Continent
Country
First author
Number of subjects
Age range
Mean age
Median age
Europe
Europe
Dratva [41]
5,288
30–60
54
North America
United States
Gold [36]
3,302
40–55
52.54
Asia 1
Japan
Yasui [48]
24,152
>40
52.1
Asia 2
Thai
Chompootweep [53]
2,375
45–59
49.5
Asia 3
China
Yang [49]
9,939
40–65
48.9
Asia 4
India
Kriplani [50]
350
46.7
48
Africa
Nigeria
Olaolorun [61]
1,189
40–60
50
Latin America
Latin America
Blumel [45]
17,150
40–59
48.6
Middle East 1
United Arab Emirates
Benera [58]
450
>45
48
Middle East 2
Iran
Delavar [57]
1,397
45–63
47.7
34.6.1 North America and Europe
34.6.1.1 North America
Within North America, the median age of natural menopause reported in the Study of Women’s Health Across the Nation (SWAN) was 52.54 years [36]. The study assessed 3,302 from across the United States and included 5 ethnic/racial groups. A similar finding was reported in a study looking at the median age of menopause for women in the United States (US) and Spain, the finding for the United States was 52.6 years [37]. While within Canada, the average age of menopause has been cited as being 51 years [7].
Regional differences were also identified within the United States. In a cross-sectional survey of 22,484 women, after controlling for covariates, it was noted that women from the Southern part of the United States reported menopause 10.8 months earlier than Northeastern women, 8.4 months earlier than midwestern women, and 6.0 months earlier than western women (p <0.05) [38]. The cause for this effect is not known.
In terms of racial differences from within the United States, Gold et al. [10] reported no difference between Caucasian and African American women in terms of menopause onset, yet within this report, they cite two earlier studies that demonstrated that African American women had an earlier onset of menopause by 6–12 months in comparison to Caucasian women. McKnight et al. [38] in 2011 found similar findings to Gold in that no racial difference in age at menopause was shown between black and Caucasian women after covariates were controlled for in a cross-sectional survey of 22,484 women in the United States [37]. A study of 17,070 women aged 35–55 years found African American women had earlier onset of natural menopause, and this was strongly associated with smoking and inversely associated with body mass index and oral contraceptive use [39].
Henderson et al. [40] reported that Japanese American women experienced late natural menopause in comparison to women of Latin heritage as well as Caucasian women in the United States. Additionally, Latin women living in the United States, but born outside of the United States, had earlier onset of menopause then women born in the United States with Latin heritage [40].
European women had a median age of natural menopause of 54 years based on a study of 5,288 women randomly selected in nine European countries between 1998 and 2002 [40]. The later age of menopause across Europe has been noted in a number of other studies [41–44]. As was seen within the United States, there are geographical variations within Europe; Southern Europe in general has an earlier age of natural menopause compared to Northern Europe [41]. In fact, the study indicated that there was also variation across countries and that the age of natural menopause was shifting toward later ages [41].
34.6.1.2 Latin America
Latin American women have an earlier age of menopause than those within Europe and North America. In a study involving 17,150 healthy women surveyed from 15 Latin American countries, the median age of menopause was reported as 48.6 years and the mean age was 49.4 ± 5.5 [45]. The onset ranged from 53 years in Cartagena de Indias (Colombia) to 43.8 years in Asuncion (Paraguay) [45]. Further it was found that women living at or above 2,000 m and those with lower levels of education were more prone to an earlier menopause [45]. In a survey of 4,548 women across all regions in Mexico, the mean age at menopause was 47.9 ± 3.82 years [46], while the median age at menopause was reported to be 50 years in a study comprising 4,056 women in seven cities within Latin America and the Caribbean [47].
34.6.1.3 Asia
There is great diversity among the various countries comprising Asia. Yet the mean and median age of menopause in Asia is fairly consistently reported. The exception to this is Japan. In fact Japanese women have one of the latest median ages of natural menopause, comparable to women in the west. This is evidenced within the Japan Nurses’ Health Study, in which a cross-sectional analysis revealed a median natural age of menopause of 52.1 years [48]. This as noted is in contrast with the general trend in Asia wherein the natural age of menopause is comparatively early in relation to that seen in the west.
