Here’s something I don’t say often: I went through medical school and never once learned about menopause. Not a single lecture. Not one afternoon. I finished my training and walked into a career treating patients for a life stage no one had taught me to recognize. That’s not a personal gap. That’s the standard we’ve all been living with.

So when I sat down with congressional staffers this week, that was where I started.

A Story I’ve Heard a Hundred Times

I told them about my patients. Women losing more than $1,000 a month, some in medical bills, some in the raise or the promotion that quietly slipped away while they were struggling to function. I want to be clear: this isn’t a handful of unlucky cases. Right now, only about a quarter of women with real menopause symptoms are getting any care at all, even though a third of them are dealing with symptoms serious enough to upend a normal day. The story I told wasn’t rare. It was representative.

Three Bills, and What Each One Actually Fixes

The first bill I brought up was the Menopause Education for Medical Students Act. It would finally require medical schools that receive federal funding to teach this. I am living proof of what happens when they don’t.

The second was the Menopausal Workers’ Fairness Act. This is the one for every woman who’s had to choose between pushing through a symptom flare and protecting her paycheck. It would guarantee reasonable workplace accommodations, so no one has to make that choice.

And the third, the Advancing Menopause Care and Midlife Women’s Health Act, is the one that funds the whole system catching up: $275 million over five years for research, provider training, and public education, already backed by senators from both parties.

What Actually Moved the Room

Here’s what surprised me. It wasn’t the statistics that shifted a meeting. It was one simple question: do you have someone in your own life who’s gone through this? A mother. A sister. Maybe even themselves. Every single time, something in the room softened. The data got us in the door. The honesty is what got us heard.

Here’s What I’m Asking You to Do

You don’t need a white coat or a plane ticket to Washington. Pick up the phone, call your representative’s office, and ask them to support these bills. Here’s the full list, so you have it on hand:

• Advancing Menopause Care & Midlife Women’s Health Act (S. 4503/H.R. 9090) — $275M over five years for research, provider training, and public education.

• Menopause Education for Medical Students Act (H.R. 9273) — requires menopause training in medical schools.

• Menopausal Workers’ Fairness Act (H.R. 9671) — workplace accommodations for menopause symptoms.

• Servicewomen & Veterans Menopause Research Act (S. 1320/H.R. 2717) — closes research gaps for servicewomen and veterans.

• Improving Menopause Care for Veterans Act (H.R. 219) — fixes gaps in VA menopause care.

• Hormone Health Data and Research Act (H.R. 9077) — directs NIH and HHS to study hormone variability.

There’s also a $5 million funding request for a Menopause Research Action Network already approved in last year’s budget. We’re just asking Congress to keep it going.

A doctor who was never taught to see this can’t catch it. A worker with no protections can’t hold a job her own body is working against. A field with no funding can’t find the answers either of them needs. All six of these bills, together, start to change that.

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The main bill is HB 5284, called the Illinois Menopause Equity and Care Act. Two related bills passed with it. Together, these three laws touch different parts of a woman’s life: her job, her insurance, and the training her healthcare providers receive.

WHAT EACH LAW DOES

HB 5284 is the most significant of the three. Starting January 1, 2027, it adds menopause-related conditions—like hot flashes, night sweats, sleep problems, brain fog, and bone loss—as a protected category under Illinois’ human rights law. Employers with four or more workers must now provide reasonable accommodations, such as flexible schedules, cooler workspaces, or remote work when needed. Another important change: starting January 1, 2028, health insurance plans in Illinois, both individual and group, must cover medically necessary care for perimenopause and menopause. This gives women financial protection, written directly into insurance law.

SB 3325 is a smaller bill, but it’s still important. Illinois already requires healthcare professionals to complete 1 hour of implicit bias training each renewal period. Starting January 1, 2027, a course on perimenopause and menopause can count toward that hour. This is an incentive, not a new rule, and Illinois is the first state to offer it this way.

SB 3688 addresses the issue even earlier. It updates the Medical School Curriculum Act so Illinois medical schools must teach menopause recognition and management. The same requirements now apply to nursing and physician assistant programs. This law is designed for the doctors who will care for future generations.

WHY THIS ADDS UP TO SOMETHING BIGGER

Consider how these laws work together. Future doctors will be trained. Current doctors have an incentive to learn more. Once a woman is diagnosed, her insurance must cover treatment, and her employer must provide support. These three bills cover the entire process, from medical school to the exam room to the insurance claim.

I created the Menopause Tax™ framework because many of the losses women face during this transition—like lost income, career setbacks, and extra expenses—often go unnoticed and unnamed. Illinois has now officially recognized this in law. When the insurance mandate takes effect in 2028, it could significantly reduce out-of-pocket costs for women. This is the Menopause Tax™ being addressed in legislation, not just in conversation.

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WHAT THIS MEANS IF YOU DON’T LIVE IN ILLINOIS

Rhode Island passed a similar law in 2025, and states from New York to California have introduced their own versions this year. Illinois is part of a larger trend, and changes like this often spread from state to state until they become standard.

If you run a company, pay attention to these changes, no matter where your business is based. Laws like this often become the new standard quickly. And if you are a woman experiencing this transition, it’s important to know that the conversations in your doctor’s office and HR department are now being shaped by real laws, not just good intentions.

Sources: Illinois Senate Democrats, Kilpatrick Townsend & Stockton LLP, LegiScan, and the National Law Review.

I know this might sound surprising. Believe me, I was just as amazed.

But here’s what I really want you to pay attention to, especially if you’re in your early 40s and your cycle has started to shift. Timing here is everything. The benefits appear when you start hormone therapy close to the transition—not years later. So if you’re in perimenopause, this isn’t something to put off. It’s something to think about right now.

Okay, so why does timing matter so much?

It turns out, the biggest reason women saved money wasn’t just relief from hot flashes. It was about protecting their hearts.

Estrogen seems to protect your heart, your blood vessels, and your cholesterol during exactly the years when all of that starts shifting. And that protection is strongest when you start near the transition. Wait too long, and you might just miss it.

Perimenopause isn’t just a waiting room. It’s the main event—the moment to take action.

The fear you’re carrying probably isn’t even yours

You know that instinct, the one that says maybe it’s not that serious, maybe it’s not worth bringing up again? I get it. That instinct is honestly older than some of our kids.

Back in 2002, a large study linked hormone therapy to certain risks, scaring a generation of women and their doctors. But here’s what isn’t always clear: that study looked at women with an average age of 63, many already a decade past menopause and dealing with other health issues. It wasn’t about women in their 40s, starting this transition now.

This newer research looks at women who are actually being prescribed hormone therapy today. And for them, the picture looks pretty different.

So if your clinician is still operating from that old 2002 mindset, you may need to be the one to bring the latest research to the conversation. It may not feel fair, but it’s reality—and I want you to feel empowered and prepared.

Now let’s talk about the actual numbers, no sugarcoating

Per 10,000 women who took estrogen alone instead of skipping treatment, the study found 259 fewer cases of heart disease, 181 fewer hip fractures, and 647 fewer deaths.

It also found 87 more cases of breast cancer. I’m not going to leave that out, because you deserve the whole picture, not just the flattering half.

Even counting that tradeoff, the treatment group still came out $13,540 ahead per woman, with more good years of health to show for it. Researchers actually have a term for that: “absolute dominance,” meaning cheaper AND more effective, both at once.

Here’s what I keep coming back to: Delaying this conversation isn’t a neutral choice. It’s a decision to skip the years when taking action is most effective—and least costly. I call it the Menopause Tax™. It’s not a single big bill, but a series of small costs that quietly add up during the years when you have the most power to make a difference.

So, what do I actually want you to do with this?

Your family history, your own risk, how bad your symptoms are, all of that still matters, and any good doctor will walk through it with you.

But please, don’t wait until you’re forced into the conversation. Bring this up at your next doctor’s appointment—while you’re still in perimenopause. Ask about your heart and bone health now, not years down the line.

That one question could be worth thousands of dollars. And a lot more good years with the people you love.

Source: Brown J, et al. Cost-effectiveness analysis of menopausal hormone therapy. Obstetrics & Gynecology, 2026.

You probably know who I’m talking about.

You’ve probably noticed this at your workplace as well. There’s the colleague who once led every meeting but now sits quietly at the end of the table. The director who no longer volunteers for big projects. Or the woman two desks away who leaves early three times a week, without explaining.

These women don’t necessarily get fired or demoted. They simply fade away.

A new study in Occupational and Environmental Medicine puts a name, a number, and a cause to this feeling. Researchers tracked about 650 working women in Japan for more than five years. They found that job conditions like workload and control over your own work were linked to a higher or lower chance of developing menopause symptoms severe enough to disrupt daily life. This isn’t just a lifestyle issue. It’s a workplace problem, and there’s evidence to prove it.

The workload itself is the real risk factor

It’s not about your resilience or coping skills. It’s the job itself.

Researchers looked at workload, job control, job strain (how much demand compared to control), and effort-reward imbalance in women ages 35 to 55 who started with no symptoms. After five years, 68 women—about 10.5%—developed symptoms that disrupted daily life. Job title didn’t matter. Whether someone worked full-time or part-time, held a management role, or worked shifts made no difference. What mattered was how the job actually felt.

