From Menarche to Menopause: Navigating the Complexities of Women's Health

Right, so it's 3. We have a lot to cover, and I really want us to be able to answer questions. So I'm going to go into the talk and then hopefully we'll have enough time for questions. Hello to everyone, and thank you for letting us know where you're listening in from. So, who am I? I'm a UK-based general practitioner with a special interest in women's health, sexual and reproductive health, and the menopause. I work in the National Health Service, but I also work in the private sector in the UK. I've got a host of postgraduate qualifications after my general practice training, which is family physician?in some countries, family physician is general practice in the UK. I also did internal medicine before I did general practice, so I've done quite a few different training programs. I'm a member of the British Menopause Society, the Primary Care Women's Health Society, the Royal College of GPs Women's Health Significant Interest Group. I'm the equality and diversity lead for the Royal College Northwest London Faculty. I teach and examine at Queen Mary?s, one of our medical schools here in London. I combine personal insight?because I myself have had quite a few women's health conditions?with professional expertise to create tailored care strategies. I'm a dedicated advocate for health equity. So, let's get into it. I want you to just kind of reflect in your head: what comes to mind when you hear "complexities of women's health"? You can put some stuff in the group chat about what you think. Someone said inequity?that's really good. Other thoughts? Access to health, lack of funding for research, underserved hormones?I love that, hormones. Menopausal management?we're getting lots of stuff in. Someone said menopause and HRT. I'm actually a menopause specialist. Contraception options, metabolism?I like that. Different presentations of illness, so women presenting differently. Longevity and chronic illness risk, thinking about health span, inequity of treatment and research. We know women were not even included in research till the '90s. Social disparities, abortion care, menopause, weight and apple?someone?s thinking about dementia care. Someone says relative recent interest in women's health. Thank you all for your contributions. All of this stuff makes sense. No one has mentioned how we treat complicated cases?I thought some people might say that?but actually you guys are really on point with what we're going to be talking about today because women's health isn't one-size-fits-all. Many things shape it, including our environment and our culture. We're going to look today specifically at how culture and beliefs affect health from periods to menopause and really look at what matters for truly personalized care. We will see how beliefs, stigma, and silence can change a woman's experience and learn how to make our care in women's health more inclusive and more human. Now, culture shapes our health beliefs and access and influences everything from periods to pregnancy to menopause in every phase of a woman's life. For example, some women, because of cultural factors, may delay seeking care, so understanding the cultural subcontext helps us improve care. This applies to all women. It's not just ethnic minority individuals who have culture?we all have cultures. We have people from Africa, Latin America, North America, Europe, Asia on this call. So many different parts of the world, and many of us live in multicultural societies. As clinicians, we need to embrace that and input that knowledge and respect into the care we deliver. There are many factors affecting women's health from a cultural standpoint: beauty and purity myths which increase shame around menstruation and even menopause; myths around fertility and pregnancy; gender roles that limit women's health choices. I was speaking to someone the other day about how what really moved the dial for women being able to be more equal participants in society has been contraception. The ability for contraception to shape women's choices?but that's not true for many women around the world. Gender and cultural roles still limit women's health choices. There are impurity beliefs that restrict access to hygiene, activity, work, and education. There is stigma and silence?someone in the group wrote about silence impacting women seeking help. Now we're going to start with a story. We have Amina Ahmed. She's 50, originally Pakistani but lives in the US. She's perimenopausal and currently has heavy bleeding. We also have Farida, her daughter, 20, a college student, born and raised in the US. Her health issue is heavy and painful periods, dysmenorrhea. Then we have Miriam Goldstein, 32, an Orthodox Jewish person living in the US, reproductive age, with infertility. Let's talk about Mrs. Amina. She's struggling with irregular periods, hot flushes, mood swings, and heavy bleeding. Her family dismisses her symptoms as normal. She tries to talk to a few friends and family, who say, "These are things women go through." She's tried to speak to doctors but feels a bit ashamed. Cost of treatment, language barriers, treatment options, and religious concerns have limited her access to care. She's tried traditional