Disparities in Menopausal Care in the United States: A Systematic Review

Abstract

Effective menopausal care constitutes a continuum of symptom management and optimization of medical health, including cardiovascular, bone, and mental health. Menopausal knowledge and prescribing patterns changed significantly after the publication of the Women’s Health Initiative. A systematic review was conducted to address three key questions about disparities in menopausal care: What are: 1) Differences in menopausal care experienced by specific populations; 2) Disparities in access to preventive care and symptomatic treatment; and 3) Interventions to address disparities in menopause management. Pubmed, PsychInfo, SCOPUS, and EMBASE were queried to identify relevant articles published in the United States between 2002 to 2023. Twenty-eight articles met criteria and included quantitative and qualitative analyses. Symptomatic menopausal patients utilize a range of therapies. Racial and ethnic minorities, veterans, women living with HIV, incarcerated individuals, patients with surgical menopause, and nursing home residents represent specifically studied populations that demonstrate differences in menopausal care. Healthcare professionals may impact access to certain therapeutics, possibly driven by lack of content knowledge or implicit bias. Insurance status and geographic location may also affect menopause management or access to care. Few interventions exist to address disparities in menopausal care. There is an urgent need to understand how patients and providers make menopausal treatment decisions and intervene to mitigate health disparities in menopausal care.

Introduction:

Although disparities in the prevalence and experience of symptoms have been demonstrated across medical comorbidities [1–3], cultural beliefs, [4–5] and psychosocial factors, [6] there is relatively little research on disparities in menopausal care. Following the publication of the Women’s Health Initiative (WHI) in 2002, hormone therapy (HT) prescriptions, the most effective treatment for vasomotor symptoms, precipitously declined by 25-72%. [7] Despite subsequent analyses clarifying safety, the initial reporting continues to provoke fear and has become enmeshed in many patients’ beliefs and provider practice, leading to a significant undertreatment of symptoms for midlife and postmenopausal individuals.

A comprehensive summary and synthesis of the literature on equity in menopausal care is warranted. For example, studies prior to 2002 describe disparities based on the social constructs of race and ethnicity, with Black patients reporting lower use of HT compared to White counterparts despite a higher prevalence and severity of symptoms. [8–9] More recent work reaffirm or demonstrate a greater disparity in menopausal care since the WHI. This review addresses three key questions: What is known about: 1) differences in menopausal management among specific populations; 2) disparities in access to preventive services and symptomatic treatment; and 3) interventions to reduce disparities in menopause management.

2. Methods

2.1. Protocol and registration

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to complete this systematic review. [10] We did not register a protocol.

2.2. Eligibility Criteria

Included studies: 1) described a population experiencing or who had experienced menopause; 2) discussed treatment for menopausal symptoms; 3) mentioned disparities in access to care; were 4) set in the United States; 5) published in English language; and 6) published since 2002 with data sets also in this time frame. Menopausal symptoms included vasomotor symptoms, mood and sleep disorders, genitourinary syndrome of menopause, and preventive care such as bone and cardiovascular health. Treatment encompassed referrals to specialists or symptom-specific healthcare visits and non-pharmacologic and pharmacologic therapies.

2.3. Information Sources and Search Strategy

Studies published from 2002 to October 2023 were identified through a search of the following databases: PubMed (https://pubmed.ncbi.nlm.nih.gov/), CINAHL Plus with Full Text (EBSCOhost), APA PsycInfo (EBSCOhost), and Scopus (Elsevier). The complete, reproducible search strategy is included in the supplementary material. The search strategy generated some interventions that focus on reducing disparities in care but was not a comprehensive search of all interventions in menopause knowledge or management.

2.4. Data Extraction and Analysis

Two researchers independently screened 151 abstracts to obtain consensus and then the remaining were reviewed. Full text screening and data abstraction was performed with any conflicts resolved by a third researcher. Extracted data included aim of study, study design and timeframe, menopause symptoms and disparities addressed, population description, and total number of participants. Risk of bias was not assessed due to including many qualitative or non-clinical trial articles, and instead the study methodology is reported in the summaries. [11]

3. Results

The search yielded 2,220 references total and 28 for inclusion (Figure 1). Table 1 outlines the articles addressing each key question. Studies included randomized controlled trials, cross-sectional studies, cohort studies, quality improvement research, and semi-structured interviews.

