Damian Sendler: Hispanic women (Latinas) make up 17% of women in the 45–54 age bracket, making Latinos the fastest-growing minority in the United States. Women’s disease risk can be affected by a variety of changes brought on by the menopause transition (MT). Many studies have improved our understanding of the menopause, but so far, most research has focused on white non-Latina women. As a result, there is a paucity of knowledge about how Latinas can manage menopause-related issues and important factors to take into account when providing culturally appropriate care and promoting lifestyles that may reduce negative health consequences. Menopausal symptoms, mental health, cognition, and cardiometabolic health are all addressed in this narrative review of the MT in Latinas. The clinical and research implications of the current literature will also be discussed..
Damian Jacob Sendler: In the United States (U.S.), 17% of women aged 45–54 identified as Latina in 2019 [1]. Among Latinas in the United States, the average age of natural menopause is approximately 51 years, which does not differ from non-Latina White women [2]. However, only 450 Latinas were included in this study. As the fastest-growing minority group in the United States, Latino women are more likely to be transitioning into menopause. Hispanic/Latino refers to a person of Cuban, Mexican, Puerto Rican, South or Central American origin, regardless of race, according to the U.S. Census [1]. [2] There is a wide range of sociocultural and historical experiences that Latinas have had, such as their nationality, racial identity, language and immigration history, as well as their religious and cultural beliefs, education, and acculturation levels. In many ways, Latinas in the United States seem to be at a disadvantage, as evidenced by the fact that they have lower levels of education and English proficiency than whites generally, live below the federal poverty line, lack health insurance, and are subject to social exclusion and discrimination [3, 4].
Dr. Sendler: In women, the MT is associated with a wide range of physiological, behavioral, and psychosocial changes. Depression symptoms [6, 7], sleep issues [7, 8], fat accumulation in the body [8], and vascular remodeling [9] have all been linked to the MT. Many studies have improved our understanding of the menopause, but so far, most research has focused on white non-Latina women. Data on midlife Latinas and menopause (Table 1) were the subject of five epidemiologic studies [10, 11, 12, 13, 14, 15] conducted across the United States. Three of the investigations collected longitudinal data [10, 12, 13], while the other two examined cross-sectional data [11, 14]. Among the longest-running cohorts of midlife women, the Seattle Midlife Women’s Health Study (SMWHS) and the Study of Women’s Health Across the Nation (SWAN) [10, 12] include Latina participants. However, only 10% of participants in these epidemiological studies were Latinas (Table 1). SWAN has the largest long-term Latina sample (n=286) (Table 1). We aim to critically evaluate and summarize evidence of the MT in US Latinas, with an emphasis on hormonal changes and menopause symptoms as well as mental and cognitive health. Due to the small number of Latinas in current epidemiological research in the United States, this narrative review also includes evidence from ancillary studies and qualitative studies with Latinas in their midlife to capture everything that is known about Latinas during the MT. There is also discussion of the clinical and research implications of the reviewed findings.
Non-Latina White women’s FSH and estradiol levels don’t differ significantly from those of Latinas across the MT [15, 16]. Findings from SWAN [18] show that Latina women are more likely to experience an increase in FSH during the menopause compared to women of other ethnicities. After menopause, women with a higher rise in FSH have a higher risk of developing atherosclerosis [19]. Only a small number of studies have found that Latinas have lower testosterone levels at midlife, but there are no differences in estradiol or FSH levels [20]. Visceral fat has been linked to higher levels of testosterone in women in their mid-life [8]. During the MT, Latinas were more likely to have an elevated risk of free sperm hormone (FSH), which has been linked to increased intima-media thickness in the carotid arteries [19, 21]. In light of these findings, it is possible that racial/ethnic differences in hormone concentrations are to blame for the increased risk of atherosclerosis in Latinas after menopause. The importance of these sex hormone trajectories in midlife Latinas could be highlighted by additional studies with a larger sample size.
