Menopause and the Skin: New Global Survey Reveals Widespread Knowledge Gaps and Rising Demand for Aesthetic Solutions
Table of Contents
- Key Highlights
- Introduction
- What the global survey revealed: scope, demographics and headline figures
- How declining oestrogen remodels skin: biology and clinical effects
- Emotional and social consequences: more than skin deep
- Which skin changes are most common — and where
- How women are responding: current behaviours and treatment preferences
- Aesthetic tools explained: injectables, biostimulators, skinboosters and more
- Non‑aesthetic options and prevention: skincare, lifestyle, and HRT considerations
- Clinical practice implications: how dermatologists and aesthetic practitioners should adapt
- Industry response and research agenda: trial design and the inclusion of menopausal status
- Cultural, access and equity considerations: geography, affordability and stigma
- Practical roadmap for women: assessment, options and questions to ask providers
- FAQ
Key Highlights
- A global survey of more than 4,300 peri‑ and post‑menopausal women finds major gaps in awareness about menopause‑related skin changes and shows aesthetic treatments produce the highest satisfaction among treatment options.
- Declining oestrogen accelerates loss of collagen, elastin and hyaluronic acid—leading to increased lines, loss of firmness, dryness and dullness—and these changes have measurable consequences for confidence and social behaviour.
- Galderma will begin including menopausal status in clinical trials and is promoting education and evidence‑based approaches to prevention and treatment, while many women say they would have acted differently if they had known earlier.
Introduction
Menopause marks a predictable shift in reproductive hormones, but its effects extend far beyond hot flashes and sleep disruptions. Skin undergoes measurable structural and functional changes when oestrogen levels fall—changes that most women experience but few anticipate. A new multinational survey presented by Galderma at the IMCAS 2026 World Congress quantifies those shifts and illuminates the emotional and behavioural toll they impose.
The findings show an unmistakable mismatch between lived experience and prior knowledge. Women reported an average of three distinct skin changes since the onset of menopause yet half said they were neutral or dissatisfied about how much they knew beforehand. That gap narrows the window for prevention and fuels demand for corrective interventions. This article synthesizes the survey data, explains the underlying biology, assesses current aesthetic and non‑aesthetic responses, and outlines practical guidance for clinicians and women navigating this life stage.
What the global survey revealed: scope, demographics and headline figures
Galderma’s poster at IMCAS reports responses from more than 4,300 women aged 45–60 across nine countries: the United States, Brazil, Germany, the United Kingdom, Saudi Arabia, the United Arab Emirates, Egypt, China and Thailand. All respondents were peri‑ or post‑menopausal and either had received or were open to aesthetic treatments, providing a perspective from women already engaged with appearance‑focused healthcare.
Key quantitative takeaways:
- Average number of skin changes experienced since menopause onset: 3.
- Awareness pathways: more than 50% of women learned about menopause‑related skin changes by going through them rather than via education or medical advice.
- Timing of awareness: most women became aware in their 40s; over 30% wished they had learned in their 30s.
- Knowledge satisfaction: roughly 50% reported feeling neutral or dissatisfied with their understanding of menopause‑related skin effects.
- Emotional impacts: 60% said skin changes made them feel less attractive; 57% reported increased anxiety; 55% felt less confident; 46% were less inclined to socialise.
- Types of changes: lines/wrinkles (face 59%, body 33%), loss of firmness/elasticity (face 58%, body 54%), increased dryness (face 56%, body 58%), and duller skin tone (face 40%, body 30%).
- Treatment preferences: 47% would consider anti‑wrinkle treatments; 41% hyaluronic acid injections; 39% hyaluronic acid skin‑quality treatments; 30% biostimulators.
- Treatment purpose: 49% currently use aesthetic treatments to address symptoms; only 26% use them preventively.
- Regret/wishes: more than 60% said they would have acted differently if they’d known earlier about expected skin changes.
The scale and international reach of the survey show that menopause‑related skin issues are broadly experienced and carry consistent emotional consequences across regions. The findings point to educational and clinical gaps that, if addressed, could change both preventive behaviours and treatment outcomes.
How declining oestrogen remodels skin: biology and clinical effects
Oestrogen operates at multiple levels in skin physiology. It interacts with receptors on fibroblasts and keratinocytes, modulates the extracellular matrix, influences glycosaminoglycan content, and supports microvascular function and sebaceous activity. During the peri‑menopausal window, fluctuations give way to a sustained decline that triggers measurable structural change.