Figure 1:

PRISMA flow diagram for included studies

Table 1:

PubMed Search Strategy

Set #
1	“Menopause”[Mesh:NoExp] OR “Menopause, Premature”[Mesh] OR ”Perimenopause”[Mesh] OR “Postmenopause”[Mesh] OR menopause[tiab] OR menopausal[tiab] OR perimenopause[tiab] OR perimenopausal[tiab] OR peri-menopause[tiab] OR peri-menopausal[tiab] OR postmenopausal[tiab] OR post-menopausal[tiab]
2	“Signs and Symptoms”[Mesh] OR “Syndrome”[Mesh] OR “Hot Flashes”[Mesh] OR “Mood Disorders”[Mesh] OR “Preventive Medicine”[Mesh] OR “Bone Density”[Mesh] OR signs[tiab] OR symptoms[tiab] OR symptom[tiab] OR symptomatic[tiab] OR syndrome[tiab] OR syndromes[tiab] OR “hot flashes”[tiab] OR “hot flash”[tiab] OR “hot flushes”[tiab] OR “hot flush”[tiab] OR mood[tiab] OR depression[tiab] OR depressive[tiab] OR affective[tiab] OR preventive[tiab] OR prevent[tiab] OR prevented[tiab] OR prevents[tiab] OR preventing[tiab] OR “bone density”[tiab] OR “bone densities”[tiab] OR “bone mineral density”[tiab] OR “bone mineral densities”[tiab] OR “bone health”[tiab] OR “vasomotor symptom”[tiab] OR “vasomotor symptoms”[tiab] OR “night sweat”[tiab] OR “night sweats”[tiab]
3	“Health Services Accessibility”[Mesh] OR “access treatment”[tiab:~4] OR “access treatments”[tiab:~4] OR “access therapies”[tiab:~4] OR “access therapy”[tiab:~4] OR “access services”[tiab:~4]
4	“Therapeutics”[Mesh] OR “therapy”[Subheading] OR “Pharmaceutical Services”[Mesh] OR “Referral and Consultation”[Mesh] OR “Women’s Health Services”[Mesh] OR therapeutic[tiab] OR therapeutics[tiab] OR therapy[tiab] OR therapies[tiab] OR treatment[tiab] OR treatments[tiab] OR treated[tiab] OR treats[tiab] OR treat[tiab] OR treating[tiab] OR management[tiab] OR medicine[tiab] OR medicines[tiab] OR medication[tiab] OR medications[tiab] OR drug[tiab] OR drugs[tiab] OR prescription[tiab] OR prescriptions[tiab] OR pharmacotherapy[tiab] OR pharmacotherapies[tiab] OR pharmaceutical[tiab] OR pharmaceuticals[tiab] OR non-pharmaceutical[tiab] OR nonpharmaceutical[tiab] OR pharmacological[tiab] OR non-pharmacological[tiab] OR nonpharmacological[tiab] OR referral[tiab] OR referrals[tiab] OR refer[tiab] OR refers[tiab] OR referred[tiab] OR referring[tiab] OR “health service”[tiab] OR “health services”[tiab]
5	“Practice Patterns, Physicians’”[Mesh] OR “Health Status Disparities”[Mesh] OR “Social Determinants of Health”[Mesh] OR “Socioeconomic Factors”[Mesh] OR “Socioeconomic Disparities in Health”[Mesh] OR “Healthcare Disparities”[Mesh] OR “Health Equity”[Mesh] OR “Race Factors”[Mesh] OR “Racial Groups”[Mesh] OR “Antiracism”[Mesh] OR Racism[mesh] OR “Bias, Implicit”[Mesh] OR “Ethnicity”[Mesh] OR “Culture”[Mesh] OR “Cross-Cultural Comparison”[Mesh] OR “HIV”[Mesh] OR “Substance-Related Disorders”[Mesh] OR “Minority Groups”[Mesh] OR “Sexual and Gender Minorities”[Mesh] OR “Health Services for Transgender Persons”[Mesh] OR “Medically Underserved Area”[Mesh] OR “Health Disparate, Minority and Vulnerable Populations”[Mesh] OR “Prisoners”[Mesh] OR “Correctional Facilities”[Mesh] OR “Ill-Housed Persons”[Mesh] OR “Insurance Coverage”[Mesh] OR “Medically Uninsured”[Mesh] OR “Poverty Areas”[Mesh] OR “Rural Health Services”[Mesh] OR “Rural Health”[Mesh] OR “Rural Population”[Mesh] OR “Urban Health Services”[Mesh] OR “Urban Health”[Mesh] OR “Urban Population”[Mesh] OR “Residence Characteristics”[Mesh] OR disparity[tiab] OR disparities[tiab] OR “health disparate”[tiab] OR equity[tiab] OR equities[tiab] OR