Almost every woman in Israel over the age of 36 suffers from perimenopausal symptoms – but most are undiagnosed, do not receive treatment, and are forced to cope alone with a long list of physical and mental phenomena. This emerges from a new, first-of-its-kind survey in Israel, conducted among 1,669 women, initiated by the #Medabrot_Peri community, which brings together women in the perimenopause period (before menopause), led by Desi (Hadas) Mandel in collaboration with the Israeli Menopause Society headed by Dr. Gideon Kopernik.
The survey findings were recently submitted to the FDA, the U.S. Food and Drug Administration, in response to its public call as part of a historic process the organization is leading to update warning labels and usage guidelines for hormonal treatments for women. This is a groundbreaking Israeli initiative that combines real-world testimonies with current scientific evidence, which could affect the lives of hundreds of millions of women in Israel and around the world.
“If you still have your period – everything’s fine”
The survey presents a troubling picture: Over 70% of women aged 41–55 suffer from six or more symptoms, and even among those aged 36–40, 57% report a similar situation. Despite this, nearly half of them never raised the issue during a doctor’s visit, and only 2.8% said their doctor initiated the conversation. Only 11.4% reported that their doctor reviewed an organized list of symptoms with them, as required by leading international professional guidelines for diagnosis and treatment planning. Only 18.7% of respondents said they received sufficient explanations from their doctor.
“At 44, I went to my doctor with insomnia, mood swings, night sweats, and irregular periods,” says Dasy Mandel, who initiated the survey. “She silenced me and said: ‘If you still have your period – everything’s fine.’ No. It’s not fine. And that’s exactly the problem – according to our survey, about 10% of women hear this same response. Most doctors are simply unaware of or fail to recognize perimenopause, leaving women to suffer without diagnosis or care.”
The survey refutes the common myth that menopause begins only when menstruation stops or that it is mainly about hot flashes. Dr. Gideon Kopernik, Chairman of the Israeli Menopause Society, explains: “According to the medical definition, menopause itself is just one day – the day marking one year since the last period. But in practice, it’s a long process that starts years earlier. The perimenopause period (before menopause) begins already in one’s 30s and 40s, sometimes while cycles are still regular and the woman is at peak fertility, yet hormone levels – estrogen and progesterone – begin to drop and become imbalanced. And that’s where most symptoms come from.”
The symptoms described by participants in the survey paint a picture far broader than just hot flashes:
Insomnia (73%), mood changes (71%), abdominal weight gain (59%), brain fog (56%), difficulty concentrating (54%), and one or more vaginal symptoms such as dryness, pain, or recurrent infections (51%). Hot flashes, the most recognized sign of menopause, ranked only 12th (37%).
“Some women come to us while their menstrual cycles are still active, and sometimes even regular,” emphasizes Dr. Kopernik, “with sleep disturbances, mood swings, cognitive changes, decreased libido, and physical symptoms that interfere with their ability to work, maintain relationships, and live full lives. This is not a ‘passing phase’ – it’s a period with deep medical, emotional, and social implications. It can start young and last five, ten, or even more years.”
Hormone replacement therapy (HRT) is intended to balance the declining levels of estrogen and progesterone during perimenopause. Fear of the treatment arose following the publication of the WHI study in 2002, which included women with an average age of 63, many years after menopause. Although the study was not designed to assess the effects of hormones on younger women, its results were presented broadly and caused global panic. As a result, the FDA ordered that all hormonal treatments carry a “black box warning” – the strictest safety warning.
More than two decades have passed since, during which additional knowledge has accumulated from the WHI study and hundreds of other studies showing that hormonal therapy, when given at the right time and in the correct dosage, is safe, effective, significantly improves quality of life, and even provides protection for the heart, brain, and bones. Leading professional associations worldwide now define hormonal therapy as the first-line treatment for perimenopausal symptoms.
“Doctors and women are still afraid of hormones because of headlines from more than 20 years ago and myths that have developed over the years,” says Dr. Kopernik. “But science tells a completely different story. According to the survey, although only about a quarter of women were offered hormonal therapy, among those who used it, nearly 80% reported significant improvement in at least one symptom, including sleep, hot flashes, night sweats, and mood. Serious side effects were reported in less than half a percent of cases, and even those lacked proven direct connection. We have safe treatments that can change lives – it’s time to dispel the myths and fears.”
Even in the field of local vaginal treatment, the data are worrying. More than half of the women reported at least one vaginal symptom – dryness, pain, recurrent infections, or discharge – but fewer than 10% used local vaginal estrogen treatment (LVE), which is hardly absorbed into the bloodstream and has been found in studies to be almost completely safe.
“The fear created by the FDA’s ‘black box’ warnings caused enormous damage, deterring doctors from offering and women from using a safe local treatment,” says Desi Mandel. “According to the survey data, more than 70% of the women who were treated reported improvement in their symptoms.”
Although studies show that vaginal symptoms directly affect quality of life, functioning, self-confidence, and intimate relationships, many women still do not receive a simple, safe, and effective treatment that can restore comfort, confidence, intimacy, and quality of life.
“During two decades in the medical industry, during which I also managed clinical trials and led FDA product approval processes, I saw how much the label wording influences treatment accessibility,” adds Mandel. “When there’s a ‘black box warning,’ even a safe and effective treatment becomes inaccessible – not only in the U.S. but also here in Israel. It’s time to update the guidelines to reflect current scientific knowledge, not outdated fears.”
The survey results were submitted to the FDA to support the removal of the “black box warning” on local vaginal estrogen treatment and to update the warnings and usage guidelines for hormonal treatments in general.
The survey was initiated by Hadas (Dasy) Mandel as part of the activities of the #Medabrot_Peri community, which serves as a center of knowledge and support for women in Israel. The community makes research- and science-based knowledge and information accessible to women so that each woman can understand what is happening in her body, learn about treatment options, and choose what’s right for her – with the goal of going through the perimenopause period in the best way possible. The initiative was conducted in collaboration with the Israeli Menopause Society, headed by Dr. Gideon Kopernik, which works with physicians to provide updated information, dispel fears, and encourage research-based discussion and treatment with patients. The survey was conducted independently, without conflicts of interest and without dependence on commercial entities.