is long past due to release menopause, along with menstruation and motherhood, from the taboos surrounding them and normalize discussion of and respect for these natural life phases in the workplace and public sphere.

Financial costs to nations

The economic costs of losing women in the workforce are staggering in every nation (Aggarwal, 2025):

· In the United States the estimated annual cost of absenteeism due to menopause symptoms is 1.8 billion dollars per year. And this does not include the cost due to presenteeism, losing employees and having to hire and train new ones, or people working reduced hours.

o If you include the medical expenses associated with menopausal symptoms, the cost to the US is estimated to be around $26.6 billion annually

· In Australia, a reproductive-leave policy report found that “unattended menopause-related reproductive health needs” were costing the country AUD 26.55 billion annually.

· In an analysis of First World nations translated into U.S. dollars, menopause-related yearly losses in working productivity were:

o UK, $2 billion

o Canada, $3.3 billion

o Germany, $9 billion

o Japan, $12 billion

Financial costs to women

While the economic and institutional costs of losing mid-life women in the workforce are high, the price for women can be astronomical. Apart from the emotional and physical toll of losing promotions, the respect of colleagues and managers, or even one’s job, there are huge financial repercussions for women who struggle with menopause symptoms:

· The Menopause Foundation of Canada has estimated Canada’s annual national financial losses due to menopause symptoms to be around 3.5 billion Canadian dollars. However, employers shoulder only a fraction of this, with Canadian women themselves suffering a 3.3-billion-dollar (CAD) loss in earned income due to reduced hours, lower earnings, or loss of employment (Aggarwal, 2025).

· Aggarwal (2025) also references a Stanford University working paper that notes that “women who sought medical support for menopause-related symptoms experienced around a 10% decline in earnings within four years, mainly because of reduced working hours or leaving the labour force altogether.”

· Women who have clinically diagnosed menopausal symptoms also tend to have much higher medical spending for doctor’s visits and pharmaceuticals (Aggarwal, 2025).

· Research has consistently shown that menopausal people experiencing difficulties managing symptoms are more likely to pass up promotions and turn down leadership opportunities (Aggarwal, 2025).

This reveals other, less quantitative, but no less critical ways in which losing older women in the workforce impacts both the workplace culture and the bottom line. Many women in mid-life have been with their companies or in their line of work for several years. They hold a tremendous amount of experience; a maturity in communicating, negotiating, and making decisions; institutional knowledge; and mentoring capacity that simply does not exist in a younger person. They are already leaders in their field or are likely to be in the process of holding explicit leadership and mentoring roles. When women are not supported in any health and life challenge—whether it be endometriosis, pregnancy and childrearing, or perimenopause—that leadership, wisdom, and experience is at risk of being lost in their chosen field of work.

Not only does this create a huge—currently unacknowledged, and therefore invisible—financial burden on employers, but this burden also drops onto women who must make the painful choice between their well-being and their work. Either way a person chooses, the cost is high for her both financially and personally.

Image: https://www.facebook.com/heather.simmons.3323/posts/we-did-it-both-of-my-menopause-bills-addressing-insurance-coverage-and-provider-/33739081205682741/

Neoliberal stance

Interestingly—and maddeningly—none of this would be challenging in the slightest if we were not operating within systems developed in support of thousands of years of misogyny and structuralized sexism and racism. These -isms have been exacerbated in recent years by the economic philosophy of neoliberalism. While neoliberalism is considered a philosophy of economics, it has social and cultural corollaries, as all economic philosophies do.

Under neoliberalism there has been an expanding, mistaken belief that we are all atomistic individuals who are completely and utterly responsible for our individual experiences. In this worldview, systemic realities and sociocultural milieu simply don’t exist except if you’re strategically placed—through skin color, gender expression, or generational wealth—to “play” the system and win.

The neoliberal view posits that:

· If you are overweight and unwell, it’s not because you live in a food desert, work the night shift, don’t have access to consistent healthcare or live next door to a landfill, but because you are lazy, unmotivated, or stupid.

· If you never got a college degree or work three jobs, but have no healthcare, it’s not because of the history of racism or discrimination in this country or because the generations before you didn’t think about their grandchildren’s well-being, but because you are lazy, unmotivated, or stupid.

· And if you have lots of money, access, and excess, that’s because you deserve it.

Many papers I read for this post referenced the ubiquity and high cost of neoliberal stances toward the worker and her health:

· “[A] dominant discourse of older female workers is evident through menopausal women constructing a personal responsibility to manage their menopausal bodies and present themselves as fit for work” (Daly et al, 2024).