equitable[tiab] OR inequity[tiab] OR inequities[tiab] OR inequitable[tiab] OR “social determinant”[tiab] OR “social determinants”[tiab] OR “structural determinant”[tiab] OR “structural determinants”[tiab] OR “structural barrier”[tiab] OR “structural barriers”[tiab] OR “health determinants”[tiab] OR “health determinant”[tiab] OR “determinants of health”[tiab] OR “determinant of health”[tiab] OR “structural factors”[tiab] OR “structural factor”[tiab] OR “social justice”[tiab] OR inclusive[tiab] OR socioeconomic[tiab] OR socioeconomics[tiab] OR poverty[tiab] OR “economic status”[tiab] OR “economic stability”[tiab] OR “economic instability”[tiab] OR “economic factor”[tiab] OR “economic factors”[tiab] OR “access care”[tiab:~4] OR “access healthcare”[tiab:~4] OR “race factors”[tiab:~4] OR “racial factors”[tiab:~4] OR “race factor”[tiab:~4] OR “racial factor”[tiab:~4] OR “implicit bias”[tiab] OR “implicit biases”[tiab] OR “hidden bias”[tiab] OR “hidden biases”[tiab] OR “unconscious bias”[tiab] OR “unconscious biases”[tiab] OR antiracism[tiab] OR anti-racism[tiab] OR antiracist[tiab] OR anti-racist[tiab] OR “racial justice”[tiab] OR “critical race”[tiab] OR racism[tiab] OR “racial prejudice”[tiab] OR “racial prejudices”[tiab] OR “racial bias”[tiab] OR “racial biases”[tiab] OR “racial discrimination”[tiab] OR ethnicity[tiab] OR ethnicities[tiab] OR ethnic[tiab] OR HIV[tiab] OR “Human immunodeficiency virus”[tiab] OR “substance use disorder”[tiab] OR “substance use disorders”[tiab] OR “substance-related disorder”[tiab] OR “substance-related disorders”[tiab] OR transgender[tiab] OR transgendered[tiab] OR “gender nonconforming”[tiab] OR minority[tiab] OR minorities[tiab] OR marginalized[tiab] OR underserved[tiab] OR “vulnerable population”[tiab] OR “vulnerable populations”[tiab] OR “insurance coverage”[tiab] OR “insurance status”[tiab] OR uninsured[tiab] OR underinsured[tiab] OR Medicaid[tiab] OR Medicare[tiab] OR incarceration[tiab] OR incarcerated[tiab] OR prisoner[tiab] OR prisoners[tiab] OR prison[tiab] OR prisons[tiab] OR “correctional facilities”[tiab] OR “correctional facility”[tiab] OR rural[tiab] OR urban[tiab] OR suburban[tiab] OR housing[tiab] OR homeless[tiab] OR homelessness[tiab] OR “ill housed”[tiab] OR ill-housed[tiab] OR unhoused[tiab]
6	#4 AND #5
7	#3 OR #5
8	#1 AND #2 AND #7
9	“United States”[Mesh] OR “State Government”[Mesh] OR “United States” OR US OR U.S. OR USA OR America OR American OR Americans OR Appalachia OR Appalachian OR “Great Lakes” OR “Mid Atlantic” OR Mid-Atlantic OR Midwest OR Midwestern OR “New England” OR Northwest OR Northwestern OR Pacific OR Southeast OR Southeastern OR Southwest OR Southwestern OR Alabama OR Alaska OR Arizona OR Arkansas OR California OR Colorado OR Connecticut OR Delaware OR “District of Columbia” OR Florida OR Georgia OR Hawaii OR Idaho OR Illinois OR Indiana OR Iowa OR Kansas OR Kentucky OR Louisiana OR Maine OR Maryland OR Massachusetts OR Michigan OR Minnesota OR Mississippi OR Missouri OR Montana OR Nebraska OR Nevada OR “New Hampshire” OR “New Jersey” OR “New Mexico” OR “New York” OR “North Carolina” OR “North Dakota” OR Ohio OR Oklahoma OR Oregon OR Pennsylvania OR “Rhode Island” OR “South Carolina” OR “South Dakota” OR Tennessee OR Texas OR Utah OR Vermont OR Virginia OR Washington OR “West Virginia” OR Wisconsin OR Wyoming
10	#8 AND #9
11	#10 AND English[lang]
12	#11 AND ((“2002”[Date - Publication] : “3000”[Date - Publication]))

