I am a Black woman.

I am a Black woman in both the traditional, archetypal sense, but I am also a Black woman who has historically been a bit unorthodox, unconventional and different. I am my own person and have never, if not rarely, fit into any standard checkbox, including common, prevailing ideas of what it means to be one.

When I realized I was in perimenopause, after a multi-month torture of horrible symptoms, of which insomnia, low-level anxiety and night sweats were my most intractable problems, I sought answers. Not only did I seek answers from medical professionals, I led the charge by doing my own research. Most of those entrusted to safeguard and care for my health fundamentally were not prepared to do so. Out of nine doctors, only three took me seriously. Of those three, one agreed that it might be perimenopause; one nudged me further to consider it as the absolute diagnosis; and the final one declared it to be so and immediately put me on hormone replacement therapy (HRT).

This process involved reading peer-reviewed studies, scientific publications, results from clinical trials and other rigorous, academic materials. I also mined stories of what real women were experiencing by watching YouTube videos, engaging in online forums, reading blogs and listening to podcasts.

Sadly, most women I know of in real life remain silent about perimenopause and menopause.

In my pre-HRT life and before I began consulting physicians, I explored many natural or easy-to-access things first. As one supplement or tincture failed after another, I began to spot a rather glaring chasm: White women seemed to be using pharmacological agents and treatments way more than Black women. While White women were using HRT to replenish their estrogen, progesterone and sometimes testosterone levels, Black women were using over-the-counter vitamins marketed as menopause remedies, in addition to tinctures that had black cohosh, sage, chamomile and chasteberry (vitex) in them.

While White women were taking antidepressants like low-dose Celexa (citalopram), Lexapro (escitalopram), Zoloft (sertraline), Wellbutrin (bupropion) or Effexor (venlafaxine) for their vasomotor symptoms (night sweats, hot flashes), hormonal anxiety / depression and  sleep problems, Black women were taking Nyquil, meditation and St. John’s Wort for the very same constellation of symptoms.

Indeed, in a post that appeared in a Black women’s wellness group I follow, someone asked what women were doing for their perimenopause and menopause symptoms, and some of the responses included: dandelion root tea, black seed oil, turmeric, elderberry, vitamin D, wild yam root, red ginseng, valerian, horny goat weed, dong quai, CoQ10, prunes, flaxseed, primrose oil, hibiscus tea, lemon water, burdock root and cranberry juice.

For those women who look to conventional pharmaceuticals as a last resort (and I was one of those women at one time), a few ideas seem to be consistently hailed by both Black and White women. They include melatonin for sleep, magnesium for sleep and muscle aches, and ashwagandha for anxiety and promoting calm.

But still, there is a definite gulf between the percentage of African-American perimenopausal / menopausal women using prescribed medications and HRT vs. White women in the same boat. While I have not uncovered any research that explores why this is, I have my own hypotheses:

Lack of information. It can be very difficult to get accurate, useful information about perimenopause and menopause, especially if one only seeks out help from her primary care physician and stops there. Most general medicine doctors receive minimal information, if any, about menopause during their medical training. Even OB/GYNs’ training focuses more on birthing babies than treating women beyond the reproductive stage. Many physicians will disregard perimenopausal symptoms and instead link them to stress or burnout, or treat / test them as other problems related to thyroid, migraine disorders, or depression, rather than viewing it is the multifaceted perimenopausal condition that it is.

Dismissive doctors. Even when women perform a root-cause analysis and figure out that their condition is likely perimenopause, their doctor may dismiss this as a possibility, often claiming that the 40-something year-old woman in their office is “too young.” Even though hormonal changes in women begin happening from the mid-30s onward, far too many physicians don’t understand that symptoms of hormone change happen way before periods stop. It also doesn’t help that many Black women don’t appear to be the age that they are. So a 45-year-old Black woman may look 35, but have night sweats, emotional turbulence, migraine headaches, hot flashes and irregular periods – only to be told that she is way too young for perimenopause to be a consideration.

Inadequate medical treatment. Even if a doctor agrees that a woman is in perimenopause, they may prescribe ill-suited solutions, like birth control pills when she really needs HRT. Most patients really respect their doctors’ opinions and believe whatever they recommend to be absolutely valid and true. So, if a perimenopausal woman fares poorly on birth control pills, she may think the problem is not the prescription, but her instead. She may seek no further solutions and wing it from that point on.