· “…many women internalize a duty of self-help that they believe will shield their careers from the effects of stereotypical views of aging women” (Quental et al, 2025).

· the “neoliberal identity of menopause endurance” (Angco, 2025)

· “’In Julie’s workplace the women who have progressed or are in senior roles have done so by denying their gender’” (Daly et al, 2024)

Ironically, the cost of a neoliberal orientation was not only apparent at the individual level, but at the societal level. By attempting to keep menopausal women closeted and menopause a “private,” individual problem, businesses, communities, and whole nations are suffering myriad losses without knowing why. Aggarwal’s 2025 article synopsizes numerous findings that “underscore how seemingly ‘private’ health conditions produce ripple effects across the labour market.”

Intersectionality

Women’s life experiences are profound and important in part because they so nakedly and controversially expose the complexity and interconnectedness of all our systems—personal, interpersonal, communal, and global.

As Aggarwal (2025) describes it: “menopause functions both as a biological variable—through symptoms of physiological and cognitive functioning—and a socio-cultural portal—mediated by stigma, organizational norms, and managerial sensitivity—that together determine workplace outcomes.” In other words, there are many aspects of our personal and social lives that affect menopause and that are affected by menopause. This complexity also makes research and legislation challenging.

What all the research points to is that a “one-size-fits-all” approach to a complex and extremely individual experience like menopause will not only fail but is also likely to contribute to or aggravate existing sexism and stereotypes (Angco, 2025).

In spite of the difficulty of recruiting a diverse group of participants into most studies, research overwhelmingly reveals that menopause—in the workplace and outside of it—is not only different for each woman, but presents unique challenges for each group of women, depending on her overlapping identities—Black, Asian, immigrant, working-class, transgender, hearing impaired, etc. (Quental et al, 2025; Walker-Bone & Davis, 2025).

Crucially, Aggarwal (2025) notes that the effects of the 10% decrease in income experienced by working women who needed to address menopausal symptoms noted in the Stanford Study referenced above “were concentrated among women in physically demanding or routine-intensive occupations, and among those without higher education, suggesting that economic burdens are unequally distributed.”

Similarly, women who have less autonomy over their time and dress code at work are those who work in more routine-intensive, less prestigious occupations. The lack of power they experience at work—for example, having to ask permission to take a bathroom break whenever they feel the need—mirrors and exacerbates the disparities and marginalization present in the larger social systems (Dalingwater & Winett, 2025).

Although the Mayo Clinic sample size was small, Faubion et al (2023) noted that Black women and Hispanic women had higher menstrual symptom scores than White women. Black women in the US generally contend with more severe vasomotor symptoms than other ethnic groups (Kochersberger et al, 2024). Not only does this make their lived experience of menopause intensely challenging but may put them at greater risk of leaving or losing their jobs.

Multiple researchers mentioned the scarcity of research into menopause generally and menopause in the workplace specifically. This lack is exacerbated by a virtual absence of research exploring the workplace experiences of menopausal women of color, trans, queer, and lesbian women, disabled women, or women in the gig economy. (Armstrong, 2025; Faubion et al, 2023; Howe et al, 2023; Walker-Bone & Davis, 2025).

To learn more about intersectionality and racial disparities in the menopause experience, please see my blog posts entitled, “Intersectionality” and “Menopause: Race and Gender.”

Image: https://www.axios.com/2025/04/09/menopause-laws-map

Legislation

The lack of evidence-based information has somewhat handicapped our ability to codify constructive change for menopausal women in the workplace. However, I would argue that the primary stumbling blocks have been our neoliberal orientation as a nation and our aversion to engaging with issues that make us uncomfortable and that historically we have been able to make somebody else’s problem.

It is telling that in spite of decades of political debate and the repeated introduction of legislation addressing menopause in the workplace, neither the US nor the UK have a national law supporting employed menopausal women in place. “Support in the workplace is still a lottery, with some employers excelling but others letting their employees down at a really difficult time” (Dalingwater & Winett, 2025).

In some ways, it could be contended that because there is no “one-size-fits-all” solution it is too difficult to make legislation about how menopause should be handled in the workplace:

· Large businesses are more likely to have the resources to enact constructive, helpful changes than small businesses: “Women working in smaller, private businesses particularly suffered losses in income due to the lack of instituted human resource policies specifically designed for menopausal needs in these smaller businesses” (Aggarwal, 2025).