3.1. Key Question 1:

What specific populations experience differences in menopause management?

Studies documenting differences focused on patient race and ethnicity (9 studies), veterans (3 studies), HIV status (2 studies), incarceration status (2 studies), individuals with surgical menopause (2 studies), and nursing home residents (1 study).

3.1.1. Race and ethnicity

In a web-based cross-sectional study of 548 midlife women by Doamekapor [12], racial and ethnic minority women were less likely to report high HT knowledge and were less likely to use HT than White women. Factors such as age and education status were associated with use but not stratified by race or ethnicity.

In a survey by Williams et al [13], more White (61%) women visited healthcare professionals for menopausal symptoms compared to Black, Hispanic, and non-Hispanic women (53%, 54%, and 57%, respectively) (p=0.017). Similarly, HT use was more frequent among White compared to all other races and ethnicities (p<0.001). Complementary and alternative medicine (CAM) use, most commonly reported as herbal supplements, diet, and exercise, did not differ by race or ethnicity.

Waetjean analyzed urinary incontinence symptoms among the Study of Women’s Health Across the Nation (SWAN), a multi-site longitudinal observational study designed to catalogue the menopausal transition of a multiracial and multiethnic cohort, to assess if race and ethnicity factored into treatment-seeking behavior. [14] Analyses showed that longitudinal nature of symptoms and frequency of symptoms were associated with treatment-seeking but not race, ethnicity, education, or socioeconomic status.

Longworth sought to examine factors influencing decisions around HT for perimenopausal and menopausal Hispanic women. [15] Nearly 60% had never used HT which limited study conclusions. However, most participants had discussed menopause with their healthcare providers and opted for non-pharmacologic symptom management.

Im et al [16] published experiences of Black menopausal women from responses to an online forum. Some women felt the experience of Black women was different than non-Black women and felt more comfortable and respected in race-concordant care. Most reported silence about menopause and did not seek treatment due to fear of embarrassment or lack of knowledge.

Helenius published a cross-sectional survey among predominantly Black and Hispanic women to assess HT use post-WHI. [17] Most women (87%) attempted to stop HT and a majority had symptom recurrence after stopping. Of those with symptom recurrence, only one-quarter received pharmacologic or CAM treatment. Patient-physician discussion of recurrent symptoms was the only predictive factor associated with stopping or continuing HT but the findings were not stratified by race.