remedies but they haven't worked. She feels isolated with her symptoms. She just doesn't feel well and doesn't know how to address this now. Let's go back to Farida. I?d like us to think about this case and what you would recommend to support this patient. You can write your thoughts in the chat. What would you think about doing if you met, heard about, or saw this patient? Answers: blood tests, FSH and LH; advocacy service is a good idea; provide a safe and welcoming offer; consider her cultural practices; first of all, validate her concerns?I love that; follow up with the primary care physician or obstetrician; work to find her a provider she may be comfortable with; listen and validate. I love that because the first thing is to hear the patient out. Many women who present with irregular periods, hot flushes, mood swings, and heavy bleeding might obviously be menopausal to us, but it might not be obvious to her. She just doesn?t feel right. She has muscle aches and pains, knows something is wrong but not what. When she?s been to doctors, maybe due to nuance or language, they haven't picked it up. It might be obvious to us but not to her, so communication is key?listening and saying, "You?re not crazy, something has changed." In a language she will understand, you might need an interpreter. It might be helpful for her to have a female doctor for that conversation, but that?s not to say she can't have a male doctor if empathetic and able to provide a comfortable space. It?s worth asking her. Then understand her cultural pressure points: why is this difficult in her day-to-day life? How is it impacting her functioning? Does she work? Is it impacting her relationship with her partner? Is she having sexual symptoms? Menopause can affect libido, vaginal dryness, painful intercourse, urinary symptoms like frequency and incontinence. Mood swings?how bad are they? Is she having dark or suicidal thoughts? These are complex issues. What is her mental load? Does she care for younger children or elderly relatives? How much is she carrying, and how does that impact her symptoms? There is so much to understand. We need to listen and validate. Yes, do blood tests and investigations if necessary, including thyroid function, prolactin, and others to ensure we don?t miss anything else. But again, how does she want to be treated? We provide a range of treatment options including HRT. We need to explain HRT in a way she understands and give her the choice. She might prefer to try something else?with explanation of benefits and risks of each treatment. Now let's move on to Farida. She has painful periods. She's Googled her symptoms and is worried, particularly about endometriosis. She?s spoken to her aunt and mom; they've talked about bad blood flow and some traditional practices that could be harmful. She?s unsure about going down that path. She?s also worried about healthcare costs and burdening her parents financially. She's at college, missing school frequently due to severe period pain, struggling to build relationships. Farida was born and raised in the US. She's a second-generation immigrant, tied to her culture but also American culture. This confuses her. She's read online?heard on TikTok not to take hormonal treatment because doctors constantly try to give hormones that worsen symptoms and future health. Her mom and aunt have said, "Don?t take hormones; it will make it difficult to have babies in the future." All of this is playing on her mind. Back to you: what would you say if you met Farida? Put your answers in the chat. Answers: discuss lifestyle changes; assess her goals?what does she want? Validate her worries; don?t dismiss or falsely reassure her. Many women find their menstrual health problems dismissed as "just part of the course." We need to avoid dismissing worries and inappropriate reassurance?appropriate reassurance comes after tests and investigations. Thank you for raising myth-busting, particularly around hormonophobia. Be respectful, demystify what she?s heard, help her understand facts, give evidence-based comparisons of options, explain the risks and benefits, listen to her concerns. Encourage her to visit a campus clinic again?thinking about low-cost, safe spaces. Actively listen and correct false beliefs respectfully. All fantastic suggestions. Now let's move on to Miriam. She has been struggling to conceive after two years of marriage. She is in a community that values early childbearing, so she feels shame and pressure. People constantly ask if she?s pregnant or make intrusive comments. I can relate to this because in the African community, where I?m from, this happens a lot. When I first got married, I had similar experiences and struggled with infertility for four years. People would touch my tummy saying, "Is something in there?" They had no idea I was weeping because my period just came again. There is a lot of emotional distress, and cultural factors add a layer. She has concerns about internal examinations during particular times in her cycle. She?s thinking about IVF with questions about embryo storage related to her faith. If you were seeing Miriam, what thoughts would you have? Answers: acknowledge her fears and concerns; be supportive of what she wants?is it her choice to conceive or