Authors: Rhea Manohar, MPH; Leah Liszak, Meghan Etsey, Brianna Clark, DO on behalf of AMWA’s Gender Equity Task Force

Asthma is one of the most common chronic diseases among women worldwide, affecting an estimated 10% of adult women in the United States (CDC, 2023). Yet, despite decades of research, its relationship to hormonal changes continues to be a gap in clinical research and practice. The cyclical fluctuations of estrogen and progesterone across the menstrual cycle have been shown to influence airway inflammation, bronchial hyperreactivity, and symptom perception (Wasti et al., 2021). For many women, this translates to a predictable worsening of asthma symptoms during the luteal phase or at menstruation; this is often termed perimenstrual asthma (PMA). Despite its prevalence, PMA is rarely discussed in clinical settings, leaving many women without tailored care or validation of their experiences.

The menstrual cycle brings about complex hormonal shifts that directly affect respiratory physiology. Estrogen can exert both pro-inflammatory and anti-inflammatory effects, depending on concentration and receptor subtype activation. In contrast, progesterone tends to enhance airway smooth muscle contractility and may worsen bronchial responsiveness in susceptible individuals (Wasti et al., 2021). These mechanisms contribute to fluctuations in asthma control across the cycle, with studies estimating that 30–40% of reproductive-age women with asthma experience perimenstrual symptom worsening (Graziottin et al., 2016).

When progesterone peaks during the luteal phase, many patients report increased wheezing, cough, and nocturnal symptoms. This correlates with evidence showing higher eosinophilic airway inflammation and reduced peak expiratory flow rates during this period (Weare-Regales et al., 2022). In some cases, hospitalization and emergency visits increase during menstruation, underscoring the physiologic burden of cyclical hormone changes on respiratory disease control (Yung et al., 2018).

Despite consistent patient-reported patterns, asthma management guidelines have yet to incorporate hormonal factors as a consideration for individualized treatment. Standard inhaled corticosteroid regimens do not account for menstrual variability in airway inflammation, and clinical trials rarely stratify participants by sex hormone status or menstrual phase. This omission has tangible consequences: women are more likely than men to report poor asthma control and medication side effects, even after adjusting for environmental and behavioral variables (Melgert et al., 2020).

Hormonal contraceptives may play a dual role by stabilizing hormone fluctuations while also influencing inflammation and drug metabolism. Some studies suggest that combined oral contraceptive use can reduce perimenstrual symptom exacerbation by blunting estrogen-progesterone variability (Nwaru et al., 2015). However, the interaction between contraceptives, inhaled corticosteroids, and leukotriene modifiers remains understudied. The lack of sex-specific pharmacologic data leaves clinicians relying on anecdotal patterns rather than evidence-based adjustments. Women’s health research has historically been underfunded and underrepresented. To combat this disparity, a multitude of funding options exists for sex-specific research such as federal funding, non-profit organizations, private foundations, and academic institutions.

At its core, the underrecognition of menstrual-cycle–linked asthma exacerbations reflects a broader gender gap in biomedical research. Historically, women of reproductive age were excluded from clinical trials due to concerns about hormonal variability; ironically omitting the very factor that contributes to disease heterogeneity. This exclusion has perpetuated a knowledge gap that disproportionately affects women’s health outcomes. Even as sex-based research becomes more common, intersectional data accounting for race, socioeconomic status, and access to reproductive health services remain sparse.

Clinically, the lack of awareness among healthcare providers can lead to dismissive care. Women reporting cyclical changes in asthma symptoms are often told that their perceptions are “stress-related” or “coincidental,” reflecting broader biases in the evaluation of women’s symptoms. This not only delays effective management but also contributes to mistrust and reduced adherence to treatment.

To better serve women with asthma, healthcare systems and research frameworks must integrate hormonal considerations into both diagnostic and treatment protocols. Practical strategies include:

  • Tracking menstrual patterns alongside peak flow and symptom diaries, allowing clinicians to identify hormone-related exacerbation trends.
  • Personalizing pharmacologic management, including potential dose adjustments or prophylactic medication use during high-risk phases of the cycle.
  • Encouraging participation of women in all phases of their reproductive life in clinical research, with transparent reporting of sex-stratified outcomes.
  • Educating clinicians on the physiologic impact of hormonal changes on chronic disease management to reduce gender bias in patient encounters.

