When Dr. Monica Christmas has hot flashes while performing surgery, she asks a nurse to tape ice packs to her neck and lower back.
When Dr. Julia Joseph-Di Caprio’s mother went through menopause, she knit tops with removable sleeves, so she could quickly rip them off during a hot flash.
Menopause disproportionately affects Black women like Christmas and Joseph-Di Caprio. Not only do they face worse symptoms, for longer periods, but they get less treatment for their symptoms compared to white women, research has shown.
These symptoms aren’t just inconvenient and burdensome; they also appear to be linked to other poor health outcomes, such as an increased risk for cardiovascular disease.
“Black women have more hot flashes that start earlier, last longer and are more bothersome,” said Rebecca Thurston, researcher for a study that has been following about 3,300 women of different races and ethnicities since 1996-1997.
Black women have more hot flashes that start earlier, last longer and are more bothersome.
researcher Rebecca Thurston
Menopause is a natural transition that usually comes with physical side effects that can moderately or severely impact daily activity. But until now, there has been little discussion of the topic, even in medical schools. Recently, media outlets, including Oprah and the New York Times, plus a Super Bowl ad paid for by the drug company Astellas Pharma, seem to have sparked a conversation. For the first time, there is both robust racial and ethnic data on menopause and a willingness to discuss it.
Black women who experience hot flashes in their late 30s and into their 60s and 70s— “superflashers”—are often met with disbelief by their providers, said Thurston, director of the Women’s Biobehavioral Health Laboratory at the University of Pittsburgh. “And you cannot explain these differences away. They persist no matter what we throw into the statistical models to explain it away.”
In other words, racism, sexism, and ageism most likely contribute to the disparity, she said. “All of the ‘isms’ come into play,” she said.
What the research shows
Menopause takes place after one year of having no menstrual periods. The transition to that point, when most women experience symptoms, sometimes over the course of years, is called menopausal transition or perimenopause.
Much of what we know about racial differences in menopause comes from the Study of Women’s Health Across the Nation, research that includes 1,550 Caucasian, 935 African American, 286 Hispanic, 250 Chinese, and 281 Japanese women. A report published last February [2022] showed that:
Forty-six percent of Black women, compared to 37 percent of white women, reported experiencing hot flashes or night sweats.
Twenty-seven percent of Black women reported symptoms of depression, compared to 22 percent of white women.
Black women were less likely to self-report sleep problems, but more likely to have objectively measured poor sleep quality.
Black women were 22 percent more likely to report physical limitations due to menopause than white women.
Other recent research has reached similar conclusions.
Before research revealed racial disparities in menopause, Christmas, then an obstetrician-gynecologist at a community hospital on the southwest side of Chicago, had seen plenty of evidence in practice.
“I noticed anecdotally that out of my patients, my Black patients and my mom were having more severe, frequent symptoms that had an extreme impact on their quality of life— impacting sleep, making mood swings worse, being able to function at work,” she said.
I noticed anecdotally that … my Black patients and my mom were having more severe, frequent symptoms that had an extreme impact on their quality of life.
Dr. Monica Christmas
For the vast majority of women, vasomotor symptoms (hot flashes and night sweats) last 4.5 years after their last period, with the most severe symptoms happening in the first couple of years around the last period, said Christmas, associate professor of obstetrics and gynecology at the University of Chicago Medicine and director of the Center for Women’s Integrated Health.
And then, “for the vast majority of people, they peter out and go away,” she said. “But for Black women like myself, they could last up to seven to 10 years.”
Christmas often felt dizzy and nauseated during surgery in operating rooms that had to be kept hot enough to support premature babies. Eventually, she stopped doing obstetric surgeries. But not everyone has the privilege to choose their work environments, she said.
At the same time, research using wearable technology to measure hot flashes has linked more frequent or more persistent hot flashes over a longer period of time to increased risk of cardiovascular disease events.
“We see more early signs of cardiovascular disease in women who have more frequent vasomotor symptoms in their 40s and 50s, and when we follow them out to their 60s and 70s, we see an increased risk for heart attacks,” said Thurston, the lead author of a 2021 study on the connection published in the Journal of the American Heart Association.
In another study, Thurston’s team combined hot flash monitoring with neuroimaging, and found that women who have more hot flashes during sleep tend to have greater white matter hyperintensities in their brains, which can be a sign of increased risk of stroke and dementia.
Stephanie Faubion, medical director of the North American Menopausal Society and the director of Mayo Clinic’s Center for Women’s Health, who is not involved in the SWAN studies, said the findings on racial disparities did not surprise her.
“It’s the sign of a bigger issue,” she said—such as structural racism.
