The importance of equal access to perimenopause and menopause care and education
• Race, ethnicity and cultural beliefs can affect a woman’s experience of perimenopause and menopause
• Language barriers and a lack of awareness can stop women accessing help and treatment
• More resources are needed for ethnic minority women
All women will become menopausal, but experiences and symptoms can vary greatly – genetics, existing health conditions, income, race and ethnicity can have an influence. Research into how perimenopause and menopause specifically affect ethnic minority women in the UK is limited, which can make it frustrating when you’re trying to find out more information about your health. But on top of any physical differences, there are cultural ones and attitudes to menopause can be affected by different communities.
Do symptoms vary in different ethnicities?
While there is limited research carried out into menopausal symptoms in British ethnic minority women, we know from other studies that ethnic variances can occur. The Study of Women’s Health Across The Nation (SWAN) is an important longitudinal study that began in 1994 – it examines menopausal changes on a racially and ethnically diverse cohort of women [1].
It has found that women of Afro-Caribbean origin reach menopause earlier (49.6 years as opposed to the average of 51) and experience a menopausal symptoms for longer. They are the most likely to experience hot flushes and sweats and experience them more severely and intensely than women of other ethnicities. They are more likely to suffer sleep problems, including shorter sleep, more awakenings and poorer quality sleep, and weight and mental health issues.
In women of southeast Asian origin (such as China or Japan), while they may not be as likely to complain of severe flushes, they suffer more from low libido and sexual pain, and may suffer more from forgetfulness, joint and muscle pains. A new study has found that, for women in Singapore (of Chinese, Malay and Indian origin), joint and muscle pain is the top menopausal symptom [2].
Meanwhile, south Asian women (India, Pakistan, Bangladesh, Sri Lanka, etc) are likely to experience menopause at a younger age than Western women – the mean age for Indian women is 46.7 years and for Pakistani women is 47.16 years. Indian women are more likely to complain of genitourinary syndrome of menopause (GSM) symptoms.
Finally, the SWAN study found that, for Hispanic women, vasomotor symptoms were more prevalent as was vaginal dryness.
It’s worth remembering though that the data is limited, and this is a broad overview of the information available. Women of any ethnicity can experience any symptom – your experience will be unique and may be vastly different from what’s described here.
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What about the impact of medical conditions?
Pre-existing medical conditions and some physiological differences between ethnicities can impact menopausal experience. For instance, weight gain, particularly around your mid-section, is common during perimenopause and menopause but South Asian women are more prone to weight gain, according to scientists, particularly around the middle, increasing the risk of insulin resistance and diabetes. The risk of cardiovascular disease (disease of the heart and blood vessels) increases after menopause and South Asian women are more likely to have hypertension, which increases the risk of cardiovascular disease [3].
A study of pre-menopausal south Asian women living in the UK found they could be more at risk of developing osteoporosis in later life than white women [4]. Bone density starts to naturally decrease in your late 30s but when hormone levels drop during perimenopause and menopause, the decline is more rapid. An estimated one in two women over 50 (and who do not take HRT) worldwide will develop osteoporosis. There is also a potential for vitamin D deficiency for women who cover up, for instance with the burqa or niqab [5]. Low vitamin D levels can increase the risk of osteoporosis.
What about lifestyle?
While there can be variations of women’s experiences of perimenopause and menopause, it’s important to remember that some differences may be down to socio-economic factors, rather than ethnicity, or cultural attitudes or lifestyle.
Exercise can have a positive impact on wellbeing during the menopause, but participation levels can vary. Among women aged 45-54 in England, 50.4% of Asian women are physically active (compared to 55.2% black women, 61.9% Chinese women and 69.8% white British women) [6].
Diet can also help alleviate menopausal symptoms and some believe that the Japanese diet, with its high soy content, could be a reason behind Japanese women experiencing fewer menopausal symptoms. Soy contains isoflavones, which mimic oestrogen, which declines during perimenopause and menopause. (However, despite reporting fewer symptoms, Japanese women can still experience future health risks, such as osteoporosis, due to low hormones.)
