Although a two-decade study of women of different races and ethnicities has provided insight into the health problems related to menopause and aging, questions persist about how the health of Black women during and after menopause, particularly their experience of hot flashes, is affected by their lived experience.
“That is the next burning question,” said Tené Lewis, associate professor in epidemiology at Rollins School of Public Health at Emory University, and one of the investigators of the Study of Women’s Health Across the Nation (SWAN).
Differences among women in the menopause transition can sometimes be accounted for when researchers adjust for certain factors such as hormone levels, financial strain, overall health and smoking.
This increased risk comes at midlife when, Lewis said, Black women already face chronic stress from another important risk factor linked to cardiovascular health: discrimination.
Menopause, when a woman has no period for 12 months, and the transition leading up to it, perimenopause, are natural parts of aging. But it is often a difficult phase, when fluctuations in the production of the hormones estrogen and progesterone trigger symptoms such as hot flashes, sleep disturbances, vaginal dryness and weight gain. Every woman who lives long enough will experience menopause, experts point out, and most will live up to one-third of their lives in the phase.
Geraldine Ekpo, a specialist in reproductive endocrinology, said menopause is a complex topic in the Black community because, historically, it has been viewed as a natural process so, “what do you need to see the doctor about?” she said. There is also mistrust of the medical system. And physicians, typically a primary care doctor once a woman has reached the age when gynecologist visits are less frequent, may not be familiar with the menopause period, she said.
“The systemic effect of race is a nuanced conversation,” she said, noting that if a Black woman feels she is not taken seriously, she may not discuss things with her provider. Physicians may make assumptions and not ask the right questions, she said. But doctors and patients need to talk about the significance of menopause.
Looking at the disparities of Black women’s health across their reproductive and menopausal years, Ekpo called for “evidence-based outrage” in an editorial she co-wrote with three obstetricians-gynecologists in the American Journal of Public Health. They noted Black women have a higher risk of experiencing hot flashes but are less likely to be offered effective hormone replacement therapy and have lower quality of care for cervical and ovarian cancers.
“Enough is enough. Race is a social construct and the overwhelming statistics we present are attributable to a broken racist system, not a broken group of women,” they wrote.
The unique experience of Black women through the menopause transition is one of many insights from the SWAN study, which has followed a cohort of Hispanic, Japanese, Chinese, Black and White women in seven cities for more than two decades. The study found Black women have the highest prevalence, longest duration and are the most bothered by hot flashes, while White women have a lower composite strength in bones, for example. Black and Hispanic women also experience poorer quality sleep, which could affect cardiovascular health.
How one experiences menopause can be looked at in a historical and cultural context, said Omisade Burney-Scott, creator of the Black Girls’ Guide to Surviving Menopause website and podcast. “What has been your personal journey or the journey of the people you claim or who claim you?” she said. She views menopause as a time of transformation and her podcast as a place for storytelling to, “disrupt the erasure of Black women and femme’s voices as they age.”
She felt her first hot flash and anxiety attack at the same time, while immersed in work fighting voter suppression, she said. Her primary care doctor helped her understand the big picture of what was happening, and worked with her gynecologist and therapist, cooperation that Burney-Scott initiated.
A multidisciplinary team is ideal during any transition, including menopause, said Laurie Zephyrin, vice president of health-care delivery system reform at the Commonwealth Fund and clinical assistant professor of obstetrics and gynecology at NYU Langone School of Medicine. Adding basic questions to a primary care visit would help demystify it, she said. Addressing systemic racism in health care takes work and commitment, with more data, more diversity in the workforce and an understanding of implicit bias, she said.
Only 6 percent of the physician workforce is Black, according to the Association of American Medical Colleges.
While there is “nothing magical about a Black doctor” being able to improve health in a Black patient, there is evidence racial concordance can improve the personal side of care, said Somnath Saha, who studies the influence of race and ethnicity in the patient-physician relationship. A consistent theme in his research is that “Black women feel that their complaints are not being heard and they are basically dismissed.” Sociologist Miranda Fricker describes such treatment as “testimonial injustice,” which in this case means that racism and sexism intersect so that Black women’s statements about their menopausal symptoms are not given the credibility they deserve.
Part of the difficulty in getting providers to discuss menopause care with women, whatever their race, is that they may not recognize their patients are menopausal. In a survey to medical residents in family medicine, internal medicine and obstetrics and gynecology, 17 percent reported caring for no symptomatic menopausal women. That statistic is striking, said Stephanie Faubion, medical director of the North American Menopause Society (NAMS) and director of the Center for Women’s Health at the Mayo Clinic, because it would imply they saw no women patients between the ages of 45 and 60.
“So, do you think they were asking them about menopause? No. they didn’t even see them as menopausal,” she said. It is unlikely most clinicians talk about the racial and ethnic experience of menopause. “We are just trying to get people to have a conversation,” Faubion said.
A gap in training emerged 20 years ago, when early interpretation of a Women’s Health Initiative study of hormone replacement therapy put “estrogen in the doghouse,” said Mary Jane Minkin, clinical professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at Yale University. The study was released around the same time residency programs cut training hours. Priorities were made: learn to deliver a baby, do a hysterectomy. Menopause care got cut, said Minkin, who blogs at MadameOvary.com.
The sentiment was, “Women will get through it. Maybe not well, but they will live,” said Minkin, who offered students a nighttime elective on the subject to compensate.
Women’s health has not been on the radar in the historically male dominated field of medicine, said Eliza Chin, executive director of American Medical Women’s Association, noting the lack of sex and gender specific data in clinical trials.
There is now a sense that the conversation around menopause is picking up, driven largely by women physicians who see the need to get women of all backgrounds to talk with their doctors, and be proactive heading into older age. Some of those changes, particularly with telemedicine, may expand equity. Healthywomen.org launched a series of weekly virtual roundtable discussions with experts, each free to stream from their website. Tech companies, Lisa Health and Gennev, are stepping into the menopause space using online assessments and artificial intelligence.
For Lewis, what’s driving her research is not how to treat symptoms such as hot flashes but how to prevent them. “We need studies prior to menopause to understand the precursors,” she said.
Burney-Scott, who as a nonmedical professional finds importance in making space for the stories of those who age, said older Black women may be “gifted with eldership,” and it is important they not be stereotyped as asexual or nonsexual. She wonders how the women in her matrilineal line took care of themselves and how those choices “intersected with aging.” If she could time travel, she would want to ask her great-grandmother Mary how she navigated during the 1918 flu pandemic and how she was taking care of herself and found joy.
And she would ask, “You’re 50, are you having hot flashes?”
Black Girls’ Guide to Surviving Menopause
Omisade Burney-Scott’s multimedia project sharing stories of Black women and femmes 50 and older.
Zine: Messages from the Menopausal Multiverse (based on the podcast)
●North American Menopause Society
Resources for help finding a menopause practitioner, FAQ’s, guidebook that includes recommended screenings for women ages 50 to 65, as well as videos and other resources.
●Healthy Women: No Pause for Menopause
Free webinars covering different topics including sleep, brain fog, mental health and hot flashes, night sweats, vaginal dryness, hormonal and non-hormonal methods to manage symptoms.
Mary Jane Minkin, clinical professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the Yale University School of Medicine. Videos, blog and “Lady Parts” podcast.