THE MANIFESTO

She is forty seven years old and she is very good at her life.

She runs a department, or a household, or both. She has kept everyone fed and clothed and loved and on schedule for two decades. She is the one people call. She is competent in a way that is so complete it has become invisible, even to her.

And then something starts happening to her that she cannot name.

She wakes at three in the morning with her heart going like she has been running. Not anxious about anything in particular. Just awake, and afraid, in the dark. She lies there until the light comes.

She loses words. Not big words. Ordinary ones. The word for the thing you put your keys in. She stands in a meeting she is leading and the sentence simply stops.

Her body changes shape and will not change back, and she is doing everything she has always done.

She feels rage she has never felt in her life. It arrives out of nowhere and it frightens her, because she has never been that person, and now she is snapping at people she loves, and then sitting in the car afterward wondering what is wrong with her.

Sex hurts, and she does not tell anyone that. Not her friends. Not her husband. Not her doctor. She has decided it is her fault.

So she does the responsible thing. She makes an appointment.

She waits 5 weeks. She fills out the forms. She gets 7 minutes. She says all of it out loud, which took more courage than anyone in that room understood.

And she is told: your labs are normal.

She says, but I am telling you something is wrong.

And she is told: you are getting older. Have you tried exercising? Would you like an antidepressant?

She drives home. And somewhere on that drive, quietly, without ceremony, she decides that she is the problem. That she is weak, or dramatic, or imagining it. That everybody goes through this and she just is not handling it as well as they are.

And she stops asking.

I want to be very careful here, because it would be easy to hear that and think it was one bad doctor, one bad day, one unlucky woman.

It was not. It is not.

That outcome is produced reliably, at scale, by a system that was built without her. And I can show you exactly how, with numbers.

In fiscal year 2023, women's health research accounted for 7.9% of National Institutes of Health grant funding.

Not 7.9% of some women's set aside. Of the whole thing. For half of the human beings alive. That figure comes from a report Congress itself commissioned, delivered by the National Academies of Sciences, Engineering, and Medicine.

And it is going the wrong way. Across the decade from 2013 to 2023 the average was 8.8%. By 2023 it had fallen to 7.9%.

Menopause research specifically received about $56 million in 2023.

The NIH budget that year was over $47 billion.

Do that arithmetic slowly. It comes out to roughly 0.1%. One tenth of one percent.

Every woman who lives long enough will go through menopause. Every single one. There is no other universal, guaranteed, biologically inevitable health event on earth that we have decided to fund at 0.1%.

And it is not only the money.

In a 2023 survey of United States obstetrics and gynecology residency program directors, only 31% reported having a menopause curriculum in their program at all. Not a good one. Any.

Meanwhile 93% of those same program directors strongly agreed that residents nationwide should have one.

They know. They have known for years.

And the residents themselves? In a national survey of residents across family medicine, internal medicine, and obstetrics and gynecology, 20% reported receiving no menopause lectures during residency. None. Not one.

And only 6.8% felt adequately prepared to care for a woman going through it.

6.8%. For the event that will define the entire second half of a woman's life.

The same survey found that 34% of residents said they would not offer hormone therapy to a symptomatic, newly menopausal woman with no contraindications at all. Not because the evidence said no. Because nobody taught them that the evidence says yes.

So when she sits across from a doctor and is told there is nothing wrong with her, understand what is actually happening in that room. He is not lying to her. He was never taught. The system did not consider it worth teaching him, because the system did not consider her worth studying.

Until 1993, women of childbearing age were routinely excluded from clinical research in the United States.

The reasoning, when it was given at all, was that our hormones were a confounding variable. Our cycles made the data messy.

Read that again, slowly.

The very thing that defines our physiology was treated as an inconvenience to be designed out of the study.

So an entire body of medicine was built on male bodies, tested on male bodies, dosed for male bodies, and then handed to us. Dosages. Symptom profiles. Diagnostic criteria. Timelines. Heart attack symptoms. Drug metabolism. All of it calibrated to a body that is not ours.

And then, when the drug does not work the same way in us, or the symptom does not present the same way in us, or the timeline does not match, we are told the problem is us.

1993 was not that long ago. A woman who is fifty today was seventeen years old when her body first became something science was legally required to consider.

Here is the pattern, and once you see it you cannot unsee it.

A woman's body is studied, funded, and attended to with enormous care for exactly as long as it can produce a child. Contraception. Fertility. Pregnancy. Obstetrics. Entire specialties, entire industries, entire wings of hospitals.

The moment that window closes, the attention closes with it.

She does not age out of medicine gradually. She falls off a cliff.

Suddenly the same body that warranted an entire specialty is told that its symptoms are ordinary. That the exhaustion is her fault. That the rage is her personality. That the weight is her discipline. That the fog is her age. That the bone loss is inevitable. That the pain during sex is something she should simply accept quietly, and probably not mention.

It is not that the medicine got harder after fifty. It is that we stopped counting her.

I use that word carefully, because it gets thrown around loosely, and this is not loose.

