Assembly Select Committee on Reproductive Health

Oh, there we go. Hi. Good morning, and welcome to the Select Committee on Reproductive Health. Today we are talking about menopause, and I could not be more excited that we're having this conversation since I know you're all going to Google my age as soon as I start talking about this. It's true

I'm 45. And like many of my peers, as I approach perimenopause and menopause, we start to ask questions of one another of our physicians. And like many women, the answer we get is often, oh, it's fine. Suffer through, know everyone goes through it. Just buck up and let it happen. And as I started to research it and as Chair of the Select Committee on Reproductive Health, I started to realize how little resources there were for women.

Every single woman who was lucky enough to live long enough will go through menopause. Over half of California's population will experience menopause. And all of the changes, both lovely and not so lovely, that come with it. And as we experience the things that we'll talk about in this committee, be it hot flashes, brain fog, sleeplessness that affect our ability to function in the workplace, our mental health, and all of the things we need to be the productive people we are at the peak of our careers.

We don't have the support we need. And so we're here today as policymakers to have that conversation, because we know that it's a conversation that's not being had enough. A study found that 90% of postmenopausal women were never taught about menopause in school. And over 60% only got information after symptoms had been started.

And I know every one of us has experienced a friend who has shown up at a doctor in the hospital with something that they don't know what it is, hospitalized for days, given every test imaginable, to be told we don't know what it is, and only later to be chatting with a friend to learn, oh, it's something that she experienced in menopause. And treatment needs to be better. That is not an acceptable way for women to be seeking and gaining healthcare information.

And so what can we do here in California, we can ensure that women have access to accurate information, comprehensive healthcare and social support system that include menopause. We need to address workplace issues, social stigma, advocating for insurance coverage and equity. I will note that men are given treatment and access to information as they age about the issues that don't affect their health in nearly as many ways as menopause does, and women do not.

So we are coming together to amplify the voices of women and others who experience menopause, which is every single one of us. Break down the barriers to care and pave the way for a future where menopause is supported. So I want to thank you for joining us in this important conversation. Today we will be looking at California's healthcare system. What do we do to teach our physicians? We have some of the top academic institutions in the world that train our doctors.

What are they learning about menopause? How are they treating women in their own institutions as they reach perimenopause and menopause? We'll be talking about research. How are those funds distributed? What are we doing to understand women as they go through this transition and the long term health impacts that result from it? And we will be having future hearings, including one focused on women in the workforce.

One of the things we've learned through beginning this is the vast impacts that menopause has on women, again at the peak of their productivity in the workforce. So we will be discussing that at a later date. And with that, I wanted to see, I have wonderful women's caucus colleagues here make any comments.

Sure. Thank you very much, Assemblymember, for putting this together and highlighting such an important subject. For years and years, we've been trying to break the stigma around periods. We should be putting the same effort into breaking the stigma around menopause and educating girls from a very young age about all the normal functions of a woman's body and beginning of their menstrual cycle to the end.

We need to normalize speaking about menopause so that we can better support women who are going through these changes, as well as support the men. Menopause can be a critical turning point for a woman's health, both physical and mental. And I want to thank you for putting this together. The lack of knowledge can be the barrier that we are seeking to care for. Thank you.

Thank you. Anyone else want to make some opening? Oh, yeah. Miss Petrie-Norris.

Well, thank you, Madam Chair, and thank you for convening us for this important and for some of us, very timely conversation. For something that affects, as you said, one half of the population, menopause is remarkably poorly understood. The symptoms and the effects are so often misdiagnosed or dismissed out of hand and altogether, and I think it's almost as if the message is, once you're past your childbearing years, women of a certain age, you got to suffer in silence.

And I think we know that that's absolutely not the message that we want to communicate to the women of California. And so I'm grateful for you for convening this hearing today. I think it's certainly first of its kind in the State of California.

I'm really looking forward to digging into the topic and to thank all of our panelists for joining us as well, and really look forward to coming out of this series of hearings with some really actionable steps that we can take as policymakers and as women of the Legislative Women's Caucus. Thank you.

Thank you. Okay, if no other, we can have more remarks after, but we will go to our first panelist, Jennifer Weiss-Wolf will speak on menopause justice, and she should be on line.

I'm here.

Perfect. Yeah, we can see you and hear you. Perfect.

All right, good. Hi, everybody. Okay. I can see myself twice now. I can see myself on screen and in my own vision, but I can't see the room. So I'm just going to keep talking straight ahead. And if there are questions or comments, please just interrupt me, because I can't see if hands are raised in any way. But it's really a thrill to be here. I want to start by introducing myself.

I run the Women's Leadership Center at NYU School of Law, so I'm across the country right now. My advocacy background has largely been in menstruation and the law, and I'm glad to hear that was raised in some of the opening remarks, because California is actually one of the first states I worked with going back a decade. Folks may know that California was actually the first state in the nation to introduce tampon tax legislation in a campaign that has since become both a national and global initiative.

And California has been really forward on menstrual access and equity policy, and I've been proud to work with leaders across the state on those initiatives. As for me personally, I've sort of shifted my attention from menstruation policy and law to menopause and policy and law. For all reasons that might be obvious, I am also of menopausal age.

It struck me as an area that was potentially untapped and could benefit from the same infusion of energy and activism as we've seen menstruation and the law happen around the country and around the world. I think what became the most obvious to me early on in this advocacy was that, like menstruation, there's a lot of stigma around menopause.

But perhaps unlike menstruation, tackling menopause in the public sphere requires science, which is not to say menstruation doesn't but a lot of the kinds of interventions that have been envisioned as a matter of policy have had less to do with research and understanding the process, and more to do with products and ways to educate young people and ensure that menstruation was something that they could handle with dignity. So it's been a really interesting journey, I think, for me as a policy advocate.

I am not a doctor. I am not a scientific expert. I'm very, very glad that there are a panel of expert medical providers who we're going to follow who will be able to probably answer far more of your granular and pragmatic questions about menopause than I am able to answer. But I am somebody who spends a great deal of time thinking about law, policy, and what kinds of interventions can improve the lives of people, and women in particular, throughout their reproductive arc and trajectory.

So I will start by saying that as I've thought about what kinds of interventions are needed on the part of policymakers when it comes to menopause, I've learned an extraordinary amount from the physicians in whose company I keep and who've taught me in particular about both the efficacies and impact of hormone treatment and the very fraught political story of menopause hormone treatment in the United States.

And I've become rather convinced that that is the heart, and that is a big piece of what we're dealing with here. When we think about the kinds of policies that are needed, that several decades worth of misinformation or miscommunicated information about a key intervention has sort of infected the entire arena in which we consider the policies that are needed and have also opened the door to interventions that can range from misguided at best to exploitative at worst.