Mechanisms and clinical manifestations:
- Collagen and elastin reduction: Fibroblast activity falls as oestrogen decreases, producing less collagen and elastin. Galderma cites a 30% reduction in collagen in the first five years after menopause. Loss of these structural proteins decreases dermal thickness and tensile strength, producing sagging, reduced firmness and increased static wrinkles.
- Hyaluronic acid decline: Levels of endogenous hyaluronic acid (a key hydrating molecule) fall, compromising water retention within the dermis and epidermis. Clinically this appears as increased dryness, itchiness and a decrease in plumpness and radiance.
- Epidermal thinning and barrier dysfunction: A thinner epidermis leads to increased transepidermal water loss. Mechanical resilience decreases, and skin becomes more sensitive to irritants and environmental stressors.
- Fat redistribution and volume loss: Menopausal hormonal shifts alter subcutaneous fat distribution. On the face this can accelerate tear troughs, midface deflation and jowling—features often addressed with volumising procedures.
- Sebum changes and texture: Sebaceous gland activity may decline in some women, worsening dryness and rough texture; in others, hormonal fluctuations can interact with metabolic factors to alter oiliness.
- Vascular and pigmentation shifts: Microvasculature changes can influence pallor and flushing; melanin distribution may shift, producing changes in pigmentation and skin tone.
The biological cascade rooted in oestrogen decline explains why multiple, concurrent changes appear. That simultaneity complicates treatment: a single topical product may address hydration but not firmness, while an injectable can restore volume but not epidermal barrier function. An effective program blends strategies targeted to the skin layers and mechanisms at fault.
Emotional and social consequences: more than skin deep
The survey quantifies what clinicians often observe in practice: skin changes intersect with self‑image, social behaviour and mental health. Reported outcomes are not trivial. Sixty percent feeling less attractive and over half experiencing increased anxiety or reduced confidence show that skin aging during menopause is a psychosocial health issue.
Real‑world vignette Consider a 52‑year‑old teacher who had never particularly thought about skincare beyond sunscreen. Over two years she noticed increased facial lines, a loss of jawline definition and marked dryness. She withdrew from school photographs and avoided social events with former colleagues. Medical appointments focused on vasomotor or sleep symptoms; nobody addressed her distress about appearance. After consulting a dermatologist, she underwent a combined plan: topical regimen emphasizing barrier repair and hyaluronic acid serums, localized neuromodulator injections for static lines, and microinjections of HA for skin quality. Three months later she reported improved sleep, increased confidence and returned to social outings. That narrative illustrates how addressing skin can restore an aspect of wellbeing that other therapies may not reach.
Clinical implications
- Providers should screen for the psychosocial impact of skin changes and incorporate quality of life outcomes into treatment planning.
- Multidisciplinary care may be appropriate. Collaboration between dermatologists, gynecologists and mental health professionals can align symptom management with broader health goals.
- Patient counselling should frame interventions as tools to restore function and self‑perception rather than as mere aesthetic vanity.
Which skin changes are most common — and where
The survey separates facial from body changes—an important distinction because treatment options and patient priorities differ by location. Women reported the following prevalences since menopause onset:
- Lines and wrinkles: face 59%, body 33%.
- Loss of firmness and elasticity: face 58%, body 54%.
- Increased dryness: face 56%, body 58%.
- Duller skin tone: face 40%, body 30%.
Interpretation
- Facial concerns dominate but body issues are common and often overlooked. Neck, décolletage, arms and legs—areas with thin skin—show significant structural decline and may respond differently to interventions.
- Dryness rates on the body slightly exceed facial dryness, reflecting a widespread systemic effect on skin hydration that warrants whole‑body care rather than spot treatment.
- Duller skin tone on the face remains a high priority for many women because it is visually noticeable and closely tied to perceptions of age and health.
These prevalences should guide clinicians in assessment: a comprehensive skin exam beyond the face, including hands, arms and chest, ensures a full understanding of the patient’s concerns and treatment opportunities.
How women are responding: current behaviours and treatment preferences
The survey captures both current behaviors and future intentions. Nearly half of the women using aesthetic interventions do so to address active menopause‑related changes rather than to prevent them. Only 26% report preventive use. This reactive trend correlates with delayed awareness—most women learned about skin impacts only after symptoms began.
