It was the guffaw of her gynecologist. That’s the thing Dannette Fogle, a 65-year-old retired schoolteacher in New York, remembers most clearly about her introduction to menopause.
She was 34 when she noticed changes in her otherwise regular menstrual cycle — a hallmark symptom of perimenopause, the transition toward the end of a woman’s fertility window.
Most women don’t begin perimenopause until their 40s, but some studies have found that Black women tend to start the transition earlier than people of other races. Ms. Fogle, who is Black, started experiencing night sweats for the first time too, another clue that her hormones were changing. So she visited the gynecologist, looking for answers, reassurance and maybe something to help with the sweats, which were beginning to disrupt her sleep.
“When I said to him, ‘I think I’m starting menopause,’ he laughed out loud as if it was the most ridiculous thing he had ever heard,” Ms. Fogle said. “Not only that, he literally called his nurse in and said, ‘Can you believe this woman?’ Like I wasn’t even in the room.”
She was so turned off by that interaction that she decided she was better off just “muddling through” without medical help, she said. Perimenopause lasts four to 10 years on average. For Ms. Fogle, it lasted over 15 years — she reached menopause (defined as not having periods for 12 consecutive months) when she turned 50.
The transition to menopause is confounding for many of the one million American women who, annually, contend with dozens of symptoms — including hot flashes; vaginal dryness; hair loss; irregular, heavy periods; and weight gain — with little medical guidance and few options for relief.
For women of color, though, the transition can be even more complicated. Research has found that the duration, the frequency, the severity and even the types of symptoms can look different across races.
When women of color seek out care, they often encounter physicians who aren’t aware of those differences and aren’t fully equipped to help them navigate the transition. That can feel like a dismissal of their concerns — a familiar experience for women of color at the doctor. The consequences can be stark: Some unmanaged menopause symptoms are associated with an elevated risk of long-term chronic diseases, like coronary heart disease and neurodegenerative diseases. They also can translate into years of discomfort that affect a person’s mental health and quality of life.
In recent years, there has been growing cultural awareness of menopause overall and a flurry of celebrity-backed start-ups focused on symptom management, but the conversation is often still centered on white women, whose experiences are seen as “the norm,” said Omisade Burney-Scott, host of the “Black Girl’s Guide to Surviving Menopause” podcast, which she started in 2019. “And whatever happens outside of the norm is othered or marginalized.”
This means that women of color often go without adequate care during menopause, signaling to them that their suffering is insignificant, said Dr. Stephanie Faubion, medical director for the Menopause Society and a director of the Mayo Clinic Center for Women’s Health. “We’re saying it really doesn’t matter if you’re not sleeping well at night. And it really doesn’t matter if you’re missing work because of these symptoms. We are disregarding this group of women’s suffering to a greater degree than we’re ignoring all the rest of the menopausal women suffering.”
‘Absolutely No Guidance’
A landmark study of the racial discrepancies in menopause, the Study of Women’s Health Across the Nation (SWAN), began in 1994. Researchers have followed a group of more than 3,000 women in perimenopause and menopause for decades and have found a few key differences: Black and Hispanic women reach menopause earlier than white, Chinese and Japanese women. They also experience certain menopausal symptoms for 10 or more years — almost twice as long as do white, Chinese and Japanese women.
Hot flashes, a common symptom of menopause, are often one of the most disruptive for all races, leading to night sweats that can disturb sleep and daily episodes that can get in the way of a woman’s ability to focus or work. But researchers have found that Black women are more likely to experience more intense and more frequent hot flashes; Black women also endure them for more years than those of other races. There are few quality studies on Asian American women — a group that includes women of Chinese, Korean, South Asian and Filipino backgrounds — but some have found that they were more likely to experience chronic pain and anxiety than hot flashes.
When Anjum Shah, a 55-year-old city planner in Orlando, Fla., started having hot flashes at 48, she knew it was connected to menopause. But she was completely caught off guard by her sudden anxiety.
“I’d be going to bed and then all of a sudden I’m up and I’m wide awake and my heart is beating so fast and I’m like, ‘What is wrong with me?’” Ms. Shah, who is South Asian, said.