And that research and shared knowledge and shared understanding is absolutely where public policy has to start and ultimately where it's going to end, too. It's really hard to talk about workplace interventions, to talk about the commercial market around menopause, to talk about how menopause is taught to medical professions without grappling with the fact that publicly funded and federally funded research is the heart of what is needed.

So in thinking about what state legislators can do on that front, considering whatever levers can be pulled to ensure that there is adequate funding for and resourcing of a wide array of studies so that we can have a shared vocabulary and a shared knowledge and a shared appreciation of everything we know, everything we don't know, and everything that creates the basis and the framework for thinking about how we improve people's lives so I don't think I can underscore that enough that if the California Legislature has any impact or any ability to influence the way funds are distributed to research institutes throughout its own state and throughout its own university system, that that is a key place for the legislature to start.

And it's interesting because it's not just what people know or don't know about one particular form of treatment for symptoms of menopause, which, again, I know you're going to discuss in reverse order here with the physicians who are joining the conversation throughout this session. But again, it's the idea that without this shared knowledge that permeates the entire ecosystem of menopause, there's almost no step that we can take that will create the kind of transformational change that is needed.

So there are several reforms that are progressing on the federal front, and I'm happy to share a little bit about those as you all think about what the state specific version or translation might be. So in addition to pushing for federal research dollars, there is also a need for federal agencies to be modernized and up to date about how they communicate about menopause and menopause treatments. And that runs from the Food and Drug Administration to the Center for Disease Control to the National Institutes for Health.

They all require, I think, a refresh and an upgrade in terms of the information that they communicate and the responsibilities they have with those communications. There is an effort underway to request or demand that the FDA have proper warnings about estrogen treatments that currently are out of date, including its black box warning on the packaging for low dose vaginal estrogen. There are both information resources and website information that is outdated on those websites.

And there is a need for, again, modern communication, whether it's through online or social media resources or even an old-fashioned press conference, just like the NIH and did via the Women's Health Initiative in 2002.

Every way that the information that is updated and current can be communicated, it needs to be in addition to the research that is needed to keep fueling more and better information. At the state level, I think some of the key interventions that follow those federal demands are to fill the gaps that have been left by these gaps in communication.

I know you're going to talk later in this hour about medical education and how medical professionals are trained to work with their patients and communicate to their patients about menopause. So any ways or levers that the state government has to ensure that is happening in the medical education system in the State of California are much needed. But it includes regular people's education too.

So whether that is PSA initiatives or other ways that menopause education and information can be translated to the general public, those are all sorely needed. There are initiatives underway in other states involving state-offered or provided sex education or health education to students that could include better both menstruation, including through menopause education. But there are nonprofits and other entities that I think the state could well partner with to ensure that information is transmitted to people.

I know that workplace reforms are quite popular, and it sounds like it's something you're going to be talking about in detail going forward, and I want to say that I often come off as the curmudgeon on workplace reforms. It's not that I don't think they're important. They are. But I will go back to the tenet that without sort of key research, it's hard to know if the workplace reforms that are being pursued are meaningful or not.

I wrote a piece recently for Oprah about not wanting to have fans to blow away our hot flashes, but actually getting to the bottom of understanding them and having reasonable interventions for them that we all have access to and that are affordable to all, I think is much more important than some of the band-aids that I've seen being put forth in terms of workplace accommodations. So I think that they're important to talk about and important to think about.

But by and large, I think that there also thus far haven't been ones that have struck me as wholly meaningful. And I want us to think really critically about that, because when we ask CEOs and companies to step up, I certainly don't want them to do the minimum and think they've done their job and move on because there are many ways they can be tapped to do more and do better.

I will say that California, as a public employee for state employees, can look to cities like New York, which has a mayor's women's health initiative that has included menopause interventions in it. Thus far, none of them have been actually employed or executed. But there are an array of proposals that are being explored here in New York. So I would certainly recommend a sharing of information so that best practices can be built together.

And then I would add that among the workplace reforms that have been more interesting looking to me are the ability to leverage economic power to ensure that adequate resources are provided to people who are experiencing perimenopause and menopause. And that includes everything from providing telehealth services and ways for employees to reach the kind of care, expert care that is available. Perhaps not through doctors or that they're accustomed to seeing or who aren't able to adequately meet their needs.

But menopause specialists who do exist across the country and perhaps telehealth and other remote or virtual care, is something that employers can ensure that their employees have access to, as well as affordable treatments. There have been other states that have taken on menopause treatments and coverage of them through both private and public health insurance. The State of Illinois has a new law in effect. It only applies to women who've undergone early or surgical menopause to have access to treatment.

So I would say that their law is incomplete. But I think that that is a logical step for state governments to undertake to ensure that all menopause treatments are covered and covered in full through both the state's health insurance program and private participants that the state engages. I would add, too, that California's own Barbara Lee introduced such a bill in Congress several years ago, and it has not progressed, but seeing state-level versions of that would be quite welcome.

There are two more things that I want to throw in the mix, too, and I realize I've just sort of been talking on for a while, and as I said, I can only see myself. So I'm hoping that this information in my voice is carrying through. But I think that it's important to note that there is such a public moment for menopause now. I'm extraordinarily proud and excited that California, that you're all having this hearing in the first place.

I do think this is one of the first of its kind in this sort of new modern era of menopause. But there's also a commercial market that is booming. New York Times called it the menopause gold rush, and I don't think that most people would agree that sort of commercial products are the answer to the woes that we have, and in fact, run the risk more than anything of being potentially exploitative or predatory.

So keeping a very close eye on that and wherever there is a possibility to ensure that advertising and other modes of commerce are not being harmful in any way is a really important thing to keep our eye on. There is clearly a large market to be tapped here, and with that, potentially comes opportunity, but also comes great risk.

And then the last state-specific, I think opportunity is to look to our fellow advocates and lawmakers in the UK, where menopause has been very high on the agenda. And among other things, they've had a distinct menopause champion at the helm of their national government, and to create a role like that in the state, I think would also add tremendous value.

California is such a leader in so many ways that while all of these things aren't sort of novel on their face, doing them together as a package and setting itself forth as a national leader, I could imagine being quite powerful in other states, wanting to follow California's lead. So with that, I will stop talking, now that I've been talking into the mirror, and I'm happy to answer any questions that I can or chat about any of this.

Again with the caveat, I am a lawyer, not a doctor, and that is where you'll be able to get any reasonable response from me.

Thank you so much. We really appreciate you laying out the framework of where government can play in this. I think it is really important. And I think one of the things you highlighted that I've been seeing is that where we don't provide good information and good access to research and healthcare, people are going out and finding bad information and bad sources of care. And that's the last thing we want for California's women.

