After years of neglect, the frenzy of social media feeds brimming with influencers touting their personally tested “hacks” to solving menopausal symptoms, celebrities promoting herbal supplements and skincare lines, and numerous products offering to ease hot flushes, improve sleep, restore libido and sharpen memory, represents a long-overdue investment – a gold rush fuelled by growing awareness and demand for better care.
But, reports JAMA Network, this surge has created a rocky menopause landscape akin to the lawlessness of the Wild West, with bold claims often reaching patients before clinical evidence does.
“It’s a level of renewed interest the likes of which I’ve never seen before,” said Nanette Santoro, MD, a professor of obstetrics and gynaecology at the University of Colorado Anschutz School of Medicine, who has led research on menopause, reproductive endocrinology, and women’s ageing for more than 30 years.
Stephanie Faubion, MD, MBA, medical director of the Menopause Society and director of the Mayo Clinic Centre for Women’s Health, ascribes this to “a highly engaged group of 40- and 50-year-old women with money, a looming deadline, and an unmet need”.
The demand has transformed menopause care into one of the fastest-growing sectors of women’s health. Women once told to simply endure the physiological changes of menopause can now seek relief from their choice of hormone therapies and newly approved non-hormonal medications alongside compounded hormones, off-label testosterone therapy, and an ever-expanding array of peptide treatments and supplements.
“The pipeline has expanded significantly, and that’s a good thing,” Faubion said. “But you’ve got a lot of people out there selling snake oil, too.”
Now, as the same forces pouring investment into the menopause marketplace have made it increasingly difficult to navigate, experts believe the central challenge has shifted. It’s no longer whether women have access to treatment but whether they are able to decipher which ones actually work.
The evidence base
Long before the menopause boom, it was largely absent from routine medical care. Hormone therapy fell sharply out of favour after the Women’s Health Initiative (WHI) reported, in 2002, that combined oestrogen-progestin therapy was linked to increased risks of breast cancer, strokes, and cardiovascular disease. The findings prompted millions of women to discontinue treatment and clinicians to stop prescribing it.
“And because few other options for menopause management existed at the time, all of a sudden, there was nothing you could do about it,” Faubion said. “For 20 years, we didn’t teach it. We didn’t talk about it. It just didn’t exist.”
Since then, a more nuanced understanding of the WHI findings has emerged. Just this year, the US Food and Drug Administration (FDA) approved the removal of black box warnings from hormone therapy products, including topical vaginal oestrogen.
Professional societies now agree that for healthy women under 60 or within 10 years of menopause onset with vasomotor symptoms like hot flushes, hormone therapy remains the most effective treatment available.
“It has the strongest foundation,” said Mary Claire Haver, MD, an obstetrician and gynaecologist and a certified menopause practitioner in Galveston, Texas, who has gained a massive following on social media for her advocacy. “The benefit-risk balance is favourable.”
Hormone therapy is no longer the only evidence-based option available. Haver also highlighted innovations in non-hormonal options with FDA approval, like fezolinetant and elinzanetant, both of which block neurokinin receptors to treat moderate to severe hot flushes and night sweats.
“Hot flushes are the thing that drives most women into the office,” Santoro said. “And we now have these two new treatments that are highly targeted and tend not to have the side effects of some of the medications we’ve backed into by trial and error.”
Before the approval of fezolinetant and elinzanetant, she noted, clinicians often relied on off-label use of selective serotonin reuptake inhibitors, or SSRIs, the anticonvulsant gabapentin, and the bladder-control medication oxybutynin to manage vasomotor symptoms.
“We don’t have long-term safety data yet, but they represent reasonable alternatives.”
Santoro said she now sees a steady stream of younger premenopausal patients in “white-knuckle terror of what’s about to happen to them” alongside older postmenopausal women who feel as though they “missed the boat” of timely menopause care.
Faubion said both demographics often arrive requesting hormone therapy because they “feel as if you’re withholding the longevity drug from them.”
But Santoro, who served as an investigator on major menopausal studies including WHI and the Study of Women’s Health Across the Nation, or SWAN, said HRT should be viewed primarily as a treatment of symptoms rather than a universal strategy for longevity or preventing chronic illness. “The effect of hormones, good or bad, on your overall long-term health is slight.”
Lauren Streicher, MD, a clinical professor of obstetrics and gynaecology at Northwestern University’s Feinberg School of Medicine and the founding medical director of the Northwestern Medicine Centre for Sexual Medicine and Menopause, said although oestrogen is still the gold standard for treating hot flushes, maintaining bone health, and improving sleep, it’s not a universal need for the 1.3m women in the US entering menopause each year.
“Does every single woman need to take hormone therapy?” she said. “No, but there’s still a long list of legitimate purposes for which women should.”
Even so, the renewed interest in menopause has not translated into widespread use of evidence-based therapies. Despite predictions that hormone therapy use would rebound, most women with menopausal symptoms still do not receive it.
A recent Mayo Clinic study led by Faubion found that its use fell to just 1.7% in 2023; a fraction of the nearly one in four women who used it before the WHI fallout.
Both Faubion and Santoro blame this on clinicians themselves, many of whom remain reluctant to prescribe hormones due to lingering misconceptions about safety and a lack of menopause training.