The impact of cultural beliefs
Another interesting thing to consider about Japanese women’s experience of menopause is their attitude towards it. The Japanese word for menopause is ‘konenki’, which means ‘renewal’ and ‘energy’.
Conversely, in some cultures menopause is firmly associated with loss. Dr Maqsuda Zaman, a GP who works in a practice with a significant number of women from various ethnic communities in Greater Manchester and who is a menopause specialist at Newson Health, says: ‘Women of Bangladeshi origin tell me menopause is associated with loss of fertility and youth. A patient of Iraqi Kurdish origin also told me it’s generally not discussed in her community as women feel embarrassed about getting older and the loss of fertility.’
For others, menopause is a taboo subject – it’s not talked about, and women may be expected to stay silent and not complain about any symptoms they may be suffering with. In some languages, there isn’t even a word for menopause. In some cultures, infertility is associated with shame and stigma – this can make it particularly challenging for women with premature ovarian insufficiency (POI) or early menopause to seek help and treatment.
RELATED: Menopause taboo in women from different ethnic groups: Dr Nighat Arif
Barriers to accessing help
In conservative cultures where menopause isn’t talked about, women suffer in silence, which means their symptoms may worsen before they do seek help, or that they try other treatments before seeking out support from a doctor. Dr Maqsuda says: ‘A common presentation is women with vaginal itching who have believed it’s due to thrush so have tried over-the-counter treatments before seeking help.’
Mental health is not frequently talked about in some ethnic communities and there can be a prevailing attitude to just “get on with it” [7]. Alternatively, some women may be reluctant to seek medical help for something they believe is a natural process.
A lack of awareness and knowledge about the menopause can also be a barrier to accessing treatment. Even when a woman from an ethnic minority background does see her GP, language can be a barrier. A woman may need an interpreter or arrive with a family member, which may inhibit her further if she needs to talk about vaginal dryness, or a doctor may miss a subtle cue they might otherwise have picked up on. Alternatively, a woman from an ethnic minority might not be familiar with the language commonly used to describe symptoms or may get misdiagnosed because of her description of symptoms and a clinician’s understanding.
Dr Maqsuda says: ‘Bangladeshi patients commonly say “I keep getting fevers” – this term is often used to describe hot flushes and night sweats, or “I have a urinary infection” – to describe urinary frequency, urgency and dysuria. Or they’ll say they feel tired all the time and have concerns over possible anaemia or diabetes, or are worried about “body pains everywhere”. Many women consult with their doctors with heavy or irregular periods but are unaware that this may be due to perimenopause. They often request treatment to regulate their periods as they are concerned about “where all the blood is going”.’
Language may be one reason behind the differences in access to care and treatment amongst women in ethnic minorities. The Fawcett Society’s 2022 report Menopause and the Workplace found black and minoritised women reported increased rates of delayed diagnosis (45% compared to 31% in white women) and lower rates of HRT uptake (8% compared to 15% in white women).
However racial bias may also be a factor – for instance black women are less likely to be offered pain relief in childbirth, and a study found black patients are about half as likely to be prescribed pain medications in hospital emergency departments than white patients [8]. Data from SWAN has shown how discrimination is associated with an increased likelihood of negative health [9, 10] and in the UK, a 10-year study of nearly 2 million women found women of black African backgrounds are 79% less likely to receive HRT than white women [11].
RELATED: Menopause specialists advocating for women of colour
What needs to be done?
More resources, posters and videos need to be created for ethnic minority women – not only in their languages but women need to see, through imagery, that menopause is something that affects them, not just white women. Dr Maqsuda agrees: ‘According to the 2021 census, approximately 18% of the population of England and Wales is from an Asian, Black or Mixed background. However, the proportion of women I have seen at Newson Health does not reflect this, and I have only had a handful of women from a South Asian, Afro-Caribbean or Arab background. All have responded very well to HRT.’
For women, the first step is to keep a symptom diary – the free balance app is an easy way to do this, or write down your symptoms on a paper calendar that you can share with your GP. Remember that there is no need to suffer in silence or deny yourself treatment, and that you can’t get help if you don’t ask for it. Open your mind to treatment options and, if it will help, take a friend or relative to any appointments for support.
