Why we don’t talk about menopause

Nobody tells you about menopause.

Sure, you hear about hot flashes from time to time, maybe from a relative or in a joke on a TV show. But the sex-ed classes that teach tweens and teens about periods rarely mention the day those periods will end. Even doctors rarely bring up menopause with their patients, and too often dismiss the symptoms when they occur.

“We get the puberty talk, but we don’t get the menopause talk,” Pauline Maki, a professor of psychiatry, psychology, and obstetrics and gynecology at the University of Illinois at Chicago, told Vox.

But now, the American population is getting older: By 2030, the median age in America will rise to 40, up from 37 today. And millennials, a generation beloved by marketers, have started entering their 40s, a decade when menopause symptoms can begin.

That means menopause is becoming a moneymaking opportunity, with companies starting to offer everything from telehealth consultations to supplements to a special ultrasound device to treat vaginal dryness (the latter is still in the testing phase).

But what people going through menopause need isn’t necessarily more ads on their social media feeds. Instead, experts say, they need an end to the stigma around this very normal phase of life, and the kind of real talk they didn’t get when they were younger.

Menopause “needs to not be a thing of shame,” Jen Gunter, an OB-GYN and the author of the recent book The Menopause Manifesto: Own Your Health with Facts and Feminism, told Vox. “We just have to figure out how to change the conversation.”

Doctors today aren’t trained to treat menopause

Menopause is technically defined as the end of menstruation and is officially diagnosed when someone has gone 12 months without a period. That happens at an average age of 51. But symptoms can start long before that, in the mid-40s or even earlier (this symptomatic period is known as perimenopause). The most common, and perhaps the best known, are hot flashes, in which the upper body suddenly becomes warm and sometimes flushed.

But there are many other possible symptoms — 34, by some counts — and some can have serious consequences for people’s health and well-being. For example, the hormonal shifts around menopause can cause changes to the vagina, including dryness and a loss of elasticity, which can lead to painful sex or urinary tract infections. Some people experience “brain fog” or problems with memory. And the transition to menopause can also trigger depression and anxiety: Among those who have previously been diagnosed with depression, more than half will experience an episode during the transition to menopause, Maki said.

But often, doctors don’t really talk to patients about any of this. In one recent survey, just 7 percent of medical residents felt prepared to treat menopause symptoms in patients.

Part of the reason has to do with the history of menopause treatment. Beginning in the 1940s, doctors began prescribing estrogen to counteract menopause symptoms. The treatment became popular, especially in the 1980s and 1990s, but in 2002, a large, high-profile study reported that estrogen therapy increased patients’ risk of breast cancer, heart attacks, and blood clots.

As a result, doctors generally stopped prescribing estrogen — but didn’t replace it with anything else. “Training in menopause medicine essentially went away,” Maki said. “We lost a couple of generations of providers.”

Now, experts say estrogen therapy actually is often safe, as long as it’s used by patients under 60 and for a limited period of time. For those patients, “the benefits typically outweigh the risks of hormone therapy,” Stephanie Faubion, director of the Center for Women’s Health at the Mayo Clinic and medical director of the North American Menopause Society, told Vox. Those benefits include around a 90 to 95 percent reduction in hot flashes and night sweats, along with a reduction in bone loss and cardiovascular risk while patients are on the medication.

Moreover, for people whose main symptoms are vaginal, more localized forms of the hormone, like vaginal rings, are now available and may not carry the same risks as oral medication.

Still, many doctors aren’t giving their patients the latest information — or much information at all. “I hear so many stories from women who’ve been dismissed by doctors,” Gunter said.

The result is that menopausal people often suffer in silence — and the stigma can affect every aspect of their lives. “You hear from women that they’re going to leave the workforce because they can’t handle their menopausal symptoms,” Gunter said. Indeed, in one 2013 survey conducted in the UK, nearly 40 percent of women said menopause symptoms had negatively affected their work, but a majority had never discussed the symptoms with their manager, often because they were embarrassed or because their manager was a man.

“You’re this person who has been incredibly productive and contributed your whole life. And now,” Gunter said, “because of this, you’re sidelined.”

Now startups are trying to fill the void

Even though medical care may be lagging behind, brands are starting to capitalize on menopause. It’s a natural outgrowth of the way women’s health has taken off as a business opportunity in recent years, with companies like Maven Clinic and Nurx springing up to offer services like telehealth maternity care and online birth control prescriptions, respectively. These companies aimed to fill a void left by a medical establishment that too often dismisses women’s concerns, making reproductive and sexual health care unpleasant, embarrassing, or even dehumanizing.