In Latinas, menopausal symptoms are the primary indicator of the menopause transition. Latinas are more likely to suffer from VMS than non-Latina White women when socioeconomic and psychosocial factors are taken into account [22, 23]. Moreover, Latinas are more likely to suffer from depressive symptoms and to engage in risky health behaviors than other racial/ethnic groups. Depressive symptoms have been linked to lower sexual function among Latinas, but we only found two studies focusing on sexual health in midlife Latinas [25]. Middle-aged Latinas have higher rates of metabolic syndrome, a worse CVD risk profile, and less carotid plaque burden than their white counterparts in terms of cardiometabolic health [26, 27, 28].
A complex interplay of various biological, psychosocial, environmental, and behavioral factors may be at play in the underlying physiology of VMS. It has been found that VMS is associated with a variety of negative outcomes, such as sleep disturbances, depressed mood, and indicators of poor cardiovascular health [31–34]. [30] According to SWAN, current smoking and depressive symptoms were more strongly linked to VMS in Latinas compared to other racial/ethnic groups. VMS was inversely related to the level of social support reported by Latinas in their midlife years [23]. Latina women’s menopause symptoms were alleviated when they had the support of their families [35].
There is a wide variation in the percentage of Latinas reporting any VMS during the MT based on national origin, cultural contexts, and acculturation. While 72% of Central American women reported any VMS in the previous two weeks, only 34% of Cuban-American women of similar age and menopausal status reported any VMS in a baseline SWAN assessment [36].[37] Women of Cuban ancestry had higher levels of education and cultural acculturation, according to this study.
Short sleep duration, difficulty falling asleep or staying awake, and poor sleep quality are all symptoms of sleep disturbance in middle age. For premenopausal Latinas, the age-adjusted prevalence of difficulty sleeping is 30 percent, while for naturally postmenopausal Latinas, the prevalence is 50 percent[7]. This association remained even after adjusting for factors such as age, level of education, household income, smoking status, alcohol consumption, and a history of depression, as found in the Sister Study (Table 2), a prospective cohort of women aged 35–74 years who had a sister with breast cancer [38]. Latinas were less likely to report difficulty staying asleep and early morning awakenings during the MT when compared to other racial/ethnic groups, according to SWAN researchers. The Sister Study [35] found that Latinas were more likely than non-Latina White women to suffer from inconsistent sleep patterns, sleep debt, and both short sleep and insomnia symptoms (Table 3). Different sleep measures and differences among Latino subgroups may be to blame for these contradictory findings. When it comes to sleep disturbances, Puerto Rican and Dominican women in the United States report higher rates than other Latinas in the SWAN Hispanic cohort [33].
Damian Sendler
Non-Latina White women reported fewer changes in mood and less energy during the MT compared to Latinas. Regardless of menopause stage, longitudinal analyses in SWAN using the Center for Epidemiological Studies of Depression (CES-D) scale showed that Latinas were over twice as likely as non-Latina White women to experience higher depressive symptoms (CES-D 16) [45]. Depressive symptom trajectories have been identified by SWAN researchers, who found that Latinas were more likely to follow the “high” symptom trajectory than the other four trajectories (very low, low, increasing, and decreasing). In other words, Latinas, regardless of age or menopause status, were more likely to maintain high levels of depressive symptoms in midlife.
Damian Jacob Markiewicz Sendler: Moodiness and anxiety during the MT have been linked to higher levels of VMS, sleep disruption, and stress all over the world [32]. Among Latinas in the United States, SWAN found that depressive symptoms were linked to a higher likelihood of reporting frequent VMS [23]. Depressive symptoms have also been linked to a longer duration of VMS in women, but this was not examined in terms of race/ethnicity. Depressive symptoms were more strongly linked to an increase in sleep problems during the MT among Latinas [6], but whether these differences are due to psychosocial sociocultural factors like acculturation stress has not been established. Other studies have looked into whether certain social roles have an effect on one’s state of mind. No matter how stressful the roles may be, SWAN analyses show that being “employed” or a “mother” reduces depressive and anxiety symptoms. Familism (e.g., prioritizing family over self) is one culturally influenced coping resource that may help alleviate depression and stress [47]. Future studies should focus on the interplay between VMS, sleep, and mood in middle-aged Latinas, especially the role of coping mechanisms in reducing negative health outcomes.