Gold and colleagues examined a SWAN cohort (n=2118) to assess impact of race and ethnicity and menopausal status on CAM use. [18] Excluding diet, non-specific exercise, prayer, and vitamins they found approximately half of participants used CAM. Most common interventions included supplements such as glucosamine, flaxseed, soy, and yoga. In multivariable models, certain CAM use differed by race and ethnicity and others were associated with type of symptom. For instance, significantly more Black and Chinese patients utilized ginseng.

Christmas similarly used the SWAN cohort (n=2514) to examine how race and ethnicity modify the effect of CAM and HT use on self-reported quality of life. [19] White women had higher HT use and Non-Hispanic Black and Hispanic patients had lowest use. Additionally, non-White women were more likely to use CAM. Quality of life (QoL) was evaluated at baseline across treatment groups among different racial and ethnic cohorts including Non-Hispanic Black, White, Japanese and Chinese cohorts. QoL scores were nearly equivalent in different racial treatment groups except for Chinese women using HT at baseline who reported lower QoL compared to non-hormonal users (P= 0.002). Longitudinally, White women using HT reported higher quality of life compared to non-users of CAM or HT (p=0.03) whereas Black women using HT alone had lower quality of life scores compared to Black women who used neither therapy (p=0.027). The cause for these disparate findings in Black women is unclear but may reflect suboptimal use of HT on a background of more frequent and intense menopausal symptoms.

The Depree et al [20] analysis of contemporary healthcare management patterns of patients with bothersome vasomotor symptoms suggest that hormonal and non-hormonal therapy differed by race and ethnicity. Asian, Native America and Alaska Native women were more commonly treated with nonprescription interventions compared to all other races and ethnicities. Of those receiving prescriptions, more White women were more likely to receive systemic HT; however Black women had higher prescriptions of compounded HT.

Racial and ethnic differences in the utilization of menopausal therapy and management of bothersome vasomotor systems may reflect differences in preference, perceptions, cultural expectations, environment, and access to care.

3.1.2. Veterans

A retrospective cohort study by Cordasco et al [21] examined adherence to seven VA-developed guidelines for systemic HT for veteran women. Overall, guideline adherence was 60% for initiated prescriptions and 57% for renewals. Of women with an intact uterus, 7% of patients (n=8) were not prescribed a progestogen concurrently with systemic estrogen therapy. Guideline adherence did not differ by provider volume or by provider type (primary care physician or designated women’s health provider).

Canter et al evaluated midlife women veterans with moderate or high cardiovascular disease (n=108) to assess risk factor management. [22] Suboptimal management occurred for all risk factors especially those with prior heart disease and smokers. Over half of postmenopausal patients continued HT despite one-third of these women having objective criteria of subclinical heart disease.

Blanken et al examined 200,901 midlife veterans and found racial and ethnic disparities in prevalence of menopause diagnoses and prescriptions. [23] Among this cohort, 5.2% had documented menopause symptoms and 5.1% and 5% received systemic and vaginal HT, respectively. Hispanic and Black patients had lower odds of systemic HT compared to White counterparts. Black patients had lower odds of vaginal HT whereas Hispanic patients had higher odds of vaginal HT compared to White women.

Collectively this data shows that menopause symptoms and preventive care are undertreated in the veteran population and racial and ethnic disparities in treatment utilization exists.

3.1.3. Women living with HIV (WLWH)

Garbose et al surveyed midlife WLWH at a HIV-clinic in Baltimore (n=23). [24] Eighty-seven percent reported menopausal symptoms to their primary care providers, yet only 20% had prescriptions for HT or selective serotonin reuptake inhibitors.

Using the Women’s Interagency HIV study (WIHS), Yin et al [25] analyzed a cohort of postmenopausal women with or without HIV to determine association of HT with fracture risk. At baseline, there was a higher prevalence of vasomotor symptoms in women without HIV than women with HIV (26 vs 17%) yet more women with HIV were using HT (8 vs 4%). Route, dose, and formulation of HT were not specified but may have relevant implications for understanding if any disparities existed in appropriateness of treatment, as women with HIV have an elevated cardiovascular risk. Of women with HIV who reported HT use, they were more likely to be White. Decreasing HT prescriptions were seen throughout the 2003-2017 study period. A complementary assessment of trends in non-HT therapies for treatment of symptoms or osteoporosis prevention was unable to be performed. This study did not show an association with HT and decreased incident fracture risk in WLWH.

