From Neglect to Dogma: What Happened to Menopause Care?

How we moved from dismissing women to drowning them in certainty.

Recently I have become increasingly aware of scar tissue that I've developed over the last many years. It's ropey and stubborn, woven thread by thread into hidden parts of me.

I’m not talking about the kind left behind by surgery, I’m talking about the kind that accumulates when you spend decades carrying responsibility for parts of other people's suffering. It forms when you make difficult decisions repeatedly, knowing there are no guarantees, knowing real people will live with the consequences, and that sometimes there is no definite right answer.

When I chose women's health, I knew it would be meaningful work and I expected endless learning and intellectual challenge. What I absolutely did NOT know, is that I was walking right into a storm. To say I’d have to learn quickly to function with a lot of uncertainty is an understatement.

For most of my professional life, the conversations we now have about menopause existed at the very edges of medicine. Long before menopause became mainstream, before celebrities, podcasters, and social media transformed it into both a topic of public discourse and a market valued in the billions, I worked alongside a physician prescribing hormone therapy to women who were suffering while the vast majority of practitioners didn’t. Almost all doctors were very hesitant to prescribe hormone therapy but more importantly, they also usually failed to recognize menopause when it was sitting right in front of them. 

We weren't trying to go rogue, god no. It was really hard doing what we did. We made the clinical decision to respond to the women in front of us and to the growing body of evidence suggesting the story had become far more nuanced than the headlines showed. The research that would eventually reshape guidelines was emerging, some of it already existed. It simply took many years for institutions to catch up and for that, we have paid dearly in trust. Women’s trust.

The shadow of the Women's Health Initiative loomed large. Fear had settled heavily over women's healthcare. The study's (mis)interpretation reshaped practice overnight, and although the truth eventually proved more layered than the headlines suggested, the damage was done. Women who had found relief in hormone therapy were pulled off treatment. Others were denied therapies that would have improved the quality of their lives. Clinicians found themselves caught between emerging evidence, professional guidelines, and women imploring for help.

We reviewed the literature constantly, documented well and followed our patients closely. We did our best to make thoughtful decisions in a landscape shaped more by fear than certainty or science. We carried the weight of choices that felt both necessary and risky because we had witnessed what the alternative looked like, and it was simply not an option we were able to live with.

Women arrived exhausted from years of existing with an unnamable sense of loss. They came frightened by anxiety that felt foreign, shattered by sleeplessness they could not solve, grieving the erosion of confidence and feeling in many ways deeply lost. Many were told their symptoms were normal, some were told they were psychiatric, almost all were prescribed medications for the collateral damage, never coming close to the actual root. A natural, predictable, complex change that, despite impacting half the humans on the planet, didn’t exist. 

Until it did. The evidence evolved, guidelines were updated, media latched on, and the conversation changed. Menopause became mainstream, and for that I am grateful. But if the first part of my career was defined by neglect, this chapter has been shaped by something else entirely.

Women went from being gaslit to being catapulted into a polarized, highly emotional landscape pregnant with dogma and “hills people will die on”. (Lord, let it end…)

The old guard insisted that the guidelines were the guidelines, that questioning consensus was reckless, that the safest path was strict adherence to the prevailing narrative.

Today's evangelists often sound equally certain and are also ever so…. loud. Everything you've been told is wrong. This is the only answer. Everyone needs hormones. Everyone needs higher doses of hormones. No one needs hormones. Conventional medicine has failed you. Conventional medicine is now here to save you! And for the love of all things holy eat your goddamn protein. And fiber. 

You’ve seen it all rolling past your feed on the daily ladies, the astonishing amount of people - including those who can’t prescribe hormones or practice medicine - hawking their wares, they have the fix you need. Many of these individuals, it bears noting, have not sat medical board exams and are not held to account by regulatory bodies, so indeed, what do they care …about what or how they sell?. And what of the women? They have marched forward with not so much as a glance back over their shoulders. They got the message loud and clear: your aging issues are not a medical priority. Good luck, sisters. Vaja con Dios.

The thing about certainty is, it is so …comforting. It quiets our anxiety offering the illusion that complex problems can have simple solutions. It also performs exceptionally well in a landscape where attention is monetized, confidence is rewarded, and nuance truly has no chance at virality. 

The old guard taught me that institutions can be too slow to acknowledge when they are failing. The new evangelists are teaching me that conviction untethered from humility can become its own form of dogma. Can trust grow in either type of soil? It does beg the question.

As a naturopathic doctor I was trained with a broad and deep scope of practice: to consider nutrition, lifestyle, botanical medicine, hormone therapy, and the many interconnected systems that shape a woman's experience of health. Long before personalized medicine became a buzzword, this was simply how we were trained. Because all of these modalities are in my direct scope and training, I don’t have to have a bias or a “hill I will die on” because I don’t need one. All of it is available to me, to use as I see it being the most effective, for each individual patient.

In the end I’ve realized that my scar tissue is in fact not cynicism or burnout, but rather a residue that's been left behind from years of holding complexity: witnessing women pay the price for institutional failures and now watching them struggle beneath the weight of endless information and competing certainties being chucked at them morning, noon and night. The noise of it all at this point, is frankly almost deafening.

There are days, (many, many days) when I wish I could lift the fog entirely, and reassure the woman sitting across from me that it will all be okay, and deliver a simple, algorithmic solution on repeat. But I can't. Nothing touches as many aspects of a woman's body, mind and life like perimenopause and menopause do, and no two women experience them in the same way or will benefit from the same treatment approach.

What I do have is the perspective that comes from almost 20 years of doing this work: helping women sort through complexity, making sense of conflicting information, finding solid ground and a path forward that honours both the evidence and the reality of the human being in front of me.

I won’t offer certainty. But I can offer clarity. 

Dr. Kirsten, ND, MSCP