The Forgotten Half of Reproductive Health: Perimenopause and Menopause
She was 47 when she started waking up at 3:00 in the morning.
At first, she blamed stress. Then came the racing heart, sudden heat across her chest, periods that arrived three weeks early and then disappeared for two months. She began forgetting words in meetings. Sex became uncomfortable. Her anxiety seemed to come from nowhere. She was still working full-time, helping an aging parent, and trying to keep up with everything everyone expected of her. So she did what women are told to do when something feels wrong.
She went to the doctor. Her bloodwork looked fine. Maybe she needed more sleep. Maybe she was depressed. Maybe she should exercise more. Maybe this was simply aging.
Nobody said the word perimenopause. It would be another two years before someone did.
Her story is a composite, but there is nothing unusual about it. And that may be the problem. We spend enormous political energy talking about women's reproductive lives when pregnancy is possible. We debate contraception, abortion, pregnancy, birth and maternal health.
Then, somewhere around midlife, the public conversation seems to lose interest. The ovaries do not.
It Is More Than Hot Flashes
Menopause technically describes a point in time: 12 consecutive months without a menstrual period. In the United States, the average age is around 51. But the transition leading to menopause - perimenopause - can last years, commonly two to eight.
During that transition, hormone levels fluctuate rather than declining in a neat, predictable line.
That can mean irregular or heavy bleeding, hot flashes, night sweats, vaginal dryness, painful sex, urinary symptoms, sleep disruption, mood changes, and problems with memory or concentration often described as "brain fog."
Not every woman experiences menopause the same way. Some have few symptoms. Others experience years of disruption severe enough to affect relationships, health, work and daily life.
And it often happens at exactly the point when women are carrying enormous responsibilities.
They may be leading organizations, working hourly jobs where disappearing into a cool room during a hot flash is not an option, raising teenagers, caring for grandchildren or becoming caregivers for aging parents.
Menopause is sometimes treated culturally as a punch line.
For many women, it is a workplace issue.
A 2023 Mayo Clinic study of employed women ages 45 to 60 estimated that menopause symptoms were associated with about $1.8 billion in lost work time annually in the United States, rising to $26.6 billion when medical expenses were included. About 13% reported at least one adverse work outcome because of menopause symptoms, and roughly 11% reported missing work.
Think about what that means in real life.
A woman who cannot sleep but still has to be at work at 7:00 a.m. Someone giving a presentation while trying to manage a sudden hot flash. A worker struggling with concentration problems she doesn't understand. Someone questioning her own competence or stepping back from work altogether.
None of that means menopause makes women incapable of working.
It means untreated symptoms can have consequences - and pretending otherwise doesn't make them disappear.
We Didn't Train Enough People to Treat It
One reason women struggle to find help is straightforward: Many clinicians have received little formal training in menopause care. A 2023 national survey of U.S. obstetrics and gynecology residency program directors found that only 31.3% reported having a menopause curriculum, while 29.3% said trainees had dedicated time in a menopause clinic. More than 80% said their programs needed additional educational resources.
A 2026 review reached a similar conclusion: menopause education remains inconsistent and fragmented across medical training. That helps explain something women frequently describe: finding a clinician is not the same as finding one who feels comfortable treating menopause. The problem can be even greater outside major cities, for people with limited insurance networks, or for those who cannot afford appointment after appointment until they find someone who takes their symptoms seriously.
A 2024 review of disparities in U.S. menopause care found differences affecting racial and ethnic minorities, veterans, incarcerated women and other groups, with insurance status and geography among the factors influencing access.
This is not simply about whether treatment exists.
It is whether someone can reach a clinician who knows how to use it.
Increasingly, specialized menopause care is also becoming an employment benefit rather than an ordinary part of health care. KFF's 2025 Employer Health Benefits Survey found that some large employers now contract with specialized menopause-care vendors, but such benefits remain uncommon.
It is encouraging that employers are paying attention.
But women should not need the right job to find a doctor who understands a normal stage of women's health.
The Hormone Therapy Whiplash
No discussion of menopause is complete without hormone therapy - and why so many women remain confused about it.