So we really owe it to California women to be leading in providing them with the access to meaningful health care. And I'm excited to hear from the second panel because I do think one of the things that people are very focused on is reducing the symptoms of menopause. And one of the things I've been learning is that there's also long term health impacts that we can help address through good care. So this is really important to the longevity and health of women. With that, any questions? Yes, Assemblymember Waldron.

Just a quick comment. I appreciate your presentation. And one of the things that I had noted prior to this hearing that I was going to mention was the concept that not all of the menopause treatments, especially HRT, is covered in health insurance. And one of the things that's interesting, and I don't know why, is that some health plans did cover it and now don't cover it. And I don't know why there was that shift.

And that's something maybe we need to look at, is if we want to have access to all the different treatments, they need to be accessible and covered in health insurance. So I don't know why it was covered and then not all of a sudden, so maybe more people are accessing it. I don't know. Just a comment.

Interesting. Yeah, no, I think insurance equity and coverage is obviously an important piece of this because making people pay out of pocket for something that can last years on end is not easy for many Californians. And we have started looking into that. The problem is insurance is typically what is medically necessary. And I don't know who gets to decide whether HRT is medically necessary for us, but that's a question that I have pending in my head, so.

Okay, well, so I think you raised the issue of research dollars. We do Fund the universities in California. We do have a constitutional mandate that we not dictate what University of California does, but we do control their budgets. And so I think you make a really good point there to better understand how those research dollars are being spent and what we're using them for.

I guess I wanted you to touch a little bit more on, I thought your focus on government as a source of good information. It's actually something we have done in the abortion space here in California.

We've worked really hard to create a public information campaign that is accurate as it relates to abortion with a website and a PSA. And I know that's work that our colleague here has done a lot of. And so translating that into the menopausal space I think is a really interesting idea. So I don't know if you could. Go a little bit further into sort of what that would look like and what you think it is important to get out into the public sphere.

Yeah, it's so interesting because I also think that government communication around menstruation is a really important item, too. So I just want to make that point as well. It's funny because one of the things that has come up in discussions even around the federal, you know there's a White House initiative as well, around inquiring into what needed research is still important around menopause and women's midlife needs.

And one of the things we've talked about in that context is how to ensure once there are research is done or there are new findings, that people are open to listening to it. And what is people's appetite for or trust in government. So it's very affirming to hear that California's PSAs or education around abortion has been fruitful.

Because in research I've done, even despite sort of this post pandemic, if that's the era we're in now, trust in sort of the government in terms of public health has its challenges. By and large, research still shows that people do expect this from public leaders and are looking to that kind of guidance.

So with all that said, I think that is at least sort of an affirmation that I am supportive, very supportive of there being public information around our health and women's health in particular. For menopause, I think that certainly some of the basics that, and I know the medical professionals will dive into this too, and they talk about sort of symptoms and care if there is basic information about even understanding or identifying what the experience is like when it starts for most people, et cetera.

I think, again, as a policy advocate, not as somebody who hears from patients, one of the things that still strikes me that people are surprised by is it the age at which menopause or perimenopause symptoms can start. I'm 56. Personally, I feel quite young, so it always surprises me when people say they think 40s is old, because that sounds quite young to me in the rearview mirror.

But point being that for people who are starting to experience perimenopause symptoms in their early to mid-40s and are being told by their medical providers that it's too early or you're not taking seriously that perimenopause could be the reason why they're experiencing certain impacts, I think that that base level of education could probably be quite powerful and simple to convey.

I think that understanding where to turn for support and where to turn for help, if that fits in the arc of what a PSA could be. There are obviously nonprofits and well-established medical associations that are deep providers of this information. And turning folks to those sources, I think, is quite important. Like you said before, with this commercial market, it's interesting. Social media makes it.

We have a democratized landscape such that information is not only date kept in doctors offices, but it's really hard to know if you're getting good information or not. As somebody who searches menopause a lot on my devices, I can say that when I scroll, I get so many menopause pop-up ads now, and it's a lot to go through and it's a lot to receive. So I think that pointing people towards trusted sources is extremely important.

And again, sometimes those are government sources, but sometimes they're not. And they're nonprofit and other institutions that are considered the gold stars in this space. From the Mayo Clinic to the menopause society, to even nonprofits like let's talk menopause, there are absolutely places to turn folks to. So those are a few ideas off the top of my head about what could be useful PSAs from the get go. But I'm sure with a little bit of thought and collaboration could even come up with more.

No, I appreciate that. I found, even to your point, whether they want to look to us for the answers, knowing what questions to ask during this period of my life is also really important because it turns out we don't just have estrogen, we have many hormones that are getting messed with at this point, and to understand them all is really critical. Assemblymember Pellerin.

Thank you, I want to thank our Chair for holding this hearing today and thank you for your testimony. And we all got really excited here about having a menopause bill package. It seems like there's a lot of places where we can do some really critical work. And you mentioned the New York Mayor's health initiative, some work that's being done in Illinois.

Are there any other states that you think really rise the top that we can look to and come up with some good legislation to basically pay this path forward for us?

Right now, it looks like, especially if you're willing to package it all as a bill, California will be in the lead, which is, again, that was my story, working with California around menstruation. So that makes me very excited to see. The DC City Council also has a very full-throated health education program for students that is holistic and complete on menstruation and includes menopause.

So between in-school education, DC City Council, sort of public workplace and other related interventions that might be New York City Council and Illinois insurance coverage mandate for hormone treatment is, I would say, is halfway there. Like I said, it's only for certain patients, and I think that I wouldn't replicate that and I would ensure that it is for all patients. But those are the three that I think that I know of to be the most live here in the United States.

This really is actually quite unmind territory when it comes to menopause policy. As I mentioned, folks in the UK are quite ahead of us on this, so they would be worth tapping as well. But I think California could really lead the way with a full menopause package.

No, I really appreciate that. And I'm 61, so I've been through menopause and there was a lot I did not know. And I recall sitting there in my Doctor's office waiting on a pregnancy test for me. I had been a year away from stopping my period, and I thought we were free and good to go, and that was not the case. And fortunately, it was negative.

But I remember at the time just thinking, how did I not know this, that I could get pregnant during this post-menopause time? So there's a lot for all of us to learn, and I think that you're really, just really inspired by your testimony. Thank you.

Thank you.

It did you want to? So I'll ask a question we were just talking about, which is okay. Yeah. So on the insurance piece, like I said, I'm 45, and I think that I understand that the research for those that go through perimenopause younger is clearer about the benefits of HRT. I don't know if that's true when you're older, because I'm not older, but is there foundational research that talks about the clear benefit and maybe we should go to the next one.

But since you're talking about insurance policy and requiring insurance, I just think from a policy perspective, we need to be sort of a baseline of how do we decide if it is medically necessary. And is that something that you've looked at from a policy perspective?