And now, startups and venture capitalists are turning their attention beyond the child-bearing years, to the growing market of women in their 40s and 50s. After all, by 2030 there will be more women between 40 and 64 in the US than girls under 18, according to a report released last October by Female Founders Fund, a venture firm that funds companies founded by women. Selling to people in menopause could be a business opportunity worth $600 billion — or more.

“This has been ignored in a lot of senses, especially as it relates to medical research and solutions,” Adrianna Samaniego, an investor with Female Founders Fund, told Vox. “Yet it’s a huge industry.”

Recent entries to the field include Kindra, a startup that sells estrogen-free supplements to treat vaginal dryness, hot flashes, and sleep problems. There are also several companies that offer telehealth appointments with doctors trained in menopause management, like Gennev, which offers both OB-GYN appointments and life coaching to deal with body image, anxiety, and other issues. And other companies are expanding into the menopause space, with Roman, a startup that first got attention for offering online prescriptions for erectile dysfunction medication, now offering telehealth visits for menopause concerns, according to Fast Company.

The companies are responding to a real need among people who aren’t being served by their doctors — or by a culture that often prefers to pretend that women over 40 just don’t exist. In addition to relief from symptoms, many people are looking for a community of people with whom to share their experiences, Samaniego said — a feature some of the startups in the space provide.

However, some of the products being marketed to menopausal people may not actually help them much. For example, a number of companies now sell tests to tell people if they are in menopause, Gunter wrote in a recent New York Times op-ed. But these tests actually have no medical use because they do nothing to predict whether someone will actually experience symptoms. Nor can they accurately determine how close someone is to having a final period — and because hormones are fluctuating so much during this time, a person could have a test indicating menopause one month and a normal test the next. “There’s no guideline that recommends testing hormones to see where you are in menopause,” Gunter told Vox.

Supplements can also be problematic. Some companies are merely taking basic, widely available compounds and marketing them as menopause aids, Samaniego said. “There’s a lot of people who are kind of just repackaging the same ingredients.”

And despite the wide variety of supplements on the market, many have little research to back them up. For example, no non-hormonal supplement has been proven to reduce hot flashes, Faubion said. And because supplements aren’t rigorously tested for safety, they could contain ingredients that are harmful.

Non-hormonal treatments may be marketed as better because they are “natural” — but, Gunter said, “natural has nothing to do with safe.”

It’s time to end the shame around menopause

What people going through menopause really need, many say, is to eliminate the stigma around this stage of life so that the symptoms can be discussed openly and taken seriously.

Take, for example, vaginal dryness. It’s not talked about much — in part because the whole idea of older women having sex is considered taboo, Maki says. But treatment is crucial to help patients lead healthy, pain-free lives, including having sex, regardless of their age. “I see this as a woman’s right,” Maki said.

Hot flashes, meanwhile, are often treated as a mere annoyance. But emerging research shows they disrupt people’s sleep, which can increase the risk of cognitive impairment and even Alzheimer’s disease, Maki said. “We need to have enough education for women about what safe treatment options they have.”

Luckily, some of that education is already happening — often driven by menopausal people themselves. Gunter decided to write her book after hearing repeated questions about menopause and is open about her own experiences. She’s gotten hot flashes in the operating room while wearing a lead shield, and “when I take my clothes off, I’m literally soaked in sweat from my neck to my knees, like literally drenched. And I’m embarrassed about that,” she told Vox. But, “why should I be embarrassed?”

Meanwhile, health educators and advocates are increasingly speaking up about what happens to people’s bodies across their reproductive lives. Omisade Burney-Scott, for example, started the podcast Black Girl’s Guide to Surviving Menopause in 2019 out of a desire to “talk to other Black women who are older around navigating life and this stage of life,” she told Vox. “What are you learning? What does love look like? What does rage look like?”

Today, she also hosts storytelling events, and highlights the stories of Black women, femmes, and nonbinary and trans people, including those who are going through menopause in their 30s or younger due to medical conditions or taking testosterone. “People who are experiencing menopause, no matter their age, no matter their identity or status in this community or society — they need to be heard,” she said.

And more and more, they’re speaking out. “Women are driving the conversation” around menopause, demanding treatment options and refusing to be defined by the status of their reproductive organs, Faubion said. “Women are not willing to experience their mothers’ menopause.”