How Medicine Got Menopause Wrong | Dr. Kelly Casperson

The medical community is currently navigating one of the most significant paradigm shifts in women’s health since the early 20th century. Led by advocates such as urological surgeon and educator Dr. Kelly Casperson, a new movement is seeking to redefine menopause not merely as the cessation of menstruation, but as a state of "physiologic hypogonadism." This transition in terminology reflects a broader effort to correct decades of medical misinformation, regulatory overreach, and systemic gender bias that have left millions of women underserved during midlife.

The Legacy of the Women’s Health Initiative

To understand the current state of menopause care, one must look back to 2002, a year that marked a dark turning point for hormone therapy. The publication of the Women’s Health Initiative (WHI) study led to a global media firestorm. The study, which primarily examined the effects of oral synthetic hormones (specifically Prempro) in an older demographic, was misinterpreted by the press and, subsequently, by much of the medical establishment.

The fallout was immediate. Fearing increased risks of breast cancer, strokes, and blood clots, millions of women stopped their hormone replacement therapy (HRT) overnight. In 2003, the U.S. Food and Drug Administration (FDA) responded to the public outcry by placing a "boxed warning"—the most serious warning a medication can carry—on all estrogen products. This included vaginal estrogen and natural estradiol products that were never part of the WHI study and did not carry the same systemic risks.

For over two decades, this "black box" served as a deterrent. Data indicates that approximately 30% of women who were prescribed vaginal estrogen—a localized treatment with negligible systemic absorption—ultimately chose not to use the medication after reading the warning labels. This non-compliance has had profound clinical consequences, particularly regarding the Genitourinary Syndrome of Menopause (GSM).

The Removal of the FDA Boxed Warning

A major milestone in the effort to modernize menopause care occurred recently with the successful advocacy to remove the boxed warning from vaginal estrogen. Dr. Casperson, standing on the shoulders of researchers who had petitioned the FDA for years, emerged as a key communicator in this effort. The argument for removal was based on the fact that the original warning was not supported by evidence; vaginal estrogen does not carry the same risk profile for blood clots or breast cancer as the oral synthetics used in the 2002 study.

Clinical data highlights the necessity of this change. Vaginal estrogen is the most effective intervention for preventing recurrent urinary tract infections (UTIs) in postmenopausal women, reducing the incidence by up to 60%. Despite this, a Stanford University study of Medicare patients found that only 9% of women diagnosed with GSM or recurrent UTIs actually received a prescription for vaginal estrogen. In Canada, the numbers were only slightly better at 17%. The removal of the boxed warning is expected to increase both physician prescribing confidence and patient adherence.

Redefining Menopause as Hypogonadism

A central tenet of the modern functional medicine approach is the rebranding of menopause. The term "menopause," coined in the 1800s, is increasingly viewed as an archaic clinical descriptor. By definition, menopause is the point in time 12 months after a woman’s last period. However, critics argue this definition is flawed because a third of modern women—due to hysterectomies, ablations, or IUDs—do not have a menstrual marker to track.

More importantly, "menopause" describes a symptom rather than the underlying pathology. Dr. Casperson and her peers advocate for the term "physiologic hypogonadism"—the state of outliving ovarian function. This shift is not merely semantic; it changes the clinical objective from "managing a natural transition" to "treating a hormonal deficiency."

This redefinition challenges the "naturalistic fallacy"—the belief that because menopause is a natural biological process, medical intervention is unnecessary. Proponents of hormone therapy point out that while puberty and pregnancy are also natural, medicine routinely intervenes to alleviate suffering and prevent complications. As life expectancy has increased, women are now living nearly half their lives in a hypogonadal state, which contributes to bone loss, cognitive decline, and cardiovascular disease.

The Testosterone Frontier: The "Underdog" Hormone

While estrogen and progesterone have dominated the HRT conversation, testosterone is emerging as the next frontier in women’s health advocacy. Often mistakenly viewed as a "male hormone," testosterone is actually the most abundant biologically active hormone in the female body before menopause.