So I haven't. And I would absolutely refer to the doctors on that. But I would say that when we think about health insurance, I also would love for us to carve out a more holistic vision for it, too, because our health includes our physical health, but it includes our ability to contribute to our family's health, to the economic health of our communities.

So all of these aspects of treating symptoms of menopause are both about our physical bodies, but it is also about our contributions, and that is part of being a healthy human. So I would want to be as broad as possible in, in carving out why these treatments are necessary for all people experiencing menopause and not give away more than is needed before we had to.

Got it. Okay. That's helpful. And I agree. I think that we shouldn't just have to suffer because it's an inevitable part of our cycle. Right. No. And I mean, I think that, to your point, suffering isn't okay. That makes it medically necessary, if you ask me. But I'm not a researcher or a Doctor. I'm a lawyer, too.

And I think as well, that suffering is part of the, is sort of deemed intrinsic to the female experience. I saw an article or a quote recently about medical interventions during labor and childbirth, and it's one of the very few medical experiences where there's somehow a pat on the back for doing it without medicine. You would never pat anyone on the back for having an operation without Anesthesia and say it made them a stronger, better, more soulful human.

So I think we also want to really dig into what it means to treat women as whole beings and eradicate any notion that suffering is noble.

Yeah, we could have a whole separate hearing about that.

So I thank you, Professor, for your testimony. I think we are resplendent with lawyers on this dais here. But one of the things, when you talk about a PSA, one of the things that would be important for me is that it really is a time of empowerment.

And so I feel like not only can you give advice about how to be physically empowered over some things that you might feel out of control over, but in society, I think it should be revered as this is a time of tremendous empowerment. And if there is any PSA's, that's the message I'd like to get across. And I love the quote, Professor, in your paperwork here, that was from Kristen Scott Thomas.

I think.

I don't take credit for that.

Yeah.

Was really not safe for work, but good.

It wasn't yours. I thought it was still a part of yours.

No, no.

I'm just saying there's some words in there that I won't repeat here.

Yeah.

But they were fantastic. Just about. This is a time when your body's not a machine anymore, and there's a lot of liberation that comes with that. So, anyway, that's my point. For what it's worth.

I appreciate that. I think a lot of messages are sent for women that need to be reprogrammed in our society. There's no question about that. So I appreciate, and I think that I want to thank, I think I started by this, but more people who joined us were joined by many Members of the Legislative Women's Caucus in a bipartisan way, but also one of our male colleagues who's here to learn as well.

So thank you to Assembly Member Jackson for being here for this very important conversation, because there's a lot to be learned in this space. Any other questions for the Professor? But I know, I appreciate you being here to testify. I know that we know how to find you. So I know you are a resource that we can come back to after this. So we really appreciate you leading in this space from a policy perspective, because obviously that's how we enter the space, not as physicians.

We do have one physician on the Committee, but I don't know if she's going to be here today. Who is an OB. You know, we are here to support California's women as they go through this very empowering life change. I'll start you. So thank you. And you have a good afternoon. I know you have to jump off. Appreciate it.

Thank you so much, everybody. Thank you for your good work.

So I think our next panelists should be on. So our next panel will be an introduction to menopause as a clinical issue. Okay. And we don't have all of our panelists, but we have most of them. So I will introduce our next panel, which is three practitioners and researchers who have insight into the many ways that menopause affects our life. So we have Dr. Stephanie Faubion, a Professor and Chair of the Department of Medicine at the Mayo Clinic in Florida who specializes in menopausal health.

Dr. Alexis Reeves, a postdoctoral scholar in the Stanford School of Medicine focusing on menopause and the aging impacts for women of color. A topic we really wanted to bring to bear is just like childbirth. This transition is experienced differently by our diverse communities. So we want that voice here today. Dr. Carolyn Gibson, an assistant Professor in the UCSF Department of Psychiatry and Behavioral Sciences and staff psychologist in the San Francisco VA healthcare system who focuses on the impact of menopause and mental health.

And last but definitely not least, Dr. Elaine Waetjen, a Professor and Vice Chair of research and Department of Obstetrics and gynecology at our very own UC Davis, who's going to be able to give us the insight into what is happening at our own UC institutions. So thank you all for being here. I don't know which panelist is not here. So, Dr. Faubion, are you on?

I am. Thank you.

Great. Perfect. So I think that just to set the stage for this panel, really what we want to learn here is what do we need to know about menopause? I don't even know that there's a shared understanding of menopause and how it affects California's women and sort of what is the state of play in the scientific community? So I will turn it over to you with that question.

Wow. That's a really broad question, but let me start with just what's normal? I heard a lot of people talking about age at menopause, and we know the mean age of menopause is 52 years. But anything after the age of 45 is considered normal. And about 8% of women are going to go through menopause before that, with about 5% between 40 and 45 and about somewhere between 1 & 3% under the age of 40.

But we refer to that time leading up to menopause, which is defined as no menstrual period for a year, as perimenopause. So we know that women can have symptoms of perimenopause for six to 10 years before they actually experience their last menstrual period. So I just wanted to emphasize that if you say anything after 45 is normal, you can back it up 10 years. And women who are in their mid 30s can be having menopause symptoms. So I think that's an important point.

And another key point is you don't have to have an absence of periods to have symptoms. So there are many women that are still having menstrual cycles, and even some that are still having fairly regular menstrual cycles who have all the symptoms of menopause. The symptoms can vary, and everybody knows about hot flashes and night sweats, so we call those vasomotor symptoms. About 75/80% of women are going to have those.

Not all of them are going to be severe, but many women do have quite severe and bothersome symptoms. And I heard there was mention about the impact in the workplace, and I can also speak to that since we published a major study on that last spring. But these symptoms can last a long time. We used to pat women on the head and say, oh, it'll last a year or two, don't worry about it.

But we now know that the mean duration is seven to nine years, and a good third of women will hot flash for a decade or longer. We also know that there's a lot of other symptoms associated with menopause, like sleep disturbances, mood disturbances, anxiety symptoms, depressive symptoms, but also things like joint aches that a lot of women may not necessarily tie to the menopause transition. We also know that palpitations are fairly common, vaginal dryness is certainly common, and difficulty with sexual activity.

So there's a broad range of symptoms, such that women often end up in a number of different doctors offices trying to figure out what's happening. And many women themselves don't even know that all of these symptoms are related. So I have women going to a cardiologist, for example, for palpitations, a urologist for urinary incontinence issues or urinary tract infections, a gynecologist for sexual pain, psychiatrists for mood symptoms, et cetera.