Debilitating symptoms also carry a big price tag, according to a Mayo Clinic study published this week led by Faubion. The report estimates that menopause symptoms account for about $1.8 billion in lost work time in the U.S., not counting medical expenses.
Treatment disparities
In 2002, the Women’s Health Initiative Study came to the mistaken conclusion that hormone replacement therapy taken at the onset of menopausewas linked to an increased risk of cardiovascular disease, stroke and breast cancer. Researchers later reanalyzed the data and showed that using hormones actually had a beneficial effect on the cardiovascular system in younger women — but not before general alarm had set in among middle-aged women.
For years, women of all races avoided hormone therapy. Gradually, though, a racial shift has become apparent.
“My Black patients, when I talk to them about hormone therapy, say, ‘Absolutely not,’” Christmas said. “Whereas my white patients are almost demanding it.”
That piqued Christmas’ curiosity, and when she realized no one was doing menopause research at the University of Chicago, she started a Menopause Program there.
Research about why Black women are treated for menopause symptoms less often than white women is limited and mixed, Christmas noted. When Christmas couldn’t get funding for an official study, she analyzed data on her own from approximately 27,000 patients aged 45 or older who presented with a diagnosis of menopause, via a partnership with AllianceChicago and Health Choice Network, organizations that support 116 safety-net organizations across the country. Only 1,900 patients were prescribed hormone therapy. Of them, 80 percent were white.
It’s not clear whether that’s because Black women refuse treatment, as Christmas has noticed anecdotally, or whether providers offer it to them less frequently, perhaps because Black women may have other comorbidities that make them less likely candidates. Or, provider bias could play a role, or Black women may be less likely to accept treatment based on historical mistreatment by the health care system.
“One of the good things that’s come out of all of this attention is that people have been able to get information,” Christmas said. “It’s opening up how we all think about it, and I do think it’s letting people take hormone therapy more into consideration.”
Various treatments are available, Thurston said. “You don’t need to suffer if you’re really feeling it’s impairing your ability to function,” she said.
You don’t need to suffer if you’re really feeling it’s impairing your ability to function.
researcher Rebecca Thurston
Currently, the two FDA-approved treatments are hormone therapy and paroxetine, an antidepressant. Drugs approved for other conditions are often also prescribed to menopausal women with hot flashes, and cognitive behavior therapy has been shown to effectively help women manage their vasomotor symptoms as well, Thurston said.
A new treatment appears to be on the horizon as well: The Food and Drug Administration is currently evaluating a drug from Astellas Pharma, the company that paid for the Super Bowl ad that featured actor Carmella Riley asking women about hot flashes and night sweats. Approval of the non-hormonal therapy could come as soon as next month.
What Black women can do
The decision of how and whether to treat menopause symptoms is very personal, doctors said.
Christmas started getting anxious before performing C-sections, she said, anticipating the heat.
“I was drenched afterward; it looked like someone had dunked me in water,” she said. “I cannot go to a meeting after that, and who can go home and shower?”
Still, it was a hard decision to start hormone therapy, she said, because there is a history of breast cancer and heart disease in her family. A higher risk from hormone therapy is associated with people who have a history of cancer, dementia, blood clots, heart attack or stroke.
For Joseph-Di Caprio, founder of Leap Pediatric and Adolescent Care, night sweats that left the bed soaked and interfered with her sleep made choosing hormone therapy relatively easy, she said. But a good doctor who explained her options clearly was also essential, she said.
“It’s a very important thing to find a provider who provides menopause care,” Thurston agreed. “Not all are trained, so women often find themselves in a position of advocating for themselves.” And they should find a new provider if they feel their care is inadequate, she said, noting that the North American Menopause Society now keeps a list of doctors trained in menopause treatment.
Also, Black women can consider that early interventions on things such as blood pressure and bad cholesterol could help reduce the risk of cardiovascular disease, according to a 2022 study published in BioMed Central.
“I think the way we should be thinking about this is that it’s a trigger to go in and say, ‘What is my heart disease risk?’ And take action,” the Mayo’s Faubion said. “Of course, if we do everything right for our health, is it going to reduce hot flashes? We don’t know. And we don’t know if treating with hormone therapy will do anything for the risk of heart disease.” (So far, there is observational data showing that hormone therapy for women in their 50s is not harmful to the heart and may be helpful, she said.)
Of course, health care systems could—and should—also play a role in improving the odds for Black women, Thurston said. The 2022 BioMed Central study concluded: “Increased attention to the role of structural factors and discrimination on midlife health is also warranted.”
“We on the provider side are trying to improve things,” Thurston said. “We don’t like that the burden has to be on the individual. We’re trying.”