Taken together, this data suggests disparities in symptom prevalence and treatment with further evaluation of racial and ethnic differences warranting investigation.

3.1.4. Incarcerated individuals

Jaffe et al conducted semi-structured interviews with four incarcerated midlife women to learn about their experience of menopause. [26] All participants described lifestyle and medical interventions for menopause in prison as inaccessible. Untreated symptoms particularly mood and mental health, contributed to significant distress. Participants reported their feelings being dismissed by medical staff.

Jaffe [27] also published a retrospective chart review of incarcerated midlife women to examine prevalence of HT and non-HT treatments for menopause symptoms. Only 3.6% of women were prescribed estrogen-containing HT. In patients with contraindications to HT, one in six were prescribed a medication that may have been an alternative prescription for menopause symptoms.

Incarcerated individuals have a high symptom burden yet unmet needs for treatment. They are an exceptionally vulnerable population as individual behaviors to mitigate symptoms are constrained by the environment and specific prison or jail policies.

3.1.5. Surgical menopause

Garg published a retrospective cohort study of HT patterns in patients who underwent surgical menopause < 45 years old. [28] Half of patients received postoperative HT. When stratified by indication, 80% of patients with pelvic pain and 45% with BRCA mutations were prescribed hormones.

Suzuki et al analyzed medical claims from 2008 to 2019 to assess trends in postoperative estrogen therapy in patients less than 50 years old who underwent bilateral salpingo-oophorectomy (BSO) for benign indications. [29] Approximately 65% of patients (n=61,980) received estrogen prescriptions for a median duration of 5.3 months, though rates declined over the study time period. Notably, 48% of the study population was less than 45 years old. Adjusted analyses demonstrate lower prescription rates with more recent surgical dates and among patients with medical co-morbidities; whereas younger age and Medicaid insurance were associated with higher likelihood of prescriptions.

Patients with surgical menopause before the average natural age of menopause have an elevated risk of cardiovascular disease, osteoporosis, and all cause-mortality. Accordingly, national guidelines recommend postoperative estrogen therapy after BSO at ages less than 45 until the average age of menopause for primary prevention. [30] The undertreatment of patients with surgical menopause reflect knowledge gaps between HT and menopausal HT and contributes to increased prevalence of preventable morbidity in this population.

3.1.6. Nursing home residents

A study of academic nursing home residents by Gupta [31] demonstrates underutilization of bone density screening and treatment for this high-risk population. Of the 66 residents included, half had bone density scans; of those scanned, nearly three-quarters had low bone mass or osteoporosis. Only 61% of patients with osteoporosis had a bisphosphonate prescription with a small proportion without a prescription having a documented contraindication.

3.2. Key Question 2: What is known about disparities in access to preventive care and menopause symptom management?

Two studies examined disparate access to preventive care. Three studies described the provision of menopausal care by provider type and one study described disparities by insurance type.

3.2.1. Differences in management for preventive care

Hamrick examined 1000 race-matched postmenopausal women (500 White, 500 Black) to assess disparities in osteoporosis care. [32] Disparities existed for referral for bone density screening, prescriptions of vitamin D and calcium, and bisphosphonate treatment with Black women having lower rates across all aforementioned categories.

Gourlay found mirroring results to Hamrick. [33] The same proportion of White and Black women described osteoporosis care as important to their health, yet White women were more like to have screening, counseling, and physician prescription for vitamin D, calcium, and bisphosphonates.