For each standard increase in workload, the risk went up by 34%. Women with the heaviest workloads had about a 73% higher risk than those with the lightest.

Job control had the opposite effect, and it was even stronger. Each standard increase in control over your work lowered the risk by 22%. Women with the most control had less than half the risk compared to those with the least.

When high demand was combined with low control, defined as high job strain, the risk increased by 77%. Effort-reward imbalance also suggested a 62% higher risk, though this result wasn’t statistically significant. It’s something to watch, but not yet proven.

This isn’t just one symptom. It affects the whole body.

The physical toll is the clearest sign of all.

A heavier workload, more strain, and greater effort-reward imbalance all increased the chances of symptoms starting in every area—vasomotor, psychological, and physical. More control lowered the risk in all areas. But once symptoms began, physical symptoms were most strongly linked to job conditions. Your body keeps the score.

Why this isn’t just about health

It’s also about careers and income, and the signs of people leaving are already clear.

The study didn’t measure income directly, but other data makes the connection clear. National figures in the paper show that 46% of Japanese women with menopausal symptoms report much lower work performance, and 9% leave their jobs entirely because of these symptoms. This is happening in a country where the employment rate for women aged 45 to 54 reached 82.0% in 2025. It’s a quiet exodus during peak earning years.

The same conditions most linked to severe symptoms—low control and high strain—are also the ones that make people less likely to get flexibility or support. Job control’s protective effect was seen in full-time workers, but not in part-time workers . The link between workload and symptom severity was even stronger for shift workers. Those with the least control over their schedules are predicted to be affected the most.

You’re not fading away because you’re weak. The data shows it’s because the job wasn’t designed to give you control.

Here’s a free step: Do a Job Strain Audit. For one week, write down every task where you had no say in. Many women tell their manager, “I’m overwhelmed.” That’s just a feeling. A manager might nod, suggest a mental health day, and nothing changes, because there’s nothing specific to act on.

A list of specific decisions you don’t control is different. Now your manager can actually help: they might give two tasks to someone else, let you move a deadline, or give you approval so you don’t have to wait. When you bring an audit instead of a complaint, the conversation becomes a negotiation, not just a pep talk.

Source: Iida M, Toki R, Miyake A, et al. Associations of employment characteristics and psychosocial work factors with severe menopausal symptoms among working women: a longitudinal study. Occup Environ Med 2026;0:1–7.

BEEF LIVER ISN’T NEW, BUT THE CLAIMS ARE BIGGER

What science supports, and what it doesn’t

Desiccated organ supplements are not new. In the 1950s, beef liver was used to treat iron-deficiency anemia before modern iron supplements were available. That history is real, and the nutrients are real too. Liver is rich in B12, iron, vitamin A, and CoQ10.

However, there is a gap. No human clinical trials have tested whether freeze-dried organ capsules improve menopause symptoms or outcomes. When researchers study menopause and B12, iron, or CoQ10, they look at isolated nutrients or food-based approaches, not these supplements.

A 2025 clinical evidence review by Acibadem Hospitals Group stated clearly: “Clinical research does not support broad claims that they improve energy, hormones, immunity, or performance in everyone.” The nutrients themselves have supporting evidence. The supplement format does not yet.

WHAT THE EVIDENCE ACTUALLY DOES SHOW

The nutrients matter, but the supplements themselves have not been tested.

What matters is that some micronutrients decrease and become important during menopause, and research supports this.

• About one-third of postmenopausal women experience bone loss, which can lead to osteoporosis and a higher risk of fractures.

  • A 2024 study in the journal Nutrients found that diets rich in B12, vitamin D, phosphorus, and iron were linked to a lower risk of osteopenia in these women. Bone remodeling takes 90 to 120 days, so timing is important.

• Iron levels change during menopause.

  • A 2024 systematic review found that higher serum ferritin levels were linked to faster bone loss in healthy women over 47, which is when menopause usually starts. The relationship is complex. High iron can lead to bone loss, but too little iron, which is common in perimenopause, can affect energy and thinking. The connection is not straightforward.

• B12 deficiency is common.

  • In one study of anemic postmenopausal women, 65% had iron-deficiency anemia and 2.6% had B12 deficiency. In the wider US population, B12 deficiency ranges from 2.5% to 60% depending on age and other factors. Absorbing B12 becomes more difficult as you get older.

• CoQ10 has strong evidence for benefits in heart disease, but not for menopause.

  • The Q-SYMBIO trial published in BMJ showed that CoQ10 reduced death and hospital stays in heart failure patients. Menopause increases cardiovascular risk, and CoQ10 supports mitochondrial energy. But no menopause-specific trials yet.

What we do not know is whether a woman with bone loss benefits more from liver capsules than from targeted B12 and vitamin D supplements. This has not been studied. It is also unproven whether CoQ10 in beef heart works better than standard CoQ10 supplements, or if freeze-drying preserves the nutrients better. These questions have not been answered in human studies.

HERE’S HOW TO ACTUALLY THINK ABOUT THIS

Do not rely on supplements to replace the information you can get from blood tests.

Step 1: Start with testing. Check your serum ferritin, B12, vitamin D, and vitamin D2/D3 levels. If your B12 is borderline, ask your doctor about a methylmalonic acid test. This only takes one visit and gives you information specific to your body. Taking supplements without knowing your levels is just guessing.

Step 2: Focus on food first. A 2025 review on diet during menopause found that overall nutrient patterns, not single supplements, predicted better bone health. Mediterranean diets with lots of leafy greens, beans, seafood, and whole grains were especially helpful. These foods provide many nutrients, cofactors, and fiber that capsules cannot offer.

Step 3: Choose targeted supplements instead of general “support blends.” If your B12 is low, standard B12 supplements like methylcobalamin or cyanocobalamin are safe and well-studied. If you need more vitamin D, D3 is supported by research. If your iron is low and you do not have bleeding, taking iron with food helps your body absorb it.

WHAT ARE THE BEST ORGAN SUPPLEMENTS FOR MENOPAUSE SUPPORT?

If you are interested in organ supplements, use them as a substitute for eating organ meats, not as a treatment. Some women do not want to eat organ meats, so freeze-dried liver can be a practical way to get these nutrients. Still, think of it as a concentrated food, not a medical therapy.

What matters if you choose this route:

• Freeze-dried, not heat-processed (preserves heat-sensitive vitamins)

• Transparent labeling of individual organ amounts (not proprietary blends hiding doses)

• Third-party tested (NSF, USP, or ConsumerLab certification)

• 3,000–6,000 mg daily is the range cited in product literature, based on traditional use, not menopause-specific trials

• Liver products require vitamin A monitoring if you’re also taking multivitamins or retinol skincare

The beef organ industry is unlikely to fund menopause research since it is not a pharmaceutical company. This means the lack of evidence will likely continue for years. If you decide to try these supplements, consider a 12-week trial. Bone changes take 90 to 120 days, while energy and sleep may change in 4 to 6 weeks. Keep track of any changes you notice. That is your personal data.

Rethink what “hormone support” means. Menopause is not caused by a lack of nutrients, but by hormonal changes. The right nutrients can help with bone health, energy, and mood, but organ supplements are not the cause of these improvements. CoQ10, B vitamins, iron, and magnesium help with energy, but they do not replace estrogen. If you have severe hot flashes, brain fog, or sleep problems, talk to your doctor. Supplements are not the answer for these symptoms.

The Menopause Tax™ is not just about the money you spend. It is about choosing treatments that have evidence to support them, or at least knowing what you are paying for.

The nutrients are important, and the menopause transition is important.

Now it’s your turn. Are you currently taking organ supplements? Share what influenced your decision and whether you have noticed any real changes. Feedback from your community helps guide my research and reporting.

So let me ask the better question. Why did it take until 2026?

The cycle tracker has been on your phone since 2019. For seven years, it gave you three reasons your period might change. Birth control. Pregnancy. Breastfeeding. That was the whole list.

There is a reason for that. Two reasons, actually. And the second one is the one I want you to sit with, because it is the one that touches your wallet.

THE APP WAS BUILT FOR YOUNGER WOMEN

Think about those three options for a second. Each one starts on a day you can name. Each one changes your body in a way a computer can predict. And each one is really asking you the same thing: are you trying to have a baby, or trying not to?

That is what the tool was for. So picture a woman at 47 whose period shows up every 24 days now instead of every 28. The app has no place to put that. It just asks if she forgot to log something. Her body is changing, and the software treats it like she made a mistake.

Now, there is a real medical problem here too, and I want to be fair about it.

There is no blood test for perimenopause. None. Your hormone levels bounce around during this time, sometimes inside a single month. A test can look normal one week and look different the next. That is why the major medical groups tell doctors to diagnose women over 45 by looking at their periods and their symptoms, and to skip the lab work.

Doctors use a set of rules for this. One of the first signs of perimenopause is when your cycles start landing a week or more apart from each other, and it keeps happening.

So think about what that means. The changing pattern is the diagnosis. There is no morning you wake up and know to check a box, because the box and the proof are the same thing.

That is why Apple built something smarter. The app now watches your cycles over time and tells you when the pattern looks like perimenopause. Honestly, that is a good design. My question is why we waited seven years for it.