pressure from others? Look for underlying causes of infertility with fertility workup, respecting cultural boundaries. I worked in an area of North London with a high population of Orthodox Jewish people. It was important to understand the faith and how people interpret it personally. You can?t make assumptions; you need to ask about her personal concerns and what she wants. Encourage advice from her community?a trusted source, maybe a rabbi or an older woman in the community who provides a safe space. Sometimes exposing people to community members who might not be safe could make things harder. Respect is vital. Check that she knows all the facts about IVF and how it can be done in ways that respect her religious concerns. All fantastic. Now, we?ve reflected on what makes each woman?s case unique and the specific complexities. Women?s health is amazing. What I love is that most of the time it is beautifully gray, rarely black and white. It?s complex, with biopsychosocial impact. There might be biological things like dysmenorrhea, endometriosis, PCOS, and menopause, but also psychological factors?cultural, psychological, or related to the heavy mental load women carry even now in 2025. There are social factors too: a woman?s role in life, whether she is working, has young family, elderly or vulnerable people she cares for, or doesn?t have or want a family. Maybe she is trying to build a career but facing workplace challenges. We still know there isn?t equity in the workplace for women, and it can be difficult to navigate. Women?s health is rarely black and white?it?s beautifully gray, and I love the gray. As clinicians, especially in medical school, you want things to be black and white?you want clear patterns from the book. But the real world is gray, which can be confusing. Please don?t let that put you off. From the chat, many of you are already embracing the gray. At menarche, young girls start puberty. Sometimes period issues are really difficult to talk about depending on how they?ve been raised, their community, or cultural background. Some have little or no education on sexual and reproductive health, although hopefully that is changing. Many have limited or incorrect knowledge. Social media often gives wrong information, so it?s up to us as caregivers and health professionals to provide support and education in a caring and empathetic manner. Family expectations can also complicate things, especially when younger girls want contraception but don?t want their families to know. Period problems can impact academic life and limit academic potential. We want young girls to know what?s normal and what?s not so they can express concerns. In midlife?well, early 30s to 50s?women juggle work and family. There?s no right or wrong in their choices. Women often put others first and their own health last. There?s a lot of self-neglect while juggling a heavy mental load. Menopause and beyond often bring stigma. The mental load continues as estrogen drops, and people struggle with menopausal symptoms. If someone has a chronic illness, is from the LGBTQ+ community, or from a socioeconomically deprived or ethnic minority background, that adds extra layers of complexity. We must be aware of complexity and support patients through it. Studies show taboos around periods in certain cultures and communities?remember, this is not just ethnic minorities. Some cultures even in the US have taboos around periods and sexual health, limiting open discussion. Religious influences can impact this too. Period poverty is real and impacts many parts of the world, including the US and UK. Young girls may not afford or access pads, making things harder. Pain and symptoms are often dismissed or receive inappropriate reassurance. Young girls hide their symptoms out of shame. Parents and teachers may lack the tools or avoid teaching menstrual health properly. Menstrual cycle length and age of menarche vary by ethnicity. Black and Hispanic girls tend to start younger than Caucasian girls. Southeast Asian girls may start younger or around the same age, while Far East Asian girls may start a little later. We should be aware of these variations. Period pain causing harm to education and limited support is impactful. If you take one message from this age group: please don?t dismiss, listen, and provide support. I struggled with heavy, painful periods in university and medical school. I was told it was "part of the course." I missed three or four days every month but didn?t seek treatment because my Nigerian mother warned against contraception affecting fertility. A gynecologist tutor listened and validated my concerns and suggested trying the pill. It was life-changing. I had no periods on it and could fully engage in studies without misery. If she hadn?t listened and validated me, I might not be here. This is why listening, validating, understanding, and communicating in a language patients understand is so important. In reproductive years, conditions like endometriosis, PCOS, adenomyosis, and fibroids can worsen period health. Endometriosis is difficult to diagnose; women of all races wait 7 to 10 years for diagnosis. It?s often dismissed, especially in women of color. Black women take even longer to be diagnosed. Women are undertreated for pain