3.2.2. Health Care Providers

As described above, Depree [20] obtained real-life practice patterns for vasomotor symptoms by surveying primary care providers (n=152) and gynecologists (n=131) who contributed patient data for analysis. HT use was more common with gynecology patients versus primary care patients (76% vs 64%). In contrast, SSRI (11% vs 19%) and SNRI (2% vs 12%) and nonprescription interventions were higher in primary care. Lastly, patients who reside in the southeast are least likely to be prescribed HT despite being a region with highest proportion of patients with insurance.

Constantine [34] conducted a cross-sectional survey of different specialty practice patterns for HT. Wellness Practitioners (WP) were more likely to prescribe HT than General Practitioners (GP) and OBGYN. Disparities existed for indications, including 28% of WP prescribing for cardiovascular benefits and wellness compared to 13% and 10%, respectively, for GP and OBGYN. WP more frequently prescribed compounded HT compared to other specialties.

A cross-sectional survey by Grant [35] assessed family medicine resident and faculty attitudes and approach to CAM for menopausal symptoms. Following no advice given, behavioral strategies were most commonly recommended. Over half encouraged herbal therapies to treat vasomotor symptoms.

In summary, very limited data suggests differences in menopause knowledge and treatment approach based on healthcare provider specialty. Physicians implementing a more psychosocial or holistic approach to treatment offer a valuable resource yet still had limited training and knowledge about CAM for menopausal symptoms.

3.2.3. Insurance status

De Mello et al [36] conducted a cross-sectional survey of two clinical sites to assess the socioeconomic impact on menopausal symptoms and care. Clinics in Phoenix and Scottsdale were used as comparators based on their demographic composition. Approximately three-quarters of the Phoenix clinic were uninsured or with public insurance and one-fifth had housing insecurity; all of the Scottsdale participants had private insurance and housing. Despite higher symptom burden as measured on the Greene Climacteric Scale in the Phoenix population, 2.9% vs 23% (p < 0.001) of Phoenix and Scottsdale participants, respectively, were taking menopausal HT.

Socioeconomic factors such as insurance and residential segregation are associated with symptom burden and disproportional access to care. Targeted resources to support providers in limited resource settings is essential to close the gap in care.

3.3. Key Question 3: What interventions exist to address disparities in access or management of menopausal care?

Four studies evaluated interventions designed to reduce disparities in care for specific populations or disparities in menopausal management, including preventive care.

Schover et al [37] designed and assessed a peer counseling intervention program in African American breast cancer survivors (n=48). There was a statistically significant improvement in knowledge and decrease in menopausal symptoms, driven by a decrease in hot flush scores, and overall emotional distress, which was sustained at three months.

Vesco et al published a clinician-focused health system intervention to improve detection and treatment of genitourinary syndrome of menopause. [38] The intervention included educational programs and embedded electronic health record (EHR) resources for OBGYN and primary care clinics. Post-intervention, vulvovaginal and urinary diagnoses occurred in 6.6% and 2.7% of well visits, respectively, and there was no difference in diagnosis or treatment between control and intervention groups. The intervention group more frequently used the embedded EHR tools and distributed patient information.

Raggio et al adapted and piloted an intervention to reduce cardiovascular disease for midlife women living with HIV. [39] Five individuals completed the program and post-treatment assessment. They reported an increase in knowledge of cardiovascular disease and their personal risk and self-reported increases in physical activity.

A randomized trial of a three-month, web-based intervention was piloted by Chee to help decrease sleep-associated symptoms by increasing physical activity in midlife (40-60 year old) Asian American women. [40] Both the control and intervention group had significant improvement in active living habits. The intervention group had a decrease in psychological and total symptoms.

In general, these intervention studies were small in size and of short duration. Several did show benefit in terms of improved knowledge, which may prove informative in future interventions designed to mitigate menopausal care disparities.

