Menopause affects around 50% of the world’s female population and “the change” impacts every man with a woman in his life.
Surprisingly, the menopause is either poorly understood or shrugged off, especially in ethnic minority groups. Despite the 2018 census showing that 13.8% (1) of the UK population is from ethnic minority backgrounds, there is little research dedicated to the experience of the menopause in ethnic minority communities. Because of this, these women have come to believe that the menopause is a “white, middle class” problem or a ‘Western phenomenon’.
I interact with a diverse group of women: some have come from Pakistan through marriage, some do not speak English as their first language and others who are high-ranking professional and fluent in English. Across the board there is lack of openness to discuss many gynaecological problems.
In my native language: Punjabi/Urdu there is no direct translation for the word ‘menopause’. Women only partially understand it; referring to that point in life where their hormones change as “old age” or “no longer able to bear children”, or simply“periods have stopped”
Although some women understand the meaning of menopause, most do not understand the health implications which can results from the change
Although some women understand the meaning of menopause, most do not understand the health implications which can results from the change, such as infertility, osteoporosis or heart disease. Others choose to ignore their menopausal symptoms due to other concomitant social factors – such as family commitments, planning their children’s marriages, a common tradition across the Muslim, Pakistani culture; which comes with its own financial and social pressures hence obscuring menopausal symptoms. So, the psychological symptoms of the menopause are put down to circumstances.
I find that the BAME community treat menopause with ambivalence- it is the endurance of being a woman – like menstruation, pregnancy and childbirth. The women I see at grassroots level, as a GP, and in my own community- the menopause is simply not viewed as a medical condition. So, they will suffer the symptoms, sometimes for decades.
In some subcontinental cultures if a women goes through the menopause early, there is considerable stigma attached to the infertility as it’s viewed as a failure on the woman’s behalf. Her husband can then consider or even be encouraged in taking a second wife.
The menopause, the HRT, sexual dysfunction is not openly discussed in BAME households. Mothers with scant knowledge themselves, don’t discuss their symptoms with their daughters. Amongst their friends, I find some Pakistani/ Indian women see the menopause as a time of celebration – it is a time of freedom from periods. No periods mean that women (from certain religious groups) can pray at the mosque or temple uninterrupted, – so they ‘just get on with it’ and ‘don’t bother the doctor’ with their symptoms. Some women turn to God as they believe tha illness is caused and healed by a divine power. Therefore, through sheer will-power and prayer, they can manage their menopausal symptoms, especially the psychological ones.
I have found that BAME women don’t always express the classical symptoms that western women experience
Symptoms experienced varies widely within different cultures. Through my work, I have found that BAME women don’t always express the classical symptoms that western women experience, such as hot flushes, night sweats, irritability. Although BAME women do experience those, the data, and my own experience reveal that BAME women (2) will report the ‘physical symptoms’ more. For example, I have had Pakistani/Indian women expressing “all over body pain”, ” fatigue” or “lack of strength”. Other studies show that Japanese women complain of “shoulder stiffness”.
In India, women complain of no symptoms of the menopause other than loss of periods. In rural parts of India women have been known to express “vision loss” as sign of the menopause, when clinically they do not have vision loss. I have had Turkish women complain less of hot flushes but more of “itchy eyes” or “blurry vision” In UAE- “hot flushes” and “vaginal dryness” is expressed only in a few consultations. Taboo subjects such as sexual dysfunction, libido, painful sex is only expressed in 10% of BAME consultations (3). So, the menopausal symptoms that predominate in
western populations cannot be brush stroked on to BAME groups. Therefore, as GP’s we risk missing menopausal diagnoses and possibly even mis-diagnosing as other medical conditions such as depression, fibromyalgia etc.
Additionally, BAME women face a language barrier- They find it hard to vocalise their symptoms in terminology that western trained doctors will understand, and then women for whom English is not their first language, they really struggle to express their symptoms. Relying on relatives to translate adds to the embarrassment and barrier to treatment. Interpreter services available on the NHS require booking weeks/months in advance and they are in short supply across different Clinical Commissioning Groups’s (CCG’s) across England.
BAME Women manage their symptoms in a range of ways. Particularly preferring to use ‘alternative’ methods such as herbs, spices and using soya based products. BAME women also use coping methods such as eating healthy diets, exercising, wearing light clothing, taking cold showers or drinks during hot flushes. One lady I met, used laughter therapy to deal with her depression.
BAME women are using HRT- HOWEVER the uptake is low (4). This is because BAME women feel that their symptoms were not severe enough. They also believe that HRT would encourage the return of menstruation or cause cancer, therefore prefer using alternatives or feel they can cope without treatment. Many women understand that HRT involves taking tablets daily, but are unaware of patches and gels which carry less risk in association with breast cancer.
The message that HRT has cardiovascular benefits, prevents osteoporotic fractures and Alzheimer’s disease and potentially bowel cancer is being lost.
Studies have shown that women did not receive adequate information from their GPs regarding HRT and would prefer GPs from their own ethnic group who might be more understanding of the social and cultural ties. The impact of sexual dysfunction that ensues with the menopause affects women and their partner equally. Women do not know about vaginal atrophy as the cause of painful sex. Men in their 40s – 60s either don’t know about the menopause or feel completely helpless in approaching or helping the woman they love.
When the menopause is seen as a gynaecological problem, a ‘woman’s problem’, the sexual difficulties encountered is viewed as a shortcoming on her part, hence shrouded in secrecy and shame. This notion of shame is carried forward into the consultation room with the GP. I have had Muslim, Pakistani women tell me they are too embarrassed and ashamed to
discuss issues with sexual intercourse with their GP, but also in turn I have had colleagues express that they feel ‘embarrassed’ asking about sexual dysfunction when they consult with a woman from a BAME community- so there seems to be a ‘stale mate’ where out of embarrassment the most intimate parts of the menopause are not openly discussed. Thus, in the end the woman is left feeling alone, and will turn to a ‘high power of divinity’ for support. Talking about ‘sex’ is still widely proscribed, which prevents open discussion around female health and this needs to be challenged. Unless we talk more, and normalise it- it will be difficult for change to occur.
However, I have already seen progression as millennials, with greater access to online information are learning and talking about the menopause, are bringing the subject into the mainstream.
Shows on the media incorporating BAME representation is a step in the right direction.
The NHS is studying BAME groups more: each CCG has a lead GP designated to actively tackle issues around health inequalities. More work with community & faith leaders, as well as outreach health professionals
is needed to deliver information in the appropriate languages so women are properly educated and able to discuss their menopausal symptoms with their clinician.
Let’s change the discussion and normalise it without it being a taboo subject, shrouded in secrecy and shame. It has already begun, and GPs – particularly from an ethnic background – must ensure it continues.
By Dr Nighat Arif, GP WSI in Women Health
1) Source: Office for National Statistics (2019) Annual Population Survey
2) 2013 Study into attitudes of menopause in Indian Regions:Stefanopoulou, Shah, Shah, Gupta, Sturdee, and Hunter.
An International Menopause Society study of climate, altitude, temperature (IMS-CAT) an vasomotor symptoms in urban Indian regions. Climacteric.
2014 Aug.Epub 2013 Nov 7.
3)Menopause around the world from the Women in Balance Institute
4) 2007 Study into Black nurses of HRT in the work place.