It seems that menopause has finally made it out of the shadows and away from being a taboo topic that was once whispered about among girlfriends or between sisters but never discussed in the public realm. This is certainly a welcome change for the 50 % of the global population who will universally experience this life transition if they are fortunate enough to live that long. As physicians who have collectively practiced menopausal medicine for over 30 years, we have seen the challenges that some women face because of menopause and the myriad symptoms that can occur during this transition (hot flashes, sleep and mood disturbances, brain fog, vaginal dryness, painful sex, urinary tract symptoms, joint aches, and palpitations to name a few). It can be an isolating experience and one with adverse effects on quality of life, physical and mental health, relationships, and in the workplace. We know that the majority of women will have symptoms related to menopause, and that hot flashes and night sweats (vasomotor symptoms), the hallmark symptom of menopause, last for a mean duration of 7–9 years and more than a decade for some [1,2]. Menopause symptoms may also adversely impact productivity at work with a substantial associated economic burden [3]. Further, while not every woman needs treatment for her symptoms, only about 4–6 % of women receive the most effective therapy, menopausal hormone therapy (HT). So why the new-found interest in menopause and, the bigger question, has this focus on the topic led to improved care for women? The reasons for the increased attention being bestowed on menopause are multifactorial, and in part are related to a gap in menopause management after the publication of the Women's Health Initiative (WHI) trials in 2002 [4]. The report of these findings resulted in the near total abandonment of the use of systemic HT for menopause symptoms. The lack of understanding of the meaning of relative versus absolute risks of HT left both providers and patients confused and led to the notion that all women should stop their HT. This, combined with deficiencies in ongoing medical provider education on the topic [5] as well as knowledge deficits about menopause among women themselves, created a void in menopause management. However, in the last couple of years, there has been increasing discourse about menopause – in our clinics, in the news, among women, on blogs and in multiple social media outlets. Not only is the topic being discussed on women-centric websites and journals, it is being covered by major television networks in primetime and by news outlets such as Forbes, Time, National Geographic and the New York Times. Another dramatic change is that celebrities are discussing their menopause experiences now when just a few years ago midlife celebrities would have been loath to mention the subject given society's bias toward youth and the negative portrayals of menopausal women in the media. It is perhaps important to note that venture capitalists have also discovered menopause and the estimated $600B [6] that the market is estimated to be worth (which a cynical person could also point to as the reason for the sudden celebrity interest in the topic, many of whom are now launching menopause product lines). Compounding pharmacies providing compounded bioidentical hormone therapy (cBHT- typically consisting of estrogens, progesterone, and testosterone alone or in combination) have also stepped in to fill the care gap left in the wake of the WHI with a market value estimated at over $21B in 2022 in the United States alone and an estimated compounded annual growth rate of about 5 % through 2031. This has occurred despite the false claims of cBHT being safer, more effective, natural, or individualized than government-regulated HT preparations available on prescription plans and recommendations against its use in multiple clinical guidelines. Another potential reason for the more open discussion of menopause could be the generation of women entering midlife. Whereas Baby Boomers did not typically discuss menopause in public, their Generation X counterparts are more open not only to public dialogue on the topic, but even to crowdsourcing solutions for symptoms. Behind them, the first of the Millennials turn 42 years of age in 2023 and will be rapidly entering the menopause transition. Like Millennials, Generation X is technologically savvy and spends as much time on the internet as Millennials, and their social media use continues to increase. These younger generations are less likely to suffer in silence and are intolerant of being told there is no solution for their symptoms. They are, in fact, helping to drive this intense interest in menopause because they see the void in menopause care and are demanding answers and solutions. That they also are at or approaching the peak in their careers and have disposable income to spend on products that will purportedly ease their symptoms is another factor fueling the menopause market. So, has this recent “discovery” of menopause benefitted women? The explosion in startups featuring products and services around menopause is staggering. Some of these offerings do provide value to women, such as virtual visits with menopause experts for those who may not have access to specialized menopause care near them. Yet questions about the quality of care received remain, with some of these including limited interaction with a clinician, inadequate medical information obtained during the visit to fully assess risks versus benefits of therapies prescribed, inadequate follow-up or communication with the primary care provider, and in some cases, use of therapies that lack scientific evidence for safety and efficacy. On searching menopause products online, one is struck by sheer volume (5 pages), the majority of which lack the evidence needed to support their use. The misinformation surrounding the topic of menopause is substantial, and social media contributes to misperceptions about this natural biological event. It is no wonder that women are confused about what is happening to them and what they can do for symptom management. How do we as women's health clinicians help to manage the menopause care gap and clarify things for midlife women? It is clear that no single solution will be adequate and that a multi-pronged approach is needed. First, education of clinicians on management of menopause is critical. Menopause care is not a niche or a subspecialty. Further, it cannot reside solely within a single medical specialty. Instead, it should sit solidly in all primary care settings, and those clinicians responsible for that care will need to ensure they have the knowledge and skills required to manage menopause. Similarly, medical education and residency training programs in internal medicine, family medicine, endocrinology, and obstetrics/gynecology should have required core competencies in menopause management that must be demonstrated prior to completion of training. Second, women also need better education on menopause so that they are more empowered and better prepared to advocate for themselves and to address the symptoms they may experience. This would ideally be provided by primary care providers by the age of 35 years given that menopause symptoms may begin well before the last menstrual period occurs. Third, better regulatory oversight of cBHT and education of women about the fact that government-approved and government-regulated bioidentical HT is available is sorely needed. There is a need to address the highly promoted but unfounded claims about cBHT which leave women with incorrect and incomplete information on the risks and benefits of these preparations. Finally, education of employers, supervisors and managers is needed for women to be better supported in the workplace. While the increased attention on menopause is welcome, it remains unclear whether it has translated to improved care for women. As we continue to advocate for the patients we serve, we also need to continue to advance the science of menopausal medicine.

Contributors Both authors contributed to the preparation of this editorial.
Funding No funding from an external source was received for the preparation of this editorial.
Provenance and peer review This article was commissioned and was not externally peer reviewed.
Declaration of competing interest The authors declare that they have no competing interest.

References

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[2] E.B. Gold, A. Colvin, N. Avis, et al., Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: study of women’s health across the nation, Am. J. Public Health 96 (7) (2006) 1226–1235.
[3] S.S. Faubion, F. Enders, M.S. Hedges, et al., Impact of menopause symptoms on women in the workplace, Mayo Clin. Proc. (2023), https://doi.org/10.1016/j. mayocp.2023.02.025. PMID: 37115119.
[4] A.R. Steinkellner, S.E. Denison, S.L. Eldridge, L.L. Lenzi, W. Chen, S.J. Bowlin, A decade of postmenopausal hormone therapy prescribing in the United States: long-term effects of the Women’s Health Initiative, Menopause. 19 (6) (2012) 616–621.
[5] J.M. Kling, K.L. MacLaughlin, P.F. Schnatz, et al., Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: a cross-sectional survey, Mayo Clin. Proc. 94 (2) (2019) 242–253. [6] Hinchliffe E. Menopause is a $600 billion opportunity. Fortune. https://fortune.com /2020/10/26/menopause-startups-female-founders-fund-report/. (Published 2020. Accessed 1/2/2022).

Stephanie S. Faubion*, Chrisandra L. Shufelt
Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL, United States of America Mayo Clinic Women's Health, Rochester, MN, United States of America

* Corresponding author at: Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, United States of America.
E-mail address: Faubion.stephanie@mayo.edu (S.S. Faubion).