Discussion:

This review identified documented differences in menopausal care for racial and ethnic minorities, veterans, women infected with HIV, incarcerated people, people with surgical menopause, and nursing home residents. Differential access to menopausal care exists by provider type, geographical region, and insurance status. Menopause and age at menopause can adversely affect bone, sleep, and cardiovascular health and result in chronic morbidity. Therefore, undertreatment and disparities in menopause care can result in preventable morbidity and reduced quality of life for vulnerable populations. Relatively few interventions to address these disparities have been described and are primarily education-based programming for the clinician and/or patient. Results have been modest, but represent fairly low-resource interventions. While there is a growing field of research on differences in prevalence and type of menopausal symptoms, research on disparities in access to menopausal treatment is still limited. There was also a notable gap in the literature describing menopausal care for other populations that face health disparities, specifically transgender and gender non-conforming people, people with premature ovarian insufficiency, substance use disorders and those living in rural areas and health care deserts.

One recurring theme was persistent confusion among patients and healthcare providers regarding the role of HT. Despite an abundance of patient-facing social media information on menopause treatments, a larger social conversation and embrace of the menopause transition as an important midlife milestone are just beginning. [41] Many physicians providing health care to women and vulnerable populations do not have adequate training to counsel and treat menopausal patients, which may manifest as symptom dismissal, leading to mistrust and/or inadequate treatment. While there has been a small increase in formalized education over the last ten years, only 31% of surveyed OBGYN residencies have a menopause curriculum in 2023. [42–43] True progress will also require integration into medical school and other healthcare professional training. All providers will care for menopausal patients and recognizing unique needs of this population in context of each specialty will allow for comprehensive management.

Development of national quality guidelines for treatment of menopausal patients could help healthcare systems identify and mitigate disparities in menopausal care. On a small scale, Cordasco et al [21] used this process in the VA system and revealed gaps in evidence-based treatment. Guideline recommendations can be integrated into the electronic medical record, although the experience of Vesco et al [38] suggests that reminders and decision-support tools without addressing knowledge gaps first may fall short.

Further research should investigate how patients and providers make decisions about menopausal treatment. Patients express desire for a range of treatment modalities, shaped by their social and/or cultural values. Shared-decision making with a provider would integrate those values into the presentation of options and the benefit, risk and efficacy profile of each. Understanding how structural racism and other individual and systemic biases contribute to treatment disparities will help focus future interventions and reduce disparate health outcomes.

The limitations of this study include the restriction to English-language publications describing populations in the United States. Given that diverse contexts influence menopause experiences and treatment, it would be impossible to reflect the global experiences of menopausal people in a single review. Although interventions aimed at reducing disparities were identified through our search strategy, it’s important to note that this review did not exclusively focus on this aspect. While other studies have evaluated EHR-focused interventions, including those targeting knowledge disparities, future reviews should aim for a more comprehensive search for evidence-based practices.[44] The strengths of the study include that it is a contemporary review, including only post-WHI trials.

Conclusion:

Populations that experience inequity in health care also experience disparities across elements of menopausal care – symptomatic therapy and preventive health care specific to menopausal people. Increased understanding of factors that contribute to disparate treatment will help inform future policy and interventions and improve the quality of life of those affected by bothersome vasomotor symptoms.

Table 2:

Key questions on disparities in access to treatment for menopausal care

Key Question No	Question	Publications addressing key question
1	What specific populations experience differences in menopause management?	1. Doamekpor 2023 2. Williams 2007 3. Waetjen 2015 4. Longworth 2003 5. Im 2010 6. Helenius 2007 7. Gold 2007 8. Christmas 2022 9. Depree 2022 10. Cordasco 2019	11. Canter 2009 12. Blanken 2022 13. Garbose 2020 14. Yin 2022 15. Jaffe 2021 16. Jaffe 2022 17. Garg 2020 18. Suzuki 2022 19. Gupta 2003
2	What is known about disparities in access to preventive care and symptomatic treatment?	1. Hamrick 2012 2. Gourlay 2007 3. Depree 2022 4. Constantine 2016 5. Grant 2007 6. DeMello 2021
3	What interventions exist to address disparities in treatment access or management?	1. Vesco 2021 2. Schover 2006 3. Raggio 2021 4. Chee 2019

Abbreviations:

HT

Hormone Therapy

CAM

Complementary and Alternative Medicine