How your background can affect your menopause

Women from disadvantaged social circumstances can face an earlier and more challenging menopause

An adverse childhood and adult life can both affect your experience of menopause
Women who need social support or with poor literacy are more likely to have their symptoms attributed to their circumstances
All women deserve equal access to information, advice and treatment

Most of us couldn’t have predicted how the perimenopause or menopause would affect us. You may have assumed your experience would be similar to your mum’s, or your friends, or not given it much thought at all. Yet while women are all individual, your background, childhood experiences, education, employment status and income can all have an impact on your menopause.

Women from disadvantaged social circumstances are more likely to experience poorer health. Dr Penny Ward, a GP and menopause specialist says: ‘We have known about the social determinants of health for some time. While this is well documented in chronic conditions such as diabetes and cardiovascular health, it is spoken about less in relation to the menopause. Given the menopause is one of the most important reproductive health events in a woman’s life, this is disappointing.’

Disadvantaged women are also more likely to reach menopause earlier, to suffer more symptoms or more severe symptoms, to undergo a hysterectomy, and have more barriers to treatment.

In order to best serve all women, we need to understand how our socio-economic background can affect the menopause and how to overcome the obstacles to ensure all women receive equal treatment.

Why might I have an earlier menopause?

The earlier you go through the menopause, the longer you will be without your hormones, which has an increased risk of osteoporosis and cardiovascular disease. Premature or early menopause is associated with adverse health outcomes and increased overall mortality [1].

There are numerous factors that can influence early menopause – one study of UK women found early natural menopause is associated with smoking, ever-use of oral contraception and sterilisation (amongst others), while surgical menopause was associated with manual social class and sterilization (amongst others) [2].

Interestingly, a study in the US found that amongst married heterosexual couples, women with lower education and income were more likely to undergo tubal sterilisation than those with higher income and education (while men with higher education and income were more likely to have a vasectomy than those less educated) [3].

Age of menopause has also been found to be affected by childhood. In a study of over 3,500 women from 23 British towns, certain indicators of adverse socio-economic position in childhood – the likes of coming from manual social classes, living in a house without a bathroom, sharing a bedroom, not having access to a car – were found to be associated with having menopause at a younger age [4]. One theory is that childhood malnutrition may lead to decreased ovulation and earlier menopause [5].

Adult indicators of adverse socio-economic position were similarly associated with earlier age at menopause. The study found that women who had 9 or 10 of these adverse indicators were on average 1.7 years younger at the age of onset of menopause than those who had none or only one indicator [6].

Why might I experience more symptoms?

Just as having a disadvantaged childhood can affect the age you undergo menopause, experiencing trauma in your childhood can affect your menopause symptoms decades later. Research has uncovered the potential long-term effects of psychosocial stressors, from childhood through to reproductive age, which include poorer wellbeing and worse menopause symptoms [7]. A history of physical abuse (reported by 37% of the women) correlated to worse menopausal, psychological, general health, and depressive symptoms. Nearly 8% of women reported a history of sexual abuse, which correlated with worse menopausal symptoms and general overall health. Those with a history of financial instability (10%) were found to have worse menopausal symptoms and general health, along with greater depressive symptoms.

Levels of education, employment status and income can also affect your menopause symptoms. Women with less education experience more severe symptoms while those with higher education are more aware of their menopausal symptoms and the strategies to deal with them, so are more likely to seek treatment [9]. Educated women are more likely to adopt a healthy lifestyle and have a higher quality of life, experience fewer sexual dysfunctions during the menopause and experience it later than uneducated women. Having a lower income is also associated with increased menopausal symptoms [10].

RELATED: menopause symptom sheet

Accessing treatment

Unsurprisingly, women from disadvantaged backgrounds are less well educated about the menopause, and are less likely to seek, and receive treatment. Dr Penny says: ‘Women who present as needing emotional and social support, or those who have poor literacy, are less likely to have hormonal changes discussed. Their presenting symptoms are more likely to be attributed to life events and circumstances or treated as depression. Some of these women will not have heard of the menopause – I spoke to one lady who thought the menopause was the single event of her periods stopping, she was unaware symptoms could start many years before this and continue many years after and had struggled alone for the best part of a decade.

Many women don’t have the resources to find the information themselves. There may be cultural barriers, lower levels of educational attainment or they may not be ‘of the age’ where medical professionals think menopause is likely. These reasons can lead to women not receiving the help they need, with many still not having access to the materials or information provided to them in a way in which they can understand.’

A 2018 study into GP’s HRT prescription rates in England found that it was 29% lower in practices in the most deprived areas compared to the most affluent [11]. Disproportionately more oral HRT was prescribed than transdermal in practices with higher levels of deprivation. The study’s authors remarked that this was interesting as cardiovascular risk (which is greater in areas of higher deprivation) is an indicator that might lead to a higher ratio of transdermal HRT prescriptions (which carries no increased risk of thromboembolism or stroke) compared with oral HRT preparations. It may also reflect patient choice.