THE MONEY WENT WHERE THE MONEY WAS

The medical problem explains what the feature looks like. It does not explain the seven years. For that, you have to look at who was paying.

Fertility apps had customers from the beginning. Women trying to get pregnant will open an app every single day, and companies could sell to that. Menopause had no buyer like that, so nobody built for it.

Then the money showed up. Bloomberg just put the menopause treatment market at $19 billion.

I want to be plain about this. Apple always knew what perimenopause was. What changed is that the market got big enough to be worth their time.

HERE IS WHY THIS MATTERS TO YOU

That missing word costs you real money. Let me show you how.

Evernorth looked at the medical records of 1.5 million insured women between 40 and 64. More than half had symptoms of perimenopause or menopause. Only eight percent had it written down as a diagnosis.

Say your periods start coming closer together and heavier. Your app asks if you are pregnant. So you see your doctor about the bleeding, and you get an ultrasound, a thyroid panel, an iron test, and a referral. Fourteen months pass before anyone says perimenopause out loud.

You paid for all of it. That is the Care Costs part of the Menopause Tax™, and it started because nobody named what was happening.

Your paycheck pays next. In a Mayo Clinic study of 4,440 working women ages 45 to 60, 13 percent missed work, cut hours, turned down work, retired early, or lost a job over their symptoms. Nationally that is $1.8 billion in lost work time a year, and $26.6 billion once you add the medical bills.

Cut hours means less going into your retirement account and a smaller match from your employer. It also shrinks your Social Security record, and that number follows you for life. Nobody bills you for that one. You just get less at 67.

That is why a decision inside a phone app belongs in a conversation about money. For seven years, the health tracker in millions of pockets had no place to write down what was happening to women in their forties. And what is never written down never gets treated, never gets covered, and never shows up as a number you can take to your employer.

The update helps women who own iPhones and log their cycles faithfully. It does nothing for the woman who was told her sore joints were arthritis, or her racing heart was anxiety, or her heavy bleeding needed one more scan before anyone would say the real word.

So here is my question for the benefits leaders reading this. Your own claims data almost certainly looks like that Evernorth number. What is your plan doing about all the years that come first?

And if you are the woman in this story and you want to know what the delay already cost you, that is a conversation worth having one on one. Book the Meno & Money™ Audit at menoandmoney.com.

Dr. Kim Derezil | MD | WMCP® | Founder, Meno & Money™

Sources

• Apple, WWDC 2026 announcement, June 8, 2026, iOS 27 Health app updates.

• Harlow SD, et al. STRAW+10 staging criteria for reproductive aging. Menopause, 2012.

• ACOG, NICE guideline NG23, and The Menopause Society guidance on symptom-based diagnosis of perimenopause in women over 45.

• Bloomberg Big Take, “The $19 Billion Menopause Economy,” August 5, 2026.

• Evernorth Research Institute, analysis of 1.5 million commercially insured women ages 40 to 64.

• Faubion SS, et al. “Impact of Menopause Symptoms on Women in the Workplace.” Mayo Clinic Proceedings, 2023. PMID 37115119.

More than 70% of women develop musculoskeletal symptoms during the menopause transition, and about 25% are disabled by them. Hormone therapy handles hot flashes, night sweats, and bone loss. Aching joints and flattened energy are less predictable, and plenty of women stay symptomatic on a full regimen.

Low-dose naltrexone is what turns up when they go looking for what comes next. Naltrexone blocks opioid receptors, and the FDA approved it in 1984 at 50 mg for opioid and alcohol use disorder. LDN means 0.5 to 6 mg daily, roughly a tenth of that dose. No manufacturer makes a tablet that small, so a compounding pharmacy prepares it.

NOBODY HAS STUDIED THIS IN MENOPAUSE

A 2026 review in Advances in Therapy collected 105 LDN studies published since 1989, spanning seven therapeutic areas. Menopause was not one of them. The trial registry says the same thing: work underway in fibromyalgia, endometriosis, long COVID, POTS, and chronic fatigue, and nothing in perimenopausal or postmenopausal women.

No trial has tested LDN against estrogen-related joint pain in any form. That includes aromatase inhibitor arthralgia, the joint pain that appears when breast cancer treatment deliberately suppresses estrogen, which is the closest thing medicine has to a controlled model of what happens at menopause.

Every recommendation you encounter is borrowed. The useful question is what it was borrowed from.

WHAT THE ADJACENT RESEARCH SHOWS

Joint pain. This is the main reason midlife women try LDN, and it is where the borrowed evidence is weakest. A randomized crossover trial in osteoarthritis and inflammatory arthritis found no benefit over placebo. In fibromyalgia, the two positive studies enrolled 10 and 31 patients. The three larger ones, at 52, 86, and 99 patients, all failed to beat placebo.

Fatigue. A retrospective review of 218 chronic fatigue patients found 73.9% reported some improvement, with nothing controlled and no placebo group. A small Gulf War illness trial classified 38% of participants as responders. Neither population was menopausal.

Brain fog. Here there is one real signal. The 99-patient fibromyalgia trial missed its pain target but pointed toward fewer memory complaints, and the authors asked for that to be studied directly. Nobody has yet.

Pelvic and vulvar pain. A 2025 case series described improvement in vulvodynia, and a trial in endometriosis pain is running now.

TWO THINGS SPECIFIC TO MIDLIFE

Insomnia and vivid dreams sit near the top of the reported LDN side effects. Sleep is the symptom menopausal women most want back, and a drug that disturbs it starts at a disadvantage in this population.

LDN also does nothing about estrogen. It will not protect bone and it will not treat genitourinary symptoms. Using it in place of hormone therapy leaves the underlying change untreated.

WHAT IT COSTS

Compounded LDN runs $30 to $60 a month, roughly $600 a year. Insurance almost universally denies it, and prior authorization for off-label naltrexone is routinely rejected. Telehealth visits add $75 to $200.

It does qualify as a prescription medical expense under IRS Publication 502, so an HSA or FSA covers it. Keep the pharmacy receipt and the prescription record.

One cost is not financial. LDN blocks opioid receptors even at 4.5 mg, so starting it during daily opioid therapy can trigger withdrawal, and it needs to stop 24 to 72 hours before surgery requiring opioid pain relief. Midlife is a common decade for joint replacement.

WHERE THIS LEAVES THINGS

For a menopausal woman with aching joints, the honest summary runs like this. Plausible mechanism. Tolerable safety record. Fifty dollars a month. No evidence in anyone resembling her, and negative results in the larger trials of the closest comparison group.

Some women will try it anyway, and that can be a reasonable choice. It is worth knowing which parts are established and which parts are inference before the first prescription rather than after the twelfth refill.

Sources: Gouda AHK, et al. Adv Ther. 2026;43:2852-2870. | Wright VJ, et al. Climacteric. 2024;27(5):466-472. | Due Bruun K, et al. Lancet Rheumatol. 2024;6(1):e31-e39. | Beaudette-Zlatanova B, et al. Clin Ther. 2023;45:468-477. | Polo O, et al. Fatigue. 2019;7:207-217. | IRS Publication 502 (2025).

There is a good chance your job already has a way to pay you back. It is called an HRA, and most women have never heard of it.

What the letters mean

HRA stands for Health Reimbursement Arrangement.

HRA stands for Health Reimbursement Arrangement.

In plain words, it is a pot of money your job sets aside to pay you back for health costs.

Your job is the only one who puts money in. You cannot add any of your own, which makes it different from an FSA or an HSA where the money comes out of your paycheck.

When the money comes back to you, it comes back tax free. It does not count as income and you do not owe tax on it.

Money you do not use can roll over to next year if your job sets it up that way.

How it works, step by step

1. Your job says it will cover up to a set amount each year. Say $1,500.

2. You go to the doctor. You pay for the visit or the medicine yourself.

3. You save the receipt.

4. You send the receipt in.

5. The money comes back to you, with no tax taken out.

You pay first and get paid back after. That is the whole thing.

Your job writes the rules, sets the dollar amount, and decides which costs count. Some plans cover almost any medical expense and some cover a short list.

Your job picks the rules. It picks the dollar amount. It picks which costs count. Some plans cover almost any medical expense. Some cover only a short list.

Why this matters if you are in perimenopause

Perimenopause is the stretch of years before your period stops for good. It can last four to eight years and often starts in your early forties.

A lot of what helps you during those years is covered badly or not at all.

Look at what you may be paying for right now:

• A hormone patch your plan put on a high tier

• A non-hormonal pill for hot flashes

• A visit with a menopause specialist who does not take insurance

• Pelvic floor therapy

• A sleep study

• Vaginal estrogen cream

• A bone density scan your plan says you are too young for

These are not small costs, and they land in the same years. An HRA can cover them.

The part almost nobody knows

Most large companies pay your medical bills with their own money. Benefits people call this being self-funded. In 2025, 80% of covered workers at larger firms were in self-funded plans.

Your card may say Aetna. If your plan is self-funded, Aetna is processing the paperwork while your company pays the bill.

That means the denial on your patch came from your company. A company can change a decision it made itself.

Adding an HRA is one of the fastest ways to do that. Your job does not have to rewrite the whole health plan, because an HRA sits on top of what already exists. It can be done in one benefits cycle.

Why your job would say yes

Money.

