Menopause in ethnic communities

The importance of equal access to perimenopause and menopause care and education

• Race, ethnicity and cultural beliefs can affect a woman’s experience of the 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 go through the menopause, but not all of us will have the same experience or symptoms. We’re all different of course and our genetics, existing health conditions, income, race and ethnicity can have an influence. Research into how the menopause specifically affects 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 our community.

Do symptoms vary in different ethnicities?

While there is limited research into menopausal symptoms carried out in British ethnic minority women, we know from other studies that ethnic variances 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 longer menopausal transition. 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 the 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 vulval and uro-gynaecological 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.

RELATED: empowering women unheard during menopause

What about the impact of medical conditions?

While the reasons behind women’s varying symptoms can be varied, pre-existing medical conditions and some physiological differences can contribute.

South Asian women are more prone to weight gain, according to scientists, particularly around the middle, increasing the risk of insulin resistance and diabetes. Hypertension is more common, increasing 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]. 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.

Afro-Caribbean women have been found to suffer from a higher allostatic load than Caucasian women [6]. This refers to chronic, ongoing stress that can have a wear and tear effect of the body – a potential factor behind their severe menopausal symptoms and longer menopause.

What about lifestyle?

While physiological differences play a part in women’s menopause, it’s important to remember that there can be variations within ethnic groups and that some differences may also 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) [7].

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 the menopause.

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’. Having a positive outlook can make a physical difference – women with a positive attitude are reported to have lower severity of menopausal symptoms [8].

Conversely, in some cultures the 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 from.

RELATED: menopause taboo in women from different ethnic groups: Dr Nighat Arif

Barriers to accessing help

In conservative cultures where the menopause isn’t talked about, women can 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 [9]. 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 present with heavy or irregular periods but are unaware that this may be due to the menopause. 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 minoritized 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 – 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 [10]..

RELATED: Menopause specialists advocating for women of colour

What needs to be done?

Clearly 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: ‘In the six months that I’ve been working for Newson Health in Altrincham, I have only seen one Pakistani and two Indian women; one was a pharmacist and the other a hospital consultant. I have had no patients from an Afro-Caribbean or Arab background.’

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.

Where to get help

• The balance website has videos, articles and factsheets on the menopause that have been translated into Punjabi (click here) and Hindi (click here). There are also podcasts with clinicians advocating for women from ethnic minorities, which contain helpful advice.
• Pausitivity has a Know Your Menopause poster in Urdu.
• Jane Lewis, author of My Menopausal Vagina, has translated her Leaflet on vaginal dryness into Urdu.
• @shadesofmenopause is an Instagram group for ethnic minority women to be heard and seen
• The British Menopause Society has a useful article on Menopause in ethnic minority women

References

1. SWAN study

2. Logan S, Wong BWX, Tan JHI, Kramer MS, Yong EL. (2023), ‘Menopausal symptoms in midlife Singaporean women: Prevalence rates and associated factors from the Integrated Women’s Health Programme (IWHP)’, Maturitas. 178:107853. DOI: 10.1016/j.maturitas.2023.107853

3. Pandit K, Goswami S, Ghosh S, Mukhopadhyay P, Chowdhury S. Metabolic syndrome in South Asians. Indian J Endocrinol Metab. 2012 Jan;16(1):44-55. doi: 10.4103/2230-8210.91187. PMID: 22276252; PMCID: PMC3263197.

4. A.L. Darling, K.H. Hart, F. Gossiel, F. Robertson, J. Hunt, T.R. Hill, S. Johnsen, J.L. Berry, R. Eastell, R. Vieth, S.A. Lanham-New. (2017), ‘Higher bone resorption excretion in South Asian women vs. White Caucasians and increased bone loss with higher seasonal cycling of vitamin D: Results from the D-FINES cohort study’, Bone, 98, pp 47-53, doi.org/10.1016/j.bone.2017.03.002.

5. Marie France Le Goaziou, Gaelle Contardo, Christian Dupraz, Ambroise Martin, Martine Laville & Anne Marie Schott-Pethelaz (2011) Risk factors for vitamin D deficiency in women aged 20–50 years consulting in general practice: a cross-sectional study, European Journal of General Practice, 17:3, 146-152, DOI: 10.3109/13814788.2011.560663

6.  Richardson LJ, Goodwin AN, Hummer RA. Social status differences in allostatic load among young adults in the United States. SSM Popul Health. 2021 Apr 2;15:100771. doi: 10.1016/j.ssmph.2021.100771.

7. GOV.UK: physical activity

8. Kwak EK, Park HS, Kang NM. Menopause knowledge, attitude, symptom and management among midlife employed women. J Menopausal Med. 2014;20(3):118–25.

9.  MacLellan J et all. Primary care practitioners’ experiences of peri/menopause help-seeking among ethnic minority women: British Journal of General Practice 3 March 2023; BJGP.2022.0569. DOI: https://doi.org/10.3399/BJGP.2022.0569

10. Astha Singhal, Yu-Yu Tien, Renee Y. Hsia. (2016), ‘Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse’. https://doi.org/10.1371/journal.pone.0159224