For years, menopausal hormone therapy was prescribed widely. Then came the Women's Health Initiative. Launched in 1991, the WHI became one of the largest women's health research projects ever undertaken. Among other questions, it examined whether hormone therapy could prevent chronic diseases such as cardiovascular disease. When findings from the hormone trials emerged in the early 2000s, concerns about breast cancer, cardiovascular events, stroke and blood clots dramatically changed prescribing.
Women heard a simple message: Hormones are dangerous.
But medicine rarely stays simple. Researchers continued examining differences involving a woman's age, how long she had been menopausal, whether she had a uterus, which hormones were used, how they were administered, and why treatment was being prescribed.
Current guidance is far more individualized. ACOG says systemic estrogen - with progestin for women who still have a uterus - is the most effective treatment for hot flashes and night sweats, while systemic and local estrogen can also treat vaginal symptoms. Hormone therapy has risks and is not appropriate for everyone, so decisions should reflect a person's symptoms, medical history and individual risks and benefits.
The Menopause Society similarly describes hormone therapy as the most effective treatment for bothersome hot flashes and notes that for many healthy women in early menopause, the benefits can outweigh the risks when used appropriately. There are also effective non-hormonal treatments. So the responsible message is neither "hormones are dangerous" nor "everyone needs hormones." It is: Women deserve accurate information and an individualized conversation with a knowledgeable clinician. Yet the legacy of decades of shifting messages remains.
In one 2024 Oregon study, more than 62% of respondents with moderate or severe menopause symptoms reported receiving no treatment. The most common reasons included the lack of treatment recommendation and concerns about safety or side effects. A national study published in 2026 also found lower hormone-therapy use among women with Medicaid than among those with private insurance, suggesting access and coverage may contribute to disparities.
Once again, having a treatment available is not the same thing as making it accessible.
The Forgotten Half
There is something revealing about the language we use around women's health. We talk about reproductive health as though reproduction were the organizing principle of women's bodies. During the years when a woman can become pregnant, her body is politically important. Governments debate it. Legislatures regulate it. Insurance plans create categories around it. Hospitals build departments around it. Researchers study it.
Then fertility begins to disappear. And somehow a transition experienced by roughly half the population has historically been treated as specialized knowledge.
That is beginning to change. Menopause is receiving more media attention. Medical organizations are producing new educational materials. Employers are considering accommodations and benefits. Researchers are revisiting treatment questions, and women are speaking publicly about experiences that earlier generations were expected to endure in silence.
Those are important developments. But there is also a risk that menopause becomes another health marketplace where people with money can purchase specialized telehealth programs, concierge physicians, testing, and treatments, while everyone else receives only 10 minutes with an overworked clinician who may never have received meaningful menopause education.
Women's health equity cannot mean access only for women who can afford to shop for it.
At SWOP Behind Bars, that matters to us.
The women we work with are often navigating health care alongside incarceration, poverty, unstable housing, substance use, stigma, and histories of trauma. Menopause does not stop at the jail door. Hot flashes do not disappear because someone is incarcerated. Vaginal and urinary symptoms do not become less uncomfortable because someone lacks insurance. Sleep disruption matters whether someone is living in a shelter, working nights, or rebuilding her life after release. A health-care system that struggles to provide consistent menopause care to well-insured women is unlikely to perform better for women living at the margins.
That is why menopause belongs in a conversation about reproductive justice.
Not because menopause is about reproduction. Because reproductive justice has to be about more than reproduction. It has to include the right to live in a body across an entire lifetime and still be considered worthy of competent medical care. We should be able to talk about pregnancy without forgetting the woman who is pregnant. We should be able to talk about abortion without pretending women's health begins and ends with abortion.
And we should be able to talk about aging without treating women's symptoms as an inevitable price they are simply supposed to pay.
The question is not whether every hot flash requires treatment. It is whether a woman who needs treatment can find it. Whether her doctor understands her options. Whether her insurance makes those options accessible. Whether her workplace recognizes that symptoms can be real without treating her as less capable. Whether medical schools consider menopause important enough to teach.
And whether our health policies continue to value women after fertility ends.
Because women do not stop needing health care when they stop being able to become pregnant. Perhaps our definition of women's health should finally catch up.