And I actually had a woman come to me at the Mayo Clinic thinking she was dying, because you can imagine this is all very scary. She's waking up in the middle of the night with panic attacks. She's gaining weight, she's losing hair, she's sweating. She's thinking something is horribly wrong with her. So we have gaps, as you've already heard, in education of women. We also have gaps in terms of education of our medical providers at all levels, including clinicians that are out in practice today.

And then we have treatment gaps, so women aren't receiving the therapies that we actually know are safe and effective. So I'll pause there and see what I'm missing.

Assembly Member Petrie-Norris is going to chime.

So thank you so much for joining us. We appreciate it. And I want to just jump right to HRT. So, as our previous panelists said, there's kind of been decades of misinformation around this. Can you just give us a summary of what is the kind of current state of play in terms of the science and research around HRT?

And she means hormone replacement therapy for everyone watching at home.

So one thing, we don't call it hormone replacement therapy anymore. We call it hormone therapy. And the reason for that, and this is kind of important, is we're not trying to replace what the ovary used to make. For the most part, we're trying to manage symptoms. And the one exception to that would be for a woman who's going through menopause prematurely under the age of 40 or early between 40 and 45, we are actually trying to replace what the ovaries used to make.

So that's the one circumstance that you would call it replacement therapy. But back to the question. The current state is that the Women's Health Initiative, which was referred to earlier, provided us with a lot of information about hormone therapy. And the results were released in 2002. And there was a lot of fear associated with the publication of the results. And part of that was related to the way they were published, which was aggregated data from women aged 50 to 79 years of age.

And I will tell you from personal experience, I don't typically have a 79 year old in my office for the first time complaining about menopause symptoms.

So when we finally really separated the data into decade and looked at those women who are typically bothered the most by menopause symptoms, those who are in the age of 50 to 59, we have come to understand, and it's well accepted now, that the benefits of hormone therapy for those women who are relatively healthy in that age group, who are under the age of 60 and within 10 years of menopause onset, that the benefits typically outweigh the risks. But we know the usage rates are down.

I'll just comment on that. So pre WHI, as many as 40% of postmenopausal women were using hormone therapy. And after publication of WHI, is somewhere in the range of 4-6%. That number hasn't been updated in the last decade or so, but we still think the prescribing rates are still low.

Okay, what you just said is that for women between the ages of 50 to 59, within a decade of symptom onset, the benefits outweigh the risk. And is that a just broadly accepted fact across the medical community?

It is fairly well accepted. But I will say it also depends on a woman's health. And there are certain women that can't take hormone therapy if they've had a heart attack or a stroke or had a history of breast cancer, for example.

Right?

Yeah, of course.

Okay.

But it's just interesting if that's kind of. We've realized that. But that then, as you said, has not trickled down into actually hormone therapy being prescribed.

Okay.

And the other thing I wanted to dig into from a comment that our previous panelists made was she was urging us to kind of use our platform as policymakers to influence research dollars and that there was still a need for kind of solid science and research. I guess, do you agree with that assessment, and can you, from your vantage point, give us a little more clarity on what needs to be researched and where could we advocate most effectively for those research dollars?

Thank you for that question. That is somewhat challenging in that the WHI, the expense related to the WHI has been estimated about $1 billion. So that study probably is unlikely to be repeated. But the study was looking at long term prevention related to hormone therapy. It wasn't meant to be a study in women who were having symptoms and who were in the typical age where women need to be managed for symptoms. So it wasn't actually looking at what we're trying to extrapolate it to now.

And it also used one particular type of hormone therapy, conjugated equine estrogens and hydroxyprogesterone acetate, which are uncommonly used now. So the type of hormone therapy that we use now, often a transdermal preparation of estradiol and micronized progesterone, we don't have as much data on in terms of safety efficacy over the long haul. One thing that's missing is we know about starting hormone therapy in your 50's, 60's or 70's.

We know nothing about starting it, say, in your 50's, when we're suggesting it be started, and continuing it on into your 60's or 70's. Because that study hasn't been done and probably won't be done because it would have to be a very long longitudinal study where women were looked at for many, many years. So the feasibility of that study is just not there. But we still have a lot of gaps in understanding the impact of hormones on different organ systems and in different situations.

For example, we're still looking at the influence of estrogen on the brain and Alzheimer's disease risk and whether early menopause is associated with higher risk. We know that in terms of bone, brain, and heart effects. And when I say early, it's really more prominent in the premature menopause group. So under the age of 40, the loss of estrogen is clearly associated with adverse effects. Giving estrogen back mitigates a lot of those effects, but may not take away all of them.

It's very much less clear when you get to menopause at the age of 50, around the average age, we have the confounding effect of aging as well. So we know that menopause, for example, is a risk for heart disease in and of itself, but we are less clear about whether giving estrogen back at that time actually helps with reducing heart disease risk.

So there are a lot of unknowns still with regard to the specific effects of estrogen on each organ system and the different types of estrogens and the impact of progesterone on that whole combination. So there's still a lot of gaps. And I know Dr. Gibson will have more to add on that as well.

I think that's actually a great segue, and I know that there'll be more questions for you, Dr. Faubion, but thank you for opening our conversation. But I do want to segue to Dr. Reeves, who is here to help dive into the experience of menopause for women of color and the disparities in the healthcare system there. And I would add to that also the research question. Right. And are there gaps in understanding those racial disparities as it relates to the research that's been done?

So, Dr. Reeves, are you on?

Yes, I'm here.

Perfect. Yeah, we can see you and hear you. Thank you.

Hi, everyone.

So, yeah, just to dive into kind of what we see for women of color. Research suggests, kind of, particularly from this study of women's health across the nation, which is a multiethnic cohort of women in the US, as they transverse the menopausal transition, that black and potentially Hispanic women have natural menopause around a year earlier than other groups. And with that, black women in the study have threefold greater odds of reporting vasomotor symptoms, which are those night sweats and hot flashes that we've been talking about compared to white women throughout the transition and experience symptoms for an average of 10 years versus 6.5 years for white women.

Despite this symptom burden, black women were less likely than white women in the study to report using hormone therapy to manage these symptoms. Also, menopause can happen surgically. I think this was mentioned by the first panelists as well. And this is having either a hysterectomy or a bilateral oophorectomy prior to natural menopause. And research suggests that black and potentially Hispanic women in the US may be more likely to experience surgical menopause than white women and other racial ethnic groups.

So my prior research, which you can read more about in the pamphlet that I put forward, and also other media coverage of this work, suggests that black women may have around double the risk of this surgical menopause compared to white women. And this is important because surgeries prior to natural menopause can cause this sharp reduction in hormone levels, rather than that natural tapering that happens during the natural transition.

And the sudden reduction in hormones can lead to a more abrupt transition, meaning worse vasomotor symptoms, potentially more adverse and earlier health consequences, such as increased risk for osteoporosis, cardiovascular conditions at earlier ages.

