Women will spend approximately one-third of their lives after the menopause transition and approximately 6,000 women reach menopause every day in the United States. While menopause is a natural process for most women — marking the end of reproductive years around age 52 — for some it comes years earlier because of surgical removal of the ovaries or from the effects of cancer therapies on the ovaries.

Symptoms of menopause include the overall decline in ovarian hormone production, sleep disturbances, mood changes, sexual dysfunction and overall decline in quality of life. Vasomotor symptoms, or hot flashes and night sweats, are the most common of menopause symptoms and are experienced by approximately 75 percent of women in menopause.

For years, menopausal hormone replacement therapy was widely prescribed to women not only for the treatment of vasomotor symptoms, but also for disease prevention based on findings from observational studies that showed reduced risk of cardiovascular disease, osteoporosis and even mortality. In 2002, the initial publication of the Women’s Health Initiative hormone therapy trial was released in the Journal of the American Medical Association. The study, a randomized controlled trial and thus more conclusive than previous studies, caused an abrupt shift in the public and professional perception of the safety of menopausal hormone therapy.

The study demonstrated an increased risk of adverse cardiovascular outcomes, blood clots, stroke and breast cancer in women ages 50-79 who took a single, fixed-dose oral pill of estrogen and progestin, which was also the most widely used treatment in the U.S. at that time. The study was discontinued prematurely due to the excess risks associated with taking menopausal hormone therapy.

As a result, thousands of women discontinued use of their hormones and most health care providers also became risk-averse to treating their patients with hormone therapy. Prescriptions declined worldwide. A few years later, a sub-analysis of the original study was published, analyzing risks based on age subgroups and found that certain risks, such as cardiovascular disease, did not increase in the younger subgroup of women aged 50 to 59 years of age; however, the damage was already done: the message that hormone therapy was too risky for menopausal women was out.

Two groups of women are most affected by the aftermath of the initial Women’s Health Initiative publication: “younger” symptomatic women typically in their 50s and older women who are over age 60, asymptomatic and had never used hormone therapy.  While both age groups experienced negative effects, the younger group suffered the most as their menopause symptoms went either untreated, or in some cases, were provided with less-safe treatment options, including untested formulations of “custom” compounded hormones.

More than 20 years later, public and professional perceptions about menopause and hormone therapy have finally shifted as our understanding of the risks and benefits of hormone therapy has improved. Subsequent, post-intervention analyses from the Women’s Health Initiative and studies exploring treatments, such as transdermal routes of delivery of estrogen, or skin patches, and the benefits of using progesterone have contributed to a safer, individualized approach to prescribing hormones to menopausal women.

Other research demonstrating the lack of education among medical students and physicians in residency training about menopause has come to the forefront, leading to the expansion of menopause curricula in medical education.

So, in a risk-averse culture, how did the message that hormones are not as risky as previously thought get out to the public?

In February 2023, journalist Susan Dominus published an article in The New York Times entitled: “Women have been misled about menopause” and the article quickly went viral. The comments section alone had hundreds of entries adding personal details from readers about their menopause experience.

And with that, along with social media, the rise in telehealth platforms, and celebrities themselves going through menopause and using their status to amplify a message: menopause is finally getting the attention it deserves.

Macaulay, M.D., is an obstetrician/gynecologist and director of the Menopause Health Program at UC San Diego Health. She lives in San Diego.