Sept. 1, 2023 -- An alarming gap bedevils menopause care in the United States – thanks to enduring myths about hormone replacement therapy and flaws in how new doctors are trained. The result: Countless women grapple with the physical and emotional toll of this life transition.
These shortcomings have led to an influx of doctors moving from traditional practice to virtual startups that focus on women’s health issues, treating patients who come to them desperate and frustrated after years of unresolved issues.
The solution is often so simple it is almost maddening, specialists say: vaginal creams containing low-dose estrogen, which can address the symptoms of menopause from vaginal dryness to recurrent urinary tract infections.
“Hands down, this is one of the most meaningful interventions I've ever offered to a patient, and yet it is underutilized,” said Ashley Winter, MD, chief medical officer and urologist at Odela Health, a digital women’s health clinic. “A lot of companies are blossoming in this menopause space because it is underserved by traditional health care – your gynecologist typically deals with reproduction, and typically when women are done with child-bearing, they're kind of discharged from the care of their gynecologist.”
More than 1 million women in the United States go through menopause each year. According to a 2022 survey, 4in 10 women report menopause symptoms that have been disruptive enough to interfere with their work performance at least on a weekly basis.
And yet, many women are not getting appropriate treatment.
Partially to blame is the harmful legacy of faulty data, doctors say. The early results of the federally funded Women’s Health Initiative (WHI), released in 2002, showed that hormone replacement therapy led to increased risks for heart attacks, strokes, and breast cancer. But further analysis showed the opposite: Hormonal therapies have a helpful effect on cardiovascular and bone health and generally reduce risk of death in younger women or those in the early postmenopausal period.
Hormone replacement therapy (HRT) delivers estrogen, sometimes with progesterone, to the body through gels, creams, patches, pills, suppositories, or a device fitted inside the uterus. Systemic HRT sends hormones into the bloodstream, while local HRT – like vaginal estrogen cream –specifically treats vaginal symptoms of menopause.
Yet while 2 decades have passed since the misinformation first started to spread, people remain woefully uninformed about hormone treatments.
The FDA still requires estrogen products carry a black-box warning on the early data, even though it has since been proven false.
“This is one of the most damaging PR misadventures of modern medicine in my opinion,” Winter said. “It has literally killed women. And it’s made them miserable.”
The public has a glaring lack of knowledge about menopause management, said Stephanie Faubion, MD, medical director for The North American Menopause Society and director of Mayo Clinic’s Center for Women’s Health.
Treating with low-dose estrogen isn’t a radical approach – in fact, it is the standard of care for women experiencing many menopause symptoms, Faubion said. But the topic does have nuance and some people get lost in the specifics.
“I don't think there's a lot of knowledge on the risk-benefits of hormone therapy in general,” Faubion said. “New information comes out so frequently, it's difficult to keep track of. The answer is complicated and depends on dose, duration of treatment, what formulation you're on. It's difficult for a lot of people to understand.”
But Winter said the lack of public knowledge reflects a bigger problem: Knowledge gaps exist among doctors, too, stemming from insufficient training on menopause-related issues.
During her 6-year urology residency, she never learned the role of vaginal estrogen on urinary problems, Winter said. Only during a 1-year fellowship on sexual dysfunction did she hear about the treatment.
“Despite dealing with urinary issues, incontinence, blood in the urine – training to manage all those concerns – the role of local hormones in the vagina for managing all them was never taught, never discussed,” Winter said. “I never prescribed any of it.”
A year ago, Winter left her job at Kaiser Permanente to join Odela. After years of prescribing medications for overactive bladder with little to no results, she said, she now uses the knowledge she gained during her fellowship by helping women who have spent years battling debilitating symptoms.
Urologists are not the only clinicians who lack appropriate training. Obstetrics and gynecology residencies offer little knowledge on menopause treatments, said Ghazaleh Moayedi, DO, an OB/GYN and complex family planning specialist for Texas-based Pegasus Health Justice Center.
The problem is partly a systems-based one, she said. Training programs often direct patients who are uninsured, or covered through public insurance, to medical residents. Patients who qualify for Medicaid or Medicare are often either pregnant or over 65, Moayedi said, so women actively going through the transition can slip through the cracks.
“What that means in a state like Texas where I’m based, where it is difficult to qualify for Medicaid, is that the people we see who do qualify are pregnant,” she said. “And you’re not on Medicare until you’re 65. So most OB/GYN residents don’t graduate with expansive experience in menopause.”
According to Medicaid.gov, 80% of the national population covered by Medicaid is age 45 and younger.
When doctors have proper training and prescribe local hormones, patients don’t always follow the treatment plan, said Andrea Rapkin, MD, professor of obstetrics and gynecology at David Geffen School of Medicine at UCLA.
That failure to follow treatment is yet another example of remaining doubts from the misinformation spread through early research, Rapkin said.
“I'll prescribe an estrogen product and I'll find out they didn't take it even though I'll reassure them,” she said. “I do think there are some lingering concerns, but I’m glad to see there is a growing interest in vaginal hormones.”