Could Your Menopause Symptoms Be Long COVID?

You Are Not Alone — the Scale of the Problem

COVID is still circulating, and long COVID — the prolonged illness that can follow a COVID infection, also called Post-Acute Sequelae of COVID (PASC) — is still being diagnosed every day. This is an ongoing public health issue that can affect people of all walks of life, but especially mid-life women. So, if you have been struggling with symptoms that are odd and don’t quite make sense, that have not responded to treatment the way your doctor expected, or that seem to have started or worsened after a viral infection, you are not imagining it. The latest statistics published in 2024 showed that:

• 18% of U.S. adults — roughly 45 million people — report ever having had long COVID.

• 7% of U.S. adults, about 17 million people, currently have long COVID symptoms right now.

• 1.3% of children in the U.S. have had long COVID, with 0.5% currently symptomatic.

More than 100 different symptoms have been linked to long COVID — things like debilitating fatigue, cognitive dysfunction, hoarseness, vertigo, problems with blood pressure and heart rate regulation (dysautonomia), and chronic pain. There is no single blood test or scan that diagnoses it, and most standard blood work comes back as completely “normal” which means long COVID is often overlooked as a possible etiology or is misdiagnosed  — sometimes as menopause.

Why Mid-Life Women Are Especially at Risk

Women are 30% to 50% more likely than men to develop long COVID. And the group hit hardest? Mid-life women!

Women are nearly twice as likely as men to currently have long COVID (4.4% vs. 2.3%).  Women ages 35–49 have the highest long COVID rates of any age group: 8.9% have ever had it, 4.7% currently have symptoms.

This matters enormously — because these are the same women who are also entering the menopause transition. The problem is that long COVID and menopause share many of the same symptoms: fatigue, night sweats, brain fog, joint pain, mood changes, and sleep disruption, aches and pains. When a woman in her 40s or 50s walks into a doctor's office with these complaints, the assumption is often “hormones” — full stop. Often it is. Sometimes it is long COVID - or both.

Compounding this, women in midlife are already a group whose symptoms are frequently dismissed or attributed reflexively to "the change." They are told to just deal with their symptoms as being a natural process and not offered any treatment or handed a hormone prescription as a blanket solution. If long COVID is part of the picture, that approach alone may not work — and in some situations, may make certain symptoms worse. You deserve a comprehensive evaluation, not a reflexive one.

The COVID-Hormone Connection

From the earliest days of the pandemic, we noticed that sex and COVID outcomes were connected. Women were more likely than men to survive acute COVID-19 infection — an advantage attributed to the protective vasodilation and anti-inflammatory effects of estrogen and progesterone. Notably, this survival advantage was not seen postmenopausal women who were not on hormone therapy, but it was for those who were on hormone therapy.

The reason likely involves a specific receptor on cells throughout your body called the ACE2 receptor — which is also the doorway the COVID virus uses to enter and infect cells and organs. ACE2 receptors are present throughout the body — including on the ovaries. Direct viral impact or secondary post viral auto-immune system responses to the ovaries might explain several patterns of ovarian dysfunction that I began seeing and tracking in my patients at Northwestern's Center for Sexual Medicine and Menopause starting in 2021 and that have since been confirmed in observational research:

• Menstrual cycles changes or sudden premature ovarian insufficiency (early menopause) following a COVID infection

• A sudden or unusually severe onset of menopause symptoms in women who had been fine before their infection

• Return of menopausal symptoms and unexplained vaginal bleeding in postmenopausal women who had been stable for years

In 2023, I was invited to join Northwestern's Comprehensive Care after COVID clinic as the gynecological expert on the team, specifically because so many female patients were coming in with hormonal symptoms tied to their long COVID. What I saw on a much larger scale confirmed what I had been observing in my own practice: long COVID and menopause transition symptoms overlap extensively. Given a lack of general training for healthcare professionals on long COVID in general, let alone the hormonal manifestations, this means many who are treating mid-life women do not consider long COVID or know how to screen for some distinctions in the symptomology. This lack of knowledge can lead inadvertently to worsening symptoms with standard hormone therapy and missed opportunities to refer to specialists for long COVID specific treatments. So all this means you need to bring it up or advocate for referrals if you feel long COVID might be contributing to your symptoms.

If your menopause symptoms started suddenly after a COVID infection, or came back after years of stability, bring this up with your doctor. The timing matters and is a clue suggesting long COVID.

 How to Tell the Difference — and Why It Matters for Your Care

Hormone therapy is often helpful for both menopause transition and long COVID-related symptoms — but it is not the answer for all symptoms. Having some clarity on what symptom is menopause related and what might be long COVID helps you and your doctor set realistic expectations and avoid making things worse. Here is what distinctions to make when describing your symptoms:

Fatigue 

• Menopause: Tiredness that is mostly driven by poor quality sleep — mostly manageable and generally responsive to treatment.

