The menopause blind spot: Why are South Asian women left out?

Menopause doesn’t discriminate, but research certainly does. Studies have long shown that women from different ethnic backgrounds experience menopause differently - biologically, psychologically, emotionally and culturally. Yet, despite its scale and significance, one of the largest ongoing studies on midlife women’s health, SWAN (Study of Women’s Health Across the Nation), completely omits South Asian women (Santoro and Sutton-Tyrrell, 2011). Let that sink in. While researchers investigate the impact of menopause on various ethnic groups, South Asian women are left in the shadows - unseen, unheard and unrepresented. This must change. Raising awareness within our communities is the first step toward breaking the silence and driving meaningful change.

This glaring oversight is more than just a research gap; it’s a public health crisis. South Asian women have unique nutritional needs, distinct cultural attitudes toward menopause and barriers to accessing mental health care that are rarely acknowledged (Prajapati and Liebling, 2022). In fact, studies from India and Pakistan suggest that South Asian women reach menopause much earlier - at an average age of 46.7 and 47.16 years, respectively - compared to 51 years in Western countries. An earlier menopause isn’t just a milestone; it’s a red flag. Research links early menopause to a higher risk of cognitive decline, dementia, parkinsonism, glaucoma, heart failure, osteoporosis, mood disorders, sexual dysfunction and even increased mortality (Dalal et al, 2015).

Yet, despite these alarming facts, South Asian women continue to navigate menopause without tailored guidance or medical attention suited to their specific needs (Williams, 2024). Why is this acceptable? Why are South Asian women still an afterthought in menopause research and care? It’s time to break the silence, challenge the biases and demand culturally competent healthcare solutions that acknowledge and address these disparities. 

Menopause is a transformative stage in every woman’s life, yet for many South Asian women, it remains shrouded in stigma, silence and misunderstanding. This article delves into the biological and neurobiological intricacies of menopause, its impact on mental health and the cultural challenges that amplify the struggle. It also explores the necessity of culturally sensitive counselling, how it can be used to inform decisions with either medical or holistic treatment choices, coping strategies and nurturing a deeper connection with our bodies to navigate this critical life stage. 

What is menopause? The biological perspective

Menopause marks the end of a woman’s reproductive years, defined by the cessation of menstrual cycles for 12 consecutive months. Typically occurring between the ages of 45 and 55, menopause is preceded by perimenopause, a phase characterised by fluctuating hormone levels, irregular periods and a range of physical and emotional symptoms.

The hormonal shifts during this time can have wide-ranging effects on a woman's body and mind. Plummeting oestrogen levels can lead to a host of distressing symptoms, from hot flushes and night sweats to insomnia, mood swings and cognitive impairment. Atrophic changes in the urogenital tract can also contribute to urinary incontinence, recurrent infections and painful intercourse. 

Moreover, the neurobiological implications of menopause on brain health are profound. Studies have shown that the loss of oestrogen can accelerate neurodegeneration and increase the risk of dementia, depression and anxiety (Dalal et al, 2015).

The decrease in oestrogen, progesterone and testosterone during this time impacts and is not limited to:

• Bone health: Lower oestrogen levels increase the risk of osteoporosis, as bone density diminishes rapidly (Szeliga, Maciejewska-Jeske and Męczekalski, 2018)
• Cardiovascular health: Postmenopausal women are at a higher risk of developing cardiovascular diseases due to changes in lipid profiles and arterial stiffness (Dosi et al., 2014).
• Cognitive function: Hormonal fluctuations can impair memory, attention and executive functioning (Greendale, Derby and Maki, 2011).
• Sexual function: Vaginal dryness, decreased libido and painful intercourse are common challenges (Dalal et al., 2015).
• Sleep patterns: Insomnia and disrupted sleep cycles become common due to night sweats and hormonal imbalances (Baker et al., 2018).
• Mood and mental health: Anxiety, depression, irritability, and mood swings can emerge or worsen (Greendale, Derby and Maki, 2011).

These physiological changes underline the importance of understanding menopause’s systemic effects on a woman’s health and well-being. 

The biological storm of menopause: How hormonal shifts impact mental and physical health

Menopause triggers a dramatic decline in oestrogen and progesterone, two hormones essential for regulating mood, metabolism and overall well-being. As progesterone levels drop, the stress hormone cortisol rises, placing the body in a prolonged state of physiological stress. This surge in cortisol is not just about feeling overwhelmed - it has tangible effects on brain function, increasing anxiety, irritability and emotional sensitivity. For women with unresolved trauma, this heightened stress response can act as a catalyst, bringing repressed emotions and past wounds back to the surface (Maeng and Shors, 2013).

