Evidence has emerged that women of color are more likely to experience more adverse health effects during menopause, and this disparity compared with white women’s experiences is likely due to structural racism in the US.
Women of color experience earlier and more extreme menopausal symptoms
Until recently, most discussion of perimenopause and menopause has focussed on the experience of white women. We now know that women of color are more likely to experience earlier menopause and more extreme symptoms lasting for longer than their white counterparts. This is one of the major findings of the SWAN (Study of Women’s Health Across the Nation).
The SWAN study
Commenced in 1994, SWAN is an ongoing, longitudinal study, the largest and longest-running of its kind. It set out ‘to examine the physical, biological, psychological, and social changes’ in premenopausal women with diverse backgrounds as they transitioned through menopause, with the goal of determining how these affect women’s health and quality of life. It is the result of a collaborative study between seven research centres across the US, comprising 3,302 participants. These represent five racial/ethnic groups (1,550 Caucasian, 935 African-American, 281 Japanese, 286 Hispanic and 250 Chinese). Data from SWAN have been used in over 500 studies to date.
Differences of menopausal experience with race/ethnicity
A number of SWAN studies have found evidence for disparities in menopause experience across racial groups. To be clear, the symptoms that the non-white cohort experience are not different from those of white women, but tend to be longer or more extreme versions.
To start with, African-American, Asian-American and Latina women begin menopause earlier than white women. African-American women tend to spend longer in the perimenopausal transition phase and experience irregular bleeding for longer than white. Along with Latina women, they experience more intense and longer-duration vasomotor symptoms (hot flashes and night sweats). White women experienced these for 6.5 years whilst for Latina and African-American women it was much longer, at 8.9 and 10.1 years, respectively. For Chinese-Americans and Japanese-Americans it was shorter, at 5.4 and 4.8 years, respectively. Latina women experience more vaginal symptoms (dryness and painful intercourse) than any of the other groups. Latina and African-American women also experienced more sleep disturbances and depression. The Asian-American cohort were more likely to report diminished libido. The median age at final menstrual period (FMP) was found to be 52.88 years for white women and 52.17 for African-American.
What causes these variations in menopausal symptoms observed across the ethnic/racial groups?
In 2022, a team of SWAN researchers published their results of a review of SWAN data in which they focussed on disparities in health outcomes between African American and white women. The Chinese, Japanese and Hispanic cohorts were excluded because of their relatively low numbers. The authors explicitly note that, ‘most Black women in SWAN were born in the United States and grew up during the Jim Crow era when racism was legally sanctioned.’ They concluded that whilst the study, ‘did not explicitly address structural racism…some of these observed disparities are likely due to structural racism in the US’. They used proxy measures such as socio-economic status to conclude this. For example, in examining the age discrepancy in FMP between the African-American and white cohorts, when they corrected for factors associated with structural racism (e.g. smoking, low employment levels), the disparity in age at FMP between African-American women and white women drops to a level that is no longer statistically significant. In other words, were it not for the life stressors and inequalities that structural racism introduces, African-American women would reach FMP at a comparable age to white.
Consequences for women of color
It’s not simply a matter of documenting ages, durations and degree of symptoms; the consequences of SWAN’s findings are vast. On average, women of color with problematic menopause symptoms require healthcare support earlier, and for longer, than white women. It also means that women may need treatment for menopause symptoms earlier than they or their healthcare provider expects. Given that we still live in a culture where many doctors are ill-informed about menopause and frequently misdiagnose, underestimate or outright dismiss symptoms, women need to be aware they could experience symptoms earlier than they expect so that they can advocate for themselves to get the treatment they deserve.
Women of color can be at greater risk of illness in old age
It is well-known that the drop in oestrogen that occurs during menopause leads to a greater risk of heart disease, stroke, depression and death. Whilst all women experience this, the risks are greater the earlier the onset of perimenopause. An earlier onset means that the body has had the benefit of oestrogen-protective effects for a shorter time. Likewise, recent results have shown that women experiencing earlier onset menopause are more prone to bone fractures in later life due to decreased bone density. Women of color and their doctors need to be aware of monitoring their blood pressure, maintaining their bone strength, checking their cholesterol levels and maintaining a healthy weight and diet from an earlier age.
What can women of color do to mitigate against the effects of earlier/more intense symptoms?
Firstly, they can be aware that symptoms may start earlier than they expect so they are more likely to recognise them for what they are when they occur. They need to be prepared to advocate for themselves in the face of a potentially unsympathetic, uninformed or disbelieving healthcare provider using the facts as determined by SWAN. Having access to a doctor or gynaecologist educated in and sympathetic to menopausal symptoms can be a zip code lottery, but it is worth trying to find one who is. Finally, research has shown that suitable exercise and a healthy diet can lower the risk of midlife women developing heart disease and type 2 diabetes. Adopting such healthy lifestyle behaviours – including stopping smoking – before transitioning into menopause will help ensure a better outcome.
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