Mayo Clinic studied 4,440 working women aged 45 to 60 and found that menopause symptoms cost $1.8 billion a year in lost work time, and $26.6 billion a year once medical costs are counted. In that study, 13% of women had a bad work outcome because of symptoms.

Carrot Fertility asked 2,000 working women about it. Eighty percent called menopause a work problem, and more than half had thought about changing jobs because of it.

Picture a 48-year-old operations manager with 20 years at the same company. She knows the systems, the people, and the customers. Replacing her costs far more than a reimbursement account would.

Where things stand today

Very few companies have set one of these up.

Mercer found 18% of employers planned to offer menopause help, up from 4% in 2023. NFP’s numbers are lower. Only 10% of employers offer any menopause support at all, and 62% of almost 800 companies said they were unlikely to add it in the next five years.

So the power sits with most companies while the benefit sits with very few. That gap comes out of your pocket. It is the Menopause Tax™.

One Thing To Do This Month

Ask HR one question. “Do we have an HRA?” If the answer is yes, ask what it covers. You may already have money sitting there.

Ask. You may be the first one.

Be honest. Had you heard of an HRA before this post? I ask because I want to know how big the gap is between what your job offers and what you were told about.

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The numbers:

• $124 trillion is moving between generations through 2048 (Cerulli Associates, via CNBC)

• $54 trillion goes to surviving spouses — and 95% of them are women (Bank of America Institute)

• $47 trillion passes to daughters and granddaughters (Bank of America Institute)

• By 2030, women will control $34 trillion — 38% of US investable assets, nearly double our 2023 share (McKinsey, via CNBC)

The industry calls this a windfall. I call it a stress test.

THE MONEY AND THE MENOPAUSE TRANSITION RUN ON THE SAME CALENDAR

Your biology was never consulted

The transfer happens in two phases. Both land inside the menopause window.

Phase 1: The $47 trillion parent-to-daughter wave hits women in their 40s and early 50s. Peak perimenopause. Sleep disruption and estrogen swings hitting the exact brain regions you use for complex decisions.

Phase 2: The $54 trillion spousal wave lands in the late 50s and 60s. Postmenopausal, newly widowed, grieving — and facing the largest financial decisions of your life.

There is no version of this transfer that arrives outside the menopause transition.

A 54-year-old operations executive inherits $380,000 from her mother the same year her sleep collapses. Ninety days of decisions: retitle accounts, evaluate her mother’s advisor, decide what to sell and what to shelter. She’s running on four hours of sleep. Nobody at the advisory firm asks. I see versions of her constantly.

UNPREPARED IS THE EXPENSIVE PART

This is the Menopause Tax™ third pillar: Compounding Costs

Only 27% of Americans have discussed wealth transfer with their families, and 35% never plan to (Edward Jones) — 38% among US women (World Economic Forum). Meanwhile, 41% of Boomers and 45% of Gen Xers have no will or basic estate documents (LegalShield).

The event isn’t what costs you. The structure you inherit into is. An inheritance parked in cash for two foggy, exhausted years doesn’t cost two years of returns — it costs their compounded value across three decades. Symptoms drive the delay: a woman who cannot sleep does not schedule the advisor meeting.

And grieving, symptomatic, newly moneyed women are the industry’s softest target — for rushed annuity swaps and “just sign here” transfers. Not because anyone thinks you’re incapable. Because everyone assumes you’ll defer.

THE PREPARED INHERITOR STRATEGY

Build the system before the money arrives

Move 1: Force the family conversation this year. Three questions: What exists, where is it held, who is named on it? You’re asking for the map, not the money. Start with beneficiary designations — they override wills.

Move 2: Close your own estate gap first. Will, financial power of attorney, healthcare directive, updated beneficiaries. You’ll also learn the vocabulary before you need it mid-grief.

Move 3: Treat your menopause as financial protection. Care isn’t a comfort expense. It protects the operating system every wealth decision runs on. A woman who is sleeping reads the document, questions the fee, and says no. The clinician protects the decisions; the advisor executes them.

THE QUESTION IS THE CONDITION YOU’RE IN WHEN IT ARRIVES

Thirty-eight percent of US investable assets is leverage — with advisors, employers, and a healthcare system that ignored menopause for decades. But leverage only counts if the woman holding it is treated, rested, and prepared.

The industry is preparing for your money. Are you?

If a transfer is on your horizon, this belongs in a 1:1. Book the Meno & Money Strategy Session at menoandmoney.com.

44% of participants reported difficulty filling their estrogen patch prescriptions.

That’s how many women — out of nearly 8,000 surveyed by Midi Health this spring — reported trouble filling their estrogen patch prescriptions. A third of them said the shortage significantly hurt their well-being.

Most coverage treats this as a pharmacy inconvenience. It’s actually a new line item in The Menopause Tax™.

THE SHORTAGE HITS YOU IN TWO PLACES

Your treatment plan and your bank account

This shortage isn’t a fluke. It’s math. In November 2025, the FDA removed the black box warning that had overstated hormone therapy risks for two decades. Demand did exactly what you’d expect: Truveta data shows estrogen therapy prescriptions among women 45 to 54 rose 184% from 2018 to 2026 — with a 20% surge between July 2025 and February 2026 alone.

Manufacturing capacity didn’t move. So ASHP now lists multiple estradiol patches on its shortage bulletin, and oral micronized progesterone — the companion hormone that protects the uterine lining — sits on the same list. Notably, the FDA’s own database still doesn’t call it a shortage. Remember that when your insurer declines to cover the workaround.

The clinical workarounds all carry trade-offs. Doubling lower-dose patches can mean two copays for one dose. Switching to oral estradiol reintroduces first-pass liver metabolism — the patch avoids the liver, which is why it doesn’t carry the same clot risk. Swapping progesterone products means a different molecule some women tolerate differently. None of these are wrong. All of them belong with your prescriber, not the pharmacy counter.

THE COSTS NOBODY IS COUNTING

What I hear from patients constantly

• Pharmacy-hopping hours. Calling five pharmacies, driving to two, repeating monthly. Price your time at your billable rate — that’s real money.

• The cash-pay trap. When the covered product vanishes and the substitute isn’t on formulary, the spread is brutal: brand Prometrium runs roughly $1,800 to $1,900 for 90 capsules cash, while generic progesterone with a discount card runs $12 to $50 for 30 days. Same molecule. What you pay depends on what’s in stock.

• The relapse cost. Treatment gaps mean symptom return — and hot flashes and brain fog follow you into the meeting where your promotion gets decided. That’s the Career Costs pillar, reactivated by a supply chain you don’t control.

THE SUPPLY-PROOF STRATEGY

Instead of monthly scrambling, build a buffer

1. Get a flexible prescription. Ask your prescriber to pre-authorize substitutions — any manufacturer, dose-equivalent combinations. That lets your pharmacist solve the problem at the counter instead of losing a week to faxes. Ask about 90-day fills when stock appears.

2. Price-check before you pay. Compare the discount-card price (GoodRx, SingleCare) against your copay — generics often beat insurance. Then run every dollar through your HSA or FSA. Pre-tax payment is an automatic discount at your bracket rate on a cost you’re paying anyway.

   

3. The No-Cost Move: Before your next refill, check the ASHP shortage database and ask your pharmacist one question: “Which manufacturers can you order from right now?” Most patients never ask.

THE BOTTOM LINE

Here’s what I want you to sit with: two decades of overstated fear created the pent-up demand, and the pent-up demand created this shortage. Women are paying — again — for a risk communication failure that was never theirs.

If this shortage has cost you money, time, or symptom control, hit reply and tell me what it’s cost you. I’m building the real numbers. And if you want to see what the disruption is doing to your full financial picture, the Meno & Money™ Strategy Session is at menoandmoney.com.

Sources: Midi Health patient survey (May 2026) · Truveta prescription data via NBC News (May 2026) · ASHP Drug Shortage Bulletin — estradiol transdermal system (updated April 2026) · Progesterone shortage clinical briefing referencing ASHP (2026) · The 19th News (February 2026) · AARP (March 2026) · Prometrium pricing (2026)

Beacon Pointe’s new HerWorth study surveyed more than 10,000 women investors and found that 38% of women who work with a financial advisor feel highly confident managing their money.

Among women going it alone, that number falls to 24%. Put another way, women with an advisor are roughly 60% more likely to report real confidence in their finances. Same intelligence. Same accomplishments. The difference is somebody in their corner.

Across the whole study, only 31% of women said they feel highly confident managing their finances at all. Sit with that. Seven in ten accomplished women, managing real wealth, second-guessing themselves.

Now, if you are a woman in your forties or fifties, I want to talk with you about why that gap matters more for you than for anyone else who read that study.

THE DECADE THAT ASKS EVERYTHING OF YOU AT ONCE

And why carrying it alone costs real money

Let me describe what this stretch of life actually looks like, because so few people say it out loud. Your body is changing in ways nobody prepared you for. Hot flashes in the middle of a presentation you spent weeks building. Nights where sleep never quite arrives. A fog that makes you second-guess yourself in rooms you used to run.

And while all of that is happening, life hands you the heaviest financial decisions you will ever face. A child heading to college. A mother who needs more help every month. Catch-up contributions. A career you may need to reshape on your own terms. Retirement money that needs positioning now, while there is still time for it to grow.

