Towards a holistic and improved clinical management of menopause

As life expectancy increases, women may spend a significant number of years that can amount to almost a third of their life in the post-menopausal lifestage.¹ Menopause represents a unique stage in a woman’s lifetime, wherein menstrual cycles cease and women experience vasomotor, genitourinary and neurocognitive changes that can impact their quality of life due to the sudden loss of estrogens.² While all women go through menopause, the experience is unique to every individual—often affected by comorbidities, socio-economic factors and cultural beliefs—making its diagnosis and treatment complex.¹ Menopause remains a sensitive topic, often resulting in healthcare providers being unable to manage symptoms and offer efficacious treatment. Therefore, there remains an urgent need to improve the clinical management of menopause globally. There is also a paucity in research on Asian women’s health that needs to be addressed, as large population health studies tend to focus on Caucasians only.

In this issue of the Annals, Aggarwal et al.³ present a timely and well-curated piece that aims to elucidate the lived experiences of Asian women experiencing menopause, their symptoms and awareness of treatment options, to improve the knowledge resolution of menopause towards optimised clinical management and policy changes. This will form an illuminating piece of work for all healthcare providers dedicated to care for midlife women, especially in the Asian population.

The authors performed a carefully conducted qualitative study, the Menopause and Ageing Research in International Environments – work package 2A (MARIE WP2A) in Singapore and analysed data from 18 women at various stages of perimenopause, menopause and post-menopause using the consolidated criteria for reporting qualitative research criteria. Data from the semi-structured interviews and video conferences were analysed using the Delanerolle and Phiri framework incorporating the interrelated biological, psychological, sociocultural and health system domains. The findings are highly interesting and reveal a diverse range of menopausal symptoms across participants, with significant variations in comorbidities.

Cross-cutting themes across the domains were eloquently described, thus forming a strategic base and framework to integrate the various domains into actionable themes for future management and implementation. For example, within the biological domain, vasomotor/sleep disturbances, musculoskeletal/bone health, genitourinary/sexual health and metabolic/endocrine disturbances of varying severity were reported among the participants. In addition, comorbidity interactions, such as Parkinson’s disease or cancer survivorship, were reported to influence menopause symptom severity and affected clinical management for the participants. Mood disturbances and cognitive change were frequently reported by the participants with coping mechanisms ranging from meditation, note-taking to emotional withdrawal within the psychological domain, with the authors sharing that participants who are healthcare professionals also tended to delay seeking menopause care owing to reasons such as time and occupational concerns. Participants also described both extremes of changes in family dynamics. Some participants described reduced intimacy with partners, while others described increased emotional support and accommodation within the sociocultural domain. Varying peer support and workplace cultures also shaped the participants’ differing experiences in this domain. Despite this dichotomy, an underlying theme was the stigma and silence of open conversations on menopause, which highlights the strong undertow of traditional and cultural beliefs. Importantly, the authors did report that individual resilience was strengthened by support networks, either from family members or from having workplace flexibility.

Interestingly, the very participation in the study prompted recognition of symptoms and triggered the participants to seek care and symptom management. Thus, within the health system domain, participants commented that access to public and private sectors varied, with private sectors perceived as lacking menopause expertise while public healthcare systems were anticipated to be dismissive. In addition, the prescription of hormone replacement therapy and continuity of care was significantly lacking. These findings highlight the potential of the MARIE survey as a structured tool and entry point to menopause care. Ultimately, the authors recognised that the mediating factor that significantly affected symptom burden among the participants was resilience, in the form of healthcare knowledge, supportive networks and coping strategies.

Singapore provides a unique study setting as a high-income nation with a multi-ethnic population and an enhanced healthcare infrastructure for this pertinent study by Aggarwal et al. The real-world data and documented lived experiences of women in the midlife stage revealed a complex network of workplace inequities, healthcare access, sociocultural, psychological and individual factors that have affected their menopause experience. To address these gaps, improvements to clinical management, personalised healthcare, public awareness and policy changes tailored to the different ethnic and religious groups could represent a path towards inclusive and equitable menopause care in Singapore, Asia and beyond.

REFERENCES

1. Talaulikar V. Menopause transition: Physiology and symptoms. Best Pract Res Clin Obstet Gynaecol 2022;81:3-7. 
2. Deecher DC, Dorries K. Understanding the pathophysiology of vasomotor symptoms (hot flushes and night sweats) that occur in perimenopause, menopause, and postmenopause life stages. Arch Womens Ment Health 2007;10:247-57.
3. Aggarwal IM, Aiyappan R, Safdar F, et al.  Navigating menopause in Singapore: Sociocultural, clinical, and policy implications from a qualitative study (MARIE-Singapore). Ann Acad Med Singap 2026:56:5-16.