After decades of misunderstanding, menopause is finally having its moment

Last spring, actor Halle Berry made headlines when she boldly shouted, “I’m in menopause!” outside the Capitol Building in Washington, D.C., challenging the silence that has long surrounded this inevitable life stage for women.

Her declaration is a part of a broader cultural shift, where women are beginning to push back against the stigma and shame that has historically defined menopause. As these conversations gain momentum, they reveal just how little we understand this phase of life, which begins for approximately 6,000 women each day, or 1.3 million women annually in the U.S. This growing openness signals a long overdue shift in how we approach menopause—one that demands understanding for patients and their health care providers.

Long-lasting misconceptions around menopause linger. A simplistic view of menopause as a sudden, binary change has shaped decades of inadequate care. We don’t expect any of our other organs to shut down overnight as we age; why is it that we’ve come to expect such an abrupt change for our ovaries?

“You were supposed to go to bed one night premenopausal and wake up the next morning postmenopausal,” remarks Mary Jane Minkin, MD, a practicing gynecologist and clinical professor at Yale New Haven Health and Yale School of Medicine with more than 40 years of experience providing menopause care. This persistent narrative, however, is far from reality.

Perimenopause: the unrecognized transition

Menopause is defined by 12 consecutive months without a period, but many people don’t recognize that ovarian function begins to decline long before menopause—even, in some cases, up to ten years earlier. This transition time is called perimenopause.

Whereas the average age of menopause in the U.S. is 52, perimenopause usually develops when a woman is in her 40s. During perimenopause, the ovaries gradually produce less estrogen and progesterone, but this decline is not steady. A perimenopausal woman’s hormones fluctuate unpredictably, making it both difficult to test for the occurrence of perimenopause and difficult to treat its possible symptoms. One day, a woman's hormones might appear completely normal on a blood test, while the next day they might show significant imbalances—creating a diagnostic challenge that standard quantitative tests can’t reliably capture. As Minkin notes, “Menopause is easy. It’s perimenopause that’s tricky.”

Think of perimenopause as a transition phase, like puberty. We don’t go from being a prepubescent teen to a sexually mature adult overnight; our bodies and brains develop over years, guided by the fluctuation of hormones. While puberty often announces itself—even before the first period—with clear physical markers such as breast buds or the first strands of pubic hair, there are far fewer markers that we’ve learned to recognize as indications of perimenopause.

Symptoms: beyond reproductive function

We’ve all likely heard of the classic symptoms of menopause: hot flashes, night sweats, and mood changes. But the transition into menopause can manifest in various different symptoms—ones that often go unrecognized as having anything at all to do with menopause.

The ovaries are involved in regulating a wide range of processes, far beyond reproductive function, as the hormones they make promote the health of the entire female body, from bone density to sexual desire to cardiovascular health to cognitive function. So, it makes sense that when those hormones begin to decline, the effects are felt throughout the body.

For example, a 2023 study found that as estrogen levels decline, menopausal women become at increased risk for developing cardiovascular disease, the leading cause of death for both women and men in the U.S. The endogenous estrogen produced within a woman’s body has protective effects against cardiovascular disease, so its natural decline during menopause contributes to this heightened risk. In addition, other risk-factors associated with menopause, such as obesity, hypertension, or type 2 diabetes, can further elevate cardiovascular vulnerability.

Menopause may also increase a woman’s risk of Alzheimer’s disease, according to a 2024 study, perhaps contributing to the disproportionate two-thirds female representation of all Alzheimer’s cases. The naturally occurring estrogen in a woman’s body plays numerous vital roles in healthy brain functioning, such as promoting synaptic growth between neurons, reducing neuroinflammation, enhancing the brain’s antioxidant defenses, and maintaining proper brain metabolism and plasticity. As estrogen levels decline during menopause, therefore, these protective mechanisms weaken, potentially accelerating the neurodegenerative processes that contribute to cognitive decline and progression of Alzheimer’s disease.

Beyond cardiovascular disease and neurological disorders, menopause is even associated with an increased risk of autoimmune disorders, osteoporosis, and sleep apnea. These connections raise a critical question: If many of the conditions that develop in middle-aged, menopausal women are promoted by the same underlying hormonal changes, could they actually be treated similarly?

Hormone replacement therapy: overcoming misconceptions

The most effective treatment of peri- and postmenopausal women to date is hormone replacement therapy (HRT), which can alleviate symptoms by replenishing declining hormone levels. After initial popularization in the 1960s, HRT gained incredible traction in the ‘90s, with nearly 15 million women in the U.S. taking an estrogen-based menopausal treatment, making it the most commonly prescribed treatment in the country.

However, in 2002, use plummeted after the Women’s Health Initiative published findings demonstrating that HRT increased the risk of breast cancer, heart disease, and stroke. The study concluded that the benefits associated with HRT did not outweigh these risks.