Concurrently, the plummeting oestrogen levels during menopause have a direct impact on cognitive function and neurotransmitter regulation. Oestrogen is crucial for maintaining healthy levels of serotonin, dopamine and norepinephrine - the "feel-good" chemicals that govern our mood, focus and sense of well-being. Disruptions in these neurotransmitter systems are strongly linked to the emergence of mood disorders, such as depression and anxiety, during the menopausal transition (Gordon et al, 2014 and Soares, 2007). 

Sleep disturbances, a hallmark symptom of menopause, can further exacerbate mental health challenges. Insomnia and fragmented sleep patterns disrupt the natural circadian rhythms, compromising the body's ability to regulate mood, stress and cognitive performance (Tandon et al., 2022).

Menopause is often misunderstood as a purely physical phenomenon, but the interplay between the hormonal, neurological and physiological changes that occur paints a much more complex picture. Recognising the multifaceted nature of menopause and its potential impact on mental health is crucial for developing holistic, woman-centred care.

Simultaneously, menopause disrupts insulin regulation, leading to a reduction in insulin sensitivity. Insulin is responsible for shuttling glucose from the bloodstream into the body’s cells for energy. When insulin levels drop, blood sugar remains elevated, causing energy fluctuations, mood instability and increased susceptibility to anxiety and depression. This biochemical shift means that mood swings aren’t just psychological - they’re directly linked to fluctuating blood sugar levels, which are further influenced by diet, lifestyle and overall metabolic health.

Melding the biological, neurological and metabolic dimensions of menopause provides a more comprehensive understanding of the profound impact it can have on a woman's mental, emotional and physical well-being.

Hormonal receptors are found throughout the body, which is why menopause is a full-body experience. The decline in oestrogen doesn’t just affect reproductive health - it influences the brain, eyes, joints, muscles, cardiovascular system, urinary tract and vaginal tissue. This is why symptoms such as brain fog, joint pain, palpitations and vaginal dryness are common. It is not only hot flushes that determine menopause, you can have all the other symptoms without hot flushes and still be menopausal.

While hormone levels do eventually stabilise, the transitional phase can be a turbulent period, with symptoms ranging from mild discomfort to debilitating distress. Understanding the biological mechanisms behind these changes is crucial, as it empowers women to take proactive steps in managing their health rather than feeling at the mercy of their hormones.

The cultural context of menopause for South Asian women

While the biological effects of menopause are universal, the cultural and social landscape in which South Asian women experience this transition is vastly different from their Western counterparts. 

In many South Asian societies, menopause is still shrouded in stigma and silence. The topic is rarely discussed openly and women are often left to navigate this phase alone, without adequate support or understanding from their families and communities (Williams, 2024).

This cultural reticence is rooted in deep-seated beliefs and attitudes that view menopause as a loss of femininity, fertility and in some cases, social status. Many South Asian women internalise these negative perceptions, leading to feelings of shame, embarrassment and isolation (Soares, 2007).  

Furthermore, the traditional role of South Asian women as caregivers and homemakers can exacerbate the challenges of menopause. As women within a collectivistic society, they are often expected to prioritise the needs of their families over their own, leaving little room for self-care and emotional processing. 

The acculturative stress faced by South Asian immigrant women in Western countries can further compound these challenges. They may find themselves caught between the cultural norms of their homeland and the expectations of their adopted country, leading to a profound sense of disconnection and disorientation. 

This cultural context sheds light on the unique obstacles South Asian women face in seeking support and accessing healthcare during menopause. 

The neurobiology of menopause and mental health

The neurobiological changes during menopause directly influence an individual’s mental health. Oestrogen plays a crucial role in regulating serotonin and dopamine, neurotransmitters essential for mood stabilisation and emotional well-being (Sandilyan and Dening, 2011). 