So kind of overall picture, the low levels of hormone therapy use in prescriptions, despite earlier occurring higher burden and longer average of burden of symptoms for black individuals experiencing natural menopause highlights kind of the disparity in the access to treatments for menopause for black women. While the high risk of surgical menopause leading to potentially higher symptomatology and adverse and earlier health effects for women of color reflects higher prescription of reproductive surgeries. But individuals with surgical, kind of touching upon the research a little bit.

Individuals with surgical menopause are often left out of menopausal research. So more systematic work on kind of the causes and consequences of this surgical menopause are sorely needed to really understand these disparities further. And I'll kind of open up for questions.

I was writing down what you said right when you paused because I thought that was so interesting. Anyone have any questions right now in this? Assembly member Jackson.

Thank you. The black caucus has just came out with doing up some follow up legislation in terms of the frankly inhumane mortality rates that are happening with black women and birth outcomes.

And it just seems to me from the time they're pregnant to the time they're going through menopause, there seems to still continue to be a difference in terms of outcomes, a difference in terms of recommendations from medical professionals as they're going through their process that seems to continue to lead them towards more drastic procedures as well as the outcomes that come out from that. What can we do?

We're trying continue training, and then when we try training, we see that training is not actually being used appropriately, and it's not really followed up in terms of efficacy and fidelity. What can we do to increase the more healthier outcomes and longevity for black women and other women of color? I'm sure there's some issues with outcomes in terms of Native American women as well, right? And so what can we do to policy wise to improve these outcomes?

Well, I think, first of all, similar to kind of what the first panelist was talking about, I think the research needs to include more women of color. It needs to include women of different gender identities so that we can understand kind of how they're transversing this menopausal transition and what leads to kind of a rougher or a rougher or a little symptom transition or whether they're having reproductive surgeries.

I think on the reproductive surgeries, kind of, some of the main indicators for having a reproductive surgery are excessive bleeding or fibroids. And so I think women of color can be, there may be a gap that needs to be filled of having more diverse treatments that are presented to women of color that don't end up with the most drastic going to hysterectomy or bilateral oophorectomy that would cause this early menopause, which we are still investigating.

What are the long term effects for health and aging for women who have this surgical menopause?

It's interesting, in the space around childbirth, one of the things that has been proven to be most effective is doulas. And that is something the state has worked to provide for women who need it, because that advocacy has been the thing that studies have shown has changed outcomes the most significantly. And I don't know, maybe we need menopause doulas or something. I don't know. I'm just putting it out there, team.

But it is part of, I think it goes back to what we're talking about, which is also a lack of information and ability to advocate for yourself as a woman as you enter this menopausal transition, when the information is so lacking. Right. And so you walk into a Doctor, you're having this problem, and you don't even understand your options and what to ask and what to look for.

And so it sort of feels the same as that support doula through childbirth that provides that extra set of eyes and advocacy. That was a very, I don't know, disheartening revelation you just provided to all of us, and a really important one, because I think that one of the things that Dr. Faubion had sort of highlighted was that this early onset of menopause, whether it be surgical or otherwise, can have long term health impacts, right?

And so you're saying we have a lack of understanding, but we have some basic understanding that really we could be harming these women in meaningful ways if they're getting recommended these surgeries unnecessarily. So I really appreciate you highlighting that for us and the need to sort of focus our research and our research participation on these communities. Although understanding there's good historical reasons why women of color often don't want to be a part of research, which we need to acknowledge and respect. But it's interesting.

I've been working on automated decision tools in the healthcare space as we move to AI making decisions around what treatments they get. And one of the learnings that I have come out of that is that one of the risks of that is we can perpetuate historical differences and discrimination in the care.

And as you were talking about it, I was thinking, zero, my gosh, if you feed this data of how black women have been treated in the menopausal space into these automated decision tools, will it perpetuate and recommend more of these surgical outcomes? So, again, this crosses so many areas of interest and concern, so things we need to look out for. Any other questions? Yeah.

Thank you so much. There's a little back chatter over here. I just came from the Doctor. That's why I was late, and they gave me this, menopause and midlife. It seemed very appropriate. But can you talk more about why do you think this is happening? Is it discrimination in health care? Is it that people don't have data and best practices and information that they need?

Are you still trying to figure this out, or do you have a good sense of why there's such a big disparity and difference in treatment of black women versus white women? And how do you dial down on that issue and address it?

I think there's a lot more work to be done in this space to understand this, and there are some experts that have been working on this longer than me that would be great to bring in on this.

But there have been some kind of preliminary research that they're showing that there are racial bias in the treatment of fibroids, given kind of the more drastic option, rather than some of the more moderate treatments, although that is not my area of expertise, but I have seen some research in that. But also there is a very high prevalence of fibroids for black women that happen earlier. They tend to be more severe.

And so that can be adding on to this increase in surgeries, early surgeries. But so much more to unpack and a lot more thinking policy wise. If research dollars can go towards unpacking this issue more and understanding this more, that would be great so that we can understand this and help black women make the best decisions for their health and long term health and aging.

Amazing. Thank you. Don't go anywhere. We're going to have more questions for you, I'm sure. But we are going to turn to Dr. Gibson to talk about the impact of psychological menopause on psychological and emotional well being. We want to talk a little bit about the state of mental health care and access for menopausal and perimenopausal women because I know one of the things that I've been learning is that women aren't being treated for menopause. Instead they're being treated on the mental health space.

And perhaps that isn't the way that we should be thinking about this. So I want to turn to you to discuss that, if you don't mind. Dr. Gibson, if you speak, you pop on the screen.

Did we lose Dr. Gibson? I can move on to Dr.--okay. So we'll come back to you, Dr. Gibson. It seems like we're having technical difficulties. So, Dr. Waetjen, I wanted to turn to you--and Dr. Faubion, if you want to weigh in on this as well--about the role of insurance reimbursement on access to care. What are the disparities--if you know--what are the disparities between the way men are covered as they age and women? And what should we be thinking about in the insurance space? So, Dr. Waetjen, are you there?

Yes, I am.

Perfect.

Can you hear me? Very good.

Hi.

I will say it's a little challenging for me to speak to this, partly because I work within a health care system where people who come to see me have insurance. And so I think probably one of the biggest issues is people who have no insurance or underinsured probably do not have access not only to the counseling, but also to the prescriptions that they might need. One of my primary interests is the genital urinary health of peri and postmenopausal women.

And one of the things that we discuss a lot is vaginal estrogen. Vaginal estrogen is often covered by people who have very good health plans, but there is a large number of women who do not have good insurance to cover medications. And in that case, a tube of vaginal estrogen cream, for example, can cost 300 to 400 dollars sometimes.

