With menopause awareness month in full swing, Dr Zoe is rethinking her possible menopause age in light of new research showing that ethnicity has a major influence on symptoms and access to HRT. Here's what women and their doctors need to know
Can you predict the age at which you’ll go through menopause? As the conversation shifts from dreading the transition to going into it prepared, obviously we want to know when it’s going to happen. We’re told by the NHS that the average age of menopause in the UK is 51, but new research is shedding light on just how inexact that is for women of colour, who on average go through menopause at least two years earlier.
This is something that GP and TV medic Dr Zoe Williams, 43 is on a mission to highlight, not just to all women but to her profession as well. “The average age at which people reach menopause both in the UK and the US is 51. And the onset of perimenopause on average is 47-and-a-half. Of course, some people are much younger, some people are much older. But research in a large US study called The SWAN Study, (the Study of Women's Health Across the Nation) started in 1994, shows that for black women, it's on average two years earlier, and also that the perimenopause is longer as well.”
What’s more, she says, women of colour are less likely to be prescribed HRT, even though they may need it earlier and for longer.
“Up until looking at this data, I'd always just thought that the average age is 51. I'd never realised that actually the average age of black women is two years less and for South Asian women, it could be more like six years less than that. It's news to me, so I'm pretty certain this will be news to most of my medical colleagues as well. It’s about education.”
We sat down with Dr Zoe to dig deeper.
How are the age of menopause and menopause symptoms different for women of colour?
“While our biology may be the same, our experiences are different and what the study shows is that black (and Latina women who were also studied, with it being US research) enter menopause earlier, have longer lasting symptoms and also have more intense symptoms.
“In addition, the types of symptoms that are predominant can vary according to ethnicity. When they looked specifically at Hispanic women, they found that they were more likely to report vaginal dryness, urine leakage and increased heart rate, whereas black women are more frequently likely to report hot flashes and night sweats. The US study didn’t publish results for South Asian women, but there are alternative sources of data that say South Asian women start their menopause even earlier, on average five to seven years earlier than white women.
“The SWAN study found that perimenopause, which on average in white women is three-and-a-half years, is also longer in black women. So the age of perimenopause is even more significantly earlier than the age of menopause. The study says that symptoms last for longer, they're more severe and they start at an earlier age.”
How should we rethink the age of menopause for women of colour?
“The statistics we have are for people in general. Now that we've got this data, we should probably be giving slightly different statistics. This study opened my eyes because we tend to think that the best indication that we have as to what age we might be when we start with menopausal symptoms is based on our mum. I'm a mixed-race woman - my mum’s white and my dad's black, so I'm not a statistic. Who knows what might happen? But according to the data, I should probably take a year off the day my mum started menopause. It might happen a year earlier than I thought.”
Why do women of colour have an earlier menopause?
“We don't definitely know why. Things that might make menopause earlier for any individual are if you smoke, and if you're from a lower socio-economic group. The more wealthy you are, the more likely you are to have a later menopause. And we know that if you're black or South Asian or if you're a person of colour you're more likely to be living in a lower socio-economic group. But a lot of the studies have accounted for that and there is still something around ethnicity. What the authors of the SWAN study propose, is that essentially, people of colour have a more stressful life and it's the stress that matters. They attribute some of the stress to structural racism in the US. But they say potentially the more stressful your life is, the more likely you could be to go into menopause slightly earlier.”
What needs to change for the menopause conversation to be more inclusive?
“We've made huge progress in recent years in talking about menopause, trying to break down the stigma. But if we're saying that women of colour are actually affected even more than Caucasian people when it comes to menopause, I don't think we necessarily see those faces being represented. I've never seen a menopause leaflet with a person of colour on it. It used to be a more elderly frail-looking lady, whereas these days, it tends to be a glamorous, blonde white lady, being active or doing something positive. The message to women of colour is that this leaflet isn't for you.
“We've seen wonderful celebrities banging the drum alongside politicians, scientists and doctors. But again, if you look at that group of women, they all tend to be white. Subliminally, I think black women aren't being given permission to have those conversations at home with their doctor with their employer, perhaps because it is not been spoken about by people who look like them. Within some communities, a cultural issue as well.”