As oestrogen levels decline, the following (and not limited to) may be experienced:

• Mood disorders: Women may experience heightened anxiety, depression and irritability. Research indicates that perimenopause is associated with a twofold increase in depression rates compared to premenopausal years (Geršak, Gersak and Turčin, 2018).
• Cognitive impairment: Hormonal fluctuations can impair memory, concentration and executive functioning, leading to a perceived decline in cognitive abilities (Greendale et al., 2010).
• Cognitive decline: The hippocampus, a brain region critical for memory, is highly sensitive to hormonal changes, leading to memory lapses and difficulty concentrating (Shilling et al., 2001).
• Trauma resurfacing: Elevated cortisol levels during menopause can trigger unprocessed trauma, exacerbating symptoms of post-traumatic stress disorder (PTSD) or generalised anxiety (Nappi et al., 1999). South Asian women are likely to have been impacted by intergenerational and enmeshment trauma due to their ancestral cultural heritage, making accessing mental health support crucial. 

Understanding these neurobiological connections underscores the need for mental health support during this transitional phase. Working on the awareness of these connections can empower South Asian women to advocate for their needs and access appropriate care. 

Cultural stigma: Silence around menopause and mental health

In South Asian cultures, conversations about a woman’s reproductive system - let alone menopause - are often considered taboo (Zou et al., 2021). Menopause is still viewed as a shameful, embarrassing condition that should be hidden from public view. Rooted in patriarchal norms and beliefs, this culture of silence can prevent women from seeking information, support and medical care. 

As the excerpt from Ussher et al., (2018) suggests, there is a prevailing attitude among South Asian communities that individuals should be able to "overcome their problems" on their own, without burdening their families or seeking professional help. 

This cultural silence contributes to:

• Shame and secrecy: Many women feel compelled to endure symptoms without seeking help, fearing judgement or dismissal.
• Misdiagnosis: Symptoms like fatigue, mood swings and memory issues may be misattributed to external stressors rather than menopause.
• Barriers to healthcare: Cultural norms often discourage open discussions about mental health, leaving many women without adequate support and in isolation with an unknowing of what to do.

Breaking this silence requires culturally informed education and advocacy to normalise conversations about menopause and its impact on women’s lives.

Menopause: The holistic impact on a woman’s life

Menopause is more than a biological event; it affects every aspect of a woman’s identity and functioning:

• Physical health: Symptoms such as joint pain, fatigue and hot flushes can disrupt daily life.
• Emotional well-being: Women often face identity crises, questioning their value and femininity in societies that equate youth with worth.
• Relationships: Intimacy may decline due to vaginal dryness, reduced libido and emotional strain.
• Career and economic status: Menopausal symptoms can impact productivity, leading to challenges at work and potential financial consequences. 
• Social connections: Isolation and loneliness may arise as women struggle to navigate the changes in their bodies and social roles.

These interconnected challenges highlight the need for a holistic approach to menopause management, one that addresses both physical and emotional dimensions. For South Asian women, the cultural context - particularly barriers to accessing help and support - can further intensify these challenges, making it even more critical to understand the multifaceted impact of menopause.

The necessity of culturally sensitive care and coping strategies

Given the unique biological, psychological and sociocultural factors at play, it is clear that a one-size-fits-all approach to menopause management is woefully inadequate for South Asian women. 

Healthcare providers must acknowledge the cultural nuances and sensitivities surrounding menopause in South Asian communities. This requires not only a deeper understanding of the physiological aspects of menopause but also a willingness to engage with the social, emotional and spiritual dimensions of this transition.

Culturally sensitive counselling and support services can play a vital role in empowering South Asian women to navigate menopause with confidence and resilience. It recognises the unique intersection of biology, mental health and cultural expectations faced by South Asian women. Such therapy provides a safe space to explore identity, trauma and self-worth without judgement, empowering women to thrive during menopause and beyond.

Why therapy is essential during menopause

Therapy can be a lifeline for women navigating menopause, particularly when compounded by cultural and emotional challenges:

• Processing trauma: Elevated cortisol during menopause can unearth unresolved emotional wounds, necessitating therapeutic intervention (Huffman and Myers, 1999).
• Strengthening coping mechanisms: Therapists can help develop adaptive strategies to manage physical symptoms, mood swings, and identity shifts (Taylor‐Swanson et al., 2017).
• Addressing mental health: Counselling can help manage depression, anxiety and emotional lability associated with hormonal fluctuations (Dalal et al., 2015).
• Culturally sensitive counselling: Therapists familiar with South Asian cultural norms can provide tailored support, bridging the gap between traditional values and modern coping strategies (Thomas, Gopal and Sasidharan, 2018).
• Building resilience: Therapy helps women develop tools to manage symptoms, reframe negative self-perceptions, and embrace this life stage with confidence (Hahm et al., 2017).