I see this pattern every day with my patients. The most capable woman in the room, quietly holding all of it, telling herself she will deal with the money once things calm down.

Things do not calm down in this decade. The decade simply ends, and the decisions you deferred come due with interest.

WHAT WAITING ACTUALLY COSTS

Here is the finding that stopped me. Nearly two out of three women with half a million dollars or more to invest are keeping over $100,000 of it in cash. Sitting still. Earning close to nothing.

Maybe that sounds safe to you. So let me show you what “safe” actually costs.

Picture $100,000 in a checking account. Now picture that same $100,000 invested and growing at a modest 6% a year. Ten years later, the parked money is still $100,000. The invested money is about $179,000.

That gap is $79,000. Gone quietly, without a single bad decision, just from waiting.

And you will need that money. AARP found that families caring for an aging parent spend about $7,242 a year out of their own pockets. The cash you park in this decade is the cushion you will reach for in the next one.

And I want you to hear the clinical piece clearly. That money sits because confidence drops, and confidence drops because your brain and body are under real physiological strain. Estrogen affects sleep. Sleep affects executive function, the mental horsepower you use to decide. This is the Menopause Tax™ at work. Your symptoms and your finances are already in the same conversation, whether or not you sent them an invitation.

WHY AN ADVISOR BELONGS ON YOUR MIDLIFE TEAM

You would never walk through this season without a doctor who takes your symptoms seriously. A financial advisor earns a seat at that same table. And the HerWorth data shows women already know where the help is needed most:

• 41% want help with retirement

• 38% with investment management

• 35% with estate planning.

Look at that list again. Those are the exact three decisions this decade puts on your desk.

Three reasons the seat matters now:

They carry decisions when your capacity is stretched thin. An advisor functions as borrowed executive function. When brain fog and a full caregiving load collide with a Roth conversion window, you want a professional whose job is to keep that window open while you handle everything else.

They position you before a career change, instead of cleaning up after one. Many women downshift, take leave, or walk away during untreated perimenopause. With planning, that becomes a managed transition with liquidity, benefits bridging, and a tax strategy behind it. Without planning, it becomes a wealth event you absorb alone.

They connect the professionals who each see one piece of you. In that same study, 25% of women said the top reason an advisor relationship fell short was poor coordination with their other professionals. Your health costs, your tax picture, and your career decisions are tangled together right now. You deserve a team that talks to each other.

The study also tells you how to choose well. When women recommended their advisor, 34% pointed to demonstrated results and 21% to an advisor who understood their goals. So interview for both. Ask for the track record, and ask whether they understand what this decade is actually asking of you.

Your free move this week: open your accounts and write down every dollar earning under 1%. That single number tells you whether you need this conversation.

We raise our daughters to ask for help without shame. Somewhere along the way, we stopped extending ourselves the same grace. So here is my question for you: who is sitting at your financial table right now, and who is missing?

If the answer unsettles you, start at menoandmoney.com. Bring your idle cash number with you.

July 11. 10 AM ET. Ten spots. Live on Zoom.

Reserve your spot — $297

If you have an investment account and you're in perimenopause, this is the article I needed someone to write for me ten years ago.

The health bills, the income you lost at work, the savings you couldn't build — they all land in the same season. Most women handle it the same three ways: drain savings, charge the card, sell investments. Every one of those moves costs you something.

But there is a fourth option. And most women have never heard of it.

It’s called an SBLOC — a securities-backed line of credit. Big term. Simple idea.

It lets you borrow money against your investment account without selling a single stock or fund. Your investments stay in place. They keep growing. You get the cash you need, often within a week. And you don’t pay a thing until you actually use it.

Fidelity has it. Charles Schwab has it. Most big investment firms do. The women who need it most are almost always the last ones to find out it exists.

WHAT AN SBLOC IS — IN PLAIN ENGLISH

Think of it like borrowing against your house. Except it’s your investments.

You know how some people take out a loan against the value of their home? This works the same way — except instead of your house, you’re using your investment account.

You tell the lender: here’s my account, I want to borrow against it. They look at what’s in it and give you a credit line — kind of like a credit card, but with much better terms. You take out what you need. You pay interest only on the amount you borrowed. You pay it back when you’re ready. Then you can borrow again if you need to.

A few things worth knowing:

The interest rate moves up and down over time. It’s tied to something called the prime rate, which was 6.75% at the end of 2025. That’s almost always lower than what a credit card charges. At most major lenders, there are zero fees to open it — no application fee, no annual fee, nothing. You only pay when you borrow.

A common setup is this: if you have $400,000 in your account, you might be able to borrow up to $200,000. It depends on what kinds of investments you hold.

One important thing: your 401(k) and IRA accounts can’t be used for this. This only works with a regular taxable brokerage account — the kind that isn’t a retirement account. Your retirement savings stay completely separate and protected.

HOW IT HELPS WITH THE MENOPAUSE TAX™

Care Costs. Career Costs. Compounding Costs.

Your Care Costs. The bills from perimenopause care keep coming whether you’re ready or not. Hormone therapy. Specialist visits. Sleep studies. Physical therapy. And then on top of that, maybe a parent who needs help. These expenses don’t care about your budget.

An SBLOC means you don’t have to sell your investments to cover them. Say you have $300,000 in your account and $40,000 in gains. If you sell to get cash, you owe taxes on those gains. If you borrow instead, you get the money you need — and your investments stay put, growing.

Your Career Costs. Some women in perimenopause step back from work. They leave a job that was wearing them down. They take time to figure out what’s next. They start their own business. That’s real, and it’s valid. But it also creates a gap in income.

An SBLOC can bridge that gap. It gives you breathing room without forcing you to cash out your investments at a bad time. And if you’re starting something new? Borrowing at 7% is a whole different story than a business credit card charging 22%.

Your Compounding Costs. This one is the quiet one. Every dollar you put on a credit card during this season charges you interest. Every share you sell to pay a bill is one that stops growing for you. Over years, that adds up to real money left on the table.

Borrowing against your investments instead keeps your portfolio in the market and keeps the growth going. The debt costs money too — but at a much lower rate, and without pulling you out of your long-term plan.

THE RISKS — READ THIS BEFORE YOU DO ANYTHING

This is the part most people skip. Don’t.

Here’s what you need to understand: your credit line is not fixed. The lender checks the value of your account every single day. If the market drops and your investments lose value, your credit line shrinks with them. If they fall below a certain level, the lender sends you what’s called a maintenance call.

You’ll usually have two to three days to respond. Your choices: put more money into the account, pay back some of what you borrowed, or do nothing. If you do nothing, the lender can sell your investments to cover themselves. They pick which ones. You don’t get a vote. And yes — most lenders put it in writing that they can do this without giving you any notice at all.

That is a real risk. Say it out loud so it lands.

Here’s the good news: it’s a manageable risk if you’re careful. Don’t borrow anywhere close to your maximum limit. Have a plan to pay it back before you use a dollar of it. Know where the money is coming from — a bonus, a tax refund, a new contract.

This tool is not right for you if your investment account is the only thing standing between you and retirement. It’s not right if most of your money is tied up in one company’s stock. It’s not right if you have no regular income coming in to cover the monthly interest.

The law requires that any broker who suggests this product to you must look at your whole financial picture first. That includes how much you’re counting on this money for retirement. If your advisor is pushing this without that conversation happening? Ask them why.

IS THIS FOR YOU?

Only you can answer that. But here’s what the right fit looks like.

You have at least $150,000 to $200,000 in a taxable brokerage account — not your 401(k), not your IRA. You’re still earning income and can afford to pay monthly interest without it hurting. You have a specific expense you can’t cover with cash right now. Your investments are spread out across different things, not all sitting in one stock. And you have a real plan to pay back what you borrow within one to two years.

You have been building something. For years. It’s sitting right there. It can work for you now — not just when you retire.

Here’s your next move. Log in to your brokerage account today — whether that’s Fidelity, Schwab, or wherever your account lives. Ask two questions: Do I qualify for a securities-backed line of credit? What’s the loan-to-value ratio on my portfolio?

That’s it. Fifteen minutes. No commitment. Just knowing the option is there changes what’s possible for you.

The Menopause Tax™ is real. The tools to fight it are real too. The only problem is that nobody put them in the same room until now.

At the same time, roughly a quarter of the U.S. workforce is currently in some phase of the menopause transition. Peak earning years. Peak asset accumulation. Peak exposure to exactly the financial risks that proper estate planning is designed to prevent.

That’s the Menopause Tax™ operating at the planning level. And it is costing women more than they know.

THE WEALTHY FIGURED OUT SOMETHING MOST WOMEN HAVEN’T

Protection requires structure. Structure requires timing.

Here’s what wealthy families understand that most of us don’t hear until it’s too late: estate plans built during a crisis are worth less than the ones built before one. The families who protect and transfer significant wealth do it during the accumulation phase — before illness, before divorce, before cognitive decline forces the conversation. They build frameworks that function even when the person at the center cannot.

Those frameworks are available to every woman reading this. You don’t need a family office. You need a financial advisor, an estate attorney, and a clear understanding of what’s at stake.

Women in their 40s and early 50s are sitting inside one of the most consequential planning windows of their financial lives. Most have built something real. Most don’t yet have the structure to protect it.