· There are many spheres of work, each with their own challenges for menopausal women and the changes that would have to be made to accommodate women’s needs (Aggarwal, 2025)

· There are multiple areas that need to be addressed, as noted above:

o Workplace awareness & education

o Environment & Dress Code

o Benefits (Insurance and Workplace policies)

However, it could also be argued that creating a federal law that explicitly prevents discrimination on the basis of menstruation and/or menopause would be a great step in promoting the well-being of menopausal women in the workplace. Without this type of explicit, legal power upheld and enforced by collective agreement, the pursuit of medical help, professional support and security, and justice becomes a stressful, expensive individual scramble:

· Women are forced to cobble together suits or defenses out of existing policies and acts and somehow prove that menopause is included in these legal protections. In the US, this might be the Occupational Safety and Health Act of 1970 or the Pregnant Workers Fairness Act of 2023.

· They may need to seek legal protections for time off or financial resources for medical help under the Family Medical Leave Act or the Americans with Disabilities Act. In any of these cases, this would be an arduous, paperwork-intensive, potentially expensive route to take with no guarantee that menopause would ultimately be recognized as a legitimate reason for being granted protections or benefits.

· In the UK, women are also forced to seek protections and help under various acts that may or may not recognize menopause as protected. It’s also true that under current legislation in the UK, when a person brings a discrimination claim, these claims require comparators. So, for example, a woman will need to show how others in her position are not being discriminated against for the same or similar issue. As MP Caroline Nokes told a Parliamentary Committee on Menopause and the Workplace, “’Members will immediately see the problem with a menopausal women having to compare herself to a sick man in order to get redress’” (Dalingwater & Winett, 2025).

· Without a federal law—which codifies a socio-cultural agreement to protect and support women’s health and well-being in the workplace—it is left to each state to enact legislation independently. This way of doing things tends to compound and aggravate existing national social and socioeconomic disparities.

o It is worth noting that in June 2025 Rhode Island became the first state to include menopause, perimenopause, and related medical conditions as protected categories under the Rhode Island Fair Employment Practices Act (RIFEPA) (Lexology, 2025).

Disappointingly, an issue that was raised by a couple of articles I read is the concern that legislation in support of women’s concerns in the workplace, whether to do with menstruation or motherhood or menopause, might actually contribute to increased sexism in the workplace (Angco, 2025; Dalingwater & Winett, 2025; Howe et al, 2023; Walker-Bone & Davis, 2025). The idea is that there will be both a backlash against women receiving “special treatment,” as well as the mistaken impression that women are receiving this “special treatment” because they are weaker or not as capable, thus inadvertently reifying existing misogynistic stereotypes (Quental et al, 2023).

At this point in time, I believe it is more important to forge ahead with recognizing explicitly and implicitly that differences do not make people better or worse than each other, and these differences are likely to require certain types of support and awareness at different times.

What can businesses do?

Interestingly, what employers and businesses can do to support women going through menopause is not actually that onerous, either from a financial or time-investment perspective, if one does not object to the idea that treating others with respect and care is desirable for multiple reasons.

· Education & Awareness: Promote and normalize discussion of menopause in the workplace; provide health and medical information so that women and their colleagues understand symptoms and their consequences; train managers and staff and inculcate a culture of support and sensitivity

· Support: Employ or cultivate women in the workplace—“menopause champions—who are willing and happy to speak to others about menopause; provide spaces in the workplace where women can seek out peer or professional support

· Policies: Implement flexible schedules and work-from-home options; modify evaluation and performance reviews so that women dealing with menopausal symptoms aren’t penalized for absences

· Benefits: Offer prescription benefits for HRT; provide paid sick leave and additional sick leave for women; provide on-site access to medical professionals and/or contract with companies that specialize in menopause education and treatments for employees

· Physical changes to jobs: Reduction in heavy lifting during certain times; shifting responsibilities to meet someone’s health needs

· Workspace/dress code: Make sure workspaces are well-ventilated and have modifiable temperature controls and/or fans; allow women easy access to restrooms that are stocked with menstrual supplies; ensure uniforms are made out of breathable fabrics and/or that women are able to dress in ways that allow them to be as comfortable as possible, for example, layering

(Aggarwal, 2025; Angco, 2025; Cahn, 2025; Fadal, 2025; Dalingwater & Winett, 2025); Faubion et al, 2023; Henpicked, 2019; WebMD, 2025)

Researchers noted that if workers are treated as autonomous individuals with choice and flexibility, who feel listened to and supported, their work experience is better regardless of age, gender, or health issues (Walker-Bone & Davis, 2025). Additionally, there is abundant evidence of a bidirectional relationship between workplace conditions and how challenging menopause symptoms are. When employers are perceived as supportive and flexible, workers feel less burdened by their symptoms, whereas workplaces that are inflexible, shaming/silencing, or have poor environments and/or benefits tend to exacerbate menopause symptoms and contribute to worker and business losses (Aggarwal, 2025; Faubion et al, 2023; Daly et al, 2024; Walker-Bone & Davis, 2025). As if to underscore the importance of workplace culture and attitudes toward women and menopause, Faubion et al (2023) found that “neither the type of job nor the physical demands of the job were linked with reported difficulties coping with menopause symptoms in the workplace.”