There is a lack of research on cognitive performance in middle-aged Latinas, despite recent evidence showing that older Latinas (age >64 years) are more likely to develop cognitive impairment and dementia than non-Latina White women. 60% of women report cognitive changes such as forgetfulness or concentration difficulties during the MT [49]. Cross-sectional studies have found no difference in cognitive performance across menopause stages, but longitudinal studies have found lower cognitive function among perimenopausal women. Small sample sizes and short follow-up periods hampered these studies. Due to their small sample size (n=21), Latinas were excluded from a longitudinal analysis that found significant declines in processing speed and verbal memory during perimenopause [53]. Although the Cognitive Symptom Index for Midlife Women does not specifically measure cognitive function, a study found that Latinas reported lower total number and severity of cognitive symptoms [54]. To better understand any racial/ethnic differences and the factors that contribute to cognitive decline, more research on Latinas in their midlife is needed. Latinas are at an increased risk for cognitive impairment and dementia, so an understanding of cognitive function during the MT could help develop early interventions to slow cognitive decline in Latinas.
Damien Sendler: As menopause progresses, evidence suggests that sexual function declines [24]. In general, 14 percent of women between the ages of 45 and 64 reported experiencing at least one distressing sexual problem (eg., low desire, low arousal, low orgasm) [55]. Latinas and non-Latina White postmenopausal women both reported a decreased libido of 40 percent, but there was no difference in this percentage between the two groups. Latinas, on the other hand, reported lower rates of arousal than non-Latina White, African American, Chinese or Japanese women at midlife in the SWAN survey [56]. Depression and sleep problems, which are more common in midlife women, may contribute to reports of sexual dysfunction during the MT, according to research [25]. Vaginal dryness and dyspareunia, which may worsen with time after the final menstrual period, are also linked to sexual health outcomes [57]. Latinas are more likely than non-Latina White women to complain about vaginal dryness, urine leakage, and bladder problems [30]. Studies on sexual health in this review excluded or lacked data on hormone therapy among Latinas [25], which is an important point to remember. Relationship factors (such as the availability and quality of a sexual partner) and mood have been shown time and time again to have a greater impact on midlife women’s sexual function than hormones.
Damian Jacob Sendler
Cardiovascular disease (CVD) is still the leading cause of death in women around the world [58]. A number of factors, including lower socioeconomic status, discrimination, and stress, have been linked to Latinas’ higher risk of cardiovascular disease (CVD) than non-Latina White women [26, 59]. Inflammatory and neuroendocrine pathways may play a role in CVD risk [62, 63] as well as through their influence on health behavior. A phenomenon known as the “Hispanic paradox” has been observed in Latinas despite having a significantly worse CVD risk factor profile than non-Latina White women. There is no “Hispanic paradox” when it comes to the prevalence of coronary heart disease in Latinas (6.1 percent) compared to non-Latina White (5.3 percent) and non-Latina Black (5.7 percent) women [66]. Women’s perimenopause is a critical time to examine because of the rise in blood pressure, lipid abnormalities, and blood sugar that occur [67]. Perimenopausal Latinas are still underrepresented in CVD research despite their higher risk.