Treatment interest and uptake:
- Anti‑wrinkle treatments: 47% would consider.
- Hyaluronic acid injections: 41% would consider.
- Hyaluronic acid skin‑quality treatments (skin boosters): 39% would consider.
- Biostimulators: 30% would consider.
Satisfaction Aesthetic treatments produced the highest satisfaction among a range of actions that included cognitive behavioural therapy, exercise alterations, supplements and traditional medicine. Women reported the greatest perceived efficacy with aesthetic approaches, particularly when treatments targeted root causes (e.g., boosting collagen or restoring hydration).
Why satisfaction may be higher with aesthetic care
- Direct, measurable improvement in visible features often produces a rapid feedback loop: appearance improves, confidence increases, perception of wellbeing improves.
- Many aesthetic treatments aim at the structural problems created by oestrogen decline—collagen loss, volume loss and hydration deficits—rather than merely masking symptoms.
- Patient expectations increasingly align with realistic outcomes thanks to advanced techniques and better clinician counselling.
Limitations to current practice
- Many patients seek corrective rather than preventive care solely because they learned too late. Earlier education could allow interventions that slow the visual trajectory and may require less intensive treatment later.
- Access and cost remain barriers. Aesthetic procedures are often not covered by insurance and affordability shapes when and whether women pursue care.
Aesthetic tools explained: injectables, biostimulators, skinboosters and more
Understanding what each category of aesthetic treatment does enables targeted choices. Below is an overview of common options cited in the survey and their mechanisms.
Neuromodulators (anti‑wrinkle treatments)
- Typical agent: botulinum toxin.
- Mechanism: reduces muscle contraction that causes dynamic lines (e.g., glabellar lines, crow’s feet).
- Role in menopause: effective for dynamic wrinkles that become more apparent as collagen support declines. Neuromodulators smooth movement‑related lines but do not restore lost collagen or volume.
- Recovery & expectations: minimal downtime; effects visible within days and typically last 3–6 months.
Hyaluronic acid (HA) fillers
- Typical agent: cross‑linked HA gels injected into specific areas.
- Mechanism: immediate restoration of volume and contour; HA also attracts water, improving local hydration.
- Role in menopause: addresses volume loss in cheeks, lips and jawline; contouring can reduce appearance of sagging.
- Recovery & expectations: immediate volumising effect; duration varies by product and placement (6–24 months or longer).
HA skin‑quality treatments (skinboosters)
- Typical agent: microinjections of stabilized HA into the superficial dermis.
- Mechanism: improves hydration, skin elasticity and radiance by increasing interstitial water and stimulating local fibroblasts.
- Role in menopause: targets decreased HA levels and dryness; improves texture and glow rather than producing dramatic volume change.
- Recovery & expectations: multiple sessions often recommended; cumulative improvements in skin quality.
Biostimulators
- Examples: poly‑L‑lactic acid (PLLA), calcium hydroxylapatite (CaHA).
- Mechanism: stimulate collagen neogenesis by inducing a controlled inflammatory response that recruits fibroblasts.
- Role in menopause: addresses deeper structural decline by promoting new collagen and improving firmness over months.
- Recovery & expectations: improvements unfold gradually over months; results can be long‑lasting (up to 2 years or more dependent on product and treatment plan).
Combination strategies
- Addressing menopausal skin often requires a multimodal approach. Clinicians combine neuromodulators for dynamic lines, HA fillers or biostimulators for volume and collagen, and skinboosters or topicals for hydration and texture.
- Sequencing and patient selection matter. For example, starting with skin quality and barrier repair before deep volumising provides a stable substrate for injectable work.
Safety and provider qualifications
- All injectable procedures carry risks: bruising, swelling, infection, nodules or overcorrection. Serious complications are rare but require prompt recognition.
- Outcomes depend heavily on practitioner skill and anatomical knowledge. Women should seek board‑certified dermatologists or plastic surgeons and confirm the provider’s experience with menopause‑related presentations.
Non‑aesthetic options and prevention: skincare, lifestyle, and HRT considerations
Aesthetic interventions excel at correcting visible features but they sit alongside prevention and general skin health strategies. A layered approach begins with education and routine care.