It’s important to note that while an Australian reproductive-leave policy found the cost of menopausal symptoms to Australian business to be around AUD 26.55 billion annually, the same policy found that to pay 12 days of reproductive leave each year would cost around AUD 920 million (Aggarwal, 2025). The cost of caring for people and promoting health and well-being is ultimately so much less than the cost of not doing this.

Unsurprisingly, the neoliberal paradigm under which the US and the global economy operate, complicates attempts to constructively address menopause in the workplace. Within neoliberal philosophy, prevention and proactivity feels like communism, unearned welfare, and undeserved charity.

The “Pink Tax” amplified

The other piece of this is that menopause itself has become big business. According to a 2023 article in AARP by Sauer et al, “women spend about $13 billion a year to treat their menopause symptoms on several measures such as dietary supplements, hormone replacement therapy (HRT), and copays for health care visits related to menopause.” And “the global menopause market…is projected to reach $24.4 billion by 2030” (Mesko, 2024).

Now, along with the “Pink Tax” we are paying out-of-pocket not only for standard, mainstream medical care to address menopause symptoms, but for specialized and niche clinics, supplements, and healthcare advice marketed to us because our biology, coupled with the systemic lack of support for our life experiences, leaves us feeling desperate, making us a lucrative demographic.

There are many companies that have sprung up and specifically market themselves to employers as avenues to becoming “Menopause Friendly Workplaces:”

(https://menopausefriendly.co.uk/free-resources/).

These include Henpicked, Peppy Health, Maven, and Midovia. While these may ultimately be helpful in changing the landscape in support of women and menopause, it’s wise for women to be cautious about the proliferating books, podcasts, on-line clinics, and sheer amount of information all telling us what we need to do and what we have to buy or who we have to pay to feel better. One size does not fit all.

Image: https://www.facebook.com/groups/427293217393546/posts/8098001266989331/

Positives of Menopause

One thing that is consistently true in all of women’s extremely challenging life experiences: There are always positives popping up, and the positives usually have to do with us becoming stronger, wiser, and more powerful, both personally and collectively.

Throughout the literature there is a sense that liberation is inherent in the menopause transition. Menopause does not just constitute a change, but a transformation. In the reckoning with all the physical, emotional, and psychic shifts and upheaval of perimenopause, an old identity is shed and a new identity—self-defined, rather than socially defined—is birthed. Specifically with regard to work, women have the opportunity during and through menopause to reevaluate who and what they are in relationship to others and what they do, confronting sexism and ageism and redefining themselves within a relational context (Angco, 2025; Daly et al, 2024; Quental et al, 2023).

There is a strong push rising in the mainstream for menopause to become something more than an ordeal to be endured or a problem to be solved (Fadal, 2025; Quental et al, 2023). The generation of women who fought for and achieved employer health benefits for fertility treatments, breast milk delivery, parental leave, and some protections for pregnant women in the workplace now want a menopause that goes far beyond merely coping with an unpleasant reality (Otterman, 2023; Quental et al, 2024).

We are that generation, redefining ourselves and our life experiences in ways that empower and support not only our individual transformation, but our collective evolution as well.

(For more on the positives of menopause, see post “The Upside of Menopause.”)

Disclaimer

This blog post is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation.

References

Aggarwal, A.S. (2025, September-October). What is the estimated economic cost of menopause-related productivity loss in the female workforce and how does it vary across industries? International Journal for Multidisciplinary Research, 7(5), 1-26. https://www.aadyashaktiaggarwal.com/assets/images/service/Multidisciplinary-Research.pdf

Angco, R.J.N. (2025, February). Women in menopause and the workplace experience: A meta-synthesis. International Journal of Public Health Research, 15(1), 2105-2113. https://orcid.org/0000-0001-5321-2371

Armstrong, G.W. (2025). Navigating the Double Jeopardy: The Intersectional Experiences Affecting Black Menopausal Women in the Workplace. [Thesis, Mississippi University for Women]. https://athenacommons.muw.edu/womenlead/8

Cahn, N. (2025, August 8). Menopause at work: How leaders can provide support in the workplace. Forbes. https://www.forbes.com/sites/naomicahn/2025/08/08/menopause-at-work-how-leaders-can-provide-support-in-the-workplace/