She turned to the same primary care doctor she had seen for years. “I said, ‘What should I do?’” she recalled. “And he’s like, ‘Well, would what would you like me to do?’ There was absolutely no guidance.”
Carol Kim-Benaissa, a 54-year-old stay-at-home mother in San Diego, spent months consulting doctors about her sudden anxiety, which led to symptoms like hyperventilation and panic attacks. Adding to the confusion, Ms. Kim-Benaissa never experienced a hot flash, which she said might have provided insight into what was going on. In the end, it was her sister’s friend, not a medical provider, who suggested it might be related to menopause. “I thought to myself, ‘Oh, my God — why are doctors not talking to me about it?’” Ms. Kim-Benaissa said.
An Inadequate System
There is growing consensus among experts that a person’s baseline health when entering perimenopause can significantly affect that person’s experience of it, said Dr. Sherri-Ann Burnett-Bowie, an associate professor of medicine at the Harvard Medical School.
In a paper published last February, researchers concluded that the menopause symptom disparities between Black and white women might be explained by “structural racism” that led to “a greater disease burden” for Black women. The Black women in SWAN, the study notes, were more likely than white women to report financial instability, instances of discrimination, “trouble with the police, experiences of violence, as well as illness or death of close family members.” Those kinds of experiences can erode a person’s overall health and accelerate aging, said Dr. Burnett-Bowie, a co-author of the paper — a process known as “weathering.”
But, Dr. Faubion said, such findings rarely make it to the providers who interact with women daily. A 2019 Mayo Clinic survey of medical residents found that 58 percent had received one lecture on menopause in their training and 20 percent had received no training on it whatsoever.
If the majority of providers don’t know much about menopause overall, she added, they’re unlikely to be aware of “these more nuanced situations with women from different races and backgrounds, and what to do about them.”
Finding providers who specialize in menopause care can be frustratingly difficult, even for those who have access to quality care. There are only 1,500 physicians around the world certified by the Menopause Society, and it’s unclear how many of them are in the United States.
Several studies, including one published last December, have found that when women of color do find a menopause specialist, they are less likely than white women to receive a prescription for hormone therapy, which isn’t a cure-all but can have benefits for a women’s overall health and quality of life. That discrepancy in prescriptions might be because of “unconscious racial biases” that lead physicians to think a patient’s symptoms don’t warrant treatment, said Dr. Monica Christmas, director of the Menopause Program at UChicago Medicine and a co-author of the study. Lack of access to providers and the cost of hormone therapy options might also be factors, she said.
In a cruel biological twist, some unmanaged symptoms of menopause can be associated with long-term negative health effects. A 2021 study, for example, found that women with frequent or persistent hot flashes who were not using hormonal treatment had an elevated risk of cardiovascular disease, including strokes or heart failure, than women with fewer or no hot flashes, said Dr. Rebecca Thurston, director of the Women’s Biobehavioral Health Program at the University of Pittsburgh and lead author of the study. Having more hot flashes, particularly at night, is also associated with a decrease in cognitive abilities.
It may all boil down to sleep disruption, said Dr. JoAnn Manson, head of preventive medicine at Brigham and Women’s Hospital and Harvard Medical School. “If the symptoms are disrupting sleep, the sleep disruption itself could be a risk factor for heart disease,” she said. Insomnia that may stem from night sweats and goes untreated for years may be also be a risk factor for developing dementia later in life.
Age at menopause, which can vary by race, may also be connected to overall longevity — in some research, women who hit menopause later live longer.
But so much is still not clearly understood. Hot flashes could be a marker of underlying health issues rather than a cause of them, Dr. Thurston said. A direct causal link between the frequent and severe hot flashes experienced by Black women and their risks for long-term health issues hasn’t been established, she said, and the relationship between symptoms and health outcomes in other races has hardly been studied.
It’s nonetheless clear, Dr. Faubion said, that the longer women of color go without adequate care, with their discomfort minimized by doctors, the longer their lives are disrupted and the more their self-confidence is upended.
“We live in these bodies, and we know when something is off,” Ms. Fogle said. But, she added, when people visit their doctors, “it’s always: ‘Oh, it’s nothing. It’s nothing.’”