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BY JENNIFER FINK
Hot flashes. Night sweats. Irregular menstrual periods.
Black women approaching menopause may experience these symptoms—and others—for a decade before their menstrual cycles cease all together. White women, on average, experience menopausal symptoms for approximately 6 ½ years.
Most people (including most women and most health-care providers) don’t realize that menopause, which is a universal experience for women, affects women of different racial, cultural and ethnic backgrounds in different ways. This lack of understanding is due to a lack of education and—in the field of medicine—a lack of focused research.
“There is a deficit in educating medical professionals about caring for menopausal women,” says Makeba Williams, MD, Washington University obstetrician and gynecologist at Barnes-Jewish Hospital and director of a recently opened menopause clinic at Washington University. “There are also very few research studies that are really addressing what the racial and ethnic experiences of menopausal women are. When my research team embarked on a review of more than 20 years of related research, we found that very few studies included women of color in numbers large enough to make it possible to discern differences.”
Lack of knowledge regarding menopause harms women’s health and their overall well-being. Improved education for all women—and for health-care providers—will help women flourish in all stages of life.
Menopause: The Basics
For most women, menopause is officially “a retrospective diagnosis that is made after a woman has gone one full year without any menstrual periods,” according to many medical definitions. On average, menopause occurs around age 51.
MENOPAUSE IS A CRITICAL TIME PERIOD FOR HEALTH. WE NEED TO PAUSE WITH WOMEN AND THINK ABOUT HOW WE CAN PRIORITIZE THEIR HEALTH AT A TIME WHEN THEY’RE ALSO EXPERIENCING LOTS OF OTHER DEMANDS IN THEIR LIVES.
The years leading up to menopause are sometimes called “perimenopause” or the “menopause transition.” During this phase of life, fluctuating levels of estrogen and progesterone can trigger a slew of symptoms, including hot flashes, night sweats, irregular periods, heart palpitations, brain fog, sleep disturbances, vaginal dryness, difficulty concentrating, mood changes and more.
Some women may begin experiencing symptoms of hormonal fluctuation in their forties, Williams says, and symptoms can continue, evolve and change over the next five to 10 (or more) years. And some women experience few, if any, symptoms as they move toward menopause. For others, symptoms are so severe that they negatively impact the ability to work and function in daily life.
“I recently treated a patient who told me she was sleeping just three hours a night,” Williams says. “She told me, ‘I used to be the smartest person in the room. I no longer feel that way because I can’t get to the next thought. I’ll be making a presentation and can’t think of the next word.’”
MAKEBA WILLIAMS, MD, OBSTETRICIAN AND GYNECOLOGIST, IS STUDYING THE RACIAL AND ETHNIC DIFFERENCES IN MENOPAUSE SYMPTOMS.
It can be difficult for women and their health-care providers to understand and untangle the cascade of symptoms many people experience during the transition to menopause. Estrogen, the dominant female hormone, affects the entire body, not just the female reproductive system.
“We may see symptoms of menopause in multiple organ systems,” Williams says. For example: Because estrogen helps maintain muscle and bone mass, women experience a loss of muscle and bone as estrogen levels decrease. Loss of muscle mass may be one reason many women gain weight as they move through menopause. Muscle burns calories more efficiently than other tissues of the body, so people who lose muscle will gain weight if they continue to eat and move as they did previously.
Decreasing estrogen levels also cause decreased blood flow to the vaginal and urinary tracts, which can cause dryness, itching and tissue loss that may result in urinary frequency and urgency, stress incontinence, painful sex and other significant discomforts. About 60% of people experience urogenital symptoms before or after menopause.
“There are some women who are unable to sit when wearing pants because this discomfort can be so potent,” Williams says, noting that vaginal and urinary changes “can impact you whether or not you choose to be sexually active.”
Estrogen receptors are found in the brain, as well, and estrogen is known to affect cognitive function, so changes in cognition may be related to changing hormone levels. Of course, lack of sleep is also known to affect thinking, memory and mood, and many women report disturbed sleep due to hot flashes and night sweats. Approximately 45% of women report experiencing anger, irritability, anxiety, depression, loss of concentration and loss of self-confidence as they experience menopause.
“Some of the symptoms that women experience can be a result of a confluence of factors,” Williams says. She notes that women at midlife may also be dealing with teenage or young adult children, increased professional demands and aging relatives. “I caution my patients not to attribute all they’re going through during menopause to hormonal changes,” she says.