Dalingwater, L., & Winett, L.B. (2025, February). “A duty of care”: National policy discourse regarding menopause, well-being, and the workplace. The Journal of Aging and Social Change, (15)1, 53-76. https://doi.org/10.18848/2576-5310/CGP/v15i01/53-76

Daly, K.L., Pike, G., & Clarke, V. (2024, April). “Difficulty mentioning the M word”: Perceptions of a woman disclosing negative menopause symptoms in the workplace. Qualitative Research in Organizations and Management: An International Journal, 19(3), 163-181. DOI 10.1108/QROM-07-2023-2562

Delameter, E., & Roux, M. (2024, September). Let’s talk about it: Menstruation and menopause at work (Issue Brief). Women’s Bureau, U.S. Department of Labor. https://www.dol.gov/sites/dolgov/files/OPA/MenstruationAndMenopauseAtWork.pdf

Fadal, T. (2025, October 17). Menopause at work: What every employer needs to know. [Video]. YouTube.

Faubion, S.S., Enders, F., Hedges, M.S., Chaudhry, R., Kling, J.M., Shufelt, C.L., Saadedine, M., Mara, K., Griffin, J.M., & Kapoor, E. (2023). Impact of menopause symptoms on women in the workplace. Mayo Clinic Proceedings. https://doi.org/10.1016/j.mayocp.2023.02.025

Gupta, A.H. (2023, August 19). The next frontier for corporate benefits: Menopause. New York Times. https://www.nytimes.com/2023/08/19/business/corporate-benefits-menopause.html

Henpicked Employer Checklist: https://www.businesshealthy.org/wp-content/uploads/2019/11/How-menopause-friendly-is-your-organisation-pdf.pdf

Howe, D., Duffy, S., O’Shea, M., Hawkey, A., Wardle, J., Gerontakos, S., Steele, L., Gilbert, E., Owen, L., Ciccia, D., Cox, E., Redmond, R., & Armour, M. (2023). Policies, guidelines, and practices supporting women’s menstruation, menstrual disorders, and menopause at work: A critical global scoping review. Healthcare, 11(22), 2945. https://doi.org/10.3390/healthcare11222945

Kochersberger, A., Coakley, A, Millheiser, L., Morris, J.R., Manneh, C., Jackson, A, Garrison, J.L., & Hariton, E. (2024). The association of race, ethnicity, and socioeconomic status on the severity of menopause symptoms: a study of 68,864 women. Menopause: The Journal of the Menopause Society, 31(6), 476-483. DOI: 10.1097/GME.0000000000002349

Lexology. (2025, October 22). “It’s Getting Hot in Here” - Rhode Island’s New Workplace Accommodations for Menopause. https://www.lexology.com/library/detail.aspx?g=157c37fd-ae26-4885-8834-7c6b47d3e78c

Mesko, B. (2024, February 22). Digital health, menopause, and the $150 billion ignorance. The Medical Futurist. https://medicalfuturist.com/digital-health-menopause-and-the-150-billion-ignorance

Muldoon, C. (2025, October 15). 7 ways to support women going through menopause in the workplace. WebMD. https://www.webmdhealthservices.com/blog/how-to-support-women-going-through-menopause-in-the-workplace/#:~:text=Because%20menopause%20symptoms%20can%20contribute%20to%20missed,of%20the%20most%20helpful%20menopause%20workplace%20benefits.

Otterman, S. (2023, May 24). A movement to make workplaces “menopause friendly.” New York Times. https://www.nytimes.com/2023/05/22/nyregion/menopause-women-work.html

Quental, C., Gaviria, P.R., & del Bucchia, C. (2023, May). The dialectic of (menopause) zest: Breaking the mold of organizational irrelevance. Gender, Work & Organization, 30(5), 1816-1838. https://doi.org/10.1111/gwao.13017Digital Object Identifier (DOI)

Sauer, J., Mehegan, L., Williams, A.R., Cozad, A.B., Lampkin, C.L., & Ekman, M. (2024, April 10). Economic impact of menopause: Individual and collective costs. AARP. https://www.aarp.org/pri/topics/work-finances-retirement/employers-workforce/menopause-workplace/#:~:text=The%20Mayo%20Clinic%20estimates%20the,care%20visits%20related%20to%20menopause.

Walker-Bone, K., & Davis, S. (2025, February). Menopause, women, and the workplace. Climacteric 28(4), 423-430. https://doi.org/10.1080/13697137.2025.2480591

Image: https://unsplash.com/@ohlamoustudio

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