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Experts estimate that 40 percent of women behind bars are either already experiencing or will soon experience menopause. (Credit: RDNE Stock Project, Pexels) This article was published on The 19th in partnership with The Marshall Project, a nonprofit news organization covering the U.S. criminal justice system. Sign up for The Marshall Project’s newsletters, and follow them on Instagram, TikTok, Reddit and Facebook. Kwaneta Harris suddenly developed intense shoulder pain in 2019. Incarcerated in Texas, she began the process of requesting a specialized medical visit, certain she needed to see an orthopedist. Then, she started having heart palpitations and tachycardia, an abnormally fast resting heart rate, and requested a visit to the cardiologist. Around the same time, acne broke out across her face, something she’d never dealt with, even as a teenager. She filed a request for a dermatologist. Once a calm and collected figure on her cell block, she began to cry easily, and struggled to recall details and words that previously felt ingrained. Her long, dark hair began to thin. Harris, a former nurse who is now 53, was quick to self-diagnose. Assuming she had a thyroid problem, she requested a visit to an endocrinologist. Getting each specialty visit took months. First, she had to exhaust any recommendations from the in-prison medical provider, a process that often took three or more months. When those remedies failed, she could request a second opinion, after which she’d wait two to three more months to get approved. Each specialty visit then required an hours-long trip across the state to Galveston on a bus, shackled to another woman. None of these appointments brought relief. Three years after the shoulder pain began, Harris was listening to NPR when a TED Talk about perimenopause came on. Suddenly, the constellation of medical symptoms all made sense. “She said the most magical words I’ve ever heard, and I felt so much better: ‘You are not crazy,’” Harris said. “I remember saying ‘thank you’ out loud.” But even once she knew the origin of her symptoms, Harris said medical providers continued to dismiss her. It took two more years for her to get a prescription for Premarin, a hormone replacement therapy (HRT). A provider agreed to prescribe a 60-day trial supply after Harris pleaded for relief, in tears. The prescription was never refilled when it ran out. Harris’ Kafkaesque journey isn’t unusual for perimenopausal and menopausal people in prison, where access to information about this life transition is scarce. Menopause is diagnosed after someone has gone without a period for 12 months. Perimenopause is the months- to years-long transitional period leading up to this cessation. Social media is crammed with celebrities sharing their experiences and influencers giving tips for managing symptoms or singing the praises of HRT. But that wave of advice and resources hasn’t reached most carceral settings. Many incarcerated people approaching menopause are left to navigate these seismic physical shifts on their own, self-diagnosing and advising each other. For some, the lack of information and knowledge about menopause makes it difficult to even name what they’re experiencing. Makeshift tools and tricks cobbled together to manage symptoms can trigger disciplinary action. Requesting menopause-related medical care in a system that often fails to provide the bare minimum can be a frustrating and ultimately fruitless process. While new networks of care are emerging, offering hope in some prisons, these advances remain inaccessible in many places. Lori Pults, 52, remembers laying on her bunkbed, working on a prison ministry course on her tablet, when she was suddenly overcome by heat. She mistook her first hot flash for a fever. “It starts in your chest, and you just have this overwhelming feeling, like you stepped under a spotlight,” Pults said. Pults, who is serving a life sentence in Missouri, lost her mother when she was young and was raised by a grandmother who never told her about menopause. Fortunately, a nurse practitioner at the prison explained it to her. But Pults’ relative ease in finding a medical provider well-versed in menopause is highly unusual in prison health care, and literature on the subject is hard to come by. Prisons sharply restrict access to news and information, wielding censorship as a tool for maintaining security. Libraries often have scant resources and unreliable hours, and doing basic online research is virtually impossible. Resources sent by mail, including medical reference books, are sometimes banned, misconstrued as pornographic. All of these barriers can make it challenging, if not impossible, for people behind bars to learn about menopause. “There is no information whatsoever available for women on this topic,” said Ann, who is serving a life sentence at Bedford Hills Correctional Facility in New York. (Because of the high-profile nature of her case, she asked that we use only her middle name.) “There was never any effort by anyone to get me any information when I asked about menopause. I would have to ask a friend to get me information off of the internet.” Thomas Mailey, director of public information for the New York State