By prioritising mental health support, South Asian women can navigate the challenges of menopause with greater ease and emerge from this transition with enhanced self-understanding and wellness.

Coping strategies and self-soothing techniques

To navigate menopause effectively, women can adopt these strategies:

1. Mindfulness practices: Yoga and meditation regulate cortisol levels and improve emotional resilience. 
2. Balanced nutrition: Incorporating phytoestrogens - found in soy and flaxseeds - can mitigate some hormonal changes. 
3. Exercise: Physical activity improves mood, strengthens bones and reduces cardiovascular risk.
4. Sleep hygiene: Maintaining consistent sleep patterns enhances cognitive and emotional well-being.
5. Community support: Joining support groups or therapy sessions encourages connection and reduces isolation.

The importance of staying connected to your body

Menopause challenges women to reconnect with their bodies and embrace the changes with compassion.

By listening to bodily cues, addressing mental health concerns and prioritising self-care, women can nurture resilience and self-acceptance during this life stage. 

This holistic approach, combined with culturally sensitive support, is essential for South Asian women to navigate menopause with grace and authenticity (Dalal et al., 2015 and Soares, 2007 and Parand avar et al., 2014).

Menopause is a natural, albeit complex, phase that profoundly affects every facet of a woman’s life. By breaking the silence, embracing holistic strategies and seeking culturally informed support, South Asian women can navigate menopause with strength and clarity, reclaiming their physical and mental well-being.

The menopause treatment dilemma: HRT, herbal remedies and the struggle for support

When it comes to managing perimenopause and menopause, South Asian women often find themselves caught between two worlds - modern medicine and traditional remedies. The decision to take hormone replacement therapy (HRT) or rely on holistic, herbal treatments is not just a medical choice; it’s a deeply personal and often culturally influenced dilemma. For many, concerns about side effects, misinformation or the stigma surrounding mental health medical intervention deter them from seeking professional help. On the other hand, while herbal and Ayurvedic remedies have been used for generations, their effectiveness is not always immediate or backed by robust scientific research, leaving women to navigate a maze of conflicting advice and uncertainty.

The complex interplay between cultural beliefs, personal preferences and medical realities underscores the pressing need for a more comprehensive, culturally sensitive approach to menopause management for South Asian women. This is where culturally sensitive counselling plays a crucial role. Rather than dictating a one-size-fits-all approach, therapy provides a private and non-judgemental space for women to explore their options, voice their fears and make informed decisions that align with both their health needs and cultural beliefs.

For some South Asian women, the confidentiality of private therapy - especially outside of NHS services - offers an added layer of reassurance, as it remains off their official medical records. This privacy can be empowering, helping women break free from the cultural silence surrounding menopause and seek the support they need without fear of judgement or scrutiny. No woman should have to suffer in silence - support is available for those who choose to take it.

