When Bertha Garcia Foster first started experiencing irregular bleeding during the month, she figured it would eventually stop and her cycle would even out.
It didn’t. And then vaginal dryness came. Thinking she had a yeast infection, she got an over-the-counter medication at the drugstore.
But when that didn’t work and some intense mood swings also began, Foster decided it was time to see her primary care doctor. He referred her to a women’s health specialist, a type of expert Foster didn’t even know existed.
After Foster endured nearly 10 months of symptoms, the specialist told her that she was perimenopausal — the clinical term for the span of time before menopause.
It was a new reality for which Foster — a mother of three, with her youngest only 9 years old — was not prepared. At 47, she had not thought much about menopause, never mind realizing she was so close. In fact, she hadn’t even known that there was a difference between perimenopause and menopause.
“I was surprised, and I feel a little betrayed by my body,” Foster says. “I just wasn’t ready for it.”
Perimenopause means around menopause. It marks the end phase of the reproductive years, with fluctuating hormones that can cause a host of symptoms. Once Foster goes through 12 consecutive months with no menstrual period, perimenopause is over and the official transition to postmenopausal life has occurred. Foster is one of many women who experience perimenopause without knowing it. That means many also are not aware that effective treatments are available for both perimenopause and menopause.
The lack of awareness, on both the patient side and physician side, is a widespread challenge, says Stephanie S. Faubion, M.D., M.B.A., the director of Women’s Health at Mayo Clinic and the medical director of The North American Menopause Society.
This means many women are completely mystified when they start experiencing symptoms. Because symptoms can vary significantly, ranging from hot flashes and joint aches to palpitations and anxiety, it can be hard to link the cause to menopause and to apply appropriate treatment, Dr. Faubion says.
“All of that seems very scary,” Dr. Faubion says. “We have women coming to the clinic thinking they’re dying.”
The treatment gap
Even if woman know they are experiencing menopause or perimenopause, she might not be receiving treatment for it. There are a variety of systemic reasons for the disconnect in treatment, Dr. Faubion says, including long-standing misconceptions about the safety of menopausal hormone therapy and a lack of knowledge from providers to broach the issue of menopause at all.
Some doctors are not equipped to discuss menopause and the range of associated symptoms because they were never trained on it in the first place, Dr. Faubion says. Most trainees in internal medicine get at most 1 to 2 hours of education on the topic, she says.
“It’s fallen out of the curriculum. Even gynecology training programs don’t offer significant education on menopause,” she says.
In 2019, Dr. Faubion, along with colleagues at Mayo Clinic, published a survey of 703 medical trainees at all postgraduate levels in family medicine, internal medicine and obstetrics at U.S. residency programs. Of 177 respondents, 20.3% reported not receiving any menopause lectures during residency, and only 6.8% said they felt prepared to manage women experiencing menopause, according to the study.
Perhaps unsurprisingly then, there is also data showing that not many women are receiving menopause treatment. A 2014 study found that among 2,020 Australian women ages 40 to 65 years, 120 of them, or 5.9%, used hormone therapy. Only 0.7% used a nonhormonal treatment for their menopause symptoms.
Hormone therapy delivers estrogen and sometimes progesterone in different forms, such as a pill, skin patch or cream. It’s a proven way to relieve menopausal symptoms such as hot flashes and help prevent bone loss, but some women may not be candidates for hormone therapy because of other health history, such as breast cancer. Others are hesitant to take it due to fear of adverse effects and the prevalence of mixed messages about its safety.
While prior studies examining the use of hormone therapy in menopausal patients revealed a higher risk of blood clots, stroke and dementia for those using the treatment after 65 years, women under the age of 65 who undergo treatment have no increased risk of these issues.
“More women need to know the evidence about hormone therapy,” says Juliana (Jewel) M. Kling, M.D., M.P.H, associate professor and chair of the Division of Women’s Health Internal Medicine at Mayo Clinic in Arizona. “There are still prevalent myths about the safety and appropriate use of hormone therapy amongst women and health care practitioners.”
“Providers don’t know how to do it, women don’t know where to go, people are scared to use hormone therapy,” Dr. Faubion says.
Dr. Faubion and others at Mayo Clinic are trying to document the extent of the treatment gap and barriers to treatment. They are working on a pilot program focusing on hot flash treatment, she says.
Still, how or whether hormone therapy could be tailored to fit one’s menopause experience is a conversation to start with a health care provider. Though there are other nonhormonal treatments, hormone therapy is considered the most effective for symptom management, including hot flashes and night sweats.
The color gap
The stigma surrounding treatment can be especially pronounced for women of color, says Foster, who is Latina.
“Especially for ethnic women like myself, we tend not to reach out for help,” she says. “But the help is there.”
Mayo Clinic researchers are currently trying to understand how women of color are disproportionately affected by menopause and perimenopause symptoms. Women of color begin perimenopause about two years earlier, on average, than white women, which can make it harder for women of color to identify menopause symptoms and pursue treatment for them. The median age for menopause for white women is 52, and around 50 for women of color.
Mayo Clinic has evaluated Latina women from different ethnic groups in the Southwest in order to gain further insight into their symptoms of menopause and sexual functioning, Dr. Kling says.
That is encouraging for Foster, who has tried to do research on her own perimenopausal symptoms.
“It’s nice to know that there is data supporting that (and) women of color are included,” she says.
Yet, there is a lot that we don’t know about, including why menopausal symptoms differ between white women and women of color, Dr. Kling says. Differences in socioeconomic factors between the two groups or factors such as access to care may explain some of the differences, but there is a lot left to learn about the menopausal transition in diverse women.
“Most of menopause practice for diverse women is extrapolated based on findings predominantly from white women,” Dr. Kling says. “We don’t fully understand all the differences in menopausal symptoms by race and ethnicity, nor why those differences exist.”
While getting suitable menopause treatment can be particularly difficult for women of color, it’s a problem that unfortunately spans all races.
“The large majority of symptomatic women are not being treated. When you talk about Black (or Latina) women not being treated, this is so much more of a global problem,” Dr. Faubion says. “We’re not doing a good job for most women.”
After her perimenopause diagnosis, Foster returned to her home in Gilbert, Arizona, with a bag full of pamphlets, replete with numbers to call and information to read.
It was too overwhelming to read them. So, she threw them all in a drawer.
“I didn’t want to look,” she says. “It’s a lot to take in at the beginning. I still feel young.”
But after a few weeks of adjusting to her perimenopause diagnosis, Foster says she is feeling better. She is using a vaginal moisturizer for dryness prescribed by her doctor and it is working. She is scheduled to get a progesterone-secreting intrauterine device (IUD) and an estrogen patch to regulate her hormone levels.
“I’m lucky I have access to the services at Mayo Clinic. It should be a basic service that should be available to every woman,” Foster says. “I think what helps, too, is to know that I have somebody supporting me and giving me science-based data to help me.”
Stephanie S. Faubion, M.D.
Dr. Faubion is Professor and Chair of the Department of Medicine at Mayo Clinic in Jacksonville, Florida, Director of the Mayo Clinic Center for Women’s Health and the Medical Director of The North American Menopause Society. Her clinical research interests include menopause and sexual health in women, and she is the medical editor of Mayo Clinic The Menopause Solution.
Juliana (Jewel) Kling, M.D., M.P.H.
Dr. Kling is an associate professor of medicine, chair of the Division of Women’s Health Internal Medicine, assistant director of the Women’s Health Center and associate chair of Equity, Inclusion and Diversity for the Department of Medicine at Mayo Clinic in Scottsdale, Arizona.