Department of Corrections and Community Supervision, said that there is a full-time gynecologist on staff at Bedford Hills available to answer questions on “all women’s health care related subjects.” There has long been a dearth of research on menopause, and even less on how it plays out in prisons. Dr. Andrea Knittel, an obstetrician and gynecologist at the University of North Carolina, published a first-of-its-kind qualitative study in 2025 with a group of researchers examining how menopause symptoms “shape experiences of the criminal legal system.” It’s the largest study of this intersection of issues to date, and one of fewer than 10 peer-reviewed studies touching on menopause in prisons. The lack of information available to incarcerated women, and their subsequent confusion, was a recurring theme in Knittel’s research. “The vast majority of people that we talked to were confused and scared,” Knittel said. “They thought maybe they had some infectious condition. They thought maybe they had taken something terrible … the first thought was not, ‘This is a normal physiologic experience that everyone goes through.’” Harris, an incarcerated journalist who has written extensively about women’s health care behind bars, often finds herself advising fellow incarcerated women in the absence of practitioners versed in gender-specific health care. More than once she scrawled a picture of the female reproductive system on a wall with a Sharpie to help explain things to her peers. Even as bits and pieces of the current menopause moment trickle into prisons through TV, radio and other media, that information sometimes merely increases awareness of resources that are just out of reach. “I know there are several new medications that I’ve seen on commercials, but the has said that they are too expensive to give here,” said Denise Hein, 72, who is incarcerated in Missouri. According to Karen Pojmann, communications director of the Missouri Department of Corrections, “Physicians prescribe medications and provide other treatments to residents based on each patient’s diagnosis and assessed needs, just as they would in the community. Hormone replacement therapy is available to residents.” Raquel Glenn, 71, who is incarcerated at Bedford Hills Correctional Facility in New York, said she still struggles with lingering hot flashes, exacerbated by a prison without air conditioning and a broken ice machine. “Our cells are a stagnant, suffocating and humid den once summer hits,” said Glenn, who resorts to sleeping on the floor on the hottest nights. Any housing unit without an operating ice machine can access ice from a neighboring unit, according to Mailey, and areas of the prison without air conditioning are “properly ventilated in accordance with national standards set by the American Correctional Association.” The population of women in prison increased by 600 percent between 1980 and 2023, and is currently growing at twice the rate of men in prison. As that number grows, so too does the segment of incarcerated people going through perimenopause and menopause. The overall prison population is rapidly aging, posing a host of challenges for older adults in facilities where basic medical care can be hard to come by. Experts estimate that 40 percent of women behind bars are either already experiencing or will soon experience menopause. Despite these swelling numbers, specialized care for women’s health issues remains difficult to access in many prisons. Nadia Sabbagh Steinberg, a professor of social work at the University of Iowa whose dissertation focused on gynecological care in prison, said during the years she conducted her research, there was only one in-house medical practitioner available to the entire Iowa Correctional Institute for Women. The doctor was a man with no specific gynecological training, whose medical license had previously been revoked. The prison has since hired more nurse practitioners. This lack of specialized care was commonly reported among incarcerated women who spoke to The Marshall Project, many of whom said they were dismissed by providers when describing perimenopause symptoms, and even chided by some male medical practitioners for using accurate language to describe their own bodies. “Every doctor I have dealt with here says they don’t know much about menopause, so they really don’t provide any help,” Ann said. Others described the lack of empathy from nonmedical staff who were unfamiliar with or misunderstood perimenopause and menopause. Linda Cayton, who was in prison in North Carolina on her 50th birthday, struggled with debilitating mood swings. “The guards were like, ‘You just came to prison, you’re supposed to be upset,’” Cayton said. Even when someone is able to access an informed provider — often after a long wait — getting consistent treatment can be yet another mountain to climb. After Harris was able to identify the underlying cause of her symptoms, she asked a friend outside of prison to print and mail her information on HRT. For many years, clinicians recommended against estrogen replacement for perimenopausal and menopausal people, relying on research from the early 2000s that suggested HRT contributed to increased risk of cardiovascular issues, cancer and neurological side effects. Harris