why it's often missed

Symptoms related to hormonal change are often diffuse and span multiple systems, making them harder to categorize. Healthcare models tend to focus on isolated symptoms rather than longitudinal patterns, which can lead to reassurance without resolution.

What research suggests:
Professional guidance recognizes vasomotor and genitourinary symptoms as closely linked to menopause-related hormonal changes, while also acknowledging that symptom experience can be broad and variable—contributing to missed recognition and inconsistent evaluation pathways.

References (APA):
American College of Obstetricians and Gynecologists. (n.d.). Menopause (topic page). https://www.acog.org/topics/menopause
The Guardian. (2025, January 17). Hot flashes and mood swings: why perimenopausal symptoms get misdiagnosed—and how to treat them. https://www.theguardian.com/wellness/2025/jan/17/perimenopause-symptoms

Hormone levels fluctuate throughout the day and across cycles, especially during perimenopause. A single lab value may fall within a reference range even when symptoms are ongoing.

Clinical context often provides more insight than isolated results.

What research suggests:
Hormone testing during perimenopause has limited diagnostic value without symptom context.

References (APA):
Santoro, N. (2016). Journal of Women’s Health, 25(4), 332–339. https://doi.org/10.1089/jwh.2015.5556

For decades, women were underrepresented in clinical research, and “women’s health” was often treated as a narrower topic rather than a core medical priority. When fewer studies include women—or analyze results by sex—there are fewer evidence-based pathways to guide clinicians, especially for midlife hormonal transitions.

This gap contributes directly to delayed recognition, inconsistent counseling, and variability in care quality.

What research suggests:
Policy changes improved inclusion, but historically women were excluded from many trials (including women of childbearing potential), and sex-based analysis has not been consistently implemented. NIH policies now require inclusion and encourage analysis by sex, but the downstream effects (training, guidelines adoption, clinical practice) take time.

References (APA):
National Institutes of Health, Office of Research on Women’s Health. (2024, April 24). History of women’s participation in clinical research. https://orwh.od.nih.gov/toolkit/recruitment/history
Berlin, J. A., et al. (2009). Inclusion of women in clinical trials: A review of statutory approaches and remaining concerns. Journal of Women’s Health, 18(2), 141–146. https://pmc.ncbi.nlm.nih.gov/articles/PMC2763864/
Bennett, J. C. (1993). Inclusion of women in clinical trials—policies for population subgroups. The New England Journal of Medicine, 329(4), 288–292. https://www.nejm.org/doi/full/10.1056/NEJM199307223290428

Hormonal symptoms often span multiple systems—sleep, mood, cognition, weight—and healthcare is frequently organized around isolated complaints rather than patterns over time.

As a result, women may receive partial explanations or reassurance without integration of the full picture.

What research suggests:
Studies and surveys show that many women report years of symptoms and multiple healthcare visits before menopause-related patterns are identified, particularly when symptoms begin earlier or fall outside traditional expectations.

References (APA):
UVA Health. (2025). Early menopause symptoms often go unrecognized. https://news.virginia.edu/content/uva-study-reveals-women-suffer-menopause-symptoms-decades-early
The Guardian. (2025). Why perimenopausal symptoms are misdiagnosed. https://www.theguardian.com/wellness/2025/jan/17/perimenopause-symptoms

Many clinicians, including OB-GYNs, receive limited formal training in menopause management during medical school and residency. As a result, menopause care is often learned informally, inconsistently, or not at all—despite the fact that most women will spend a third of their lives post-menopause.

This training gap can lead to uncertainty around hormone therapy prescribing, over-reliance on outdated information, or avoidance of treatment altogether.

What research suggests:
Multiple surveys of U.S. residency programs and practicing clinicians show that menopause education is not standardized and is often limited to a small number of lectures or optional modules. Many clinicians report low confidence in prescribing hormone therapy despite clear clinical guidelines.

References (APA):
Allen, J. T., et al. (2023). Needs assessment of menopause education in U.S. obstetrics and gynecology residency programs. Menopause. https://pubmed.ncbi.nlm.nih.gov/37738034/
The Menopause Society (formerly NAMS). (2023). Lack of menopause education for residents. https://menopause.org/wp-content/uploads/press-release/lack-of-menopause-education-for-residents.pdf
ACOG. (n.d.). Menopause management. ACOG Clinical Guidance. https://www.acog.org/womens-health

Much of the concern traces back to early interpretations of the Women’s Health Initiative in the early 2000s. Although subsequent analyses clarified risk differences by age, formulation, and timing, public perception was slow to change.

Fear often persists despite updated guidance.

What research suggests:
Recent regulatory updates and position statements emphasize individualized assessment and acknowledge that earlier messaging overstated risks for many women. Current guidance focuses on personalized benefit–risk evaluation rather than blanket avoidance.