• Long COVID: Post-exertional malaise (PEM) — a profound "hit by a bus" exhaustion that crashes in after activity, even mild activity, and cannot be pushed through. This is qualitatively different from menopause related fatigue and sleep does not help. 

Sleep Disruption

• Menopause: Waking early in the morning, restless or disrupted sleep, night sweats pulling you out of deep sleep.

• Long COVID: Trouble falling asleep, a "wired but tired" feeling, and sleep that never feels restorative no matter how many hours you get.

Central Nervous System Symptoms

• Both: Palpitations (feeling your heart race or flutter), blood pressure changes, hoarseness or weak voice (dysphonia), ringing in the ears (tinnitus).

• Long COVID: Dizziness or lightheadedness when standing up from sitting, heart rate spikes with position changes or mild exertion, internal vibrations, loss of smell (anosmia) or taste (ageusia), trouble swallowing (dysphagia), and vertigo or balance issues -  symptoms point more strongly toward a problem with the autonomic nervous system (dysautonomia).

Musculoskeletal

• Menopause: Aching in larger joints — hips, shoulders, knees. Weight gain that tends to shift toward the midsection due to body composition changes favoring visceral fat deposition.

• Long COVID: Muscle weakness and wasting, pain and swelling in smaller joints like wrists and fingers, nerve pain (neuropathy), and diffuse muscle aching (myalgia). Weight changes can go either direction — general gain from inactivity, or weight loss from muscle wasting in more severe cases.

Cognitive Dysfunction

• Menopause: “Brain fog”: forgetting words, short-term memory lapses, difficulty concentrating — frustrating, but generally not as severe or impactful.

• Long COVID: More severe impairment of speech (dysphasia), word retrieval, processing speed, and executive function (planning, organizing, attention). This can seriously affect your ability to work and manage daily life.

Describing your symptoms with this level of detail — especially the severity, and whether they started or worsened after a suspected or known COVID infection — gives your clinician the information they need to evaluate you properly.

Three Long COVID Sequelae That Change the Hormone Therapy Conversation

If you have long COVID alongside menopause symptoms, hormone therapy is still absolutely appropriate for you — but you and your doctor should know about these three specific conditions, because they affect how hormone therapy should be approached:

1. ME/CFS — Myalgic Encephalomyelitis / Chronic Fatigue Syndrome

ME/CFS is a serious condition that has long been known to follow viral infections, and it affects roughly 45–50% of people with long COVID. It is defined by severe post-exertional malaise, muscle weakness, poor balance, unrefreshing sleep, and cognitive dysfunction. In the most severe cases, people become completely bedbound.

Hormone therapy alone will not fix PEM or the cognitive dysfunction of ME/CFS. If you have this condition, pacing (carefully managing your energy to avoid crashes), cognitive, physical and occupational therapy, and workplace accommodations are essential parts of your care. Hormones can help with overlapping menopausal symptoms, but your care plan needs to go beyond hormones. In addition, progesterone, even if not required, should be considered due to its neuroprotective effects, as long as it’s not contributing to grogginess.

 If you feel like you "crash" after even small amounts of activity — and it hits a day later or takes days to recover — tell your doctor those exact words, not just that you feel tired all the time.

2. POTS — Postural Orthostatic Tachycardia Syndrome

POTS is a more severe and challenging form of autonomic nervous system (the system that controls automatic functions like heart rate and blood pressure) dysfunction. It affects roughly 30–50% of long COVID patients. Symptoms include a racing heart rate that comes unexpectedly or sometimes is positional, sudden drops in blood pressure, dizziness, feeling the need to lie down to recover, and cognitive dysfunction.

Here is the important hormone connection: estradiol is a vasodilator — it relaxes and widens blood vessels. For most women, that is a good thing. But in POTS, where blood pressure is already unstable and often low, too much estrogen can worsen symptoms. If you have POTS, your doctor should start hormone therapy at lower doses, increase slowly, and pay careful attention to the form and delivery method

3. MCAS — Mast Cell Activation Syndrome

MCAS affects about 28% of long COVID patients and causes the immune system's mast cells to overreact, releasing histamine and other inflammatory chemicals inappropriately. Symptoms include rashes, hives, swelling, food sensitivities, bloating/GI distress, and allergy-like symptoms such as a runny nose or watery eyes.

The hormone connection here is that estradiol activates mast cells — meaning it can directly trigger or worsen MCAS symptoms. Even low doses of estrogen can cause flares in some women. On the flip side, progesterone actually stabilizes mast cells, so it works in your favor and should be considered even in women with hysterectomy or progestin IUDs. If you have MCAS, make sure your doctor knows before starting or adjusting hormone therapy. Starting very low and going slow is essential, and progesterone may be your ally.

Before starting or changing hormone therapy, tell your doctor if you have been diagnosed with — or suspect — any of these three conditions. They may need to change their plan slightly to better align with your condition.