Soon after, however, follow-up research repeatedly rebutted the study’s conclusions by exposing several critical methodological flaws. Most notably, the study had exclusively studied women who were on average ten years post-menopause, with an average age of 63—a demographic already vulnerable to cardiovascular issues. Further limiting its applicability, the study evaluated only one delivery method—a daily pill combining estrogen and progestin—with preparations and methods of hormone administration that have largely been replaced with more effective options.

Despite this reassessment, it was too late to influence public perception as use of HRT had declined by almost 50% within six months of the study’s publication.

In the decades since the Women’s Health Initiative study, research has continuously refined our understanding of HRT. Today, the literature suggests that HRT can be beneficial for women within 10 years of menopause (or below the age of 60), with many physicians recommending starting treatment early in perimenopause to maximize the benefits and avoid complications. Unlike the single delivery method tested in the WHI study, HRT may be tailored to each woman’s individual needs, considering factors such as symptoms, medical history, and risk profile. Treatment options vary and include oral pills, transdermal patches, vaginal rings, and topical gels, as well as different amounts and types of hormones—each offering different benefits and potential risks.

Despite these advancements, many women still hesitate to consider HRT, often because of persisting fears sparked by the 2002 study. Amidst this uncertainty, though, there are encouraging signs of progress. Minkin reflects on how she once had to persuade women to consider HRT. Today, the conversation is shifting—patients are often initiating discussions about HRT before she even has the chance to raise it as an option.

A persistent knowledge gap in health care

Advancements in menopause care will remain limited if doctors and patients lack education about the stages of life for women. Health care providers may not connect symptoms to perimenopause, while patients often naturally seek help from specialists for individual symptoms without realizing their diverse health complaints could all stem from the same hormonal changes. For example, for mood changes, a woman might be sent to a psychiatrist, or for insomnia, she might be sent to a sleep specialist. While these specialists certainly provide valuable expertise, if they don't recognize the underlying hormonal changes, the patient might receive multiple separate treatments whereas addressing hormone imbalance could help with several symptoms at once.

As a medical educator, Minkin recognizes this gap in knowledge. She explains, “When I teach my medical students, I’m assuming that none of them are going to be OB/GYNs. Statistically, they won’t be. But I am assuming if they’re going to be taking care of patients, they’re going to come across somebody who’s perimenopausal who’s going to not necessarily triage herself to the gynecologist. If she’s not sleeping well at night she’s not going to think of the gynecologist as her first call.” Minkin encourages her students to keep hormonal shifts top of mind when treating women in their 40s, who might not suspect the underlying cause of their discomfort.

Unfortunately, many doctors are not receiving this guidance—even amongst those training to become obstetrician gynecologists. A 2023 survey found that over 90% of obstetrics and gynecology residency program directors in the U.S. agreed that residents should have access to a standardized menopause curriculum, yet less than a third reported that their programs actually offer one. This critical knowledge gap risks leaving many health care providers ill-equipped to address menopause causes and symptoms effectively, ultimately compromising women’s access to appropriate care.

Expanding the conversation

As Halle Berry’s moment on Capitol Hill illustrates, there is growing recognition of the need for better awareness and understanding of menopause, a demand that is becoming difficult to overlook. With the global menopause market set to expand from $17.66 billion in 2024 to $27.63 billion by 2033, we’re observing a push to develop effective diagnostic tools, pharmaceutical advancements, and preventive technologies to improve the health of women.

At the same time, as educators step up, we’re seeing a proliferation of educational resources (such as Minkin's own podcast, “Madame Ovary”) for both health care providers and patients. With the rise of social media, we are presented with the opportunity to challenge harmful taboos, yet we also face the risk of oversimplifying and commercializing the complex health issues women encounter during this confusing transition.

Amidst a flood of information—some helpful, some misleading—it can feel like everyone has something to say about aging, so it’s essential that women have access to accurate, reliable information. As Minkin puts it, “If a woman understands her physiology, she’ll do much better in the long run.”

Ultimately, health care providers must adopt comprehensive, holistic, and research-based approaches to care for the more than a billion women who will be in menopause globally by 2030. Recognizing menopause as a critical health stage, beyond merely a reproductive milestone, will transform how medical professionals across all specialties understand and address its far-reaching implications for women’s health.

Kira Berman (Yale College ‘25) is a Women’s Health Research at Yale Undergraduate Fellow, majoring in English while pursuing a premedical track. Over the course of this semester, she will contribute articles that illuminate critical gaps in health care knowledge, aiming to empower women to better understand their bodies. By combining her writing experience with her dedication to women’s health, on this blog, Kira strives to bridge the gap between medical research and public awareness, making complex topics more accessible and relatable to readers.

If you have suggestions for topics that make you ask “Why Didn’t I Know This?” please email Kira at kira.berman@yale.edu.