The first thing I want to say about menopause is that it is not a disease. It is a natural biological transition — the permanent end of menstruation, occurring on average at 51 in the UK — that every woman with a uterus will experience if she lives long enough.
The second thing I want to say is that for many women, it is genuinely difficult. Not because they are weak or unable to cope, but because the hormonal changes involved — and specifically the decline in oestrogen — can produce symptoms that are severe, disruptive, and lasting. And because the cultural silence around menopause in many African communities means that women navigate this transition without information, without the language to describe their experience, and often without support.
The third thing I want to say is that effective treatment exists. The WHI study of 2002 — which frightened millions of women and their doctors away from Hormone Replacement Therapy — has since been substantially reanalysed and largely corrected. For most women, HRT is safe, effective, and significantly improves quality of life during menopause. The fear of HRT that persists in many communities is largely based on outdated information.
How menopause differs in Black and African women
Research consistently shows differences in the menopausal experience for Black women:
Earlier onset: Black women experience natural menopause approximately 2 years earlier on average than white women.
More severe vasomotor symptoms: Hot flushes and night sweats (vasomotor symptoms) are more frequent and more severe in Black women than white women. The Study of Women's Health Across the Nation (SWAN) — a landmark longitudinal study that specifically included a substantial Black participant cohort — documented this clearly.
Longer duration of symptoms: Vasomotor symptoms persist for longer — an average of 10 years in Black women compared to 6.5 years in white women.
Less HRT use: Despite experiencing more severe symptoms, Black women are significantly less likely to be prescribed or use HRT. This appears to reflect a combination of healthcare provider assumptions, cultural attitudes, and under-presentation.
More cardiovascular risk at menopause: The oestrogen decline at menopause increases cardiovascular risk for all women. For Black women who already have higher baseline hypertension and cardiovascular risk, this transition is particularly significant from a cardiac health perspective.
The WHI study — what actually happened
In 2002, a large US study called the Women's Health Initiative (WHI) published results suggesting that HRT increased the risk of breast cancer, heart disease, stroke, and blood clots. The media coverage was dramatic. HRT prescriptions fell by 50–60% almost overnight. Many women stopped HRT abruptly. Many doctors became reluctant to prescribe it.
What subsequent analysis revealed:
The WHI study used conjugated equine oestrogen plus medroxyprogesterone acetate — an older, synthetic form of HRT — in women who were on average 63 years old (many years past menopause) and who had pre-existing cardiovascular risk. This is not the same population as women in early perimenopause using modern HRT.
For women who:
- Start HRT within 10 years of menopause (the "timing hypothesis" or "window of opportunity")
- Are under 60 or within 10 years of their last period
- Use modern transdermal oestrogen (patch, gel, spray)
- Use micronised progesterone (Utrogestan) rather than synthetic progestogen
The risk profile is fundamentally different. Transdermal oestrogen does not carry the blood clot risk of oral oestrogen. Micronised progesterone has significantly lower breast cancer association than synthetic progestins.
The current position of the British Menopause Society, NICE, and most major menopause organisations worldwide: for most women under 60 without specific contraindications, the benefits of HRT outweigh the risks.
Case study: Veronica's dismissal at 47
Veronica, 47, came to see me after her previous GP had told her she was "too young for menopause." She had been experiencing irregular periods for 18 months, hot flushes up to 12 times per day including at night, significant sleep disruption, and what she described as "brain fog" — difficulty concentrating that was affecting her work as a project manager.
She had also developed anxiety that was new for her, mood swings she found distressing and out of character, and joint aches. She had gained weight she found difficult to explain.
She had mentioned these symptoms twice to her previous GP and had been prescribed antidepressants. She did not feel depressed — she felt hormonal.
When she came to me, I checked her FSH (follicle-stimulating hormone) and oestradiol levels — both consistent with perimenopause at her age. I discussed HRT.
She started a transdermal oestrogen gel and micronised progesterone (Utrogestan). Eight weeks later: hot flushes reduced from 12 to 2 per day. Sleep improved significantly. Brain fog largely resolved.
"I feel like myself again," she said. "I just needed someone to take me seriously."
Her symptoms had been present for 18 months before she received appropriate treatment.
Symptoms — the full picture
Menopause and perimenopause cause far more than hot flushes:
Vasomotor: Hot flushes, night sweats, palpitations Sleep: Insomnia, often secondary to night sweats but also independent Genitourinary: Vaginal dryness, discomfort during sex, urinary urgency, recurrent UTIs — this is called the Genitourinary Syndrome of Menopause (GSM) and is chronically underreported and undertreated Psychological: Anxiety (often new or worsened), low mood, irritability, poor concentration, memory difficulties Physical: Joint aches, weight gain (particularly central), reduced muscle mass, hair thinning, skin changes Sexual: Reduced libido, reduced arousal, pain during sex
Many women do not connect these symptoms to menopause — particularly the psychological symptoms, which may be their primary presentation.
Treatment options
HRT: Most effective treatment for vasomotor symptoms, sleep disturbance, mood, brain fog, and GSM. Types:
Oestrogen: Available as gel (Oestrogel, Sandrena), patches (Evorel, Estradot), spray (Lenzetto). Transdermal is preferred over oral due to lower VTE (blood clot) risk.
Progesterone (for women with a uterus): Micronised progesterone (Utrogestan) is the preferred form — lower breast cancer risk than synthetic progestins. Taken cyclically in perimenopause, continuously post-menopause.
Testosterone: Not yet licensed for women in the UK but widely used off-label for low libido and energy. Increasingly prescribed by menopause specialists.
Non-hormonal options (for women who cannot use HRT): Certain antidepressants (venlafaxine, paroxetine) reduce hot flushes. Clonidine. Fezolinetant (Veoza) — a new non-hormonal option specifically for vasomotor symptoms approved in the UK in 2024.
Vaginal oestrogen: For GSM (vaginal dryness, urinary symptoms) — local vaginal oestrogen (Vagifem, Estring, Ovestin) delivers oestrogen directly to the vaginal tissue with minimal systemic absorption. Safe even for most women with breast cancer history. Should be used indefinitely — symptoms return when stopped.
Sources: Avis NE et al, JAMA Internal Medicine 2015 (SWAN study — racial differences in menopausal symptoms); NICE Clinical Guideline NG23 — Menopause: Diagnosis and Management (2015, updated 2023); Rossouw JE et al, JAMA 2002 (WHI study); Manson JE et al, NEJM 2013 (WHI reanalysis); British Menopause Society — HRT and Breast Cancer Risk 2022; Hamoda H et al, Menopause 2023.