Medication stigma. Multitudes of women are prescribed antidepressants when they hit perimenopause and menopause. In the U.S., one out of every four women in their 40s and 50s is on an antidepressant, and the uptick in their use at the time perimenopause happens is likely not accidental. There are many reasons for this, including the rationale that this class of drugs helps with vasomotor symptoms (hot flashes and night sweats), insomnia, anxiety, depression and panic attacks – all of which are perimenopausal symptoms. And though antidepressants are now used to treat various issues, such as nerve pain, headaches, low libido and smoke cessation, in the Black community, the common idea remains that if someone takes a drug in this class, they must be “crazy.”

Strong Black Woman Syndrome. Black girls are raised to become Strong Black Women. We are groomed and nurtured to believe in ourselves, never trust anyone too much, always be ready to provide for and fend for ourselves, and to “tough out” some of the most irreconcilable and devastating situations, from racism at the workplace and marginalizing beauty standards to everyday micro-aggressions and undeniable assaults on our humanity. Perimenopause is a time of vulnerability, and Black women are not given much space in this society (or in our families or communities) to take that sorely needed time for our own selves and sanity during this phase of life. Sadly, doing so can even seem like a sign of weakness.

Hormone Replacement Therapy (HRT) can be expensive. Sadly, most women who would really benefit from HRT never receive it. Part of the reason for this is its cost. Honestly, it can be expensive, even for those with ample insurance coverage. Some women are spending at least $70 out of pocket each month for their estradiol patches and oral micronized progesterone capsules, even after insurance pays its part. Others are paying $130 or more a month out of pocket, with no insurance coverage. And some women are spending even more if they pursue alternative HRT routes, such as pellets or custom-compounded HRT. In an inflationary economy and with many vital monthly expenses, and where incomes aren’t keeping up with the cost of living, some just don’t have the financial bandwidth to comfortably afford HRT.

Downplayed by doctors. Sadly, maltreatment within the medical industrial complex is still a major problem for Black patients. All too often, our concerns are sidelined; our pain complaints are maligned as “pill seeking” or complaining; and many of our medical problems just aren’t taken too seriously. Consider how bad White women are treated when seeking help with perimenopause, and for Black women, it’s probably at least 10 times worse. Mainly, it is only the most well-researched, the most valiant and the most well-funded (or willing to spend the funds) women who get proper, timely perimenopause treatment. And by virtue of circumstances, including implicit bias and a lack of healthcare equity, those women who get the care they desperately need usually aren’t Black.
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Belief in God. Now, don’t get me wrong. There isn’t a thing wrong with having a belief in a Higher Power, and standing firm and resolute in the promise of healing, restoration and deliverance from our mortal ails as a result. But sometimes our characteristic spirituality and faith cause us to delay treatment and scoff at medical interventions – seeing such as a sign of weakness, a lack of faith and evidence of a soul too focused on worldly, or ephemeral, things. I believe in God, pray every day and feel that God has given human beings the information, capability and talent to create interventions and medicines to treat the frailties of the human condition. I believe that God wants us to have quality of life, not merely quantity of years.

In the United States, most adult men are married. As of the year 2019, 53 percent of adults ages 30-34 were married, followed by 62.5 percent between ages 35-39, 66.1 percent aged 40-44, and 65.6 percent between 45-49 years old. This means that many men are married to women who are likely perimenopausal, as female hormones can start their decline from the mid-30s onward.

We are seeing an increase in coverage about menopause and perimenopause. From across the pond, the UK government is going to lower the cost of HRT, Davina McCall is launching a call for more workplace protections for women going through menopause, and a widower is now calling upon all men to be mindful of the mental health implications “the change” can introduce, after losing his wife to suicide. 

And even singer and ‘80s chart-topper Rod Stewart is speaking out, saying that if men learned more about menopause, their marriages would survive.

Here, in the States, we’re seeing slightly more traction about perimenopause and menopause, with celebrities like actress Tracee Ellis Ross going public about perimenopause and former supermodel Paulina Porizkova almost baring it all in recounting her menopausal journey. Such coverage should help amplify the voices about perimenopause and menopause that are growing louder, larger and looming over conversations and dialogues about women’s health. And, it is.