Topical skincare: fundamentals
- Sunscreen: the single most important preventive measure against photoaging. Daily broad‑spectrum SPF reduces cumulative damage that compounds menopause‑related structural changes.
- Moisturisers and barrier repair: ceramide‑rich creams and occlusive emollients restore barrier function and reduce transepidermal water loss.
- Hyaluronic acid serums: topicals improve surface hydration and plumping.
- Retinoids: topical retinoids promote epidermal turnover and can increase dermal collagen density over time. Use cautiously with appropriate guidance to avoid irritation.
- Antioxidants: vitamin C and other antioxidants protect against oxidative stress and can brighten skin tone.
Lifestyle measures
- Nutrition: adequate protein and vitamin C support collagen synthesis. Omega‑3s and micronutrients influence skin health.
- Smoking cessation: smoking accelerates collagen degradation and reduces microvascular supply.
- Sleep and stress management: chronic stress and poor sleep dysregulate repair pathways and contribute to inflammatory skin conditions.
- Physical activity: exercise supports circulation and systemic health but needs to be paired with other measures to influence skin structure significantly.
Systemic hormone therapy (HRT)
- Role: HRT restores circulating oestrogen and has been shown in clinical settings to improve skin thickness, elasticity and moisture.
- Considerations: HRT is a medical therapy with systemic effects and contraindications; decisions should follow individualized risk–benefit assessment in consultation with a gynecologist or primary care clinician.
- Integration with aesthetic care: some patients may opt for HRT as part of a broader program that includes topical and procedural interventions. HRT does not eliminate the need for localized aesthetic treatments but can complement them.
Supplements and traditional remedies
- Many women try supplements (collagen peptides, hyaluronic acid supplements) or traditional medicine. Evidence varies; controlled trials are limited and quality differs by product.
- Providers should discuss safety, interactions and realistic expectations.
Prevention timing
- The survey indicates a missed window. Education beginning in the 30s or early 40s could prompt earlier adoption of sunscreen, targeted topicals and lifestyle measures that preserve the skin’s structural reserve.
- Women with risk factors for accelerated aging (smoking, significant sun history) should be prioritized for educational outreach.
Clinical practice implications: how dermatologists and aesthetic practitioners should adapt
The combined clinical and psychosocial data from the survey point to concrete steps clinicians can take.
Screening and history taking
- Record menopausal status as a routine part of dermatology and aesthetic intake forms. Ask about peri‑menopausal symptoms and the timeline of changes.
- Document psychosocial impact with validated patient‑reported outcomes when possible. Ask direct questions about confidence, social activities and self‑perception.
Patient education
- Provide anticipatory guidance. Explain the typical trajectory of collagen and HA decline and how that translates into visible changes.
- Offer a staged plan that includes prevention, conservative measures and escalation options so patients can make informed, cost‑sensitive choices.
Tailored treatment plans
- Combine topical, minimally invasive and injectable treatments according to the dominant mechanisms. For example:
- Predominant dryness with minor lines: barrier repair + HA skinboosters.
- Volume loss with sagging: HA fillers and biostimulators with adjunctive skin quality treatments.
- Dynamic wrinkles: neuromodulators together with collagen stimulators for long‑term structural improvement.
- Manage expectations: clarify maintenance schedules, likely duration of effect and that treatments address manifestations rather than replacing hormone therapy.
Safety and training
- Ensure injector competence. Anatomical knowledge is essential when working with older skin that may have altered tissue planes.
- Monitor for adverse events promptly and educate patients about normal post‑procedure expectations and warning signs.
Documentation and outcomes research
- Add menopausal status to outcomes registries. Collect and analyse data on treatment efficacy and durability stratified by menopausal stage.
- Contribute to prospective registries examining how menopausal status modifies response to injectables and other procedures.
Industry response and research agenda: trial design and the inclusion of menopausal status
Galderma’s commitment to include menopausal status in future clinical trials addresses a persistent blind spot. Trial designs that ignore hormonal status risk conflating heterogeneous responses and missing subgroup effects.
Key research needs
- Stratified randomized controlled trials comparing peri‑menopausal vs post‑menopausal responses to the same injectable modality.
- Longitudinal studies that measure trajectories of collagen, HA and elasticity and correlate biological markers with clinical endpoints.
- Trials that include patient‑reported outcomes focused on quality of life, social engagement and mental wellbeing.
