Hot flashes, insomnia and brain fog are just a few of the symptoms that may upend a woman’s life as she approaches menopause.
Research misconceptions and a dearth of menopause education among healthcare providers have contributed to a gap in women’s midlife care, with just five percent of women receiving menopausal hormone therapy (MHT) – also called hormone replacement therapy – despite evidence of safety and effectiveness.
Hormone therapy hesitations
Courtney Shihabuddin
Courtney Shihabuddin, DNP
MHT, a form of HRT that replenishes ovarian hormones, is one of the most effective treatments for alleviating menopause symptoms, though its reputation was tarnished for some time.
In 2002, the Women’s Health Initiative released findings –since debunked by research –g associating MHT with an increased risk of heart disease and breast cancer, which sent MHT usage plummeting.
The study’s average participant was 63, with 70 percent being 60 or older –g a demographic known to have an elevated risk for health issues. And this was just one issue with its validity, says Courtney Shihabuddin, DNP, founder of telehealth women’s clinic Empowered Wellness.
“Estrogen does not act the same way in the body when it’s been estrogen-deprived for years,” she says. “We know that timing matters. Hormone therapy has significant benefits and lower risks when started either before the age of 60 or within the first 10 years of menopause, and it can actually reduce the onset of cardiovascular disease, diabetes and osteoporosis.”
Additionally, the hormones studied – specifically, oral conjugated equine estrogen and the synthetic progestin medroxyprogesterone acetate – aren’t as regularly prescribed for MHT today, Shihabuddin.
“The type of hormones that we use matters. Transdermal estrogen... has significantly less risk for cardiovascular events... than taking oral estrogen. We also know that micronized progesterone is the same chemical structure as to what our body produces over a synthetic progestin, like what was used in the Women’s Health Initiative,” she says. “So the route that we use, the dose that we use, the formulation, all of that changes the risk profile for patients.”
Amanda Stevens
Mind the gap
Despite extensive reevaluations of the 2002 study, MHT remains underutilized, especially since the Food and Drug Administration placed black box warnings on estrogen from 2003 until this past November.
healthmindandlife.com
Estrogen molecule
“Generations of women were told that hormones were dangerous. Providers stopped learning about menopausal medicine,” Shihabuddin says. “I’m hoping that with the black box being removed, it changes who is willing to prescribe.”
Shihabuddin acknowledges that updating clinicians will take time, as MHT is nuanced and menopause education is not sufficiently widespread.
A 2024 survey conducted by The Menopause Society connected with 99 U.S. obstetrics and gynecology residency programs and found only 31 percent had a menopause curriculum. Even fewer primary care providers receive menopause training.
Lack of specialized care, stigma and a desire to manage symptoms naturally can be contributing factors for some women who choose not to treat their menopause symptoms. A 2025 Mayo Clinic study found 84 percent of women ages 45-60 don’t seek treatment, despite symptoms impacting many of them.
Managing menopause
Among women who seek treatment, many do not find adequate support. The 2025 nationwide State of Menopause survey found 41 percent reported conflicting advice from providers and 24 percent had a provider incorrectly attribute perimenopause symptoms to anxiety.
Shihabuddin, who went through medical menopause following breast cancer treatment at 35, has encountered difficulties of her own.
“When I went to my doctors, they basically shrugged their shoulders and said, ‘Well, this is how it is,’” she says. “And that I struggled with for years. … I felt like that was not a satisfactory response to how I felt.”
Even after doing her own research on MHT, it took years for Shihabuddin to get a prescription for estrogen, which, she says, changed her life. Her struggle to procure menopause treatment inspired her to establish Empowered Wellness, which serves women across Ohio.
Though Shihabuddin doesn’t blame healthcare providers for training gaps, she emphasizes addressing women’s experiences and encouraging them to focus on identifying symptoms, seeking specialist care and engaging in individual risk discussions with their providers.
“Menopause is a natural transition that occurs over time, but having to live with the side effects or the symptoms of that transition does not have to be,” Shihabuddin says. “If we can treat that and help women feel better and feel like themselves again, then we’re doing wonderful things for our gender.”
Amanda Stevens is a contributing writer at CityScene Media Group. Feedback welcome at feedback@cityscenemediagroup.com.