WHAT THE ULTRA-RICH ACTUALLY DO

1. Build the structure before you need it.

Start here: an updated will, a durable power of attorney for finances, a healthcare proxy, an advance directive, and a full review of every beneficiary designation you have. That last one matters more than most women realize. A beneficiary designation on a retirement account or insurance policy takes legal precedence over a will. The ex-spouse named in 2014 will inherit the IRA. The will you updated last year won’t change that.

Now add this: research from the University of Pennsylvania published in Human Brain Mapping confirms that estrogen fluctuations directly affect the prefrontal cortex — the part of the brain that handles complex decision-making, future planning, and weighing long-term tradeoffs. Perimenopause is not the time to start building a financial protection structure. It is the time to already have one.

2. Use trusts as a financial tool.

When structured correctly, irrevocable trusts remove assets from the taxable estate, so heirs receive more. A life insurance policy held inside an irrevocable life insurance trust (ILIT) passes a tax-free lump sum to heirs entirely outside the estate and outside probate. Special needs trusts protect disabled dependents without disqualifying them from government benefits. Charitable gift trusts reduce taxes while honoring philanthropic commitments.

For women who are caring for an aging parent, a child with a disability, or both — and many of us are doing both at once — each of those obligations has a corresponding trust structure that protects the person you’re supporting and your estate at the same time.

3. Use permanent life insurance as a wealth-building vehicle.

Most women think of life insurance as a death benefit. The ultra-wealthy think of it as a tax-advantaged growth account. A permanent life insurance policy — specifically whole life or indexed universal life — builds cash value over time that grows tax-deferred and can be accessed tax-free through policy loans. For a woman in perimenopause who is still 15 to 20 years from retirement, a policy structured correctly right now produces a compounding asset that serves her during her lifetime and her heirs after it. The earlier the policy is funded, the more time the cash value has to grow. But for the woman who has maximized her retirement accounts and is looking for the next tax-advantaged vehicle, this is where the wealthy have been parking money for decades.

The Menopause Tax™ takes from us in three directions: care costs, career costs, and compounding costs. Estate planning gaps belong to that third category. Five years of deferred decisions — made while managing symptoms, career transitions, and the caregiving load most midlife women carry — produce losses that investment returns cannot fully undo.

The women who will look back at this decade with financial security built it during it. The window is open right now.

What you do with that is yours.

Dr. Kim Derezil, MD | WMCP® | Founder, Meno & Money™ — the only platform at the intersection of perimenopause medicine and financial strategy for high-performing professional women. Assess your Menopause Tax™ risk at carecostworkshop.netlify.app.

If you’ve ever asked your doctor about hormone replacement therapy and been met with hesitation — or an outright no — there’s a good chance that response traces back to a study published more than two decades ago. Understanding what that study actually said, and what it didn’t, is one of the most useful things a woman in perimenopause can do for her health and her finances.

What the WHI study actually found

In 2002, the Women’s Health Initiative published findings that sent shockwaves through the medical community.

Headlines declared that HRT caused breast cancer and heart disease. Prescriptions dropped by half almost overnight. An entire generation of physicians became reluctant — or flatly unwilling — to prescribe hormones for menopausal symptoms.

Here’s what the headlines left out.

The WHI study used a specific formulation: oral conjugated equine estrogen combined with synthetic progestin (medroxyprogesterone acetate), given to women whose average age was 63 — well past the menopausal transition. Many participants had pre-existing cardiovascular risk factors. The study was not designed to evaluate HRT in perimenopausal women in their late 40s and early 50s. It was designed to test whether hormones could prevent chronic disease in older women who were already postmenopausal.

When researchers went back and analyzed outcomes by age, the picture shifted significantly. Women who began HRT close to menopause — within ten years of their final period, or before age 60 — showed a different risk profile entirely. In some analyses, early initiators showed reduced cardiovascular risk, not increased. The blanket warning that defined a generation of clinical practice did not hold up when applied to the population it was most often used to justify.

The science moved. The clinical culture didn’t keep up. Women paid the difference.

The cost of navigating outdated care

When a woman’s primary care physician isn’t current on menopause medicine, she has options — but none of them are free. Finding a provider who will have a real, evidence-based conversation about HRT often means stepping outside the standard care pathway.

The specialist shortage compounds this. Menopause-certified providers are concentrated in major metropolitan areas. Telehealth platforms have helped, but the most accessible ones often operate on subscription models that add another monthly line item. Women who can’t afford that path cycle through primary care appointments, get told their symptoms are “normal,” and go another year without answers.

That delay has downstream costs — in untreated symptoms that affect work performance, in bone density loss that begins in perimenopause and accelerates without hormonal support, in cardiovascular risk that estrogen was partly buffering against. The confusion tax isn’t just the money spent navigating a broken system. It’s the compounding cost of the years spent in it.

What you can do with this information

Knowing the history puts you in a stronger position in the exam room. A provider who cites the WHI as a blanket reason to avoid HRT is working from a 2002 headline, not 2026 evidence. You are entitled to ask which guidelines they’re using and when they last reviewed them.

The Menopause Society maintains a certified provider directory.

If your current provider isn’t able to engage with updated evidence, that’s information too. Finding someone who can may cost money upfront. Across a decade of undertreated symptoms, it is almost certainly the less expensive option.

That’s not an oversight. That’s a decision.

And if you’ve ever shown up to work in a cold-sweat haze, running on three hours of sleep, wondering why nobody in HR seems to notice — you deserve to know exactly why that decision was made, and what it’s costing you.

YOUR EMPLOYER KNOWS. THEY CHOSE SOMETHING ELSE.

And that choice was never made with you in the room.

Here’s what the benefits consulting data actually shows: demand for menopause workplace support is going up. Fast. Women in their 40s and 50s are the fastest-growing segment of the workforce. Perimenopause typically starts between 40 and 44. That math is not complicated.

What’s complicated is what happens when HR sits down to figure out what to do about it.

I want to walk you through exactly why three out of five companies are sitting on their hands — because understanding the resistance tells you everything about what you need to do next.

REASON #1: HR IS ALREADY DROWNING

Corporate HR departments are not under-resourced because nobody cares. They’re under-resourced because every single benefit category has a compliance trail, a tracking system, a verification protocol, and a lawyer reviewing it before it goes live.

When a benefits leader looks at a proposal for “menopause leave,” here’s what they see: a new legal definition they don’t have yet, a medical verification process they’d have to build from scratch, a tracking system that doesn’t exist in their current software, and a compliance question that opens the door to every other employee who wants a condition-specific leave category.

Their answer is almost always: no. Bundle it under existing frameworks instead. Short-Term Disability. FMLA. General PTO.

Which sounds reasonable until you realize that those frameworks were not built for episodic symptoms. Night sweats don’t come with a diagnosis that meets STD criteria. Brain fog doesn’t qualify you for FMLA. Taking a personal day every time your sleep was destroyed is not a sustainable strategy — and your manager notices the pattern before your HR rep ever does.

The administrative friction is real. But the burden of that friction lands entirely on you.

REASON #2: THEY’RE AFRAID A POLICY WILL BACKFIRE

This one will make you angry.

Some HR and executive teams are avoiding menopause leave policies because they’re worried the policy will harm the women it’s supposed to protect.

The argument goes like this: if we create a menopause leave category, hiring managers will start seeing women in their 40s and 50s as a flight risk. A woman who might need significant accommodations. A promotion candidate who could suddenly go quiet for a month. The fear is that naming the benefit creates a bias that didn’t exist before — or amplifies one that was already there.

They call this the “Mommy Track” parallel, and they’re not entirely wrong that it’s a risk.

But here’s what they’re leaving out: the bias is already there. Women in perimenopause are already being passed over, already stepping back, already declining opportunities they’re qualified for because their symptoms are unmanaged and their workplace has nothing to offer them. The absence of a policy doesn’t protect you from discrimination. It just makes the discrimination invisible.

The second piece of this argument is what I call the Utilization Paradox. Companies say: women in their peak earning years won’t use this benefit anyway. They’re too worried about signaling vulnerability. So why build it?

And they’re right that utilization would be low at first. Women in their 40s and 50s have spent careers learning to perform capacity they don’t always feel. They are not going to raise their hands and declare a private biological transition to their boss in year one of a new policy.

But low utilization in year one is not an argument against building the benefit. It’s an argument for building the psychological safety alongside it.

REASON #3: FLEXIBILITY IS CHEAPER THAN LEAVE

When companies do decide to act, most of them are not writing new leave policies. They’re adjusting workplace conditions instead.

The NFP Trend Report data breaks this down clearly:

• 65% of companies now allow flexible scheduling when symptoms are affecting work

• 37% offer some form of workspace alteration — a desktop fan, a desk near a window, temperature control access

• 21% provide wellness or telehealth support that covers menopause

• 10% provide any form of explicit extra paid time off

Read that last number again. One in ten.

From a CFO’s perspective, this makes sense. Letting someone log on two hours late after a night sweat destroyed their sleep is a low-cost fix for an immediate productivity problem. No paperwork. No legal review. No precedent.

From your perspective, it means you’re expected to make it work — through symptoms, on your own time, with a flexible schedule that still has the same deadlines attached to it.