An Important Warning About Blood Clots After COVID

COVID infection raises your risk of dangerous blood clots or strokes (thrombotic events) for up to three to six months after the acute illness, due to accelerated vascular aging caused by the virus. This has direct implications for estrogen therapy.

Oral estradiol (pills) increases clot risk, whereas transdermal estradiol (patches, gels, sprays) does not. Transdermal estrogen is absorbed through the skin and bypasses the liver, which is where the clot-promoting effects of oral estrogen originate.

In my own practice, I had several patients with recent COVID histories who developed clots while on oral estradiol — before I fully understood how much COVID elevates that baseline risk. I now routinely screen patients for recent or suspected COVID infection before starting oral estrogen based hormone therapy.

If you have had COVID in the past six months and are starting or already taking oral estrogen pills, ask your doctor about switching to a patch, gel, or spray. It is a simple change that may reduce your risk of a thrombotic event.

The Good News

The FDA removed the black-box warning on hormone therapy in late 2025, and more women than ever are now being offered and using estrogen and progesterone — which, as mentioned, are protective against severe COVID outcomes. This is good news since the virus continues to mutate and cause infections.

Hormone therapy, used thoughtfully, can address permanent or temporary hormonal symptoms, even when long COVID may be contributing. Hot flashes, joint aches, sleep disruption, and mood changes primarily driven by hormonal changes should respond as expected. Some long COVID symptoms — like post-exertional malaise, feeling “wired but tired”, muscle weakness, dizziness, severe cognitive changes, or loss of smell — may not respond to hormones alone. That is important to be prepared for so you do not feel like the hormonal treatment failed you when it was simply never designed to fix post-viral sequelae.

 If You Suspect You Have Long COVID, What Can You Do Right Now?

Here is how to advocate for yourself and get better care:

• Keep long COVID in mind as a possibility if you have had a COVID infection in the past year — even a mild one. Long COVID can follow infections that did not seem serious at the time.

• Talk to Your Doctor — and Be Specific. Tell your doctor if your symptoms started or significantly worsened after a COVID infection as timing is a critical clue

• Keep long COVID in mind if your symptoms look like menopause but something feels different — especially if you also have features like post-exertional crashes, autonomic symptoms, or loss of smell and taste that are not typical of menopause transition.

• Keep long COVID in mind if your symptoms are not improving on hormone therapy, or if they have gotten worse since starting it. This is a signal worth investigating — not a reason to give up on treatment, but a reason to revisit the diagnosis with your doctor.

• Describe your fatigue in detail. If normal physical or cognitive activity takes days to recover from, say that clearly — it points to post-viral post exertional malaise and not ordinary menopause  transition fatigue.

• Mention any autonomic symptoms: dizziness or heart racing when standing, internal tremors, loss of smell or taste. These are not typical menopause symptoms.

• Ask specifically: "Could this be long COVID, or could long COVID be contributing to what I am experiencing?"

• If you have had COVID in the past six months, ask about transdermal estrogen rather than oral pills before starting hormone therapy.

• Ask to be screened for or referred for testing for POTS, MCAS, and ME/CFS if you have significant autonomic symptoms, allergic-type reactions, or episodic crashing fatigue and weakness.

• Long COVID clinics exist at a few medical centers that offer multidisciplinary care — it helps if the specialist physicians, physical therapists, occupational therapists, cognitive therapists who understand these conditions work together.

• If there is no long COVID clinic near you, ask your doctor for a referral to a specialist in dysautonomia, immunology, or infectious disease or one with long COVID experience.

• Remember that those with long COVID have often been dismissed or misdiagnosed for years and deserve empathy, good medical care, and options for work accommodations or short-term disability.

The bottom line is, long COVID is not uncommon in mid-life women, so if something does not feel right, or if a hormone treatment is not working the way it should, keep asking questions. The intersection of long COVID and menopause is new territory — even for many clinicians — and you may need to help educate your care team as much as they help you.

Written by : Dr Traci Kurtzer is a clinical advisor for Alloy and as a menopause/hormone expert was also the referral gynecologist for the Northwestern Hospital Comprehensive Care after COVID-19 clinic. She advocates for disability awareness for her patients needing menopausal care and for patients afflicted by long COVID. 

Key Sources:

Prevalence data: CDC NCHS Data Brief No. 480 (2023); KFF Long COVID Tracker (2024); Fang et al., JAMA (2024); Vahratian et al., JAMA Network Open (2024)

Sex differences & hormones: Parsemus Foundation/NIH RECOVER cohort analysis (2025); CDC NCHS Long COVID by sex (2022); Stewart (2021), Liu Y (2023)

Long COVID overlap symptoms, ME/CFS, POTS, MCAS comorbidities: Blumell (2023); PNAS patient-reported outcomes study (2025); ScienceDirect LISTEN study (2025); Nature Reviews Microbiology, Davis et al. (2021 & 2023); Medina-Perucha (2022)

Clotting risk: Bruno et al. (2025), European Heart Journal 46(39): 3905–3918; Katsoularis et al., BMJ (2022).