- Comparative effectiveness research that positions hormonal therapy, topical regimes and injectables in multimodal strategies.
Practical trial design considerations
- Define menopausal status clearly (e.g., based on menstrual history, hormone assays when necessary).
- Include diverse populations representing different ethnicities and skin phototypes to ensure results generalize globally.
- Standardize outcome measures: objective metrics (e.g., dermal thickness via ultrasound, biomechanical measurements) and validated subjective scales.
- Consider real‑world pragmatic trials to capture treatment combinations and maintenance patterns typical in practice.
Regulatory and ethical dimensions
- Transparent reporting of menopausal status and subgroup analyses aligns with regulatory expectations for precision medicine. It strengthens claims about efficacy and safety for populations most affected by the condition.
- Ethical recruitment should avoid paternalistic narratives that medicalise normal aging; consent must emphasise realistic outcomes and risk profiles.
Cultural, access and equity considerations: geography, affordability and stigma
Although the survey spans nine countries, cultural attitudes and economic access shape how women perceive and pursue care.
Cultural attitudes
- In some regions, discussing menopause and aging remains taboo; women may learn late because of social silence. Community education campaigns must be culturally sensitive and leverage trusted local channels.
- Perceptions of appearance and the acceptability of aesthetic treatment vary. Providers should tailor messaging to local norms and individual patient values.
Access and cost
- Many aesthetic interventions are elective and self‑pay. Cost influences timing and type of treatment selected. Payment structures, financing options and tiered treatment plans can expand access responsibly.
- Public health systems and insurers rarely cover aesthetic treatments, even when they carry psychosocial benefits. Advocacy for coverage of medically necessary interventions (e.g., severe skin conditions causing distress) may be appropriate.
Equity in research and product development
- The industry must ensure diverse representation in trials and marketing. Ethnic differences in skin aging patterns and complications exist; products and techniques should be validated across skin types.
Stigma and marketing ethics
- Avoid messaging that stigmatizes natural aging. Education should empower informed choice, distinguishing between therapeutic interventions for distressing symptoms and optional aesthetic preferences.
Practical roadmap for women: assessment, options and questions to ask providers
Women seeking to understand or treat menopause‑related skin changes need a pragmatic pathway from education to action.
Step 1: Self‑assessment and education
- Note the timing and progression of changes: When did you first notice lines, dryness, loss of firmness? Are symptoms worsening rapidly?
- Track psychosocial impact: Are you avoiding social situations, photos or interactions because of appearance? That is relevant medical information.
Step 2: Find the right clinician
- Seek board‑certified dermatologists or plastic surgeons with experience in injectables and skin quality treatments.
- Ask about the clinician’s experience with menopausal patients and request before‑and‑after photos from comparable cases.
Step 3: Baseline workup and goals
- Discuss overall health, medications and any hormone therapy. Consider gynecologic consultation if systemic HRT is under consideration.
- Define realistic goals: Are you aiming for improved hydration, restored volume, fewer dynamic lines or overall radiance?
Step 4: Conservative measures first
- Begin or optimize a routine: daily sunscreen, barrier‑repair moisturiser, hyaluronic acid serums, and a retinoid if appropriate and tolerated.
- Implement lifestyle changes: smoking cessation, nutrient‑dense diet, sleep hygiene and stress reduction.
Step 5: Procedural planning
- For hydration and radiance: consider skinboosters and medical‑grade facials.
- For volume loss and contouring: HA fillers or biostimulators depending on the desired durability.
- For dynamic lines: neuromodulators.
- For global firmness: combine collagen stimulators with topical maintenance.
Step 6: Maintenance and monitoring
- Understand maintenance intervals and total cost of ownership. Some treatments require yearly touch‑ups; others provide multi‑year durability.
- Monitor for side effects and maintain follow‑up appointments. If considering future surgeries, coordinate timelines and scar considerations.
Questions to ask your provider
- What is my menopausal status and how could it affect treatment outcomes?
- Which procedures do you recommend for my primary concerns, and why?
- What are the realistic timelines and duration of effect?
- What are the risks and how will you manage complications?
- Can you show me comparable cases among menopausal patients?