Flexibility without financial protection is not a benefit. It’s a workaround.

HERE’S WHERE THIS IS HEADED

The voluntary hesitation from corporate America is about to collide with legal mandates that were not there five years ago.

Rhode Island now requires employers to provide reasonable accommodations for menopause. Philadelphia has reclassified menopause as a legally protected category. Washington State issued Executive Order 26-01 this year specifically addressing menopause workplace accommodations.

More states are watching. More cities are moving.

Companies that spend the next five years waiting are going to spend the five years after that scrambling to build compliant programs under regulatory pressure, without the goodwill of having built them voluntarily.

The women who work for those companies will have paid the price of that delay in career capital, earnings, and health outcomes that compounded while leadership was still deciding whether the problem was real.

The Menopause Tax™ does not wait for HR to catch up.

The policy gap is real. It is not going to close on your timeline. Build your strategy around the world as it is, not as it should be.

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What does not come with that shift is a manual. And one of the most expensive pages missing from that manual is this: when you leave a W-2 job, the IRS does not stop expecting to be paid throughout the year. The mechanism just changes. And if you do not know about it, you pay for not knowing.

June 15 is the Q2 Estimated Tax Payment deadline. That is tomorrow. This article is what you need before then.

THE TAX SYSTEM WAS BUILT AROUND EMPLOYMENT. YOUR LIFE MAY NO LONGER BE.

And the gap between those two things has a dollar amount

Here is how withholding works in a traditional W-2 job: your employer takes a portion of every paycheck and sends it directly to the IRS. You never see it. You do not have to think about it. In April you file, reconcile the difference, and move on.

That system is built on the assumption that you are employed. Full-time. By someone else. With a human resources department and a payroll system running quietly in the background on your behalf.

Perimenopause broke that assumption for a lot of women. Research shows that nearly one-third of working women contemplated moving from full-time to part-time employment because of menopause symptoms. Forty-seven percent explored remote or hybrid arrangements. One in ten left their jobs entirely.

These are not small numbers. And the women making these moves are not stepping back. They are restructuring, protecting their capacity, and in many cases building something more sustainable than what they left. But consulting income does not come with automatic withholding. Speaking fees do not. Board stipends do not. Private practice revenue does not.

The IRS still expects payment on all of it. Four times a year. On a schedule most women in transition were never told about.

WHAT A QUARTERLY ESTIMATED TAX PAYMENT ACTUALLY IS

An estimated tax payment is a direct payment to the IRS from individuals whose income does not have automatic withholding — or whose withholding does not cover their full tax liability.

The IRS requires these payments quarterly using Form 1040-ES. For the 2026 tax year, the four deadlines are:

• Q1: April 15, 2026

• Q2: June 15, 2026 — due tomorrow

• Q3: September 15, 2026

• Q4: January 15, 2027

Q2 covers income earned from April 1 through May 31. If you have not paid, today is the day to act.

The IRS requires these payments from anyone who expects to owe at least $1,000 in federal taxes after withholding and refundable credits. For women in this transition, that threshold is cleared quickly. A single consulting retainer, a speaking engagement, a part-year reduction in clinical hours supplemented by contract income — any of these can create a tax liability that partial W-2 withholding does not cover.

THE PIECE NOBODY TALKS ABOUT: WHAT PERIMENOPAUSE DOES TO FINANCIAL ADMINISTRATION

This is where I need to be direct with you, because financial guidance rarely is.

The cognitive symptoms of perimenopause are clinically documented. Up to 60% of women report subjective cognitive symptoms during the menopausal transition, including memory concerns and brain fog. Objective assessments confirm it — poorer verbal memory, reduced verbal fluency, diminished attention, and measurable declines in executive function. These are not complaints. They are findings.

Executive function is the set of mental skills that gets you from “I need to pay estimated taxes” to “I have submitted the payment and saved the confirmation number.” It covers planning, organizing, deadline tracking, multi-step task completion, and initiated action on complex financial obligations. It is also among the cognitive domains most affected during the menopausal transition.

So here is what we are actually talking about: a woman restructures her career because perimenopause made her previous work environment unsustainable. That restructuring creates new tax obligations that require the same executive function that perimenopause has temporarily disrupted. And no one — not her former employer, not her CPA, not any standard financial planning resource — draws that line for her.

That line is the Menopause Tax™. The career shift was not optional. The penalty was not inevitable. The information gap between the two is the problem we are here to close.

WHAT HAPPENS IF THE DEADLINE IS MISSED

The IRS assesses an underpayment penalty when estimated payments are late or insufficient. This penalty applies even if the full balance is paid in April at filing.

The penalty accrues from the missed due date forward, based on the IRS underpayment rate, which adjusts quarterly. It stops accruing the day the IRS receives payment. Every day of delay after June 15 adds to the calculation.

Each quarter is assessed independently. A woman who misses all four payments and pays the full balance in April will still owe underpayment penalties for all four quarters. There is no catch-up provision that erases prior quarter penalties. The only correction is timely payment.

Paying today means no penalty on Q2. The window is open until midnight tomorrow.

The health transition and the financial transition are happening at the same time. The IRS schedule does not account for that. Your financial plan has to.

“Is menopause genetic?” she asked. “Because I never knew how to ask about it, and my mother never told me anything.”

That question stopped me. Not because it was complicated. But because it was honest. Because it showed me that there are women walking into their 40s and 50s without the most basic information about their own bodies—not because doctors didn’t tell them, but because their mothers couldn’t or wouldn’t.

And then I saw the real question in her face: If my mother never told me, how would I know what to look for? How would I plan?

Here’s the answer: Yes, menopause age runs in families. And more importantly, it matters to your money.

The Genetics Are Real

According to research in the Journal of Evolutionary Biology, your mother’s menopause age is one of the strongest predictors of when yours will happen. This isn’t coincidence. It’s biology.

On average, women reach menopause around age 51. But if your mother crossed that threshold at 45, you’re carrying that pattern in your DNA. If she was 55, that timeline is relevant to you. Recent research has identified specific genetic variants that shift the age by 1.5 to 2.2 years. These are measurable, heritable differences.

Your genes don’t determine your destiny. But they determine your timeline. And that timeline is financial information.

Here’s What Nobody Tells You

If you inherit an early-menopause pattern—perimenopause starting at 41 instead of 48—you’re looking at 4-10 years of medical decisions, doctor visits, tests, and treatments. That’s not just time. That’s money.

Here’s what the care costs look like:

Early menopause means earlier bone loss and cardiovascular risk. That translates to bone density scans, cardiovascular workups, potentially hormone replacement therapy, ongoing monitoring. If you’re managing symptoms—and most women do—there are doctor visits, lab work, possibly imaging. Some women need sleep specialists or cognitive function assessments. There are supplements, medications, time off work for appointments.

Late menopause extends that window. More years of hormonal fluctuation means more years of potential treatment needs, more appointments, more costs accumulating.

Not knowing your family timeline means you can’t plan for the care costs coming. You don’t budget for the specialist appointments, the testing, the treatments. You don’t anticipate the time investment—time that costs money when you’re taking it off work. You don’t know whether to push for HRT early, how aggressive to be with bone density management, what your long-term healthcare bill might actually look like.

This is The Menopause Tax™: Care Costs—the real, measurable expenses (medical visits, tests, treatments, medications, time away from work) that arrive when you’re not prepared for them.

You deserve to know what’s coming. And you deserve to plan for it.

One Thing to Do

Call your mother. Ask her when she entered menopause. Ask what her care looked like—doctor visits, treatments, tests, time management. Write it down. This is data about what your care costs might be.

Then do this: Understand what your care timeline will look like.

If early menopause runs in your family, that means more years of bone density monitoring, cardiovascular assessment, possibly hormone replacement therapy decisions. If late menopause runs in your family, that’s a longer care window to plan for. Both matter. Both have costs—financial and time-based. Both deserve planning before they happen.

Not next year. Not when symptoms hit. Now. While you have time to actually budget for it.

That’s what changes everything.

Look, I’m going to be honest with you because you deserve honesty.

When I turned 40, I started noticing something uncomfortable, especially if I was at home working telemedicine. I’d catch myself hunched over my desk, shoulders forward, neck craned. And I didn’t think much of it—I was busy, managing the house, managing work, managing everything. But then I realized: my body was telling a story I didn’t want to tell. A story of collapse, of giving away my space.

Here’s what the science says, and this matters: Decreasing estrogen is associated with loss of type II muscle fibers and subsequently decreased power. Your back—your posterior chain—gets hit first during perimenopause. And when your back weakens, everything else follows. Posture breaks down. Pain moves in. You start showing up to work, to meetings, to your life—but you’re not present. You’re managing pain. You’re managing the story your body is telling.

That has a cost. Employers spend an estimated $51,400 annually per 100 employees on diminished efficiency due to back pain, with presenteeism accounting for $34,600 per 100 workers. But here’s what I really care about: the cost to you. The promotions you don’t ask for. The raises you don’t negotiate. The leadership roles you let slip because you’re too tired, too uncomfortable, too diminished.

Your Posture Is Your Power

This is where it gets real. When you slouch, your body doesn’t just look weak—it feels weak. Slouching increases measures of helplessness and stress, while expansive postures increase testosterone, decrease cortisol, and amplify feelings of power and risk-tolerance.