and not believed by clinicians. The gold standard diagnosis is invasive surgery, which can cause damage and scarring. Thankfully, a new blood test panel is coming that may help diagnosis, but availability is uncertain. In young women with normal scans, I often discuss whether laparoscopic surgery is worth the risk or if hormonal treatment as a diagnostic trial might be better. If endometriosis is found on surgery, hormonal treatment is recommended to prevent recurrence, but women trying to conceive may avoid hormonal treatment. This illustrates why there is no one-size-fits-all approach. We must talk to and respect patients, give facts, validate, and believe them. Black women can get more aggressive gynecological cancers. Although white women have higher overall cancer risk, black and Hispanic women often have more invasive cervical cancer due to delayed diagnosis. Ethnic and cultural factors impact equity in women's healthcare. Fertility rates vary by ethnicity. Cultural beliefs affect pregnancy and contraception choices. Hormonophobia?a fear or distrust of hormonal treatments?impacts younger generations and ethnic minority groups. Addressing this requires a non-judgmental approach, listening to fears and mistrust, and explaining evidence-based knowledge. There are many types of hormonal treatments?it's not just combined or mini-pills. There are different progesterone-only pills, combined pills with different progesterones, and even body-identical estrogen. Some have anti-androgen effects helpful for PCOS. There are multiple generations of progesterones with varying activity. This is postgraduate knowledge, but as medical students and junior doctors, understanding there are many options helps educate and empower patients. Besides pills, there are patches, injections, coils, implants, and new options emerging every day. Media and social media have amplified hormonophobia, with worries about side effects, mental health worsening, libido loss, fertility, and anxiety. Distrust in healthcare among ethnic minority communities is real, often due to historical injustices, amplifying these fears. During pregnancy and childbirth, cultural barriers impact care for ethnic minority and immigrant women. Religious beliefs influence choices, so it?s important to honor a woman and her choices while providing safe, evidence-based information. It?s a meeting of two experts: the woman is expert in her body; we are experts in clinical knowledge. Trust is always a big issue. You may have heard black women are four times more likely to die in pregnancy than white women?this is true in the US and UK. Risks include preterm birth, low birth weight, preeclampsia, and severe maternal health complications. Other ethnicities, like Hispanic and Southeast Asian women, have doubled risk of death in pregnancy. All of this is critical when supporting women. Now, menopause. The SWAN study showed black, Asian, and Latina women have earlier menopause. Black and Latina women have longer menopausal symptoms like hot flushes, whereas Chinese and Japanese women have shorter periods of hot flushes. Black women often have longer transition and more severe symptoms. Latina women report more vaginal symptoms. There are ethnic variations in menopausal experience. Asian women might report fewer hot flushes but more all-over body pains. As a junior doctor in A?E, I saw clusters of women from Asian, African, Turkish, and Arab groups presenting with body pains and feeling unwell with normal tests. Years later, I realized they were experiencing menopause but lacked the right language to describe it. Cultural attitudes affect symptom presentation and treatment choices. I mentioned the mental load?this impacts all women throughout life. Women carry the burden of invisible cognitive labor: working full-time while supporting the home, caring for younger and older family members, providing emotional care. It can be draining, often giving more than receiving, resulting in severe stress worsening health outcomes. Women delay care because they are too busy or skip medications, miss screenings and checkups because of overload. This adds complexity. I want to introduce cultural competence in women's health. We?ve talked about many issues already. Care must reflect diverse cultural backgrounds. Respect and understanding lead to better communication, trust, higher satisfaction, and better outcomes. It?s key to effective patient-centered care. What does this mean in practice? Be curious. Ask about her life, not just symptoms. A woman is not just her symptoms. Ask about who she lives with, what she does for work, and how her condition impacts her quality of life. Show humility: you are an expert in medicine but she?s the expert in her body. Think about trauma?we haven?t unpacked trauma, but many women experience sexual violence, domestic violence, infertility, divorce, unexpected singlehood, over-sexualization of younger women, desexualization of older women, miscarriage, and more. Many traumas are hidden and unspoken. Think about trauma-informed care: create safety, listen without judgment, believe her, take symptoms seriously. Educate clearly using simple, respectful, culturally aware language. Intersectionality matters: many layers compound, including discrimination