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Black women's perceptions of menopause and the use of HRT

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VOL: 103, ISSUE: 02, PAGE NO: 34

Juliet Ozuzu-Nwaiwu, MSc, BEd, RGN, is staff nurse/part-time lecturer, Bedford PCT


This study was undertaken due to the paucity of research on black and minority ethnic (BME) women in the UK. The aim was to provide a starting point for other research and increase healthcare professionals' awareness of how BME women make decisions on and manage menopausal symptoms.

The sample consisted of 22 BME women aged 45-61 years from a range of minority ethnic groups in Northampton. Data was collected by semi-structured interviews that included the following questions:

- What do you understand by menopause?

- Do you experience any symptoms?

- How do you manage your symptoms?

- Do you use HRT or intend to use it?

- What are your views regarding HRT?

- Do you use any other alternative or coping methods to manage the symptoms?

- Did your mother experience symptoms?

Common symptoms were hot flushes, night sweats, headaches, high blood pressure, tiredness, irritability and forgetfulness.

Meaning and understanding of menopause
Only four participants clearly understood the term 'menopause', although seven partially understood it, for example referring to it as old age or no longer being able to bear children, while another seven described the process in terms of the symptoms they experienced. The remaining four women did not understand the term.

Symptom management
The participants managed their symptoms in a range of ways. Some used more than one method, particularly those who used 'alternative' methods such as evening primrose, cod liver oil and black cohosh (a plant-derived natural remedy).

These women also tended to use coping methods such as eating healthy diets, exercising, wearing light clothing, having cold showers or drinks and opening doors or windows during hot flushes. One felt that making others laugh helped her to deal with depression.

Only one participant was taking HRT at the time of interview, while six had done so in the past. The participant taking HRT described it as the best thing that had ever happened to her and encouraged other women to consider it.

The eight using no management methods felt their symptoms were not severe enough, believed that HRT would encourage the return of menstruation or cause cancer, preferred using alternatives or felt they could cope without it.

Deciding to use HRT
The participants who had used HRT in the past did so because their symptoms became difficult to manage. It was not always clear how they came to conclude that HRT was best suited for them, although it appeared that they were not given full information on the use of HRT before it was prescribed. The women also said that no alternative treatment was suggested to them before HRT was prescribed.

How they received information
Most of the women obtained information on the menopause and HRT from friends, colleagues and relatives, media, books, the internet and their doctors. Those who reported receiving their information from their doctors, however, said their GP surgeries had information leaflets on menopause and the use of HRT but none on alternatives to HRT. Three of the women had made no attempt to obtain information but it was not clear why.

Doctors' attitudes
The six women who had used HRT in the past said they had done so because their doctors wanted them to and that they felt they had no choice. There was a general feeling that women did not receive adequate information from their GPs and would prefer GPs from their own ethnic group.

Experiencing parental symptoms
Eight women did not witness their mother go through the menopause and most of these said the subject was never discussed. Seven women were unsure if they had witnessed their mother experience the menopause while the remaining seven had witnessed it. Of these, it appeared that the women whose mothers did not use anything for their symptoms did not tend to use anything either.

There was a range of reasons why women did not opt for HRT. Some felt their symptoms were not severe enough to justify it or that they could overcome them through willpower. Cancer scares had deterred some, while others did not want to interfere with a natural process.

Some participants believed that HRT involved taking tablets daily, showing a lack of understanding that HRT can be used in different ways, such as patches and creams. The only participant taking HRT at the time of the study felt positive about it and claimed that she could not manage without it.

Two participants believed that God would heal their symptoms. This appears to be consistent with studies by Nixon et al (2001), who found that African American women managed their symptoms through the use of prayer, and Holland and Hogg (2001), who stated that people of African and Caribbean origin perceived illness to be caused by or treated with a supernatural force.

The information available to participants had often been insufficient to enable them to make informed decisions about HRT and most of that available was not properly geared towards BME women. Their GPs did not take time to explain the risks and benefits associated with HRT. It also appeared that their doctors did not understand all the symptoms that could present in BME women. Some of the women said their doctors misinterpreted their symptoms and made incorrect diagnoses, while some felt their doctors prescribed HRT without explaining what they were being given or why.

Although some women understood the meaning of menopause, most did not understand the health implications of some of the symptoms. Some chose to ignore them due to other social factors happening at the same time as their menopause - such as family commitments and changes, and financial issues - which were competing with menopause in their lives.

Most of the women in this small study sample did not choose HRT to treat their symptoms. They generally adopted a rather positive attitude towards menopause and ignored their symptoms or used natural and coping methods to manage them.

- Some healthcare professionals may assume the health needs of BME women can be met in the same way as those of white women. However, this fails to take account of social and cultural diversity issues.

- The King's Fund (2006) states that a major issue affecting BME groups in the UK is access to healthcare itself. An NHS Patient Survey on GP services (DH, 2002) also found that BME patients reported more negative experiences than other patients, including in their ability to book GP appointments.

- One of the benefits of HRT is the prevention of cardiovascular disease (Paoletti and Wenger, 2002), while the Women's Health Initiative (2002) study showed a high rate of cardiovascular disease among African American women.

- The most widely known risk associated with HRT is the development of breast cancer. However, research also suggests that short-term use tends to be safer.

- Nixon et al (2001) found that BME women have used strategies other than HRT to manage symptoms, such as prayer and alternative medicines. They also found that rural African American women rely on willpower to overcome their symptoms, only visiting doctors as a last resort.

- The WHI (2002) study highlighted several issues regarding HRT and BME women, including higher incidence of chronic disorders such as cardiovascular diseases and cancers during and after menopause.

- Healthcare professionals should understand that BME women have different methods of managing and coping with menopausal symptoms and do not necessarily want HRT as their first line of treatment. They should be assessed adequately before being prescribed HRT, as there could be other underlying factors.

- This study should be replicated with a larger sample and should be conducted in two localities so that comparisons can be made to inform practice.

- Healthcare professionals must be aware of the cultural, social and economic differences that affect the experience and management of symptoms among BME women.

- Proper communication systems should be put in place to ensure that all women receive information about the risks and benefits of HRT and the health problems women may experience during the menopause. The information should be appropriately delivered to enable women to make informed decisions and take control of their lives.

This article has been double-blind peer-reviewed.

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