Midlife is a high-risk period for cardiovascular disease [68]. Midlife Latinas are more likely to have abdominal obesity and a higher BMI than non-Latina White women, according to a number of studies. More than half of Latinas over the age of 50 are prehypertensive, according to a previous cross-sectional study [70]. Latina and non-Latina Black women had the lowest rate of control of hypertension (140 mmHg/ 90 mmHg) among women treated for the condition. At the time of diagnosis of hypertension, Latina women had higher mean blood pressure than non-Latina White, Chinese, or Japanese women [71]. According to the current literature review, many studies defined hypertension according to the Joint National Committee’s Seventh Report; thus, it is possible that rates of elevated blood pressure are even higher if current guidelines are used. Perimenopausal Latinas had the highest levels of LDL-C and the lowest levels of HDL-C at the beginning of the SWAN study [70]. Women from the Dominican Republic and Central America had higher HDL-C than Puerto Rican women, while Cuban women had lower LDL-C [70]. During the MT, HDL subclasses may have different effects on the vascular system [73]. In addition, the triglyceride levels of midlife Latinas are significantly higher than those of non-Latina White women. There are, however, only a few studies looking at the relationship between HDL-C particle changes and cardiovascular risk in Latinas in their mid-life.
For Latinas aged 45–64, metabolic syndrome is more prevalent than for those aged 18–44 and 43–44, respectively, according to data from the Hispanic Community Health Study/Study of Latinos (HCHS/SLS). [74] The incidence of metabolic syndrome in Latinas is higher than in non-Latina White women, according to a recent SWAN study that found that 6% of participants met all five clinical components of metabolic syndrome. Latinas were nearly twice as likely to develop metabolic syndrome during the MT as non-Latina White women, with obesity/hypertension/low fasting HDL-C as a most common constellation of incident metabolic syndrome. Latinas with a higher level of religiosity progress to metabolic syndrome at a lower rate than non-Latina women, despite having lower levels of education, higher levels of stress, and a worse CVD risk profile. Identifying early risk and protective factors of cardiovascular disease (CVD) in perimenopausal Latinas is critical, according to these findings.
Intima-media thickness, arterial plaque, and coronary artery calcification have been shown to independently predict future cardiovascular events [76]. Subclinical cardiovascular disease (CVD) in Latinas is understudied, despite evidence that perimenopausal Latinas have a higher CVD risk factor burden [26]. Carotid intima-media thickness did not differ significantly between Latinas and non-Latina White women during the MT, according to a recent SWAN study. Nevertheless, Latinas had a lower prevalence of plaque [28]. After adjusting for sociodemographic and atherosclerotic risk factors, the Northern Manhattan Study found that Latinos had significantly less carotid atherosclerosis than non-Latina Black and non-Latina White participants [77]. Subclinical CVD has been linked to a variety of racial/ethnic differences in CVD risk factors, according to these studies.
Several markers of subclinical cardiovascular disease and menopause have been linked. Women who reported VMS early in the MT or who reported consistently high levels of VMS had greater carotid intima-media thickness than women with consistently low VMS, according to SWAN researchers [21]. Additionally, women with a high rise in FSH had a larger intima-media thickness than women with a lower rise in FSH [19]. Latinas had a higher percentage of VMS and a higher rise in FSH, but whether these associations differed by race/ethnicity was not investigated, possibly due to the small number of Latinas in the study. Research on the link between menopause and cardiovascular disease (CVD) shows that historically underrepresented groups, such as Latinas, need more representation in cohort studies.
In terms of nationality, immigration, religion, cultural beliefs, education, and acculturation, Latinas are a diverse group. Latinas’ health and way of life are directly impacted by these factors. As a result, when studying Latinas in their forties and fifties, researchers must take sociological frameworks into account. This could be a contributing factor to the disparities in health outcomes observed in the MT. Latinas, particularly those with lower socioeconomic status and less social support, are more likely to suffer adverse changes in multiple health indicators during the MT, according to the results of a recent study A number of resiliency factors, such as religiousness, social support, and favorable attitudes toward the MT, have been identified [35, 75]. For example, identifying risk and resilience factors in this population may shed light on the mechanisms by which the MT affects disease development and the potential targets for health promotion and disease prevention in midlife Latinas. For Latinas, the midlife period is an ideal time to implement healthy behaviors that can delay or even prevent poor health outcomes in later life, but there is a need to examine these outcomes across a wide range of ethnic and socioeconomic backgrounds.