A cross-sectional study conducted in China including a total of 9,939 women reported 48.9 years as the mean age of natural menopause [49]. While a series of studies involving women in India closely mirrored the age reported in China with an average age at menopause calculated as 48.0 [50], and at 48.7 for two other studies [51, 52]. Further, a study of Thai women in Bangkok reported an average age of menopause of 49.5 ± 3.6 [53], and a study in Singapore reported a mean age of 49 years among 2,354 women [7].
34.6.1.4 Middle East
Studies within the Middle East revealed a median age of menopause that is somewhat comparable to Asia in that on average it is on the younger side of the age range continuum. This includes a median age of 50 reported in a study including 858 Saudi Arabian women of which 391 were postmenopausal [54], a median age of natural menopause of 49.3 years for 298 women in Lebanon [55], and a median age of 50 based on a study of 143 women in Jordan [56]. The mean age recalled by a sample of 1, 397 women in Iran was 47.7 ± 4.9 years [57]. While a study involving a sample of 450 United Arab Emirates women aged 45 years and above, the median age of natural menopause was 48 years [58].
34.6.1.5 Africa
Relatively few studies were found that evaluated menopause in African women. However, two studies, one in Ghana and one conducted in Nigeria reported a median age of 50.2 years [59, 60]. Further, a cross-sectional community-based study with a total of 1,189 Nigerian women reported the median age of menopause as 48 years [61]. Lastly, a small community-based study in Nigeria among 273 menopausal women reported a mean age at menopause as 51.41 ± 3.26 years [62].
34.7 Geographical or Cultural Expression of Symptomatology
There is an ongoing controversy as to whether there are universal menopausal symptoms. There are a number studies from North America and Europe that report relatively high numbers of menopausal symptoms in comparison to studies that have been conducted in Asia. As well, there appears to be differing perspectives in the experience of menopause across cultures. For example, women in Japan see menopause as an event which is not considered to be a negative experience, while about half of American women believe menopause is a disagreeable event [63]. However, irrespective of country, it has been reported that the majority of women pass through menopause with no or very little symptoms of discomfort [64]. Differences in FSH, estradiol, and luteinizing hormone have been shown across populations; however, the clinical significance of these findings is currently unclear [65]. Yet, these findings provide some rudimentary indication in favor of the existence of cross-cultural differences.
34.7.1 Vasomotor Symptoms
There are varying rates of vasomotor symptoms, such as hot flash, hot flush, and night sweats, reported in the literature. These differences are shown across geographic areas and ethnic categories; refer to Fig. 34.1. It has been suggested that menopausal status may also have a role in the expression of these differences: premenopausal women appear to have the lowest rates, while perimenopausal women experience the highest rates of this symptom cluster [66].
Fig. 34.1
Percentage of vasomotor symptoms by region (US by race/ethnicity)
34.7.1.1 North America and Europe
Vasomotor symptoms are commonly reported within North America and Europe. The North American Menopause Society [67] notes that about 55 % of women report experiencing hot flashes. Freeman et al. [65] cite results from prior analyses of the Study of Women’s Health Across the Nation (SWAN) that revealed African American women had the highest rates of vasomotor symptoms; this included both hot flushes and night sweats. African American women had these symptoms at a rate of 46 %, followed by Hispanic (35 %), Caucasian (31 %), Chinese (21 %), and Japanese (18 %) [65]. The publication further reports that another analysis of the SWAN data noted that African American women had the highest reported prevalence of night sweats and that the group with the lowest proportion of premenopausal women had the highest prevalence of hot flushes or night sweats [65]. While studies conducted in Europe also show high rates of night sweats in fact up to three fourths of the women in these studies experienced hot flashes [35]. Yet, there are country differences, for example, Dutch women reported the symptoms at a rate of 80 % and women within Britain reported these symptoms at a rate of about 54 % [68].
34.7.1.2 Latin America
Latin America is reported to have high rates of severe menopause transition symptoms. In terms of the rate of vasomotor symptoms, a range between 50 and 68.9 % has been noted in the literature [69]. A 2011 Blumel et al. paper [69] found that 54.5 % of 8,373 women from 16 Latin American countries reported vasomotor symptoms and that these symptoms persisted into late postmenopause. It was also reported from this same study that the vasomotor symptoms negatively affected quality of life [69].