Recognizing hormonal influence on asthma is a necessary step toward precision medicine that respects biological and gender diversity. When women’s symptoms are contextualized rather than minimized, the path toward equitable care becomes clearer. Understanding how estrogen and progesterone modulate respiratory health is not just a matter of academic interest; it’s a vital step toward closing the gender gap in chronic disease care and ensuring that medicine truly serves all bodies as they are.

References: 

  1. Centers for Disease Control and Prevention. (2024). Asthma surveillance data. U.S. Department of Health and Human Services. https://www.cdc.gov/asthma-data/about/index.html
  2. Graziottin, A., & Serafini, A. (2016). Perimenstrual asthma: from pathophysiology to treatment strategies. Multidisciplinary respiratory medicine, 11, 30. https://doi.org/10.1186/s40248-016-0065-0
  3. Holguin F. (2020). Sex Hormones and Asthma. American journal of respiratory and critical care medicine, 201(2), 127–128. https://doi.org/10.1164/rccm.201910-1923ED
  4. Melgert, B. N., et al. (2020). Sex differences in asthma prevalence and pathophysiology. Respiratory Medicine, 170, 106021. https://doi.org/10.1016/j.rmed.2020.106021
  5. Nwaru, B. I., & Sheikh, A. (2015). Hormonal contraceptives and asthma in women of reproductive age: analysis of data from serial national Scottish Health Surveys. Journal of the Royal Society of Medicine, 108(9), 358–371. https://doi.org/10.1177/0141076815588320
  6. Wasti, B., Chen, Z., He, Y., Duan, W. T., Liu, S. K., & Xiang, X. D. (2021). Role of Sex Hormones at Different Physiobiological Conditions and Therapeutic Potential in MBD2 Mediated Severe Asthma. Oxidative medicine and cellular longevity, 2021, 7097797. https://doi.org/10.1155/2021/7097797
  7. Weare-Regales, N., Chiarella, S. E., Cardet, J. C., Prakash, Y. S., & Lockey, R. F. (2022). Hormonal Effects on Asthma, Rhinitis, and Eczema. The journal of allergy and clinical immunology. In practice, 10(8), 2066–2073. https://doi.org/10.1016/j.jaip.2022.04.002
  8. Yung, J. A., Fuseini, H., & Newcomb, D. C. (2018, May). Hormones, sex, and asthma – annals of allergy, asthma & immunology. Anals of Allergy, Asthma, and Immunology. https://www.annallergy.org/article/S1081-1206(18)30023-1/fulltext 

About the Authors

Rhea Manohar, MPH, MS3

Rhea Manohar is a third year medical student from St. George’s University. She has a Masters in Public Health with a concentration in Maternal and Child Health from George Washington University Milken Institute of Public Health and a Bachelors of Science in Microbiology, Immunology, and Public Health from the University of Miami. She served as Co-VP of OB/GYN Education for St. George’s University’s Women in Medicine chapter in St. George, Grenada where she developed and implemented hands-on workshops to further reproductive health issues and bolstered medical students abilities to navigate physician-patient communication. Prior to medical school, she was a Research Associate for Fors Marsh Group, where she led qualitative and quantitative public health research and campaign development for federal agencies (e.g., CDC, NIH, DHHS, CPSC). She is also a member of the Gender Equity Task Force and Reproductive Health Coalition within the American Medical Women’s Association. When she is not pursuing medicine, you can find her reading, exploring artistic passions, and spending time connecting with friends and family.

Meghan Etsey, MS4

Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world. 

Leah Liszak, MS3

Leah Liszak is a third year medical student from St. George’s University. She has a Bachelors of Science in Biomedical Science from Oakland University in Auburn Hills, Michigan. She served as the SMILEs Orphanage Home Coordinator of the St. George’s University Humanism Service Organization in St. George, Grenada where she fostered impactful relationships with at-risk female youth and developed seminars to educate, encourage, and engage their personal growth. She is also a member of the Gender Equity Task Force with the American Medical Women’s Association. When she is not pursuing medicine, you can find her enjoying time with friends and family, working towards athletic pursuits in the gym, and testing new pastry recipes.

Dr. Brianna Clark is a proud osteopathic physician.  She has completed fellowships in Breastfeeding Medicine at the University of Rochester Lessons in Lactation Advanced Curriculum ( LILAC) and Climate Health Equity Fellowship ( CHEF) through the National Medical Association ( NMA). She spends her spare time thinking about innovative ways to provide equitable health care to all and create sustainable advocacy.