FAQ
Q: Are menopause‑related skin changes preventable? A: They are partly preventable. Sun protection, barrier maintenance, avoiding smoking and timely topical interventions can slow visible change. Hormone replacement therapy can improve skin parameters in some women but requires individualized medical assessment. Some degree of structural change is expected as oestrogen falls.
Q: Do aesthetic treatments stop the hormonal process causing the changes? A: No. Aesthetic treatments correct or mitigate visible manifestations—volume loss, decreased hydration, wrinkles—or stimulate collagen production. They do not alter systemic hormonal decline; hormone therapy is the medical option that changes circulating levels.
Q: At what age should I start preparing my skin for menopause? A: Many women wish they had started earlier. Initiating preventive measures in your 30s or early 40s—sunscreen, barrier repair, antioxidant protection and targeted topicals—builds skin resilience and may reduce the intensity of later interventions.
Q: Are injectables safe for post‑menopausal skin? A: Injectables can be safe and effective when performed by qualified practitioners. Older skin may present different anatomical considerations, such as thinner tissue and altered vasculature, making clinician experience essential. Discuss medical history, medications and expectations with your provider.
Q: What’s the difference between hyaluronic acid fillers and skinboosters? A: Fillers are designed to replace lost volume and reshape contours by placing a gel into deeper tissue planes. Skinboosters are microinjected into the superficial dermis to improve hydration and skin quality rather than to create volume. Both use HA but serve different functions.
Q: How do biostimulators work and are they suitable for menopausal skin? A: Biostimulators induce collagen production by activating fibroblasts. They provide gradual structural improvement and can be particularly useful for firmness and long‑term texture enhancement. They are appropriate for many menopausal patients but require careful patient selection and counselling on the timeline of results.
Q: Should menopausal status be included in clinical trials for aesthetic treatments? A: Yes. Menopausal status influences tissue biology and likely modifies treatment response. Including it as a stratification factor will improve evidence‑based guidance for this large patient population.
Q: How do I choose between hormone therapy and aesthetic treatments? A: The decision depends on symptom profile and medical history. HRT addresses systemic effects of oestrogen deficiency and can improve skin parameters; aesthetic treatments target localized manifestations. Discuss risks, benefits and goals with both your gynecologist and dermatologist to develop a combined plan if appropriate.
Q: Will treatments be covered by insurance? A: Most aesthetic procedures are elective and self‑pay. HRT, when medically indicated, may be covered depending on healthcare systems and individual plans. Discuss financing and prioritization of interventions with your provider.
Q: What role does mental health play and how should it be addressed? A: Skin changes can produce significant anxiety, reduced social engagement and lowered confidence. Mental health support—counselling, support groups or cognitive behavioural therapy—can be integral to comprehensive care. Addressing appearance concerns often improves wellbeing but should be part of a holistic plan.
Q: Are there differences in menopausal skin changes across ethnicities? A: Patterns and visibility of aging features vary by skin phototype and facial structure. Pigmentation issues, for example, may be more prominent in some groups. Clinical trials and treatment plans should reflect diverse populations to ensure safe and effective care across ethnicities.
Q: How soon will I see results from aesthetic treatments? A: Results vary by modality. Neuromodulators show effects within days; fillers provide immediate volume; skinboosters and biostimulators yield progressive improvements over weeks to months. Your provider should give a timetable based on chosen interventions.
Q: Can lifestyle and supplements replace clinical treatments? A: Lifestyle measures and certain supplements support skin health but rarely replicate the localized structural improvements achieved by injectables and procedural treatments. A combined strategy optimizes outcomes.
Q: If I start aesthetic treatments now, will I need more later? A: Maintenance is common. Frequency depends on product choice, biological response and ageing trajectory. Effective early intervention can, in some cases, reduce the intensity of future procedures.
Q: How do I verify a practitioner’s qualifications? A: Check board certification, training in dermatologic or plastic surgical procedures, ask about specific experience with menopause‑related cases and request before‑and‑after photos of comparable patients. Patient reviews and clinic accreditation are additional indicators.
— End of FAQ —
Menopause initiates a predictable biological pathway that reshapes the skin in ways women notice and that clinicians can address more effectively if armed with the right data and tools. The Galderma survey highlights a striking educational gap and a clear patient appetite for both preventive education and evidence‑based interventions. Better screening, inclusion of menopausal status in clinical trials, and coordinated care that blends conservative and procedural options will improve outcomes for women facing these changes.