References (APA):
FDA. (2025). FDA updates labeling for hormone therapy. https://www.fda.gov/news-events/press-announcements/hhs-advances-womens-health-removes-misleading-fda-warnings-hormone-replacement-therapy
AP News. (2025). FDA removes long-standing hormone therapy warning. https://apnews.com/article/f26a8208fd3f5174ec96d61140439561

In 2002, the WHI estrogen-plus-progestin trial was stopped early after risks exceeded benefits under the study’s predefined monitoring rules. The headlines that followed led many women and clinicians to broadly avoid hormone therapy, even though later analyses emphasized that age, timing since menopause, and individual risk factors matter.

This shift influenced medical practice for years and contributed to persistent uncertainty and inconsistent menopause training and counseling.

What research suggests:
The WHI population skewed older (commonly cited average age ~63), and subsequent expert discussions emphasized that results should not be applied as a simple “hormones are bad” message for all women. Separately, national survey work has shown that menopause education remains limited in many residency programs—contributing to uneven clinician confidence and variable care.

References (APA):
Writing Group for the Women’s Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA, 288(3), 321–333. https://jamanetwork.com/journals/jama/fullarticle/195120
Pinkerton, J. A. V. (2005). After the Women’s Health Initiative: Menopausal women and hormone therapy. AMA Journal of Ethics, 7(11). https://journalofethics.ama-assn.org/article/after-womens-health-initiative-menopausal-women-and-hormone-therapy/2005-11
Lobo, R. A. (2013). Where are we 10 years after the Women’s Health Initiative? The Journal of Clinical Endocrinology & Metabolism, 98(5), 1771–1780. https://academic.oup.com/jcem/article/98/5/1771/2536695
Allen, J. T., et al. (2023). Needs assessment of menopause education in United States obstetrics and gynecology residency programs: A national survey. Menopause. https://pubmed.ncbi.nlm.nih.gov/37738034/
The Menopause Society. (2023, August 9). Lack of menopause education for residents (press release). https://menopause.org/wp-content/uploads/press-release/lack-of-menopause-education-for-residents.pdf

Because menopause care is not consistently taught or standardized, treatment approaches can vary significantly between providers. In the absence of clear training, some clinicians rely on personal experience, anecdotal approaches, or practice models that fall outside mainstream guideline-based care.

This variability can feel like “trial and error” to patients, especially when treatments differ widely from one provider to another.

What research suggests:
Professional organizations have raised concerns about the growing use of non-standardized hormone formulations and delivery methods (such as compounded hormones or pellets), noting limited safety data and inconsistent dosing. 

Financial incentives and practice-specific business models may also influence which options are offered, particularly when therapies are not covered by insurance.

Guideline-based care emphasizes FDA-approved formulations, individualized risk assessment, and ongoing monitoring rather than experimental or one-size-fits-all approaches.

References (APA):
The Menopause Society. (2022). Compounded bioidentical hormone therapy position statement. Menopause. https://pubmed.ncbi.nlm.nih.gov/35797481/
U.S. Food and Drug Administration. (2020). Compounded hormone therapy: FDA concerns. https://www.fda.gov/drugs/human-drug-compounding/compounded-hormone-therapy
ACOG. (2020). Compounded bioidentical menopausal hormone therapy. ACOG Committee Opinion No. 532. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2012/08/compounded-bioidentical-menopausal-hormone-therapy

Hormone therapy is primarily prescribed to treat bothersome menopausal symptoms. However, when started at the right time in appropriate candidates, it may also help preserve bone density and reduce fracture risk. These potential longer-term benefits are often overshadowed by older messaging that framed hormone therapy as uniformly risky.

It’s important to distinguish between therapeutic use and preventive intent. Hormone therapy is not prescribed solely to prevent disease, but symptom-driven treatment may have broader physiological effects.

What research suggests:
Major medical societies acknowledge that systemic estrogen therapy prevents bone loss and reduces fracture risk when initiated in suitable patients. Ongoing research continues to clarify how timing and formulation influence long-term outcomes.

References (APA):
The North American Menopause Society. (2022). Hormone therapy position statement. Menopause. https://menopause.org
Compston, J. E., et al. (2019). Osteoporosis. The Lancet, 393(10169), 364–376. https://www.sciencedirect.com/science/article/pii/S014067361832006X

Menopause has historically been treated as private, embarrassing, or something to “push through,” which shaped how many women talk about symptoms—and whether they seek care early. That stigma can also influence clinicians and systems: if symptoms are minimized socially, they are more likely to be minimized clinically.

The result is a pattern many women recognize: years of symptoms, limited education, and delayed support.

What research suggests:
Studies show many women have limited knowledge and negative attitudes toward menopause, leaving them unprepared for symptoms and less likely to seek help early. Broader stigma around aging and menopause can worsen symptom experience and reduce support-seeking.

References (APA):
Tariq, B., et al. (2023). Women’s knowledge and attitudes to the menopause: A systematic perspective. BMC Women’s Health, 23, 424. https://pmc.ncbi.nlm.nih.gov/articles/PMC10469514/
HealthyWomen. (2023, January 18). How the stigma of menopause and aging affect women’s experiences. https://www.healthywomen.org/your-health/stigma-of-menopause-and-aging-affect-womens-experiences