had experienced resistance to getting a prescription for HRT in light of this research. Then last year, the “black box” FDA warnings were removed from prescribing HRT related to menopause. In the past two decades, additional research was conducted, revealing new findings about the benefits of HRT, and researchers highlighted methodological flaws in the early 2000s analysis. While age and individual medical histories dictate whether HRT is a safe and appropriate option for each person, clinicians are now far more likely to prescribe this treatment. Armed with an article she tore out of an issue of Good Housekeeping and research from the North American Menopause Society, Harris finally convinced a doctor to prescribe HRT. The hard-won prescription was life-changing. For most of her life, Harris prided herself on having a great memory and “the kind of brain where before the teacher finished solving the math problem, I had already figured it out.” But during a period of multiple years when she was in solitary confinement, something shifted. “I started noticing that I was writing stuff down on the walls of my cell with a pencil, using it like a whiteboard,” Harris said. “Something was off with my memory … I kept forgetting words.” She assumed the memory loss was a byproduct of her isolation or a symptom of long Covid. It wasn’t until she was prescribed HRT that she felt the brain fog lift, and realized that it too, was a symptom of perimenopause. “It was like I was back to me. My skin cleared up, my hair got thick, I was able to sleep, my memory improved,” Harris said. But after the prescription ran out, Harris struggled to get a refill for the next year, and her symptoms returned. Chronic health problems, undiagnosed illnesses and inadequate nutrition all contribute to poor health outcomes for incarcerated people. Substance use and mental health problems are more prevalent among incarcerated people than in the general population, and some symptoms of menopause, such as irritability and insomnia, can be misinterpreted as longer-term symptoms of withdrawal from multiple kinds of drugs. Combined with what is often substandard medical care and the prevalence of sexual trauma among incarcerated women, linking symptoms to menopause can prove challenging. “There are lots of different ways where learning to not trust your body, learning to not trust the world with your body, would lead to it being really complicated to interpret what was going on in your body through a big physiologic change like menopause,” said Dr. Knittel, the OB/GYN and researcher from the University of North Carolina. A lack of trauma-informed medical providers and staff, coupled with distrust of medical systems that have previously failed people in and out of prison, can also pose a barrier to care. “They didn’t trust the medical system in there, and they didn’t trust that they would get accurate information,” Sabbagh Steinberg said of the incarcerated women she interviewed in Iowa. Others had simply neglected to care for their health for years while caring for other people, like their children. The fact that for women incarcerated in Iowa there was only one male provider available was “very triggering for many women in prison, in particular, who have sexual trauma histories.” Dismissing or declining to treat menopause symptoms can dramatically impact quality of life as people age, leading to serious medical issues that may compound: osteoporosis, heart conditions and major depressive disorder, to name a few. Menopause accelerates bone loss, and osteoporosis is the most prevalent disease in postmenopausal people; without treatment, patients run the risk of fractures and chronic pain. In Missouri, Hein suffers from osteopenia, or lower than average bone density. Without regular testing, she isn’t sure how fast the problem is progressing. She said that calcium tablets are the only medication she’s provided with at Chillicothe Correctional Center. “You have to look at the long-term ramifications of osteoporosis,” Hein said. “That’s inexplicable not to treat a long-term illness like that.” The failure to treat menopause can ultimately cost prisons more to treat in the long run. “By our estimation, it was at least four times less expensive to just treat menopause at the source than to not treat it,” said Kelly Stewart Danner of Impact Justice, a criminal justice reform organization that conducted a cost-modeling exercise to determine the long-term cost to prisons of not treating menopause. Ideally, perimenopause and menopause care would include a combination of regular preventative screenings; adjustments to diet and exercise; stress management tools and practices; and access to hormonal and nonhormonal medication options to manage symptoms. Incarcerated people are forced to be creative to manage symptoms of menopause and perimenopause. To ease the discomfort of a night of hot flashes, Cayton filled every little vessel she could find with cool water — empty pill bottles, cups and shampoo bottles — and took them to her cell. An older woman advised her to wet her clothes to get through the night (and to do so at a certain time to avoid getting caught by guards), so she’d shower in her nightgown and slip under the covers soaking wet, pouring more water on