Menopause Care Should Not Be A Luxury Good

Nine percent. That is the share of nearly 1.8 million Medicare women carrying a diagnosis of genitourinary syndrome of menopause who ever filled a prescription for vaginal estrogen

Nine percent. That is the share of nearly 1.8 million Medicare women carrying a diagnosis of genitourinary syndrome of menopause who ever filled a prescription for vaginal estrogen — a generic cream that is barely absorbed, costs almost nothing, and works.

A woman comes to the office at fifty-four. She has not slept a full night in two years. Sex has become painful. She has had three urinary tract infections in eight months. Her mood, she says, no longer belongs to her. The doctor listens kindly, tells her that this is a natural stage of life, and she goes home with nothing.

Start with the definition, because most writing about menopause never bothers.

Menopause is a single day: the day twelve months have passed since the last menstrual period.

Genitourinary symptoms of Menopause Estrogen Navigator

Everything before it is perimenopause, which can run four to eight years and is where most of the suffering lives. Everything after it is postmenopause, which now lasts three or four decades. Falling estrogen drives the symptoms. Hot flashes and night sweats are called vasomotor symptoms. The dryness, burning, painful sex, urgency, and repeated urinary infections are called genitourinary syndrome of menopause, or GSM. Unlike hot flashes, GSM does not fade on its own. It progresses. Between 27 and 84 percent of postmenopausal women have it.

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In 2002 the Women’s Health Initiative stopped its estrogen-plus-progestin arm early, and prescribing collapsed overnight. Here is what that trial actually found. The average participant was sixty-three years old, more than a decade past menopause — not the woman sitting in the office asking for help. Over about five years, for every 10,000 women treated for one year, there were 8 more invasive breast cancers, 8 more strokes, 7 more coronary events, and 8 more pulmonary emboli. There were also 6 fewer colorectal cancers and 5 fewer hip fractures. The net excess on the trial’s own global index was 19 events per 10,000 women per year. Nineteen. That is the number that emptied the pharmacies.

Genitourinary symptoms of Menopause Estrogen Navigator

The other arm of the same trial — estrogen alone, in women who had a hysterectomy — showed fewer breast cancers than placebo, and fewer deaths from breast cancer. And when the investigators followed all 27,347 participants for eighteen years, all-cause mortality was 27.1 percent among women who had taken hormones and 27.6 percent among women who had taken placebo. No difference.

That is not what the profession heard. Hormone therapy use among American postmenopausal women fell from 26.9 percent in 1999 to 4.7 percent by 2020, a decline of more than 80 percent. A generation of women passed through the transition untreated because a trial conducted in sixty-three-year-olds was applied to fifty-one-year-olds.

In November 2025 the Food and Drug Administration began removing the boxed warnings about cardiovascular disease, breast cancer, and probable dementia from menopausal hormone products, and the revised labeling recommends starting systemic therapy within ten years of menopause or before age sixty. The boxed warning about endometrial cancer for systemic estrogen used alone remains, correctly, because that risk is real and preventable with a progestogen. It is rare for a regulator to say, in effect, that it frightened people for twenty-three years with the wrong number. This one did.

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But the most damning figure in menopause medicine has nothing to do with systemic hormones.

In a cohort of 1,838,732 Medicare women carrying a diagnosis consistent with GSM, only 9.0 percent ever filled a prescription for vaginal estrogen.

Among women whose only recorded symptom was recurrent urinary tract infection — the precise group in whom vaginal estrogen prevents infections — 1.4 percent filled it.

Black women had roughly 40 percent lower odds of filling it than white women. Low-dose vaginal estrogen barely enters the bloodstream. Among 45,663 women followed in the WHI observational study, users showed no increase in stroke, cancer, or venous thromboembolism. It is a generic cream. Nine women in a hundred get it.