And so I don't know if this is still true, but we used to talk about how coverage for things like Viagra was often considered, whereas for women, the estrogen cream was more expensive. So that's one example that I can think of. I don't know if Dr. Faubion has any other comments.

Yeah. Dr. Faubion? Yeah.

Well, I would say I'm also in a health system, so the people who get to me are insured and also have access to care, mostly. So I agree with the vaginal estrogen issue. When you have a tube of estrogen that probably costs three dollars to make, and it's passed on to the patient as a 300 dollar expense, it becomes something that they can't use. So there are all kinds of workarounds we try to use in the clinic to manage this, but it's truly challenging.

And when you think about the fact that it's often considered a lifestyle drug, women don't just use vaginal estrogen to have sex. They use vaginal estrogen to be able to wipe after urination, to be able to wear jeans, to be able to get on a bicycle. So it's not a lifestyle drug, it really is kind of essential for health.

And when you think about even older women who have frequent urinary tract infections, you wonder how much could be saved if these women had a little bit of vaginal estrogen. And we're reducing the incidence of urinary tract infections in a subsequent hospitalization for urosepsis. So, again, not a lifestyle drug, but beyond that, the cost or the insurance coverage of the systemic estrogen therapies is so highly variable.

There are generics available, but if we go much beyond a standard regimen, for example, because a woman has an allergy to an adhesive and can't use a patch and needs a different formulation, sometimes those are just absolutely, prohibitively expensive. And with the new drugs--there was a new drug recently approved in the last year, fezolinetant, for non-hormonal management of hot flashes, and it's great that we have a new drug.

It's too bad that nobody can afford it because it's listed as, like, a third tier thing, and you have to fail an antidepressant and something else to actually get it. And if you get that far, it's incredibly expensive. So it's sad that we have new therapies that straight out of the gate no one can actually use.

Wow. Thank you. That was super helpful. Any questions on this? Yes. Assembly Member Aguiar-Curry.

I just have a quick question. There are products over the counter. Vaginal creams. So are they that different than from what the 200 dollar--yeah, because there's some that are on here. I just thought I'd Google it, and it's like 40 bucks or 20 bucks. So I'm just curious.

They're not the same thing. No. So they're not the same product at all.

And how would someone know they're not the same product?

The only products are FDA approved and available at your pharmacy. There's no product that will do what we're talking about that is over the counter. Not one.

But Google has misinformation, which shocks none of us, Assembly Member Aguiar-Curry.

But the purpose is a little bit different too. So, for example, vaginal estrogen can treat recurrent urinary tract infections. Over the counter is often lubricants that people can use either for that dry feeling that people have with wiping or can use for sexual pain and dryness.

And I have a question. Who sets the cost at 300 dollars if it costs three dollars to make it? Who's making that decision that it's 300 dollars? And what did you say? How much does it cost to get Viagra?

I don't know if it's still true. It used to be true that Viagra was better covered than vaginal estrogen. And I assume that the pharmaceutical companies are the ones that are making those determinations.

Assembly Member Schiavo.

So back to part of the earlier discussion about kind of the struggle around women not having information they need and some of the treatments being very disparate in how they're applied, how is--as someone who's not a physician--how is information shared with physicians in terms of new research, best practices, things that have been found to be not effective?

Is it kind of everyone for themselves and do your own research or is there a clear pipeline and funnel that you can get information into and you can feel confident that that's going to get out to most physicians in that space? Like, how does that happen?

Well, I can try to address that. So I am Medical Director of the Menopause Society, formerly the North American Menopause Society, and we do put out guidelines on a regular basis that are evidence-based. And just published one on non-hormone therapies for hot flashes last year, and the year before that, published our updated hormone therapy position statement. We've also published one on genital urinary syndrome of menopause and how to manage that and all the evidence behind it.

We published the same one on management of genital urinary syndrome and breast cancer survivors. So it's out there. Physicians do have to access it or any kind of medical provider. They have to know where to access data. So if you just try to get on your local feed of the latest study coming out, people aren't going to be able to sift through the information. But there are ways to go to reputable sources that have guidelines and statements out.

And I think as a follow up to that, though, Dr. Waetjen, if you can touch on the UCs, right? I mean, you're in one of our UC hospitals. What are people being trained? I mean, I have to say, I went to my doctor and asked questions about menopause and was sort of waved off and had to research and find a member of the Menopause Society who would then sit with me and actually give me the answers and clearly had sought it out himself--he was a male doctor--but I'm just curious, how are we as a state training doctors around this? How are we disseminating information to people in our UC institutions, et cetera?

Yeah, it's a very good question, and I think it's challenging. I will say from the perspective of an OB/GYN and OB/GYN residency training, there is unfortunately little emphasis on learning about menopause and older women's health. I think that part of it is structural in the sense that there is a huge need for providers to be taking care of pregnant patients. And I think there's also more financial gain, shall we say, in that arena as well for just institutions in general.

So it leaves less time for residents who are seeing mostly OB patients in their clinics to actually see more older women and be able to learn this kind of in the clinical setting. So I really think that there is a lack of curriculum in general for a lot of residency programs and a lack of opportunity for residents.

And can you talk about continuing education, right? So you go through continuing education as a physician in your field. Is this a part of it? Is it something that's available?

Yeah. So there is requirements, obviously, for us to have continuing medication--education, excuse me--and I think that, again, this becomes--people in medicine are becoming more and more subspecialized, even within the regular specialties. So, for example, there are more programs where physicians are being divided up into people who do predominantly obstetrics and people who do predominantly surgical gynecology.

And so people tend to go to the continuing medical education things that inform their particular interest in their particular practice rather than necessarily kind of as generalizable to all aspects of practice. So not everybody is going to go to a menopause meeting in order to learn more about how to manage menopause. They may go to lectures or do reading for articles that come out in journals, but it's a little bit more hit or miss in that regard.

Awesome. Thank you. That was helpful. Dr. Gibson, is your audio working now?

All right--

There we go. I hear you. So we'll come back to you on this question around mental health that I asked earlier. Did you hear it?

Yeah, absolutely. And I'll note, I mean, following up on this question about training, in mental health, we get, and with psychologists, there's certainly really no training, very limited on women's mental health, certainly none around menopause. And that's something I'd really like to expand. Thinking about the impact of menopause, menopause symptoms on mental health and well-being, and I appreciate the framing of well-being included in there, too, because I think especially--we spoke to the confluence of factors that happens during the menopause transition.

So certainly the hormonal changes, the chronological aging, role and social changes, as well as some of these bothersome menopause symptoms really just kind of have an overall effect on quality of life, well-being, day to day functioning. We know that there is some kind of specific increased elevated risk for depressive symptoms, for depressive episodes, also potentially anxiety, PTSD exacerbation, other common and less common mental health concerns specific in the perimenopause relative to other points in the lifespan.