Gaslighting is when a person's own perception of reality is systematically denied by someone with authority until she stops trusting herself.

That is the clinical encounter for millions of women in this chapter of life. Not occasionally. Routinely.

She reports a real physiological event. She is told the event is not happening. She is offered a medication for a condition she does not have, to treat a symptom no one investigated.

And she does what any reasonable, intelligent adult does when reality is denied to her face by an expert. She revises her own reality instead of theirs.

That is not a communication failure. That is not a bedside manner problem. That is an outcome the system produces on purpose, because it is cheaper than knowing.

In 2002, one study frightened an entire generation of women and their doctors away from hormone therapy.

The findings were misread. They were over generalized. The average age of the women in the Women's Health Initiative hormone trial was 63, most of them well past the menopause transition, and the results were applied to a woman of 48 in the middle of hers as though she were the same person. The absolute risks were small and were reported in a way that made them sound enormous.

The corrections came later, and quietly, the way corrections always do.

But the fear stayed. It is still sitting in exam rooms right now. Women are still being denied hormone therapy today on the basis of a headline from twenty four years ago, by clinicians who were never given the training to know better.

An entire generation of women went through this transition without help, in the dark, because of it. And the generation before them was never prepared either.

So we now have grandmothers, mothers, and daughters who all walked the same road alone, and none of them told the next one, because none of them had the words.

Things are getting better.

I want to say that clearly, because I refuse to write anything that leaves a woman feeling that nothing can be done. Something can be done. A great deal has already been done.

In November 2025, the FDA removed the black box warning from menopausal hormone therapy. The warning that terrified a generation, the one printed on the box, the one that made a whole profession afraid to prescribe. Gone. The agency reviewed the literature, looked again at the women who started therapy within ten years of menopause, and acknowledged what the evidence had been saying for years: for most women in that window, the benefits are real, and the risks were overstated.

That is not a small thing. That is a public correction of a twenty three year old error that cost women their sleep, their bones, their hearts, their minds, and in some cases their marriages.

There is more. The World Economic Forum and the McKinsey Health Institute finally put a number on the gap and called it what it is: a $1 trillion opportunity. The Gates Foundation committed $2.5 billion to women's health research. The federal government has begun funding it seriously for the first time. The Menopause Society has published position statements that say plainly what the data has said all along.

The tide is turning. It is turning slowly, and it is turning late, but it is turning.

Because look at where we are turning from.

Roughly 5% of global research and development funding goes to women's health.

And of that, only about 1% goes to conditions that are specific to women and are not cancer.

1%. That is endometriosis. That is preeclampsia. That is heavy bleeding. That is menopause. Hundreds of millions of women. 1%.

Women spend, on average, 25% more of their lives in poor health than men do. Not sicker at the end. Sicker throughout. A quarter more of her one life, spent unwell, and much of it is preventable, and much of it is simply unstudied.

So yes. We are improving.

We are improving from a starting line so far behind that improvement is not the same thing as arrival.

A man's heart has been studied for a century. A woman's transition has been studied for about ten minutes. We are celebrating the removal of one warning label, and I will celebrate it, and I will also tell you the truth: a woman walking into a clinic in North Carolina next Tuesday is still overwhelmingly likely to meet someone who has had two lectures on the thing that is happening to her body.

The label changed. The training did not. Not yet.

The evidence is in. The evidence has been in. It just has not reached the room she is sitting in.

And now, into that gap, the platforms have arrived. Dressed up as progress.

One intake form. One prescription. The same protocol for everybody. No history. No bloodwork. No follow up. No relationship. No one who knows her name.

They call it access. They call it convenience. They call it finally listening to women.

It is not access. It is extraction.

It is a woman's desperation, monetized, and sold back to her as medicine. It is the same dismissal she got in the 7 minute appointment, except now it is automated, and she is paying monthly for it.

Because here is the tell. If a company treats every woman the same way, it is not treating women. It is processing them. A protocol that never changes is not personalized medicine, it is a vending machine with a doctor's name on it.

And the ones who do not get processed get denied. Still. Denied because nobody was willing to do the work of learning. Denied because it is easier to say no than to find out.

They did not solve the problem. They found a faster way to charge her for it.

I am not saying that clinicians are the enemy. There are extraordinary, devoted, exhausted people in this field, and I am one of them, and I am grateful for every single one of them.

And men are not the enemy either. Let me say that plainly, because I mean it.

The woman I described at the beginning of this essay is somebody's mother. She is somebody's wife. She is somebody's sister and somebody's daughter and somebody's boss and somebody's best friend. When she disappears into that fog and stops sleeping and stops wanting to be touched and stops trusting herself, the people who love her lose her too, and most of them have no idea why, and neither does she.

Nobody wins here. Not one person.

But I am saying this: not knowing is no longer an acceptable place to stand.

The information exists now. It is published. It is free. It is a search away. If a clinician does not know how to help a woman through this, the answer is never to send her away believing that nothing is wrong. The answer is to say so honestly. To refer her. To go and learn. To advocate for her until she is in the right hands.

