Empower Her: Black women and menopause

There is so much misinformation about menopause in the Black community, and so little understanding, that it has caused a great deal of confusion. As a UK-based GP with a special interest in women's health and menopause, and a member of the British Menopause Society, I want to share accurate information about what menopause is, how it affects Black women differently, and how it can be treated.

Before you read on, ask yourself two questions: what do you know about menopause, and what questions have you always had about it?

Menopause and perimenopause, explained

Menopause is the natural point at which a woman's periods stop, confirmed once she has had no period for 12 consecutive months. Perimenopause is the transition leading up to it. Periods may stop for two or three months and then return, and they can become lighter or heavier.

Symptoms often begin in perimenopause, because oestrogen does not simply decline. It rises and falls erratically, which is why symptoms can be especially marked during this stage.

What is different for Black women

Menopause happens to women in every culture, but the timing and experience vary. For Black women:

• Menopause tends to come earlier, on average around one to two years earlier than for white women.
• Symptoms last longer: in one large US study, hot flushes and night sweats lasted a median of about ten years in Black women, compared with six and a half years in white women.
• We are slightly more likely to have an early menopause (before 45) or a premature menopause (before 40).

The reasons are complex. Genetics may play a part, but there is growing thinking about epigenetics: how our genes change in response to what we are exposed to. Many believe these changes are rooted in structural racism, discrimination, and the toxic work and home environments Black women have faced over generations. Chronic stress from a heavy mental load is a huge contributing factor.

The mental load Black women carry

That load has many layers:

• The image of the strong Black woman. Our resilience is real, but this image means we are expected to cope with impossible situations alone, and the load keeps piling on.
• Misogyny, in wider society and in some of our own communities.
• The weight of history, including our mothers' and grandmothers' stories, and our own experience of civil rights and women's rights struggles.
• Family and cultural expectations, to marry and have children, to be extremely successful, or both at once.
• The weight of perceived potential, the sense of what we could have been without impossible choices between career and family, made worse by comparisons with false equivalents on social media or abroad.
• Hidden traumas, such as infertility, miscarriage, divorce, unexpected singlehood, anxiety driven by the biological clock, and the de-sexualisation of the older woman.
• Socioeconomic challenges.

All of this drives chronic stress, which can heighten symptoms in perimenopause and after menopause. Unprocessed pain often resurfaces at this stage. The mental load a woman carries shapes her experience of menopause.

Causes, symptoms and complications

The most common cause is the natural decline in oestrogen as our eggs run out. Menopause can also happen suddenly after surgery to remove the ovaries, or temporarily or permanently after chemotherapy or radiotherapy. Primary ovarian insufficiency, when the ovaries stop working in a young woman, usually has no known cause.

Common symptoms include:

• Irregular periods
• Difficulty regulating temperature: hot flushes, chills and night sweats
• Disturbed sleep
• Sore breasts and vaginal dryness
• Headaches, and weight gain, especially around the abdomen
• Mood changes, such as new anxiety or irritability
• Memory problems, word-finding difficulty and brain fog
• Thinning hair and dry skin

Oestrogen also protects us, so after menopause we face a higher risk of heart disease, osteoporosis and fractures, genitourinary syndrome of menopause (vaginal dryness, urgency, leaks and painful sex), lower libido, and dementia. Perimenopause can also bring very heavy bleeding, especially for women with fibroids, which are more common in the Black community.

My top tips for a smoother transition

• Move more. I do not say "exercise", because many women struggle for time. Sit less, walk more, join a class, play a sport, or run around the park with the grandchildren.
• Reduce your mental load. Aim for four hours of self-care a week. Most women laugh when I say that, but you cannot pour from an empty tank. Spend time in nature, enjoy the arts, and have fun. Turn off news and social media notifications, and engage intentionally.
• Watch alcohol and caffeine. Keep alcohol to 14 units a week or less, as wine in particular can worsen hot flushes. And if you smoke, stop.
• Eat well, with fewer processed foods and more fruit and vegetables.
• Protect your bones. Use an online calcium calculator to check your intake, and take 10 micrograms (400 IU) of vitamin D a day. The NHS advises people with dark skin to take this all year round, and your doctor may recommend a higher dose if your levels are low.
• Strengthen your pelvic floor.
• Change your perspective. See this as a new phase of life to be enjoyed, not endured.

When to see a doctor

See a doctor if your symptoms affect your quality of life, if you want to discuss treatment, and always if menopause comes early. Early menopause (before 45) and premature menopause (before 40) carry greater long-term risks, so HRT is recommended unless there is a reason you cannot have it, such as breast cancer.

HRT, explained

Hormone replacement therapy replaces the hormones you have lost. It is the most effective treatment for menopausal symptoms, from flushes and sleep disruption to mood, brain fog and genitourinary symptoms.

• Oestrogen: the oestradiol we prescribe is body-identical and derived from yams. Most women use it through the skin, as a patch, gel or spray, which carries lower risk than tablets.
• Progesterone: if you still have your womb, you need progesterone to protect its lining. I am a big fan of the Mirena coil, which does this and also works as contraception. Utrogestan, a body-identical tablet taken at night, is another low-risk option that can help sleep.
• Testosterone can be added if your sex drive is still low on HRT.
• Vaginal oestrogen treats genitourinary symptoms locally. It has very little risk and can be used for life.

HRT is not a contraceptive. Use contraception until you have had no period for one year if you are over 50, or two years if you are under 50. All women can stop contraception at 55.

Benefits and risks in perspective

HRT relieves symptoms and supports bone health and mood, and research is exploring whether it may protect against dementia. HRT is not used to prevent heart disease: for women under 60, research shows it has little or no effect on the risk of coronary heart disease, and the benefits usually outweigh the risks.

For most women, the benefits outweigh the risks. Heart disease kills far more women than breast cancer. Combined HRT slightly increases breast cancer risk, by roughly 5 to 10 extra cases per 1,000 women who take it for five years in their fifties, while oestrogen-only HRT, for women without a womb, causes little or no increase, but there is no evidence that it increases the risk of dying from breast cancer. HRT through the skin is not thought to add any risk of blood clots. Starting HRT after 60 needs more careful thought. Your own risks depend on your history, so always decide with a healthcare professional.

Caring for your whole health

• Heart: monitor blood pressure, HbA1c and cholesterol.
• Bones: ask about your FRAX score, and a bone density scan if it is high.
• Joints: strength, flexibility and balance work, such as Pilates, yoga or tai chi.
• Brain: omega-3-rich foods, good sleep and staying active.
• Mental health: therapy or support groups for trauma or loss.
• Breasts: monthly self-checks and mammograms when invited.
• Cervix: keep attending cervical screening.
• Intimate care: never wash with soap; use an emollient instead, plus vaginal moisturisers and lubricants.

You deserve support

Seek professional guidance, lean on each other, and remember that the right support can make this one of the most fulfilling stages of your life.