The history of testosterone regulation is rooted more in sports politics than clinical safety. The Anabolic Steroids Enforcement Act of 1991, passed in response to Olympic doping scandals involving the USSR and East Germany, placed testosterone on the DEA’s list of controlled substances. This classification has created significant barriers to access, including privacy concerns for patients on controlled substance lists and a lack of FDA-approved female-specific formulations.

Currently, the U.S. has no FDA-approved testosterone product for women, forcing clinicians to "off-label" microdose male formulations or use compounded creams. This stands in contrast to countries like Australia, the UK, and South Africa, which have approved female testosterone for the treatment of Hypoactive Sexual Desire Disorder (HSDD).

However, recent research, including a study of telehealth patients published in 2025, suggests that the benefits of testosterone extend far beyond libido. The study found that energy and mood improvements were the primary benefits reported by women, followed by sexual desire. As a cognitive neurohormone, testosterone plays a vital role in mitochondrial function and the health of myelin sheaths in the brain.

The Timing Hypothesis and Healthspan

Modern clinical guidelines, such as the 2022 Menopause Society (formerly NAMS) position statement, now emphasize the "Timing Hypothesis." This theory suggests that the benefits of hormone therapy are greatest—and the risks lowest—when started within 10 years of the final menstrual period, typically before the age of 60.

During this "window of opportunity," estrogen is profoundly anti-inflammatory and supports DNA repair and cellular metabolism. While starting hormones later in life (the "pissed Boomer" demographic, as Dr. Casperson notes) can still offer benefits for bone density and sleep, it may not provide the same primary prevention against dementia and heart disease.

Data from the HERS trial (Heart and Estrogen/Progestin Replacement Study) showed that even in women who had already suffered a heart attack, oral synthetic hormones did not perform worse than placebos over a four-year period. This suggests that the absolute risks of modern, bioidentical transdermal estradiol are likely negligible for the vast majority of healthy aging women.

Clinical Implications and Patient Autonomy

The evolving landscape of menopause care places a heavy emphasis on patient autonomy and individualized medicine. Evidence-based medicine is increasingly defined as a triad: available research data, clinician experience, and patient desires.

In the absence of 20-year randomized controlled trials for every possible hormonal outcome—such as the prevention of dementia—clinicians are increasingly looking to observational data and physiological plausibility. For many women, the risk-benefit analysis favors intervention. Dementia is currently the leading cause of death for women in Australia and the UK, and heart disease remains the leading killer of women globally. If hormone therapy can mitigate these risks while improving quality of life, the argument for proactive treatment becomes compelling.

Beyond Hormones: The Lifestyle Foundation

Despite the focus on HRT, experts emphasize that hormones are not a panacea. The "hard stuff" of lifestyle remains the foundation of healthy aging. Dr. Casperson identifies several key pillars that must accompany hormone therapy:

1. Exercise: Resistance training is essential for maintaining muscle mass and bone density, particularly as estrogen levels decline.
2. Alcohol Cessation: Alcohol acts as a depressant and a disruptor of sleep and metabolism, exacerbating many of the symptoms of menopause.
3. Sleep Hygiene: Hormones can assist with sleep, but they cannot replace the necessity of consistent rest.
4. Cardiovascular Fitness: Walking and zone 2 cardio are identified as "low-hanging fruit" for metabolic health.

The Future of Regulatory Change

Looking ahead to 2026 and 2027, the focus of advocacy is expected to shift toward making vaginal estrogen available over-the-counter (OTC) and deregulating testosterone at female-specific doses. The FDA held a roundtable on hormones in July 2025 to discuss these issues, and a Men’s Health Panel in December 2025 signaled a willingness to expand indications for testosterone therapy.

The movement led by figures like Dr. Casperson represents a shift from "dismissive medicine" to "empowered medicine." By reframing the conversation around biology rather than just symptoms, and by leveraging social media to bypass traditional information gatekeepers, women and their physicians are successfully rewriting the standards of care for the second half of life. The ultimate goal is a medical system where gender bias is eliminated, and women have the same access to hormonal optimization as their male counterparts.