Same Heat, Different Treatment: Racial/Ethnic Disparities in Menopause Care
- Sheila Thompson, RN CPHQ
- 6 hours ago
- 5 min read
Picture two mid-life women fanning themselves in a waiting room. One leaves her appointment armed with coping tips and a prescription for hormone replacement therapy; the other is met with a shrug and opts to just ride it out. Can you guess what was different about these two women? For something half the population experiences, menopause remains surprisingly misunderstood. And for women from marginalized racial and ethnic groups, it can be both misunderstood and undertreated.
Menopause 101
Menopause has been defined as “a normal condition involving the permanent end of menstrual cycles due to the cessation of the production of reproductive hormones from the ovaries for at least 12 consecutive months”. This typically occurs between 45 and 56 years of age (median age in the United States is 51), but for many women, symptoms begin several years before the final menstrual period and may continue long afterward.
Vasomotor symptoms, such as hot flashes, night sweats, heart palpitations, and migraines, are the most common, affecting approximately 75% of women.
50 to 75% of women experience genitourinary symptoms, including vaginal dryness, burning, and itching, and urinary urgency and frequency.
Psychogenic symptoms may include sleep disturbances, anger/irritability, depression, and anxiety, and affect nearly 70% of women.
Upon physical examination, women may have gained weight but lost height due to osteoporosis, may exhibit decreased muscle mass and strength, and may have elevated blood pressure due to vasoconstriction.
Treatment goals include minimizing disruptive symptoms and preventing long-term problems. Hormone replacement therapy, or HRT, is the most common treatment, and is effective for vasomotor and genitourinary symptoms, sleep disturbance, and bone loss prevention. It may be given in various forms (pills, patches, creams) and as estrogen or progestin alone or in combination. There may be associated risks and benefits, including coronary heart disease, breast cancer, stroke, and blood clots. Nonhormonal treatment for vasomotor symptoms and osteoporosis are also available. Certain dietary changes (vitamin E, omega-3 fatty acids, milk thistle) may help alleviate vasomotor symptoms, and lifestyle changes may help one feel better (breathable clothing, using fans and cooling devices, yoga, exercise, weight loss).
What the Data Reveals
Despite menopause being a transition nearly all women go through, they may experience it differently and receive different treatment from healthcare providers. In a 4-year study evaluating the correlation of race, ethnicity, and socioeconomic status (SES) with the severity of menopausal symptoms in almost 69,000 women, those identifying as Black, Hispanic, or Indigenous/First Nations reported more severe symptoms than women identifying as White. Asian and South Asian women in the same study reported less severe symptoms. These differences persisted after adjusting for SES, suggesting race/ethnicity is an independent factor in symptom severity.
But treatment patterns might not align with the higher symptom burden in women of color. In another study involving more than 200,000 women veterans, Black participants were less likely than White ones to have symptoms documented or have hormone therapy prescribed. Hispanic/Latinx women were also less likely to be prescribed systemic hormone therapy but were more likely to receive a prescription for vaginal estrogen. These findings point to possible racial/ethnic disparities in the reporting and/or documentation of symptoms, and in the frequency and type of hormone therapy prescribed.
A menopause clinic noted differences between Black and White women in the acceptance of hormonal therapy as part of a pilot study conducted between 2018 and 2021. During that timeframe, 49% of White women who were eligible for systemic hormone therapy accepted it, compared to only 24% of Black women. The Study of Women’s Health Across the Nation (SWAN) found that White women not only had the highest rates of hormone therapy among all ethnicities, but they also reported having better quality of life than those not receiving treatment. As seen in other studies, Black and Hispanic women were the least likely to receive hormone therapy. Surprisingly, Black and Chinese women on hormone therapy reported poorer quality of life compared to women using no treatment at all.
What’s Driving the Gap?
At least some of the differences in the use of HRT are likely due to structural access barriers that accompany SES, such as geographic access to care, the cost of newer nonhormonal therapies, access to telehealth platforms, and whether a woman has health insurance. Since the differences persist after adjusting for SES, we need to look deeper.
We saw in the study of women veterans that Black women were less likely to have their menopausal symptoms documented, even though their symptoms tended to be more severe. It’s unclear whether they were asked about symptoms, and whether they didn’t report them or the clinician failed to document them. Other studies observed that women in marginalized ethnic groups tend to downplay symptoms or may view menopause as an inappropriate topic, while some accept the aging process more positively, associating it with earned maturity and respect.
In the SWAN study, Black and Hispanic women reported having more comorbid medical conditions overall, so it’s possible that HRT was prescribed less frequently (or accepted less frequently) due to concerns about the potential for adverse effects in women with other health risks. A much higher percentage of Hispanic women in the SWAN study reported using complementary alternative medicine despite the lack of evidence that these options are effective. Differences in HRT acceptance and preferences for unproven complementary alternative treatments suggest possible education gaps or cultural influences.
Clinical Implications
How can healthcare providers address potential clinical bias and communication gaps? There are several ways to promote equitable care, beginning with expanding clinician training and cultural awareness. Women’s health practitioners may want to re-examine assumptions related to how women in different racial and ethnic groups experience menopause symptoms, and ensure they are well-versed in the latest treatment guidelines. Some women may misinterpret HRT-associated risk based on outdated recommendations or assume hormonal therapy is contraindicated due to other conditions they have.
In the clinical setting, routinely using symptom screening tools and counseling protocols for HRT risks and benefits can help standardize care pathways. Building these tools into the electronic health record is a best practice to support consistent use and documentation. Practitioners should be aware that certain ethnic groups may be underrepresented in clinical trials, so risk models and guidelines may not reflect all women. Ensuring treatment rates are reported by race/ethnicity can aid in data transparency and better understanding. Tying quality metrics to equitable care is a next-level approach for health systems and may already be required by some regulatory bodies.
What Savvy Patients Should Know
Patients should be empowered to ask questions about HRT and other treatment options and be prepared to discuss cardiovascular and breast cancer risks openly. They should be encouraged to fully disclose their symptoms and any complementary alternative treatments they are using. When needed, women should advocate for insurance coverage and referrals to menopause specialists.
The Stakes: Mid-life Health is Long-Term Health
When we think of mid-life health as part of long-term health, it’s clear how impactful adequate support through menopause can be. Untreated vasomotor symptoms may correlate with cardiovascular risk, and sleep disruption, depression, and decreased work productivity may affect overall health, relationships with family and friends, and employment status. Examining how women experience the menopause transition and the care they receive can open a window into broader women’s health equity issues and warrants further
study.
References
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