34.7.1.3 Asia
Asian countries are reported to have relatively low rates of vasomotor symptoms ranging from 10 % to 20 % in countries such as Hong Kong, [70] India, Indonesia, and Thailand [64]. In Japan, rates of vasomotor symptoms range from 12 to 25.7 % [71]. When reviewing two multinational studies based in Asia, the ranking of the most common symptoms tended to differ from those seen in the west. The most common symptoms, reported in the Pan-American Study, representing 11 countries from the region were not those related to vasomotor symptoms, but rather were body and joint aches (86.3 %) and memory problems (80.1 %) [72]. In fact hot flushes were reported at a rate as low as 5 %, based on responses from women within Indonesia [72]. In the Asian Menopause Survey, the most common symptoms were sleeplessness (61.7 %), irritability (60 %), followed by migraines (55.9 %), while hot flashes were reported at a rate of 49.9 % [73]. Barber [65] suggests that symptom ranking may differ between Eastern and western women and further notes that Asian women are less aware of treatment options than their western counterparts.
34.7.1.4 Middle East
Studies within the Middle East vary in terms of reported rates of vasomotor symptoms but have been noted to be in keeping with western rates. Sallam et al. [74] reported in a study of 200 Egyptian women who experienced hot flashes that the rate was 87.7 %. Further, a cross-sectional study of 450 women in Egypt noted that 90.7 % experienced hot flashes [75] and a study involving 143 women in Southern Jordan showed a rate of 62 % [56]. A cross-sectional survey conducted in Libya reported vasomotor symptoms at a rate of 76.6 % [76]. In contrast, a study within Iran reported a rate of 49.3 % in a sampling of 1,397 women [57] and a study within the United Arab Emirates noted a vasomotor symptom rate of 40 % [58].
34.7.1.5 Africa
There is limited information found regarding African women; however, two studies from within Africa reported relatively similar findings. A prospective survey involving 152 women in Akosombo District in Ghana reported hot flash rates of around 57 % [59]. A cross-sectional survey in Nigeria involving 186 women noted hot flashes were experienced by 58.1 % of the respondents and that this symptom was viewed as the most problematic one [77]. A second study in Nigeria among 273 women reported a similar rate of 57 % [62].
34.7.2 Vaginal Atrophy
Vaginal atrophy is experienced, at rate reported to be as high as about half of all postmenopausal women. This cluster of symptoms often negatively affects quality of life [78]. Symptoms of vaginal atrophy include vaginal dryness, itching, burning or soreness, as well as dyspareunia. Additionally, urinary tract symptoms can also be present in some women including nocturia, dysuria, urgency, frequency, and incontinence which includes leaking urine and recurrent urinary tract infection [79]. Sexual dysfunction is also associated with vaginal atrophy, and this cluster of symptoms is believed to be linked to a reduction in estrogen [78, 79].
34.7.2.1 North America and Europe
The prevalence of vaginal atrophy within the United States has been reported as being as high as 51 % (80) in contrast to a reported rate in Canada of 34 % [81]. Interesting, however, is that only 24 % of women in the United States attribute their symptoms to menopause [82]. Further, in a survey conducted within North America, 60 % of women over 45 years of age who had used hormone therapy in the past or who had never used hormone therapy had vaginal atrophy complaints and the majority (90 %) of these women considered these to be problematic [83]. Yet, multiple studies found that relatively low numbers of women (25 %) seek medical consultation for this type of symptom [81].
The international online survey, Vaginal Health: Insights Views and Attitudes (VIVA) included 3,250 postmenopausal women (last menses was more than 12 months before entry) between the ages of 55 and 65 [80]. This included women from Canada, Denmark, Finland, Norway, Sweden, United Kingdom, and the United States and concentrated on assessing perceptions about vaginal distress. Almost half of the respondents (45 %) reported having a symptom related to vaginal atrophy with the lowest rate being reported in Sweden (38 %) and the highest in the United States (51 %) [80].
Another survey (CLOSER) that was conducted in Canada, Denmark, Finland, France, Italy, Norway, United Kingdom, and the United States reported that more than half of the North American respondents avoided sexual intimacy due to vaginal symptoms [78]. Additionally, half of the surveyed women responded that their clinician had not initiated a discussion of postmenopausal vaginal wellness [78]. There were country differences present with regard to this point; on the higher end were women from the United Kingdom (60 %), Canada (59 %), United States (56 %), and Norway (53 %), and on the lower end were women from Sweden (35 %) and Finland (33 %) [78].