I’m not talking about fake confidence or “power posing” your way to success. I’m talking about the simple, undeniable truth: how you carry your body changes how you carry yourself in the world. Your nervous system knows the difference between collapse and strength.

And then there’s the pain piece. People with pain missed approximately nine more days of work per year than respondents without pain, and chronic pain was associated with lower vocational fulfillment and feelings of being ostracized in the workplace. Chronic pain is lonely. It’s isolating. It tells you that you don’t belong, that your body is letting you down. nih

That’s not true.

What Actually Works—And Why You’re Worth the Investment

Decreasing estrogen is associated with loss of type II muscle fibers; resistance training during perimenopause is one of the most effective non-controversial prevention and treatment approaches for musculoskeletal symptoms.

This is not about aesthetics. This is not about “toning.” This is about reclaiming your infrastructure—the literal foundation that holds you up while you do your best work.

Three exercises. That’s it. You don’t need complicated. You need consistent.

Rowing (machine or barbell): This recruits your latissimus dorsi, trapezius, and erector spinae—the muscles that pull your shoulders back and open your chest. Start twice a week, 8 to 12 reps. Think about what it feels like to pull back, to make room for yourself. Your body will remember.

Deadlifts or trap-bar deadlifts: This one movement recruits nearly every muscle on your posterior side. Once a week is enough. And listen—form matters more than weight. I’d rather see you lift light with intention than heavy with your ego.

Farmer carries: Hold weight at your sides and walk. Five minutes. Twice a week. It’s that simple. Your grip gets stronger. Your upper back gets resilient. You remember what it feels like to carry something—literally and figuratively.

The Return on Your Investment

Within 8 to 12 weeks, something shifts. Your posture changes. Your pain baseline drops. And here’s the neuroscience: When bodies are held in a position of power, hormones react immediately—testosterone goes up and cortisol goes down—resulting in calm confidence.

That confidence? That’s not fake. That’s neurological. That’s real.

Long-term, here’s what you’re doing: you’re preventing the $3,000 to $15,000 per year in physical therapy costs that come in your 50s and 60s. You’re preventing the surgeries, the missed work, the slow fade of independence. You’re preventing a version of yourself that has to apologize for the space she takes up.

Prevention is always cheaper than repair. And you are worth preventing for.

This Is About Your Legacy

Your back carries you through everything—your career, your family, your life. When your back is strong, you stand differently. You negotiate differently. You claim space differently.

And the women around you? They see that. Your daughters see that. Your colleagues see that.

This isn’t vanity. This is dignity. This is saying: I am worth the effort. I am worth the fifteen minutes twice a week. I am worth taking up space.

So start this week. Pick one exercise. Commit to it. And feel your body remember what it means to be strong.

You deserve that.

Ready to Calculate the True Cost of Back Pain—and What You’re Actually Losing?

Your care costs are real. The physical therapy, the specialist visits, the days you’re managing pain instead of managing your life. But most women don’t know what number to put on it.

I built the Care Cost Workshop to show you exactly what perimenopause is costing you in healthcare—and more importantly, what you can do about it right now.

Join the Care Cost Workshop and get your number. Bring it with you everywhere. Because once you see it, you can’t unsee it. And once you can’t unsee it, you can change it.

Sources:

• Menopause musculoskeletal syndrome, Taylor & Francis Online (2024): https://www.tandfonline.com/doi/full/10.1080/13697137.2024.2380363 Taylor & Francis Online

• On-Site Massage corporate study (2024): https://onsitemassage.com/corporate-chair-massage/how-pain-affects-productivity/ Onsitemassage

• Adams & Salomons on presenteeism and chronic pain (2021): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8210861/ nih

• Thibault & Raz on posture and neural signaling (2016): https://pmc.ncbi.nlm.nih.gov/articles/PMC5073137/ PubMed Central

• Wharton Knowledge: Power Posing research (2016): https://knowledge.wharton.upenn.edu/article/the-2-minute-power-pose-that-can-boost-your-performance/ Wharton School

Let me start with a number.

Women spend over $13 billion a year managing menopause symptoms. Not lifetime. Per year.

When you break that down, the story gets uncomfortable. Over $10 billion goes to nonmedical treatments — supplements, herbal remedies, sleep stacks, products with “hormonal balance” somewhere on the label. $2.7 billion goes to hormone therapy, the treatment with the strongest clinical track record. And only 26% of women have full insurance coverage for menopause-related prescriptions.

The money is flowing away from what works.

WHERE THE MONEY DOESN'T GO

What she’s buying. What the evidence says. And who benefits from the gap.

The out-of-pocket story doesn’t stop there.

Spending alot to feel better?

Women aged 45–64 pay over 35% more in out-of-pocket healthcare costs than men the same age, according to GoodRx. A Deloitte analysis of 16 million insured Americans found women pay $15.4 billion more per year than men — and less than 2% of that gap comes from maternity care.

The rest is perimenopause. The rest is menopause. The rest is women seeking care for a transition the system was not designed to manage well.

One in five women has delayed or skipped treatment because of the cost.

So women are spending more. Receiving less. And when the cost gets too high, opting out entirely.

This is the Menopause Tax™ before anyone has named it for her. It’s running whether she tracks it or not.

YOUR NEXT BEST STEP

Here’s where the data problem becomes a decision you can make today.

Before you come to the workshop, do one thing.

Pull the last 90 days of supplement purchases. Add them up. Write the number down.

Not to feel bad about it. Because right now that number is sitting in a mental category called “health and wellness” where spending quietly disappears. When you see it as a line item, it changes how you think about what comes next.

Bring that number with you.

In the Stop Paying the Care Tax Workshop, we calculate the full picture — Care Costs most women don’t know to close — and you leave with five specific moves to start lowering what you owe.

May 30. 10 AM ET. Ten spots. Live on Zoom.

Reserve your spot — $297

It’s Mental Health Awareness Month.

And I want to use this moment to say something that is not being said loudly enough in clinical offices, in corporate wellness programs, or in the conversations women are having with their doctors:

Perimenopause is a mental health risk factor. A documented one. A significant one. And most women walking through it right now have no idea.

That is not a personal failure. That is a systems failure. And we need to name it clearly before we can fix it.

THE DATA IS IN. THE CARE HASN’T FOLLOWED.

What the research says about perimenopause and depression — and why it changes everything

In 2024, researchers at University College London published a meta-analysis of 9,141 women across multiple countries in the Journal of Affective Disorders. The finding was unambiguous:

Perimenopausal women are 40% more likely to experience depression than premenopausal women.

Forty percent.

And that’s not the sharpest number in the data. Research from the MGH Center for Women’s Mental Health found that women with no prior history of depression who entered the perimenopause were twice as likely to develop significant depressive symptoms compared to women who remained premenopausal.

This is not a mood swing. This is a biological vulnerability window. Estrogen regulates serotonin and dopamine — the chemicals your brain uses to manage mood, motivation, and focus. When estrogen begins to fluctuate in perimenopause, which can start in a woman’s early 40s, the neurological effects are real and measurable. The emotional consequences follow.

And yet, the clinical system is largely responding the same way it has for decades: with a depression diagnosis and a prescription.

A 2024 clinical audit of 250 women aged 45–55 who had been formally diagnosed with depression found that 78% had significant perimenopausal symptoms that had been entirely overlooked at the time of their original diagnosis. Of those women, 82% were being treated primarily with antidepressants.

The treatment wasn’t always wrong. But the clinical frame was incomplete. And women paid for that gap — with time, with money, and in some cases, with their safety.

A study of 1,212 perimenopausal and menopausal women found that mood and mental health symptoms affected 98% of participants. 1 in 6 reported thoughts of self-harm prior to starting treatment.

That is not a statistic we get to scroll past.

Here’s what I want every woman — and every clinician — to understand:

Perimenopause is not a reason to dismiss mental health symptoms. It is a reason to investigate them more carefully. The 40% elevated risk means these women need more support, not less. It means the standard screening tools may not be sufficient. It means we need providers who are trained to ask: Is this depression? Is this perimenopause? Is it both?

Because it can be both. And the treatment path is different depending on the answer.

Fewer than 4% of U.S. women aged 50–59 are currently prescribed hormone therapy — the treatment with the strongest evidence for mood stabilization, sleep, and cognitive function in this window. That number tells us the gap between what the research supports and what women are actually receiving is wide. It is measurable. And it is costing women their mental health.

This is what the Menopause Tax™ looks like inside the mental health system. Not neglect on the surface — but a structural gap that women absorb, quietly, for months and years.

Mental Health Awareness Month asks us to break the silence.

If you’ve been in therapy, cycling through medications, or leaving appointments without answers — that spend has been accumulating in your bank account you haven’t seen yet. The Care Cost is real whether you’ve named it or not. And it compounds every month the root cause goes unaddressed.

That’s exactly what we work through in the Stop Paying the Care Tax Workshop. In 90 minutes on May 30th, you’ll calculate what you’ve actually spent, identify where the gaps are, and leave with five specific moves to lower your out-of-pocket costs — before the end of the week. Ten spots. Live on Zoom.

Reserve your spot — $297

Bring your care spend with you.