Women in the workplace at midlife often reap the rewards of decades of experience, reaching their peak earning power and professional success. And then menopause occurs. Hot flashes, mood disturbances, sleep problems—these common symptoms can cause problems both at home and at work. About 1 in 4 women reported that their symptoms caused them to miss at least one day of work in the preceding year or that they experienced reduced productivity, fewer hours or even job loss.
Those are the results of a 2023 Mayo Clinic study, in which researchers surveyed 4,400 employed women about adverse work outcomes and tallied workdays they had missed. By extrapolating to the number of women in the U.S. between 45 and 60, they calculated that uncontrolled menopause symptoms cost the U.S. economy $1.8 billion a year.
“If women aren’t taking an offered promotion because of their menopause symptoms or aren’t putting their name in for the next position, or are even exiting the workforce, that’s a massive economic loss,” says Stephanie Faubion, the study’s lead author, who is also medical director at the North American Menopause Society. And when excess medical spending is included, according to calculations a Yale-led team reported in 2015, the loss skyrockets to $26 billion in the U.S. alone.
Biologists have known for a century that falling levels of estrogen, a primary female sex hormone, drives menopause. Yet it’s the symptoms of menopause, not estrogen levels, that alter women’s lives. Until recently, biologists knew little about the underlying physiology of those symptoms, and to develop treatments to ease their effects, biologists first need to understand them.
Biological drivers
Early in life, rising levels of estrogen, particularly a form of estrogen called estradiol, leads girls through puberty. When estrogen levels fall in mid-life, it triggers perimenopause, a span of up to a decade marked by fluctuating hormone levels and irregular periods. Then the ovaries stop making estradiol, progesterone levels plummet, and the ovaries stop releasing eggs. Menopause occurs when a woman reaches 12 months without having a menstrual period. At that point the woman’s menstrual cycle—and natural fertility—ends permanently.
Beginning in the 1980s, many doctors began prescribing estrogen, sometimes accompanied by progesterone, the hormone involved in the menstrual cycle and pregnancy, to manage menopause symptoms, an approach known as menopause hormone therapy (MHT, formerly known as hormone replacement therapy). Today estrogen—taken via pill, skin patch, gel, cream, spray, or ring, with or without accompanying progesterone—can relieve major symptoms like hot flashes, sleep disturbances, vaginal dryness and painful sex.
Up to 75 percent of women experience hot flashes during perimenopause, and one in four of them seek relief from their doctors, according to the North American Menopause Society. Other menopause symptoms can be equally disruptive, including difficulty falling or staying asleep, mood disturbances like irritability, anxiety and depression, reduced libido, and weight gain. How do shifting hormone levels cause this range of symptoms?
Menopause and the brain
The research push started with the classic symptoms of menopause—hot flashes and night sweats. These symptoms, known by scientists as vasomotor symptoms, occur when blood vessels suddenly dilate, or widen, causing increased blood flow and feelings of heat in the face, neck and upper body. They can be tolerable for many women, but debilitating for some.
The causes of hot flashes remained mysterious for years, with biologists attributing them to various causes. Some even suggested that women’s brains were addicted to estrogen and that hot flashes in menopause were symptoms of estrogen withdrawal.
New clues came in the early 1990s, when researchers from Rockefeller University showed that in rats, changing levels of estradiol, the most potent form of estrogen, altered the structure and function of the hippocampus. These seahorse-shaped brain structures, located above each ear, modulates learning, memory and emotion. It also regulates the hypothalamus, the body’s thermostat, and today scientists know that a group of neurons in the hypothalamus trigger hot flashes.
Menopause myth-busting
To understand other symptoms women deal with, in 1996 medical researchers from seven major institutions recruited a multiracial, multiethnic group of 3302 pre- and perimenopausal women in the U.S, then kept tabs for decades on their health and physiology. Like the famous Framingham Heart Study, which revealed how smoking and high cholesterol and blood pressure increased the risk of heart disease, the Study of Women’s Health Across the Nation (SWAN) has yielded multiple insights into menopause symptoms.
Through years of observation, measurement and analysis, the SWAN study has uncovered insights around symptoms as varied as memory issues, bone health, depression and vaginal dryness and pain during intercourse. It found that forgetfulness and other memory complaints are common, occurring in two-thirds of menopausal women. It busted the “use it or lose it” myth, which had suggested that women in mid-life must keep having intercourse to prevent sexual pain, instead finding no link between the two.
SWAN and subsequent studies have confirmed that menopausal women tend to have more sleep trouble, especially trouble staying asleep, than younger or older women, and that it may not be just hot flashes that wake these women up. Sleep disturbances are a common menopause symptom that is often overlooked, despite the importance of preventing the long-term health risks of chronic sleep deprivation, such as cardiovascular disease, anxiety, depression and cognitive impairment.
Beyond hormone replacement
As the biology of menopause symptoms grows clearer, new treatments have emerged and research to develop new therapies continues. A short-term course of cognitive behavioral therapy, for example, can help manage hot flashes by “calming” the central nervous system, says Monica Christmas, a gynecologist who directs the Center for Women’s Integrated Health at the University of Chicago. To treat moderate to severe vasomotor symptoms during menopause, including hot flashes, gynecologists prescribe an FDA-approved antidepressant.
Despite the progress, many women don’t receive effective treatment for their menopause symptoms, in part because physicians don’t receive enough training in how to treat menopause, Faubion says. Though training is improving, she adds, many different types of doctors see women in perimenopause and menopause, and more of them need learn how to manage menopause symptoms.
But there’s much more to be done, says Christmas. “We owe women a commitment to scientific exploration to more accurately understand menopause and potential treatments,” she says. To advance that work, Christmas sits on the steering committee of the Menopause Priority Setting Partnership, a global effort to identify the Top 10 unanswered questions in menopause research. “There have been priority-setting partnerships for about 150 other medical conditions, ranging from asthma to dementia to diabetes,” she says. “Now it’s time for menopause to get the attention it deserves.”