34.7.2.2 Latin America
The Collaborative Group for Research of the Climacteric in Latin America (REDLINC) assessed sexual dysfunction in 7,243 women aged 40–59 year of age. The survey was conducted in 11 Latin American countries and sexual function was assessed using the Female Sexual Function Index (FSFI) [84]. The FSFI is comprised of 6 domains: desire, arousal, orgasm, pain, lubrication, and satisfaction [84]. Of the 5,391 women who were sexually active, 56.8 % of the respondents reported sexual dysfunction and the prevalence of sexual dysfunction varied per center; it ranged from 21 to 98.5 %. The sexual dysfunction domains with the highest scores also varied by center [84]. Desire was the domain with the highest score across sites and vaginal dryness was the factor most associated with sexual dysfunction [84]. In a cross-sectional survey among 125 Native-American Bolivian women, the chief complaint was loss of libido, and this symptom was reported by 51 % of the respondents, followed by genital itching 40.8 % and dyspareunia 40 % [85].
34.7.2.3 Asia
Overall, the highest rates of symptom complaints reported by women within the pan-Asia menopause study were not related to vaginal atrophy, but rather related to muscle and joint pains. These occurred on average at a rate of 86.3 % and ranged from 76 % in Korea to 96 % in Vietnam [72]. In contrast vaginal atrophy symptoms were reported at the following lower rates: vaginal dryness 55.7 %, vaginal itching 39.7 %, dysuria 37.4 %, and painful intercourse 29.9 % [72].
In a cross-sectional study of 1,000 postmenopausal women from China, Malaysia, Taiwan, Thailand, and Hong Kong, most women (66 %) reported no reductions in sexual function [73]. Yet, symptoms of vaginal atrophy were on average reported by 37.4 % of the women. The countries with the higher rates were Hong Kong 51 %, Taiwan 47.9 %, and Thailand 45 %, and those reporting lower rates included China 31 % and Malaysia 29.6 % [73]. Further, awareness of hormone therapy (HT) was low; over 30 % of women were not able to mention one benefit of this treatment [73].
34.7.2.4 Middle East
Research on vaginal atrophy within the Middle East was not readily identified. Gynecological matters, by virtue of cultural mores, remain a private and somewhat of a shameful matter [86]. Yet, in a retrospective study conducted in Iran, a statistical increase in urinary frequency was identified for women entering menopause, and a statistically significant increase of complaints of dry vagina were identified postmenopause [57]. Further, a cross-sectional study of 450 Egyptian women aged 50–59 years of age noted that 89.1 % of participants reported decreased sexual desire [75].
34.7.2.5 Africa
Lastly, within Africa a study in Nigeria revealed urinary frequency at a rate of 38.7 % and vaginal dryness and discomfort or discharge at a rate of 35.5 % [77]. A South African study involving structured interviews with 102 women in Durban found the women experienced a number of vaginal and urinary complaints related to atrophy, such as painful sex 43 %, dry vagina 51 %, loss of libido 41 %, pruritus 32 %, dysuria 39 %, and urinary frequency 40 % [87].
34.8 Attitudes and Symptom Experience: Cultural Implications
There appears to be some relationship between a woman’s attitudes toward menopause and their experience of symptoms. Avis and McKinlay [88] in 1991 reported from the Massachusetts Women’s Health Study that women with negative attitudes toward menopause prior to the transition reported higher frequencies of hot flashes. Ayers et al. [9] note in their review of 13 studies that pre- and perimenopausal women as well as younger women had the most negative attitudes toward menopause. This seems to align with the perception that the perimenopausal transition is most fraught with physiological changes. Another explanation is that women ultimately adapt to the symptoms over time. Further, countries such as the United States, whose culture and healthcare system tends to “medicalize” menopause rather than view it as a life course process, have higher frequencies of “negative symptoms” [9]. As well, there is evidence that supports the notion that the more negative a woman’s attitude is to the transition, with or without the existence of comorbid mood disorder, the greater the number of menopause-related symptoms [9].
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