What are some of the cultural barriers to talking about menopause?
“In certain cultures and even in certain languages, there isn't a word for menopause. It's not really the done thing to talk about it in some South Asian communities, for example. But it affects them more and more intensely for a longer period of time.
“In my experience, women of colour are less likely to be aware that the symptoms they are having could be caused by perimenopause. If it’s their period stopping, they're more likely to pick that up. It may be that it’s less likely to be talked about within their community but also from media and the conversation we’re all having now – they may have been somewhat excluded from it.
Why are black women less likely to be prescribed HRT?
“In short, we don't know the reason why, but we do know that black women are much less likely to be prescribed HRT than white women and there's no scientific reason why they should, if anything, it probably tips slightly the other way.
“A number of mostly US studies have looked at this and what they tend to show is that in groups of women of the same age, with the same social background, treated in the same clinic, if you're white, you're twice as likely to be prescribed HRT than you are if you're black.
“It could be that perhaps women of colour are less likely to come forward and share their concerns. There are links then into some of the racial discrimination that we know that is evident in the NHS and wider healthcare systems, as to reasons why they might be less inclined to come forward and seek support - their expectations about getting the right support might be lower. But also, does it tie into these harmful and incorrect ideas that we know exist, that black women have higher pain thresholds or are better able to tolerate symptoms?"
How are the protective benefits of oestrogen HRT for black women different white women
“HRT is protective against osteoporosis and osteoporosis is more common in white women than black women. But black women are more likely to get heart disease – and HRT is also protective against heart disease. There's a lot of research to be done. I think as a healthcare professional, knowing this should and will change my practice. If women are coming in to see me in their early or mid-40s, I’ll always be thinking about perimenopause and menopause anyway, but I should do even more so if the woman is South Asian or black.”
Dr Zoe Williams' advice: "If you think you may have symptoms of menopause, try these tips..."
1. Talk about it.
“Talk about it to people that you think may be going through it, but also talk to everybody else around you. Let them know what you're experiencing. Give them permission to help you – that could be your family at home. It could be your employer, your parents, your colleagues or your friends.”
2. Find out how to help yourself
“If you're from a community where this isn't discussed openly, do some research and find out about the positive things as well. Interestingly, in Chinese culture menopause is deemed as a really positive thing. They say that the energy previously needed by your womb moves to your heart. They talk about it as a ‘second spring’ to be celebrated.
"It's really a time to stop focusing on and looking after all of those around you and look after yourself. And there are lots of things you can do with your lifestyle that can really help, from meditation to making some dietary changes to thinking about which types of physical activity might benefit you.”
3. Identify who's the best person in your GP practice to have the conversation with
“You can speak to a nurse if you feel more comfortable, who might be able to just have a chat with you and recommend which GP will be best. You can request a female GP. Be really honest with them and share as much information as possible.”
4. Keep a log of your symptoms
“There are lots of apps and forms that you can use online (see below). If you've tracked your symptoms over time even better, but it doesn't matter if you haven't. So make sure you're knowledgeable. Tell them ‘I think my symptoms are due to perimenopause, or I think my symptoms may be due to menopause’. The doctor should be thinking about it but may not be, so just help them out by letting them know that that's what you think.”
5. Find your tribe
“Find a way to share what you're experiencing with like-minded people. These are some I recommend.”
- Issviva online menopause platform, which has a community for other women who are experiencing what you're experiencing.
- Black Women in Menopause a private Facebook and events group started by a black woman several years ago, who recognised that she didn't feel that any of the leaflets or websites were representing her. Find them on Instagram @blackwomeninmenopause
- Black Menopause And Beyond Instagram @blkmeno beyond.
- Feelgoodwithlavina.com by Lavina Mehta MBE. The British South Asian PT shares accessible strength workouts, health tips and her own perimenopause experience
- Take the Issviva online menopause test to see where you are in your menopause journey
- Download this symptom questionnaire form from the British Menopause Society.
Dr Zoe Williams is a GP and ambassador for Issviva. Visit www.issviva.com to sign up to Issviva’s free online community.