Countless online groups and communities are each brimming with tens of thousands of women in search of answers, explanations and solutions for unmanaged and mismanaged symptoms. They are seeking recommendations for doctors and providers. They are leaning on each other for emotional and moral support. They are sharing lifestyle regimens and supplements taken.

But what is missing from this percolating brew of a perimenopausal uprising? The voices of men.

For months, I’ve mentioned to my husband that the treatment of women entering perimenopause and in the throes of menopause would be an absolute game-changer, only if more men got up to speed and spoke out about how it affected – or could affect – the women in their lives. So much would change: Industry would have to adjust. The workplace would re-think what health and wellness really includes. Science would commit to new understandings. Big pharma would develop sustainable solutions that fine-tune hormone replacement therapy beyond its current incarnations – perhaps even one that couples the best of HRT and the best of antidepressants into one seamless pill for the women who need both. There would be fewer suicides of midlife women, fewer midlife divorces and less misunderstanding in general.

If one considers that the average man has not only a wife, but also a mother, aunts, nieces, female cousins, daughters, and friends, co-workers, supervisors, neighbors and acquaintances of the opposite sex, the web of potential influence expands dramatically. So why aren’t men using their gender capital to support women in this phase of life? How can they heighten awareness that will lead to change in policy, medicine, science and daily living?

Let me count the ways.

Create online support groups. There is a major void in the virtual perimenopause landscape – a watering hole for men who need the insight, resources and camaraderie to support not only themselves, but also their wives and girlfriends through this period of change. As they rally together, their voices will coalesce and magnify awareness and the need for more options, both socially and medically.

Propose policy changes. Men are overrepresented in government and business at all levels; as such, they have the numbers and representation to drive serious conversations about policies in the workplace, government (and related programs) and the educational system about perimenopause and menopause. Women are not necessarily seeking special accommodations, but they are interested in wellness programs and workplace-sponsored resources that provide education and advocacy, as well as insurance plans that cover treatments like HRT.

Speak with their primary care physicians about aging. Men go to the doctors, too, albeit usually less frequently. After all, they are human beings who get physicals and other routine checkups. Even though it might not be on the agenda of a typical office visit, men can ask their primary care, internal medicine and family medicine physicians what kind of menopausal medicine options they offer to patients. You know, asking for a friend? Or, if that’s too direct for comfort, they can ask about getting their own testosterone levels checked as a gateway for more conversation. Such inquiries could heighten the awareness and pique the curiosity of doctors, one by one, perhaps eventually creating a groundswell of expanded understanding to serve their women patients.

Talk to their guy friends. Most married men are friends with fellow married men, who have wives of a certain age. Though men are comfortable talking shop about sports, current events, music and celebrities, they tend to tread lightly when it comes to more personal matters. It will take some brave souls to bring up the topic of perimenopause among a crew of cronies, but whomever does will likely be surprised by the shared observations and experiences they’re having with their wives, fiancées or girlfriends.
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Start a campaign. Most of the awareness about perimenopause and menopause is being done by women, predictably so. The few male voices in this space tend to be anti-aging, reproductive and naturopathic doctors who have some monetary skin in the game. If men launched a campaign to raise awareness, it would certainly stand out if for no reason other than the gender of those behind it. 

What are you ideas for how men can become part of the change? Are the men in your lives supporting you during this time? If so, how?

Getting an HRT prescription can be like running across a battlefield and dodging landmines in enemy territory before finally reaching the safe zone. So pervasive and unnecessarily complex are the hurdles perimenopausal women face when they ultimately figure out that their hormones are in decline, and they try to take the next logistical step to help: replacing them.

Many women start at the first reasonable stop on this juncture – their primary care physician, family medicine doctor or gynecologist – often only to leave with bad advice (“dress in layers,” “start doing yoga,” and “drink herbal tea,” among them) or undesired prescriptions for antidepressants. And this frequently spells the end of what had previously been a pleasant, diplomatic patient-doctor relationship, as women feel minimalized, marginalized and made to feel absolutely crazy.

