Former middle school teacher Lorraine Carter Salazar isn't easily embarrassed. But when she began having hot flashes at school about a decade ago, she worried about how she came off to co-workers, students and parents.
"It doesn't convey competence," said Carter Salazar, 62. She recounted how parents could tell she was uncomfortable in meetings. One time, a student even fanned her and remarked that she was used to seeing her grandma feeling the same way.
When she took her concerns to her doctor, he didn't take them seriously.
"So you sweat," Carter Salazar recalled him saying. "And he's right. Nobody dies from sweating."
People experiencing perimenopause and menopause symptoms — which can range from hot flashes and night sweats to mood changes, decreased libido and cognitive issues — often complain of unresponsive doctors and inconsistent care. Symptoms can impact quality of life in the moment, and long-term health.
Many doctors are ill-equipped to handle these conversations.
A needs assessment published in the medical journal Menopause in 2023 showed just under a third of the residency programs in obstetrics and gynecology it surveyed offered training on menopause, even though half of the population experiences it.
That's led lawmakers in California and nationally to try to intervene.
In California, legislators introduced two bills this legislative session on menopause education for doctors. Assembly Bill 360, which would have required a state agency to look into education gaps and how to fill them, was tabled last month. But Assembly Bill 432, which would require menopause coursework for doctors to renew their licenses — if at least 25% of their patients are women under 65 — is still moving through the legislature.
"It reflects my own experience having to go to three doctors before a doctor could adequately have a conversation with me about menopause," said Democratic Assemblymember Rebecca Bauer-Kahan, who introduced the measure.
She says when she was going through menopause, her brain fog became so intense that she worried she might have early-onset Alzheimer's disease.
And California's efforts are part of a national trend.
"Thirteen states, including California, have introduced a total of 21 bills [related to menopause] this legislative session, which is pretty stunning actually for an issue that really wasn't on any legislator's radar, certainly three years ago," said Jennifer Weiss-Wolf, who runs the Birnbaum Women's Leadership Center at New York University and tracks menopause bills.
Several of those bills also touch on doctor education. In New Jersey, for example, one bill would allow providers to use continuing education credits toward their license renewal. Arizona and Massachusetts introduced bills this year to provide more information on menopause to providers and patients.
In recent years, Illinois and Louisiana have started to mandate insurance coverage for some menopause treatments.
Treating symptoms instead of letting patients endure them
Training is available for doctors who want it — and treatments are available for people who need them.
"There's no reason that somebody should suffer with those symptoms," said Dr. Monica Christmas from the University of Chicago. She runs the menopause program at the Center for Women's Integrated Health.
Christmas, who has practiced gynecology for over 20 years, fell into the specialty because her colleagues kept sending her their menopausal patients.
"I didn't know the answers, but I listened," she said.
After hearing their concerns, she researched their symptoms before coming back with treatment ideas. They, in turn, told their friends at work, over coffee, and while waiting for the train about the doctor who took them seriously.
"And so very quickly, I got super busy," she said.
Christmas said the training a school offers on menopause usually depends on how well-resourced it is. Since few schools have a robust program, many physicians also seek out information and training elsewhere.
Christmas also works for The Menopause Society — a national organization that provides training for doctors on how to treat women at this stage of life.
Christmas said it's imperative that doctors know how to work with lots of different people — because symptoms vary, and so do people's tolerance levels and trust in the medical system.
"Black women like myself were very reluctant to take anything for the symptoms that they were experiencing," she said. She never understood why and heard myriad reasons when she asked. Some patients explained that menopause is simply a natural process meant to be endured. "Yet, I could see in front of me them having hot flashes in the conversation."
Specialized care for Black women
Kim Robinson, with the advocacy organization Black Women for Wellness, said Black women have to navigate discrimination on top of seeking helpful information from health care providers.
She added that doctors should be better versed in how Black women experience this time of life differently from other women.
For instance, Black women often experience fibroids, or benign growths in the uterus, at higher rates than white women, according to a recent study in the American Journal of Obstetrics and Gynecology.
As they reach menopause, Robinson said many doctors suggest Black women get hysterectomy, which is the removal of the uterus, without fully explaining the risks or alternatives. According to the Mayo Clinic, several alternatives exist, such as hormone regulation, but nearly 60% of women who receive a hysterectomy are offered other treatment first.
"It's not just this one invasive thing, remove your parts and the problem is solved," she said of the procedure.
Robinson knows from experience. When her doctor suggested she get a hysterectomy, she knew to push back and ask questions, eventually finding a less-invasive alternative.
But, she said, the burden shouldn't be on patients to advocate for themselves. Doctors, she said, should get more training and education on symptoms and treatments.
Challenges to passing a menopause education law
In California, the measure that would require doctors to study menopause builds off a bill that Democratic Gov. Gavin Newsom vetoed last year. In his veto message, Newsom said the bill was "too far-reaching" because it would have required health insurance plans to cover expensive and non-FDA-approved treatments.
However, Newsom encouraged lawmakers to "continue to work towards a more tailored solution that can improve access to perimenopause and menopause care, inform patients of their options, and encourage providers to stay informed of the latest clinical care recommendations," he wrote.
But Bauer-Kahan, the assemblymember, kept the provisions that Newsom cited as a problem. However, she added education requirements, when last year's bill strictly focused on insurance.
"We've doubled down," she said. "I think one of the things I learned last year through the hearings we held on menopause and this work is how little is understood about menopause."
Newsom's office declined to comment on the measure.
Opposition within the medical field is also an obstacle.
Dr. Tanya Spirtos, former president of the California Medical Association, which represents doctors, said the bill is well-intentioned but misguided. Doctors generally know they must stay up to date and informed about the latest treatments, she said.
"We do the reading and the education, as I say, to stay one step ahead of our patients," she said.
Spirtos, a gynecologist, also said there are lots of areas — like diabetes or nutrition — where doctors need to stay current, but requiring training in each one would create too much of a burden. She said doctors should decide for themselves what kind of training is most relevant to their practice.
"Every area that touches on bones or brain or heart or vagina or hot flashes has literature available that's really easy for our physicians to get a hold of and educate themselves," she said.
NYU's Weiss-Wolf's says she hopes to see access to good menopause care take off. Her focus on women's health also includes advocating for making tampons and pads more accessible.
"Certainly when I started working on periods, people weren't talking about it in any sort of public and systematic way," she said. "And I would say that 10 years later, that feels different to me."
She thinks something similar is happening now for menopause.
This story is part of a series produced for the USC Annenberg Center for Health Journalism's 2025 California Health Equity Fellowship.
Copyright 2025 NPR