Also that just mood symptoms, things like irritability or feeling on edge or kind of off can be commonly reported in the menopause transition, and then that a number of these symptoms and common health changes that occur just have or can have a profound effect on general, kind of emotional well-being.

So things like body shape and weight changes, genital urinary symptoms, sleep disturbance, all of these things that are incredibly common can have a huge impact on how people are kind of feeling and functioning during this time period. Particularly as we talked about, if those symptoms, things like bothersome hot flashes, night sweats, are interfering with sleep or interfering with relationships, are kind of getting in the way of a lot of things that are important to emotional well-being and they're continuing on, right, kind of for a long into folks' 50s, 60s, into their 70s, those can be some pretty lasting emotional health impacts.

Thank you. Yeah. So interesting. We've been talking a lot about information out there, right? And I think that personally, I think we all know people who've been going through the menopause transition who have had the need to get more mental health support during that time and have not received information that it could be menopause, right, and that treating their menopause may be one avenue for relief. What do you think about that piece? What information should we be getting out there? Feels like an important part of this.

Yeah. Well, I think just speaking about it today, having this kind of hearing, I think just like kind of normalization and conversation around menopause and things that may happen during that time is a really essential piece, just kind of being kind of more open and upfront about it. And then to a certain extent, we approach mental health the same way at this point in the lifespan than others.

I mean, I'm a psychologist, not a prescriber, so I lean more on behavioral interventions and evidence-based practices like cognitive behavioral therapy or mindfulness and compassion-based approaches, which can be helpful for mood across the lifespan, including during this period, but also think it can be really helpful to just incorporate sort of knowledge and discussion and conversation around how menopause and menopause symptoms may be complicating the picture or adding to the picture during this time.

So talking about sleep disturbance in the context of depression or PTSD or anxiety and talking about how night sweats or other symptoms may also be playing a role that we kind of can address those a little bit more directly, and also working within a team-based approach.

So certainly kind of work closely with my primary care and OB/GYN colleagues to make sure that people are getting kind of appropriate hormone therapy or other treatments as needed that are also helpful during this time, that it's kind of a fuller picture of addressing the whole person.

Amazing. Thank you so much. So we are almost at time, but before we go, I want to ask each of you one final question, which is, you have, I think, a very eager group of mostly perimenopausal and menopausal women here who want to help California women as they approach this transition. And if you could wave your magic wand and see a policy change happen to support women's reproductive health in this period of their life, do you have any recommendations for us for what we can do as policymakers? And I'm happy to start. I know we've covered somewhere of that, but I want to give you an opportunity to really focus on it. Dr. Faubion, do you want to start?

Wow. I wish I could give you one thing that would move the needle. I think we need some practice standards that ensure that women's health is actually being addressed adequately during this time. I don't know quite how to have that documented, but just like we have standards of care for other things, another consideration would be, I've heard it proposed that there be a Welcome to Menopause visit, just like there's a Welcome to Medicare visit.

When and where that should be delivered and who's responsible for it is another question. I think we're going to have to try to get that information to women sometime around age 35, certainly no later than 40, because many women are having symptoms by then. But who's responsible for giving it? Is it all primary care doctors who creates the material? But that could be one way of getting some information to women. Those are some initial thoughts. Certainly we need lots more funding for research.

Yeah. I also often say, do we need more funding or do we need funding to start focusing on women and our health? But, you know, sometimes it's a prioritization issue rather than a total allocation issue. Moving to Dr. Reeves.

So, policy is not my area of expertise. So I'm not going to recommend any magic wand-specific policy. But I think just in general, just to think about some things to highlight that I think are really important when thinking about creating legislation around menopause, first to make sure that both natural and surgical menopause are included in policies that are defining and affecting menopause.

Second, that the diverse experiences of menopause, whether someone experiences little to no symptoms, many symptoms, excessive bleeding, little bleeding, are supported and destigmatized as each individual really has a unique transition. And three: to think about how policies are going to affect and reflect the diverse range of experiences of people that go through menopause.

So, for example, by making sure to prioritize the inclusion of minoritized persons, individuals of varying gender identities, which we have very little research on, and the individuals with varying access to health care and treatment options. Thanks.

Awesome. Thank you. That's really important. And Dr. Gibson, anything you'd like for us to think about in this space you specialize in?

I think I'm lucky to provide care within the VA health care system, which know our kind of national health care system, where I don't have to think about insurance coverage and I don't have to think where we have mental health, behavioral health, nutrition, social work, different specialties all sort of embedded and integrated within care teams. And I think spreading that model wherever possible, however that can be supported by kind of policy and coverage, is really helpful. Being able to have comprehensive, team-based, integrated care to address menopausal health in all health care settings would be incredibly helpful.

I love that. I often think about how much we could put all the money into research that we spend giving women tests they don't need because we didn't realize it was actually just menopause that was causing the thing that they're looking into. So there are a lot of resources being wasted because we don't understand this period in women's lives, as I see it. And lastly, Dr. Waetjen. Thoughts for us?

Yeah, I think that, I know that there are many people who are turning to apps or resources outside of the standard medical system in order to get care, and I actually find that sad. I think my focus would want to be on more training, and I think about one of the grants that came up through California that our institution received, which was more training for opioid use disorder in pregnancy. So it was a grant to kind of improve primary care training in that particular area.

And I think that that could be an effective way to increase knowledge about menopause and management of menopause by improving the education of primary care providers and OB/GYNs more broadly.

Thank you. And I have to say a huge shout out--as someone who commutes to work every day and listens to a lot of podcasts--to the physicians out there who are doing in a puzzle podcast to provide real, accurate, science-based information in this space because people are turning to things like podcasts because they just have no other way of getting information. So those physicians are partially my heroes in all this.

So I just want to thank you all for being here, for working with us. I don't know if you could see us because it sounded like there were some issues on the visual end, but we really had a lot of members here that were very engaged in this. So I want to thank you all for helping answer our questions. I'm sure this isn't the end of them. This is just the beginning.

As I mentioned, we're going to have more hearings on the topic, including the impacts on social and medical fields of this major reproductive health shift that each of us goes through. So we'll be back on March 4th for a discussion of menopause in the workplace.

And we have a lot of work ahead of us, and I think we're all excited to be a part of the destigmatization of menopause and a real transition to supporting women through this inevitable part of their lives that, as Assembly Member Papan said, should be a moment of transition that is empowering rather than one that is confounding, confusing, and hard to find good care in. So thank you all. Really appreciate it. With that, we'll see--I don't know if there's anyone in the room with public comment, but I'm opening it up. Great. Then we will adjourn the hearing. Thank you.