What this means for a woman. If you are within ten years of your last period, under sixty, and you have hot flashes, night sweats, or shattered sleep, hormone therapy is the most effective treatment that exists, and its absolute risks are small and countable.

If you have vaginal dryness, painful sex, urinary urgency, or repeated urinary infections — at any age — vaginal estrogen should be offered to you, and a history of breast cancer is a conversation with your oncologist, not an automatic wall. Ask for absolute numbers — how many women in ten thousand. A clinician who answers only in percentages of percentages is not informing you.

My take. Great menopause care is neither exotic nor expensive. It is a long visit, an accurate history, an honest recitation of absolute risk in both directions, and a prescription. It is available today, at generic prices, to any physician willing to read.

Two failures stand in the way. The first is the phrase natural stage of life. So is a fractured hip. Natural is not an argument. Telling a symptomatic woman nothing and calling that respect for her autonomy is not respect — it is abandonment. Informed consent means she hears the real numbers, both the harms and the benefits, and then decides. The physician’s obligation is to recommend, not to fan out a menu of options and step back from the table.

The second failure runs the opposite direction, and it is in fashion. Hormone therapy relieves vasomotor symptoms, treats GSM, and protects bone. That is established. It is not proven to extend life, prevent dementia, or optimize anything. The eighteen-year mortality curve is flat. When menopause care is marketed as longevity, as biohacking, as a way to buy a better decade, it has left the evidence and entered the marketplace. Overselling estrogen is the same error as fearing it. Both substitute a story for data.

And there is the part no one wants to say aloud. Care that is superb at thirty thousand dollars a year and absent at Medicaid rates is not medicine. It is a market. The vaginal estrogen numbers prove the barrier was never price. Nine percent is not a pricing problem. It is a training problem, an attention problem, and a fifteen-minute-appointment problem. Women do not need a concierge. They need a clinician who has read the eighteen-year follow-up and has forty minutes.

Bottom line: the evidence for treating menopause well has been in plain sight for more than a decade, and most women still leave the office with nothing. Send this to a colleague who still says natural stage of life.

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References

1. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-33. doi:10.1001/jama.288.3.321

2. Manson JE, Aragaki AK, Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, et al. Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the Women’s Health Initiative randomized trials. JAMA. 2017;318(10):927-38. doi:10.1001/jama.2017.11217

3. Chlebowski RT, Anderson GL, Aragaki AK, Manson JE, Stefanick ML, Pan K, et al. Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the Women’s Health Initiative randomized clinical trials. JAMA. 2020;324(4):369-80. doi:10.1001/jama.2020.9482

4. Yang L, Toriola AT. Menopausal hormone therapy use among postmenopausal women. JAMA Health Forum. 2024;5(9):e243128. doi:10.1001/jamahealthforum.2024.3128

5. Gallo K, Zhang CA, Burton C, Kamdar N, Enemchukwu EA. Vaginal estrogen utilization among Medicare beneficiaries with genitourinary syndrome of menopause. JAMA Netw Open. 2025;8(12):e2549822. doi:10.1001/jamanetworkopen.2025.49822

6. Crandall CJ, Hovey KM, Andrews CA, Chlebowski RT, Stefanick ML, Lane DS, et al. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study. Menopause. 2018;25(1):11-20. doi:10.1097/GME.0000000000000956

7. Kaufman MR, Ackerman AL, Amin KA, Cassidy N, Chen A, Chung DE, et al. The AUA/SUFU/AUGS guideline on genitourinary syndrome of menopause. J Urol. 2025;214(3):242-50. doi:10.1097/JU.0000000000004589

8. The North American Menopause Society Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-94. doi:10.1097/GME.0000000000002028

9. US Food and Drug Administration. FDA requests labeling changes related to safety information to clarify the benefit/risk considerations for menopausal hormone therapies. November 10, 2025. Available from: https://www.fda.gov/drugs/drug-alerts-and-statements/fda-requests-labeling-changes-related-safety-information-clarify-benefitrisk-considerations