Good care is attention. It is the willingness to keep learning. It is the refusal to look away.

You cannot treat a woman you will not take the time to know. If you do not have her history, her bloodwork, her whole picture, you are not treating her. You are guessing at her.

And women deserve far more than a guess.

I know this from both sides.

I am a nurse practitioner. I have cared for women through this for more than a decade. And then last year I walked into it myself. The fog. The grief. The strange, quiet disappearance of the woman I used to be. I was diagnosed with ADHD at forty five, in the middle of all of it, and I sat with that diagnosis and I cried, because it explained an entire life.

And here is the thing that still stops me cold.

I was one of the lucky ones. I knew the medicine. I could read the studies. I could advocate for myself in a language the system respects. And I still felt ashamed. I still hesitated to say it out loud. I still wondered if I was making it up.

If it happened to me, with everything I have, what is happening to the woman who has none of it? Who does not know the words. Who was never told she was allowed to ask.

So I stopped waiting for the system to correct itself on its own schedule, and I built the practice I went looking for and could not find.

At Vieora we treat the whole woman, because she is whole. Her hormones. Her metabolism and her weight. Her mood, her focus, her sleep. Her bones, her heart, her brain. Her history, her bloodwork, her life, her language.

One clinician who actually knows her. A full 60 minutes at the first visit, because you cannot hear a life in 7. Real follow up. Body identical hormone therapy when it is right for her, and an honest conversation when it is not. Care built slowly and carefully, because she is not a click, she is not a subscription, she is not a number, and she is not a problem to be cleared off a list.

The years the world calls a woman's decline are meant to be some of the most powerful of her life.

She has given everything. She has poured from an empty cup for years, for everyone, and she has done it without applause and mostly without help.

She is not fading. She is arriving.

And she deserves to walk into that chapter believed, supported, and cared for. Not dismissed. Not processed. Not medicated for a condition nobody bothered to check for.

We are done being quiet. We are done suffering in silence. We are done being told it is nothing.

It was never nothing. It is everything.

The evidence is in. The treatments exist. We know now.

There is no excuse left.

This is Vieora. And this is my calling.

With warmth, and with fire,

Wahiba

Wahiba Kartaoui, MSN, FNP-C
Founder, Vieora Health

Every figure in this essay is sourced. If you want to check me, please do. That is the entire point.

1. Women's health research was 7.9 percent of NIH grant funding in fiscal year 2023, down from a 2013 to 2023 average of 8.8 percent. National Academies of Sciences, Engineering, and Medicine, A New Vision for Women's Health Research, 2024. Commissioned by Congress under the Consolidated Appropriations Act of 2023.

2. NIH menopause research funding was approximately $56 million in 2023, against a total NIH budget exceeding $47 billion. Nature, editorial: "Menopause research is globally underfunded. It's time to change that," 2025.

3. Only 31.3 percent of responding US OB-GYN residency program directors report having a menopause curriculum, while 92.9 percent strongly agree that a standardized curriculum is needed. Survey of 99 program directors. Menopause, "It is time to standardize menopause curriculum in residency," 2023. PMID 37643377.

4. In a national survey of 183 residents across family medicine, internal medicine, and obstetrics and gynecology at 20 US residency programs: 20.3 percent reported receiving no menopause lectures during residency, only 6.8 percent felt adequately prepared to manage menopause, and 34.4 percent said they would not offer hormone therapy to a symptomatic, newly menopausal woman without contraindications. Kling JM, MacLaughlin KL, Schnatz PF, et al. Mayo Clinic Proceedings, 2019;94(2):242-253. PMID 30711122.

5. Women of childbearing potential were routinely excluded from US clinical research until the NIH Revitalization Act of 1993, which required the inclusion of women and minorities in NIH funded clinical research.

6. The mean age of women in the Women's Health Initiative hormone therapy trial was 63. Rossouw JE, Anderson GL, Prentice RL, et al. JAMA, 2002;288:321-333. PMID 12117397.

7. In November 2025, the FDA initiated removal of the boxed warnings from menopausal hormone therapy products, citing a reassessment of the evidence, including data from women who begin therapy within ten years of the onset of menopause. The boxed warning for endometrial cancer remains on systemic estrogen alone products. US Food and Drug Administration, "FDA Approves Labeling Changes to Menopausal Hormone Therapy Products," and US Department of Health and Human Services fact sheet, November 2025.

8. Approximately 5 percent of global research and development funding is directed to women's health, and only about 1 percent to female specific conditions beyond oncology. McKinsey & Company analysis, 2021.

9. Women spend on average 25 percent more of their lives in poor health than men, and closing the women's health gap could add more than $1 trillion to the global economy annually by 2040. Closing the Women's Health Gap, World Economic Forum and McKinsey Health Institute, January 2024.

10. There are approximately 4.13 billion women on earth, roughly 49.7 percent of a global population of about 8.3 billion. United Nations population data, 2026.

If you are the woman in the first section of this essay, you are not imagining it, and you are not alone, and there is a great deal that can be done. Begin your application at vieorahealth.com.