Holly Byrd Miller thought she was in tune with her body. But in her late 40s, she noticed shifts that were both physical and mental. “I was really emotional with mood swings, and I had severe hair thinning. Washing my hair would make me sad because I could see clumps of hair in my hands,” she recalls.
Miller attributed her unease to a big life transition: She had resigned from a corporate job to become a full-time entrepreneur as CEO and founder of Makeup by Holly Beauty Partners. She thought what she was experiencing was related to stress from making that change, until she had a regular checkup with her gynecologist, who suggested another type of change might be to blame.
“The doctor asked me a series of questions, including when was my last [menstrual] cycle,” Miller says. “I had to think about it. It was the previous year. She told me, ‘You’re in menopause and went through perimenopause without knowing it.’”
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After that eye-opening conversation, Miller dug into research — some provided by her gynecologist, some self-initiated — and began to talk with friends. She soon realized she wasn’t alone in facing hot flashes, weight gain centered in the belly, and joint pain. She learned about hormone replacement therapy (HRT) and found a clinic that provides her with quarterly monitoring so her dosages can be adjusted as needed. She’s also attentive to daily routines. “I became a pescatarian and more thoughtful about what I was putting into my body, more intentional about going to the gym,” she says. “Health and wellness is the new currency. Women need to talk about what they’re experiencing with other women and especially their medical practitioner.”
For many years, “The Change,” if it was referenced at all, was spoken of in hushed tones and with no small amount of embarrassment.
“There’s been a cone of silence and a sense of stigma around menopause,” says JoAnn Pinkerton, M.D., professor of obstetrics and gynecology at the University of Virginia and director of UVA Health’s Midlife Health Center. “Hormonal and physical changes and stressful life circumstances make these middle years much more complicated. You’re aging, you’re having symptoms, you’re worried you’re not going to be a candidate to be promoted [at work].”
While there’s no one-size-fits-all approach, increased conversation and research are now being focused on how to help women for whom the symptoms of menopause are disruptive to their daily lives. “We want to understand the hormonal changes, develop safe and effective treatments, and provide information,” Pinkertons says. “This is a significant life transition.”
What we know
“Menopause” refers to the moment when a woman has lived a full year without menstrual bleeding; the average age for menopause in the United States is 52. But the symptoms of menopause start well before, usually in a woman’s 40s. “Perimenopause” can include changes to sleep habits, mood, “brain fog,” and monthly cycles as well as hot flashes: the name often used for symptoms that are one of the most obvious indicators the ovaries are producing less estrogen. Pinkerton notes that the length of time needed for a woman to reach full menopause is highly variable, with Asian women averaging five years, Caucasian women averaging seven to eight years, and Black and Hispanic women averaging longer.
Hormone replacement therapy — now sometimes simply “hormone therapy” — was first introduced in the 1940s and has been used for decades in different formulations to alleviate unpleasant symptoms of menopause. Hormone therapy became widely popular in the 1990s but fell out of favor following the 2002 release of results from a study that seemed to show a link to increased medical risks, including heart disease and stroke. That study had two specific elements, Pinkerton says: It focused on women over 60 and incorporated synthetic medication. “There was widespread misinterpretation of the data,” she notes. “We have learned that hormone therapy is very safe if you start under the age of 60. There are lower doses, safer therapies, and nonoral options. We can tailor the dose and minimize the risks. We are still trying to get the word out to providers and women about the safety and efficacy of hormone therapy.”
It's now recommended that hormone therapy begin within 10 years of menopause and before a woman turns 60. In November 2025, the U.S. Department of Health and Human Services announced the Food and Drug Administration would end the requirement of placing warnings on hormone packaging, with a few exceptions. And, Pinkerton says, progress is being made to identify ways to settle brain receptors that, as estrogen declines, can trigger hot flashes. “Treatments targeting these pathways are being tested for women who can’t use estrogen,” Pinkerton says. “It’s really exciting to see new treatments that are safe and effective.”
Beyond medication
Nonprescription solutions for menopause include several over-the-counter options that use plant-based ingredients, but both Pinkerton and Jane Limmer, M.D., an OB-GYN physician at VCU Health, note that the efficacy of these remedies is not supported by research. Instead, studies indicate weight loss, better sleep hygiene, antidepressants, and cognitive behavioral therapy are likely better nonhormonal approaches.
“Just as in any difficult life event, patients will do better if they have more coping skills,” Limmer says. “Cognitive behavior therapy, which helps patients identify and restructure negative or problematic thoughts and actions, has been shown to decrease the severity of menopausal symptoms. CBT can help women understand how negative thoughts and emotions affect what they are experiencing physically, and in so doing, help reframe their perception of how bothersome vasomotor symptoms are.”
Limmer also notes that recent data indicate testosterone is at its highest in women around the age of 18 and then begins to drop, reaching its lowest level around age 60. “Many women have come to believe that testosterone levels fall precipitously during and after menopause, but this decline happens irrespective of the age of natural menopause,” she notes. “This does not mean that women may not benefit from testosterone therapy, however it does mean that women should not necessarily take testosterone simply because they have gone through menopause.”
Pinkerton and Limmer agree that maintaining fitness into upper years is also useful, with Pinkerton advising exercise for 150 minutes a week and seven hours of sleep nightly. “When you’re stressed, you’re more likely to have hormonal fluctuations,” she notes.
“Physicians are not necessarily experts in diet and exercise science, so partnerships in these areas can be incredibly valuable,” Limmer adds. “I recommend women look for places that are focused on evidence-based fitness — exercise that will help women avoid and/or delay the muscle loss that occurs with age and exercise that helps maintain bone density. I would also look for fitness centers that provide nutrition counseling. Weight gain is a natural trend with aging for both men and women, but it can be prevented with the right approach to what we eat and how much we move.”
Limmer advises to steer clear of practices that seem to be focused more on selling than caring. “I caution all my patients against visiting a ‘wellness’ practitioner who is offering an array of expensive, cash-only products,” she says. “At best, most supplements are nothing more than placebos; at worst, they contain toxins and allergens because they are neither studied nor regulated by the FDA. This is also true of compounded hormones and hormone pellets. In short, if someone wants to sell you supplements or compounded hormones or expansive panels that they profit from you buying, approach with caution and a hefty degree of skepticism.”
Moving forward
Pinkerton notes longer lifespans and shifting societal roles can make a woman’s middle years more complicated. Menopause “has become more of an issue with expectations of women working outside the home, in the home, and in the community,” she says. “There are also stresses of aging parents, children leaving the nest and, maybe, returning to the nest.”
But, she says, aging has its benefits. “Wisdom that comes with age and experience is something that should be valued,” she says. “Menopause is a great time for women and their clinicians to devote attention to overall health and reduce the risk of chronic disease. You want a provider who is evidence-based, listens to your concerns, and will follow you over time. It’s a process and a transition.”
Limmer notes that each woman’s journey through middle age will be her own. Not everyone will have symptoms that are so severe they disrupt daily life. Menopause “is the same as with any other medical experience, and that answer is that people experience changes in their health in different ways,” she says. “Often, the healthier you are to start, the easier a change, of any kind, will be. Every woman is unique, and thus her experience of any major health event will be uniquely her own.”
Now in her early 50s, Miller is feeling better in every dimension. “I feel like I’m living my best life, my most authentic life,” she says. “I’m so encouraged by women who are embracing their age and embracing their experiences. I would not go back to my 20-something self for anything.”
To find a practitioner who focuses on menopause care, visit menopause.org.
