It is time that menopause be treated as the urgent matter of public policy it is.
Menopause is having its moment, so say daily news headlines. A new essay series in the medical journal The Lancet, published to coincide with International Women’s Day, argues all that hype—combined with “over-medicalization” and reliance on menopausal hormone therapy (MHT)—harms women by framing menopause as a disease.
But, in fact, the real disservice to women is the lack of consideration of menopause in the halls of government.
As a lawyer who helped make periods go public, I have spent the last decade crafting laws to ensure the affordability and accessibility of menstrual products, and advocating for their passage in Congress, state legislatures, city councils and local school boards.
Menopause policy requires a two-pronged approach: countering stigma while interrogating and investing in science. Smack in the middle of that Venn diagram is a society-wide information gap about the safety and efficacy of MHT.
In 2024, hormone treatment is only prescribed to a tiny fraction of menopausal women in the United States. MHT is still recovering from the reputational hit it took two decades ago when the Women’s Health Initiative (WHI) was abruptly halted, by way of an alarming statement that estrogen-plus-progestin therapy was associated with breast cancer, heart disease and stroke. The panic that ensued still looms large today, even though those findings have been soundly debunked by experts, including at the WHI.
Public policy can help undo that damage.
The U.S. Food and Drug Administration (FDA) still requires low-dose vaginal estrogen to bear a “black box” warning, even though data shows the label is inaccurate. As a result, patients are scared to use the gold standard for treatment of vaginal dryness and urinary tract infections. For perspective, the U.K.’s equivalent agency recently reclassified vaginal estrogen to be sold over-the-counter based on its safety profile.
To be clear, the need for policy is not merely to ensure accurate information about and access to MHT (although we deserve and need both). It is to issue a course-correct, given that everything we as a society do not know—or think we do know—about MHT is the catalyst for a spiral of systemic failures. These range from the current dearth of federally funded clinical trials about midlife women’s health and potential brain and heart health benefits of MHT, to a paucity of menopause education for doctors, to a burgeoning and potentially predatory industry dubbed the “menopause gold rush.”
If we truly want to rise to the so-called moment for menopause, here is a policy agenda that can best serve us:
First and foremost, investment in an inclusive modern research agenda—a menopause moonshot. This undergirds all other change and requires commitment from the top, already underway.
- Last November, the White House created a Women’s Health Research Initiative to determine gaps and infuse new funding; First Lady Jill Biden recently announced the first tranche of $100 million.
- A bipartisan congressional bill, the Menopause Research and Equity Act of 2023, would reinforce the White House order.
- State and municipal leadership can also contribute to this effort; the California Assembly recently held hearings about its potential role.
- All new research must address known racial disparities in menopause symptoms, impacts and care.
Second, a public commitment to robust menopause education and care. Another WHI casualty is medical education. Today, only 20 percent of U.S. residency programs offer a formal menopause curriculum. The result is a generation of doctors unable to identify menopause symptoms, let alone offer expert guidance or treatment.
A new bill in Congress—the We’re Addressing the Realities of Menopause (WARM) Act of 2023—would incentivize robust instruction and national accreditation standards, as well as establishment of and funding for university menopause clinics.
Another way to fill the vacuum in quality menopause care is telemedicine, which Congress can support by extending flexibilities millions of patients and providers came to rely on during the pandemic.
Third, protection from inequities in the workplace. We need to bolster anti-discrimination laws for menopausal status, as is now being newly enforced in the U.K.. Possibilities for employee protection may exist within a combination of landmark civil rights laws like the Protecting Older Workers Against Discrimination Act, Pregnant Workers Fairness Act, Family and Medical Leave Act, and Americans with Disabilities Act.
Meanwhile, workplace benefits have become increasingly popular—accommodations like flexible time, dedicated human resources support, and access to menopause resources. While these interventions may offer some relief for executive-level office workers, they are not a long-term solution nor are they likely to reach women in low-wage and service jobs. CEOs should use their influence to advocate for and advance research and systemic change.
Finally, oversight of booming menopause markets. A vast menopausal ‘wellness’ industry is estimated to reach $24 billion by 2030, and peddles everything from beauty and hygiene products, to clothing and home accessories, to sexual health and dietary supplements. But most over-the-counter and online offerings are not required to be tested for safety or efficacy. Worse, many capitalize on public confusion by advertising as ‘all-natural’ or safer alternatives to FDA-approved hormonal treatments. (Ironically, this strategy works well in part because the FDA saddles vaginal estrogen with that “black box” warning.) Watchdog agencies like the U.S. Federal Trade Commission must do better at curbing these practices.
Women have been long underserved by research, industry, and government alike when it comes to our healthcare. It is time that menopause be treated as the urgent matter of public policy it is.
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