It is important, though, to acknowledge the impact these symptoms have on women’s lives. The physical changes associated with menopause increase a woman’s risk of heart disease, stroke, urinary tract infections and osteoporosis. And women in this phase of life may find it is difficult to work, to sustain relationships and enjoy life when they are frequently uncomfortable and not sleeping well. Rather than enduring this phase of life, Williams notes, women need to know they have the option of addressing their symptoms and risks with their health-care providers.
Gaps in understanding
In generations past, women rarely spoke openly about menopause, and even today, most people, including physicians and other health-care providers, receive very little education about menopause. A 2019 study published in Mayo Clinic Proceedings found that one out of five postgraduate residents reported not receiving any lectures about menopause during residency, and only 6.8% reported feeling “adequately prepared to manage women experiencing menopause.” Even medical residents specializing in obstetrics and gynecology don’t get a lot of education regarding menopause, Williams says.
Further complicating matters is a lack of knowledge regarding how women of diverse backgrounds experience menopause. For instance, Williams’ research has revealed that Black women in the United States experience a higher prevalence of hot flashes, night sweats and other vasomotor symptoms (including heart palpitations) than white women, and that Black women typically experience menopause-related symptoms for a longer time. However, Black women are less likely to report sleep disturbances and cognitive challenges, even though objective measurements show that Black women going through the transition to menopause tend to sleep fewer hours than white women. Black women also are less likely than white women to receive medical treatment for their symptoms.
“In some communities, there may be positive acceptance that menopause is a natural process. But that acceptance can foster the minimization of symptoms,” Williams notes. “A woman of color may not bring this issue up during a doctor visit, and if her health-care provider doesn’t raise the issue in a systematic, objective way, the tolerance may continue, even if the women is, in fact, very bothered by her symptoms.”
More research that includes women of diverse backgrounds is needed to understand “what women are comfortable with, in terms of menopause, how they view it, and how they may want to have their symptoms addressed,” Williams adds.
Most women today do not receive treatment for troublesome menopause symptoms. According to a National Poll on Healthy Aging published in 2022, just 44% of women who experienced menopause-related symptoms over the previous year discussed potential treatments with their health-care providers, even though nearly one in three women said their symptoms interfered with daily life.
Unfortunately, the message many women get from health-care providers is “you need to grin and bear it,” Williams says. After the Women’s Health Initiative studies raised concerns about a possible link between hormone-replacement therapy and breast cancer in the early 2000s, many health-care providers hesitated to prescribe it for their patients—and many women were reluctant to take it. That fear and hesitation still lingers, even though, says Williams, “subsequent research has found that hormone therapy is safe, particularly if you’re within the first 10 years of menopause and don’t have a personal history of gynecologic cancer, estrogen-sensitive breast cancer, stroke or blood clots.”
With little menopause-savvy guidance from their health-care providers and often awake and drenched in sweat in the middle of the night, many women search online for relief. Unfortunately, Williams notes, “you may end up with ‘solutions’ that are not evidence-based and could be harmful.” Seeking treatment outside the medical system may also be more expensive “because you end up buying things that can be costly and are not effective.”
Williams hopes that, instead of treating themselves, women will ask their health-care providers: “What does menopause mean for me and my health?” If the provider doesn’t give a satisfactory answer, Williams recommends a calm response: “If you are uncomfortable addressing this, is there someone to whom you can refer me?”
Hormone therapy can be extremely helpful—even life-changing—for some women. Non-hormonal treatment options are also available.
“Many physicians caring for women aren’t aware that we have good, FDA-approved, non-hormonal therapies,” Williams says. For example, low-dose paroxetine received FDA approval in 2013 to treat moderate-to-severe vasomotor symptoms, including hot flashes and night sweats. Research published in the International Journal of Women’s Health indicates that paroxetine is “a safe and effective therapy” for the treatment of menopause-related vasomotor symptoms, regardless of a patient’s history of breast cancer. Over-the-counter herbal remedies, Williams says, “do not have good data to support their use.”
Women have another FDA-approved, non-hormonal menopause treatment option called fezolinetant, an oral medication that’s been shown to decrease hot flashes and other vasomotor symptoms. An international, randomized, double-blind, placebo-controlled study published in The Lancet on March 13 noted improvements in frequency and severity of symptoms after one week of treatment with fezolinetant, with symptom control maintained over 52 weeks.
Williams encourages women to discuss their menopause symptoms and treatment options with their health-care providers—or seek out a specialist in menopause care—so they can achieve optimal health and quality of life. “Menopause is a critical time period for health,” she says. “We need to pause with women and think about how we can prioritize their health at a time when they’re also experiencing lots of other demands in their lives.”
The menopause clinic at Washington University treats people experiencing a range of menopause symptoms. To make an appointment, call 314-362-4211.
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