References

• '"'Age of despair', or 'when life starts': migrant and refugee women negotiate constructions of menopause” (no date). doi:10.1080/13691058.2018.1514069.
• Baker, F.C. et al. (2018). “Sleep problems during the menopausal transition: prevalence, impact, and management challenges,” Nature and Science of Sleep. Dove Medical Press, p. 73. doi:10.2147/nss.s125807.
• Dalal, Pronob K.; Agarwal, Manu. (2015). Postmenopausal syndrome. Indian Journal of Psychiatry 57(Suppl 2):p S222-S232, July 2015. | DOI: 10.4103/0019-5545.161483
• Dosi, R. et al. (2014). “Cardiovascular Disease and Menopause,” Journal of Clinical and Diagnostic Research. JCDR Research and Publications Private Limited. doi:10.7860/jcdr/2014/6457.4009. 
• Geršak, K., Gersak, Z.M. and Turčin, A. (2018). “Reproductive Aging: Perimenopause and Psychopathological Symptoms,” in InTech eBooks. doi:10.5772/intechopen.74159.
• Gordon, J.L., Girdler, S.S. (2014). Hormone Replacement Therapy in the Treatment of Perimenopausal Depression. Curr Psychiatry Rep 16, 517. https://doi.org/10.1007/s11920-014-0517-1
• Greendale, G.A. et al. (2010). “Menopause-associated Symptoms and Cognitive Performance: Results From the Study of Women’s Health Across the Nation,” American Journal of Epidemiology. Oxford University Press, p. 1214. doi:10.1093/aje/kwq067.
• Greendale, G.A., Derby, C.A. and Maki, P.M. (2011). “Perimenopause and Cognition,” Obstetrics and Gynecology Clinics of North America. Elsevier BV, p. 519. doi:10.1016/j.ogc.2011.05.007.
• Hahm, H.C. et al. (2017). “Asian Women’s Action for Resilience and Empowerment Intervention: Stage I Pilot Study,” Journal of Cross-Cultural Psychology. SAGE Publishing, p. 1537. doi:10.1177/0022022117730815.
• Huffman, S.B. and Myers, J.E. (1999). “Counseling Women in Midlife: An Integrative Approach to Menopause,” Journal of Counseling & Development. Wiley, p. 258. doi:10.1002/j.1556-6676.1999.tb02449.x.
• Maeng, L.Y. and Shors, T.J. (2013). “The stressed female brain: neuronal activity in the prelimbic but not infralimbic region of the medial prefrontal cortex suppresses learning after acute stress,” Frontiers in Neural Circuits. Frontiers Media. doi:10.3389/fncir.2013.00198.
• Nappi, R.E. et al. (1999). “Memory Functioning at Menopause: Impact of Age in Ovariectomized Women,” Gynecologic and Obstetric Investigation. Karger Publishers, p. 29. doi:10.1159/000010058.
• Parand avar, N. et al. (2014). Menopause and crisis? Fake or real: comprehensive search to the depth of crisis experienced: a mixed-method study. Global journal of health science. (Online) 6 (2), 246–255.
• Prajapati R, Liebling H. (2022). Accessing Mental Health Services: a Systematic Review and Meta-ethnography of the Experiences of South Asian Service Users in the UK. J Racial Ethn Health Disparities. Apr;9(2):598-619. doi: 10.1007/s40615-021-00993-x. Epub 2021 Mar 8. PMID: 33686621; PMCID: PMC8897382.
• Sandilyan, M.B. and Dening, T. (2011). “Mental health around and after the menopause,” Menopause International. SAGE Publishing, p. 142. doi:10.1258/mi.2011.011102.
• Santoro, N. and Sutton-Tyrrell, K. (2011). “The SWAN Song: Study of Women’s Health Across the Nation’s Recurring Themes,” Obstetrics and Gynecology Clinics of North America. Elsevier BV, p. 417. doi:10.1016/j.ogc.2011.05.001.
• Shilling, V. et al. (2001). “The effects of oestrogens and anti-oestrogens on cognition,” The Breast. Elsevier BV, p. 484. doi:10.1054/brst.2001.0311.
• Soares, C. N. (2007). Menopausal transition and depression: who is at risk and how to treat it? Expert review of neurotherapeutics. (Online) 7 (10), 1285–1293.
• Szeliga, A., Maciejewska-Jeske, M. and Męczekalski, B. (2018). “Bone health and evaluation of bone mineral density in patients with premature ovarian insufficiency,” Menopausal Review. Termedia Publishing House, p. 112. doi:10.5114/pm.2018.78552.
• Tandon, V. et al. (2022). “Menopause and sleep disorders,” Journal of Mid-life Health. Medknow, p. 26. doi:10.4103/jmh.jmh_18_22.
• Taylor‐Swanson, L. et al. (2017). “The dynamics of stress and fatigue across menopause: attractors, coupling, and resilience,” Menopause The Journal of The North American Menopause Society. Lippincott Williams & Wilkins, p. 380. doi:10.1097/gme.0000000000001025.
• Thomas, T.M., Gopal, B. and Sasidharan, T. (2018). “Towards a Culturally-Informed Counselling and Psychotherapy,” in Springer eBooks. Springer Nature, p. 241. doi:10.1007/978-81-322-3782-2_17.
• Ussher, J. M., Hawkey, A. J., & Perz, J. (2018). ‘Age of despair’, or ‘when life starts’: migrant and refugee women negotiate constructions of menopause. Culture, Health & Sexuality, 21(7), 741–756. https://doi.org/10.1080/13691058.2018.1514069
• Williams, M. (2024). Culturally responsive care for menopausal women. Maturitas. (Online) 185107995.
• Zou, P., Shao, J., Luo, Y., Thayaparan, A., Zhang, H., Alam, A., Liu, L., & Sidani, S. (2021). Facilitators and Barriers to Healthy Midlife Transition among South Asian Immigrant Women in Canada: A Qualitative Exploration. Healthcare, 9(2), 182. https://doi.org/10.3390/healthcare9020182