One ray of hope for women from deprived backgrounds in England is that the HRT Prescription Prepayment Certificate (PPC), which was introduced last year, made HRT more affordable – at a cost of £19.30 per year (all NHS prescriptions are available free of charge in the rest of the UK). Since the PPC was introduced the number of HRT items prescribed on England increased 47% from 2021/2022, totalling 11 million items [12]. While there were more than double the number of patients prescribed HRT in the least deprived areas of England than the most deprived, we do not yet know if the PPC has lead to a proportional uptake in deprived areas.

How can we improve things?

While it’s worth acknowledging that many of the studies on childhood factors that might impact menopausal age are retrospective, and could be limited by recall bias or a lack of in-depth analysis, we know that more help is clearly needed for women of disadvantaged backgrounds.

Recent conversations about the menopause have highlighted that many women are mistakenly prescribed anti-depressants for low mood, when they may in fact be experiencing symptoms of the perimenopause or menopause. Dr Penny Ward says: ‘I spoke to a lady who was prescribed anti-depressants for her low mood and anxiety. She had never experienced this before and thought it was bizarre that it would occur for the first time in her life at age 48. Due to previous visits to her doctor looking for respite care for her son with a life limiting condition she felt the scene had been set for the diagnosis of depression to fit. She received carer benefits and her postcode was in the poorer part of town. If she had been asked about other menopause symptoms she was experiencing, a connection might have been made but she just hadn’t the knowledge, time or resource to know this for herself.’

We know that we don’t need to be limited or defined by our life experiences, and that if women are given the knowledge and resources to help themselves, they embrace it.

The balance app is free – use it to track your symptoms and get expert advice on all things perimenopause and menopause.

Newson Health has a Confidence in the Menopause course, which is designed to increase awareness of the menopause. Click here for a free taster that will give you access to presentations on topics including an overview of the menopause and HRT, information ono testosterone and the importance of shared decision making with your healthcare professional.

Finally, the Dr Louise Newson podcast is another great way of getting free, expert-led information that can help inform and empower you – click here to see the archive.

References

Faubion S.S., Kuhle C. L., Shuster, L.T., Rocca W. A. (2015), ‘Long-term health consequences of premature or early menopause and considerations for management,’ Climacteric, 18(4) pp.483-491. doi: 10.3109/13697137.2015.1020484
Pokoradi A.J., Iversen L., Hannaford P.C. (2011), ‘Factors associated with age of onset and type of menopause in a cohort of UK women,’ American Journal of Obstetrics and Gynecology, 205(1) pp34.e1-34.e13. doi: 10.1016/j.ajog.2011.02.059
Anderson JE, Jamieson DJ, Warner L, Kissin DM, Nangia AK, Macaluso M. (2012), ‘Contraceptive sterilization among married adults: national data on who chooses vasectomy and tubal sterilization’, Contraception. 85(6), pp552-7. doi: 10.1016/j.contraception.2011.10.009
Lawlor D.A., Ebrahim S., Smith G.D. (2003), ‘The association of socio-economic position across the life course and age at menopause: the British Women’s Heart and Health Study,’ BJOG, 110(12) pp1078-1087. https://doi.org/10.1111/j.1471-0528.2003.02519.x
Gold E.B. (2011), ‘The timing of the age at which natural menopause occurs’, Obstet. Gynecol. Clin. North Am, 38(3) pp425-440. doi: 10.1016/j.ogc.2011.05.002
Lawlor D.A., Ebrahim S., Smith G.D. (2003), ‘The association of socio-economic position across the life course and age at menopause: the British Women’s Heart and Health Study,’ BJOG, 110(12) pp1078-1087. https://doi.org/10.1111/j.1471-0528.2003.02519.x
Faleschini S., Tiemeier H., Rifas-Shiman S.L., et al. (2022), ‘Longitudinal associations of psychosocial stressors with menopausal symptoms and well-being among women in midlife’, Menopause, 29(11) pp1247-1253. doi: 10.1097/GME.0000000000002056
Carson M.Y., Thurston R.C. (2019), ‘Childhood abuse and vasomotor symptoms among midlife women’, Menopause, 26(10) pp1093-1099. Doi: 10.1097/GME.0000000000001366
Namazi M, Sadeghi R, Behboodi Moghadam Z. (2019), ‘Social Determinants of Health in Menopause: An Integrative Review’, Int J Womens Health, 11 pp637-647.
https://doi.org/10.2147/IJWH.S228594
Brzyski R.G., Medrano M.A., Hyatt-Santos J.M., Ross J.S. (2001), ‘Quality of life in low-income menopausal women attending primary care clinics,’ Fertility and Sterility, 76(1) pp44-50. https://doi.org/10.1016/S0015-0282(01)01852-0.
Hillman S., Shantikumar S., Ridha A., Todkill D., Dale J. (2020), ‘Socioeconomic status and HRT prescribing: a study of practice-level data in England’, British Journal of General Practice, 70(700), e772-e777: DOI: https://doi.org/10.3399/bjgp20X713045
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