based on socioeconomic status, LGBTQ+, ethnicity, religion, and more. Each woman has unique needs. Another take-home message: one size doesn?t fit all. Tailor care and be inclusive. This is what we?re doing right now: training providers, teaching cultural, religious, and social influences on women's health. Cultural competency improves outcomes. Partner locally. Work with community leaders to share accurate information and reach every community so no one is left out. Go digital wisely to counter misinformation. If you are a clinician and feel up to it, making helpful and accurate content online can help, as many women turn to digital spaces for information. Think about language barriers; use interpreters. Care is expensive, so try to reduce barriers: provide transport support or digital ways to interact without excluding people. Cultural outreach aims for fair, easy access for all women. Remember culture shapes things, but respect beliefs and values, and empower all women to own their health. Just before we close: what is one thing you will take forward to better support the complexity and diversity of women's health needs? Put it in the chat. Answers: "You?re the expert in your own body," "Taking time to listen always validates your patients," "Cultural sensitivity," "Creating safe spaces," "A woman is not her symptoms," "Look beyond symptoms and ask how it impacts her life," "Validate and empower," "Help educate and advocate for symptoms," "Educate women online and provide safe, healthy spaces," "Educate the general public," "Make her as comfortable as possible," "Make patients active partners," "Teach them how to break stigma," "Earn the trust of the patient." If you have questions, put them in the chat. Someone asked about learning cultural specificity. Honestly, the best way is to ask nurses, medical assistants, and others from the same culture. Be interested in people and culture. Many live in multicultural communities. Don?t just stick to what you know as a doctor. Be curious, open, and learn from your communities. When I was in medical school in London, I embraced many different cultures?Greek, Jewish, LGBTQ+, Indian, Hindu, Sikh, Muslim. Have an open mind and learn from others. Thank you, D. Soraniano, for saying we need more providers like yourself?that's very kind. Are there resources to guide hormone replacement? Plenty. In the UK, the British Menopause Society. In the US, the North American Menopause Society. Unfortunately, emphasis is sometimes lacking and attitudes can be close-minded, so focus on your own ability to deliver care to patients in the moment. That will be valuable and helpful. Keep pushing, inch by inch. It?s difficult, especially when it?s not a priority for everyone, but thank you for your efforts. Someone asked how to be competitive for jobs compared to students in specialized fields. How would you recommend students in general practice or family nurse practitioners get into women?s health specialty upon graduation? Good question. In my training, during self-directed learning afternoons, I emailed a local community gynecology clinic asking if I could sit in. I did this for most of my training while doing diplomas and extra courses. I told everyone I was interested in women?s health, so patients started coming to me, and I developed expertise. Postqualification, I did more courses and training. I do education online for patients and colleagues. Sometimes there?s no straightforward path from family medicine to women?s health. You have to seek places to develop skill sets. There are fellowship options you can apply for. If you want to do women?s health, don?t give up. Keep building expertise, find someone who will listen and train you. For PCOS management, Osmosis has a really helpful tool. There are lots of helpful guidelines in the UK and Europe, recently updated. I?m teaching a course on PCOS soon, open to medical students in the UK called "PCOS Time." Amazing resources from guidelines help shape knowledge. Someone asked for a link to the study that helped distinguish menopause experiences. Just Google the SWAN study. It has been posted in the group. Someone asked if it?s bad to relate to patients and their symptoms, especially as a female doctor. No, it isn?t. I?m passionate about women?s health because I live with PCOS and infertility. Sometimes I use that to help patients know I understand them. You have to be careful, but if appropriate, support the patient and help them know they?re not alone. My full name is Itunu Johnson. Someone thanked me for this, saying "We can't adequately address..." I?m sorry to hear that. Do the best you can. No health system is perfect. It's hard, especially in the UK, with limited resources. Sometimes it feels like hitting your head against a wall advocating for patients. Remember, as a healthcare provider, you can only do your best. Look after yourself to avoid burnout. As you care for patients and provide the best support, please look after yourselves. It?s difficult worldwide to provide holistic, culturally competent care. Thank you for all you do and for learning?it shows you want to learn and support. I really appreciate you joining. Thank you for listening. Helping current and future clinicians focus, learn, retain, and thrive. Learn more.