herself as hot flashes struck. The heat in her North Carolina prison, where there is no air conditioning, was intolerable as her hot flashes worsened. “I was drenched in sweat, and my emotions were all over the place. I was miserable,” Cayton said. But self-management of symptoms, and a failure to understand the shifts in mood that can accompany perimenopause and menopause, can result in disciplinary infractions when misinterpreted by corrections staff. In Texas, Harris said women are often denied an adequate supply of menstrual products — a particular problem for the subset of perimenopausal women who experience heavier than typical bleeding during their periods. Lacking sufficient pads and tampons, Harris said women have ripped up sheets and folded them to absorb menstrual blood, a hack that is then punished and written up as “destruction of state property.” These infractions add up. “The consequences just ripple outward,” Harris said. “When we get disciplinary infractions, these can justify parole denials.” According to Amanda Hernandez, director of communications for the Texas Department of Criminal Justice, there is “no limit on the amount that can be requested and provided,” and the department previously launched an education campaign to teach incarcerated women about these products. Among the 29 incarcerated people across five states whom Knittel interviewed for her research, disciplinary action in response to menopause-related symptoms and their management was a common thread. Multiple participants in Knittel’s study described receiving write-ups for having uniforms soiled by blood. Others described being written up for not having the covers pulled over them at night while trying to stay cool, or getting sent to solitary confinement for mood swing-related behavior. “I saw women go from being model inmates to getting back-to-back write-ups,” reported one participant in the study, identified as Rhonda. “My patients are so creative and resourceful in trying to get their needs met, and often that creativity and very genuine trying to get to a base level of humanity is met with the assumption that they are being manipulative, that they are trying to game the system and get something that they’re not supposed to have,” Knittel said. In California, Stewart Danner and her colleagues at Impact Justice are piloting a first-of-its-kind project to address the lack of information and adequate medical care for perimenopausal and menopausal incarcerated women. In January, the organization launched a novel program to train prison medical providers to identify and effectively treat the symptoms of perimenopause and menopause. Ultimately, they hope to train all corrections staff to increase awareness of menopause, not just medical providers. The California Department of Corrections and Rehabilitation has worked closely with Stewart Danner and her team to help facilitate the program. Providers who participate in the program — including OB/GYNs, lead nurses, primary care providers and mental health providers — will earn continuing education credits, a requirement for many in health care. In addition to medical training, the program has a significant focus on education for incarcerated women. Impact Justice is providing infrastructure for peer support groups, and distributing flyers, posters and bookmarks with information about menopause throughout the state’s two women’s prisons. “We’re really just trying to canvass these institutions, so that at the provider and the patient level they have all the training and awareness they need to both provide great menopause and perimenopause care, and then also request it and advocate for themselves and know the basics of what menopause even is,” Stewart Danner said. In addition to education about pharmaceutical interventions like HRT and antidepressants, which are commonly prescribed to treat people in perimenopause, the organization’s training for providers includes modalities of care such as meditation, yoga and pelvic floor therapy, and they are disseminating information about these methods through books and other resources. While the project is in its infancy, Stewart Danner and her colleagues are in talks with corrections departments in Idaho, Michigan and South Carolina, where they hope to provide more practitioner training, information and tools. Meanwhile, in the many places without such programs, women are trying to care for each other in the absence of information and institutional support. In Missouri, Ginny Twenter, 64, has been tiptoeing around an increasingly moody 56-year-old friend she plays cards with, encouraging her to get help. “We just finally told her she’s going through perimenopause, and she agreed to go to medical and see what they have to say,” Twenter said. “To me, that’s a good start … but they need to make more information available, whether on tablets or pamphlets. Sometimes people believe more what they read than what they hear.” In Texas, Harris is trying to spread the word and support the women around her who are struggling to navigate this bodily sea change. “We have to remove the stigma of talking about it,” Harris said. “We really need community, instead of hoping you can go through it alone.”

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