by Rupa Palanki
In May 2024, a bipartisan group of female senators introduced the Advancing Menopause Care and Mid-Life Women’s Health Act. The bill allocates $275 million over five years toward strengthening and expanding federal research, health care provider training, and public health education on menopause and mid-life women’s health issues. If enacted, it would be the most comprehensive federal effort to improve health care related to menopause. However, further action related to the labeling of low-dose estrogen and workplace support is still necessary to support individuals experiencing menopause.
Unmet Needs for Legislative and Policy Action
Menopause is the natural stage of life when an individual has not had a menstrual period for twelve consecutive months, signifying the end of their fertile years. Half of the American population will eventually experience this transition. Currently, 75 million American individuals are either in menopause, perimenopause (the time before menopause when menstrual cycles may become irregular), or postmenopause (when an individual has not had a menstrual period for longer than a year). Another 6,000 reach menopause daily.
Menopause can considerably affect quality of life, causing symptoms like mood changes, difficulty concentrating, joint pain, and weight gain. Its impact is also economic. An estimated 20 percent of the American workforce is in some phase of menopause. A Mayo Clinic study estimated an annual loss of $1.8 billion annually in the United States due to workdays missed as a result of menopause symptoms.
Despite its prevalence and impact, menopause has long been disregarded by policymakers and health care providers in the United States. There is a dearth of clinical trials studying menopause, and there are significant gaps in scientific knowledge regarding this stage of life. Fewer than one-third of OB-GYN residency programs provide training on menopause care, and 80 percent of OB-GYN residents feel ill-prepared to discuss menopause with patients.
The Advancing Menopause Care and Mid-Life Women’s Act addresses a critical and long-overdue need for investment in menopause care. However, additional legislative and policy reforms could further the larger goal of supporting individuals throughout the menopause transition. Below, I outline other key reforms that should be considered alongside this legislation.
FDA Reconsideration of the Boxed Warning on Low-Dose Estrogen
The U.S. Food & Drug Administration (FDA) should reconsider the boxed warning currently required for low-dose estrogen, which is a key treatment for menopause symptoms. Boxed warnings are the highest-level safety notices that the FDA provides, typically indicating risk of serious injury or death. New data may indicate that a boxed warning for low-dose estrogen is unnecessary.
Use of hormone replacement therapy (HRT) for menopause is controversial. After a 2002 National Institutes of Health research study linked high-dose HRT pills to an increased risk of breast cancer and cardiovascular disease, the FDA instituted the boxed warning and HRT prescriptions dropped substantially. However, further research, which analyzed twenty years of follow-up data from the original study, found that the risks of breast cancer were lower than initially reported and the benefits of HRT outweigh the risks for many patients. Some experts suggest that the original study was flawed and that advances in dosing and administration of HRT have reduced risks of adverse events. Ongoing research also suggests that HRT not only ameliorates menopause symptoms but also protects against bone loss and cardiovascular disease.
To be sure, HRT may not be appropriate for all patients. Menopause symptoms and risk factors vary significantly across patients. Treatment for menopause is not a one-size-fits-all approach, and an informed provider can provide guidance on the appropriate type and dosage used. Further investigation into the long-term effects of HRT is also necessary and may be facilitated by the Advancing Menopause Care and Mid-Life Women’s Health Act.
But the current boxed warning on low-dose estrogen, specifically, may exaggerate its safety risks and discourage individuals going through menopause from considering a treatment option that could significantly improve their quality of life. In 2018, the FDA rejected the North American Menopause Society’s petition to remove the boxed warning on low-dose estrogen products, citing a perceived lack of sufficient data. Since then, not only has there been additional research demonstrating the relative safety of low-dose estrogen, but the United Kingdom’s medical regulatory agency has also approved over-the-counter low-dose estrogen in 2022. In this context, the FDA should reconsider whether the boxed warning is still warranted for low-dose estrogen.
Legislative and Agency Action to Facilitate More Menopause-Friendly Workplaces
Congress and the Equal Employment Opportunity Commission (EEOC) — the federal agency that enforces civil rights laws against workplace discrimination — should also make clear that menopause-related discrimination is a form of sex discrimination deserving federal protection.
Currently, there are no explicit legal protections for employees seeking workplace accommodations for menopause symptoms. Menopause is typically not considered a disability under the Americans with Disabilities Act because it is a natural part of aging, although it may be classified as such in instances of severe impairment or atypical onset. In some cases, individuals may also qualify for sick leave under the Family and Medical Leave Act or similar state laws. Most individuals experiencing menopause, however, have no protections under these laws.
The Pregnant Workers Fairness Act (PWFA) protects workers from discrimination on the basis of pregnancy, childbirth and related medical conditions, but it remains unclear whether menopause qualifies as a “related condition.” The EEOC issued guidance for the Act’s implementation that defined “related conditions” broadly, including menstruation, postpartum depression, and breastfeeding as examples. However, the agency did not provide menopause as an example in its list of likely “related conditions.” Although the EEOC received feedback during the notice-and-comment period urging the agency to include menopause, the EEOC declined to do so. They noted that their existing list was non-exhaustive and that determination of whether something was a “related condition” would ultimately be a fact-specific inquiry. If the EEOC cannot resolve this ambiguity by explicitly stating that menopause is protected under the PWFA, Congress should pass a bill that specifically prohibits menopause-related discrimination. Congress has considered similar legislation aimed at protecting older workers from age-related discrimination but efforts have been unsuccessful thus far.
The EEOC should also issue guidance that encourages employers to actively support employees experiencing menopause. This may include modifying uniforms for better breathability, providing desk fans, and facilitating access to menopause experts, among other practices. While some employers have already implemented these changes on their own, the EEOC can drive broader adoption of these practices through its regulations.
Takeaways
As actress and menopause advocate Halle Berry has explained, “The shame has to be taken out of menopause. We have to talk about this very normal part of our life that happens. Our doctors can’t even say the word to us, let alone walk us through the journey.”
By pushing Congress to pass the Menopause Care and Mid-Life Women’s Health Act and implementing additional legislative and policy reforms, we can bring menopause out of the shadows and create a society that is more inclusive of individuals going through menopause.
Rupa Palanki is a law student (J.D. 2026), whose research interests include innovative medical technologies and chronic disease policy. She is a graduate of the University of Pennsylvania, where she studied Economics and interned for the U.S. Department of Health & Human Services and the Louisiana Department of Health. Prior to law school, she worked as an analyst at ClearView Healthcare Partners.