Emerging interventions
Increasingly, women are seeking guidance about compounded bio-identical hormones, peptide therapies, glucagon-like peptide-1 (GLP-1) receptor agonists, and even cannabis to help them manage symptoms well beyond the hallmark hot flush. Sleep disturbances, increased irritability, decreased libido, memory lapses, skin and hair changes, and weight gain often top the list.
“The single biggest misconception is that one protocol fits everyone,” Haver said. “There’s enormous enthusiasm right now for a range of interventions, and the evidence behind them is uneven.”
The following therapies illustrate how interest has outpaced the research supporting their use:
Compounded hormones
Tens of millions of compounded “bioidentical” hormone prescriptions are filled annually in the US.
Even though professional societies, including the Menopause Society, the American College of Obstetricians and Gynaecologists, and the Endocrine Society, recommend FDA-approved formulations over compounded ones, they’ve been marketed as a more personalised alternative, often accompanied by direct-to-consumer testing intended to tailor treatment to individual needs.
However, Faubion considers the “reams of paper” charting a patient’s hormone levels are “close to worthless” because of how they fluctuate daily. The idea that every woman should achieve a target hormone level, she said, “is actually the antithesis of personalised medicine” considering that symptoms, not laboratory values, should guide treatment.
Compounded hormones, available as vaginal inserts, oral capsules, or pellets implanted under the skin, carry many of the same risks as FDA-cleared oestrogen products but aren’t subject to the same manufacturing standards for consistency.
Streicher added that women often assume replacing hormones means recreating the body’s natural physiology.
“Making hormones is not the same as taking hormones. You can’t assume this will have the same impact as someone making it on their own.”
Testosterone therapy
The current momentum around testosterone therapy for women is “at an all-time fever pitch,” noted Santoro, who regularly sees patients who incorrectly believe testosterone drops dramatically during menopause.
Testosterone replacement can improve sexual desire in select postmenopausal women, and the Menopause Society recommends it only for those with hypoactive sexual desire disorder. Evidence, however, remains limited that it can offer benefits in energy, cognition, or muscle mass. Meanwhile, adverse effects can include permanent voice changes, hair loss, and clitoral enlargement.
Although some clinicians, like Faubion, do not prescribe it, others are willing to consider its use through shared decision-making and close monitoring.
Supplements
Unregulated supplements may represent the largest segment of the menopause market, and it is also where the knowledge gap is widest, Haver said.
A review found insufficient evidence that black cohosh relieves hot flushes, she noted, whereas creatine, traditionally known as a bodybuilding supplement, has emerging evidence for improving muscle strength in middle-aged women when paired with resistance training.
Over-the-counter brands – like Amberen, which claims to relieve up to a dozen menopausal symptoms – have been routinely investigated for deceptive marketing tactics, and Nutrafol, which sells hair growth formulation for women aged 45 or older, has faced multiple class action lawsuits alleging false advertising.
“There are some supplements with essentially no data at all,” Faubion said.
Kathleen Jordan, MD, an internal medicine physician who serves as the chief medical officer at Midi Health, a telehealth clinic focused on women’s midlife, cautioned against dismissing all supplements as a single, unstudied intervention.
She pointed to research on calcium, vitamin D, fibre, and botanicals, such as ashwagandha and lavender, which have demonstrated short-term benefits in small trials.
Goldman added that she often recommends layering supplements with lifestyle changes or prescription therapies.
Professional organisations, namely the Menopause Society, do not recommend supplements as first-line therapy.
Influencers as experts
In a recent study comparing online menopause discussions with electronic health records, researchers found that women described psychosocial and cognitive symptoms, including emotional effects, far more often in online forums than via clinical documentation.
“Menopause is one topic where people feel underserved by existing health care information systems,” said Raffael Heiss, PhD, a professor at the Management Centre Innsbruck in Austria and a founding member of its Centre for Social & Health Innovation.
His research examines the role of influencers in promoting prescription drugs and how commercial interests can blur the lines between authentic and sponsored content. “Women in particular are looking for personal advice and personal anecdotes, and influencers are really good at telling those stories.”
Although Santoro noted that “the plural of anecdote is not data”, Heiss maintained that for many, parasocial relationships – one-sided connections that make followers feel as though they’re receiving advice from a trusted friend – can be “more important than knowing whether someone is an expert”.
Haver recommends women consider a series of consistent questions when confronted with a potential treatment: “What is the evidence, and is it from rigorous research or from testimonials? Is this FDA-approved, and if not, why not? Does it address my specific symptoms and goals, or is it a general ‘optimisation’ pitch? What does it cost relative to a proven alternative?”
Telehealth filling gaps
The rise of telehealth companies, Faubion said, reflects a broader failure of the healthcare system, where patients struggle to find clinicians with menopause expertise and face long waits for a litany of specialists. As she noted, a patient may be asked to “see a urologist for urinary leakage and a rheumatologist because their joints hurt and a psychologist because their mood’s terrible”.
See more from MedicalBrief archives:
Some menopause supplements better than others, say experts
Hormone therapies best for menopause symptoms, new review finds
New drug cuts number and severity of hot flushes