Sadly, far too many stop here. They give up and give in to all sorts of unproven antidotes for their hormonal symptoms of anxiety, insomnia, hot flashes, migraine headaches and more. They assemble a medicine cabinet full of tinctures, herbs and supplements like magnesium, chasteberry, St. John’s Wort and black cohosh. They order all sorts of lotions and creams that supposedly contain progesterone and estrogen from online retailers with absolutely no regulatory skin in the game.

And they continue to suffer.

Fortunately, the ubiquitous nature of online shopping has intersected with telemedicine. And this means that women can now shop around like a well-informed consumer with choices in obtaining a prescription for hormone replacement therapy (HRT). Here are some of the best-known virtual HRT providers, all staffed by actual physicians, nurse practitioners and registered nurses.

Defy Medical – Focuses on compounded, customized (not pre-packaged the ones you get off the shelf via prescription at the regular pharmacy) hormone therapy options, all intended to remediate perimenopause symptoms. These include estrogen in the form of capsules, creams, pellet implants, vaginal suppositories and injections, plus progesterone as capsules, creams, injections and vaginal suppositories. Unlike some other providers, Defy also prescribes testosterone to women and focuses on other hormones, like thyroid and pregnenolone, too.

Evernow – Offers perimenopausal treatment in the form of estradiol patches, pills and vaginal creams, as well as oral micronized progesterone. They also offer combined estradiol / norethindrone pills and ethinyl estradiol / norethindrone birth control pills (generic Loestrin 1/20). For those interested in non-hormonal options, Evernow has Brisdelle (generic paroxetine), which is a low-dose SSRI used for treating vasomotor systems like hot flashes and night sweats, with some potential benefit for low-level depression or anxiety, too. Finally, they also have venlafaxine, which is the generic for the SNRI antidepressant Effexor, which, too, treats hot flashes and night sweats. Evernow often runs a special promotion that allows women to try whichever treatment best suits them for free (paying only about $6 in shipping) for the first month.

Gennev – Provides virtual perimenopause care at a rate of $55 for a 20-minute appointment or $85 for a 30-minute appointment with a trained menopause specialist. Some online reviews suggest a level of dissatisfaction among women who wanted actual HRT but were prescribed standard birth control pills instead. However, Gennev claims to offer hormone replacement therapy, in addition to a range of supplements, like vitamin D, omega-3 and others.

HelloAlpha – Prescribes supplemental estrogen and progesterone in the form of capsules, patches and gels, offering name brand prescriptions and generics, with a fully transparent price list. They also offer combined pills and conventional birth control pills as options. For perimenopausal sleep problems, they have doxepin and Ramelteon. And if non-hormonal options are a need or preference, HelloAlpha offers brand name and generic Brisdelle (paroxetine) and Effexor (venlafaxine).

Winona  - An emerging player in the HRT market, Winona offers the full panoply of hormone management options for women. They have estrogen in the form of tablets, patches and body creams, as well as vaginal estrogen. Progesterone is available as a combined cream with estrogen, as standalone oral capsules or as a body cream. Winona also has DHEA, which may help women who need a testosterone boost. Winona stands out in that they offer both FDA-approved, regulated hormone products as well as custom-compounded formulas.

Now, many people will wonder if these providers accept insurance? In most cases, the answer is likely “no.” Most providers require or expect out-of-pocket payment for HRT, though some may be willing to provide a statement developed for a patient’s potential insurance reimbursement. Some patients use HSA (health savings account) funds toward their HRT; some grapple with their insurance to cover at least part of it and, most, sadly, pay for it themselves – even if they have “good” insurance. The headaches of bickering with insurance administrators and going back and forth to doctor’s offices in person just isn’t worth it to them.

So, for those interested in HRT who have faced unreasonable hurdles with conventional, in-person doctors, there are alternatives available. The online HRT providers are staffed by medical personnel and most use FDA-approved body-identical hormone replacement products, not unscrupulous, questionable products from “the streets” or underground.

As with most things, buyer beware. Research online reviews, have an informational visit with a provider, check the doctors' credentials and history with the medical board in the state in which they are registered, ask as many questions as you need, comparison shop and even see how what they recommend corresponds with science and best practices. And then make a decision.