SPECIAL REPORT

Menopausal symptoms and ethnicity:

the Study of Women’s Health Across
the Nation
Robin Green & Nanette Santoro†
A number of studies have suggested that ethnic background influences a woman’s perception of
her symptoms. The Study of Women’s Health Across the Nation (SWAN) is a multiethnic,
longitudinal, cohort study of US women that includes non-Hispanic Caucasian, African–American,
Chinese, Japanese and Hispanic women. The initial strategy for this seven-site study involved
community-based recruitment of non-Hispanic Caucasians at each site, plus one minority ethnic
group. Since ethnicity varies with many other factors, measures of education, acculturation, social
status, psychological wellbeing and financial strain were all taken into account in interpreting
symptom onset, frequency and severity of the common menopausal symptoms. Biological and
physical measures were also assessed and related to symptoms. Most symptoms varied by ethnicity.
Vasomotor symptoms were more prevalent in African–American and Hispanic women and were
also more common in women with greater BMI, challenging the widely held belief that obesity is
protective against vasomotor symptoms. Vaginal dryness was present in 30–40% of SWAN
participants at baseline, and was most prevalent in Hispanic women. Among Hispanic women,
symptoms varied by country of origin. Acculturation appears to play a complex role in menopausal
symptomatology. We conclude that ethnicity should be taken into account when interpreting
menopausal symptom presentation in women.

Menopausal symptoms are reported by a major-
ity of women [1] . Their prevalence and severity
vary considerably based upon a number of differ-
ent factors, including race/ethnicity [2] and other
demographic and lifestyle factors [3,4] . The vari-
ability of these other influences on menopausal
symptoms gives rise to many questions:
• How do symptoms differ by ethnicity?
• What characteristics are related to ethnicity
itself and how can we examine ethnicity
independently of its common covariates,
such as socioeconomic status, acculturation
and language?
• To what extent does genetic background
influence susceptibility to symptoms?
• How does perceived discrimination contribute
to symptoms?
• Do acculturation, discrimination and ‘othering’
contribute to symptoms?
The Study of Women’s Health Across the
Nation (SWAN) is a longitudinal, multiethnic,
community-based, observational study of
women traversing the menopause. It was the first
NIH observational study of its kind that sought
to include women from a variety of ethnic back-
grounds in order to encompass the menopausal
experience of as many women as possible and,
thus, to fully characterize the menopause of
American women. This article will review the
strategies utilized by SWAN in order to accom-
plish timely recruitment of minority and nonmi-
nority women, highlight some of the challenges
that were encountered and describe our initial
findings and their interpretations.
Strategy of recruitment: SWAN
†
The Study of Women’s Health Across the Author for correspondence
Albert Einstein College of
Nation recruited its community-based sam-
Medicine, Department of
ple by beginning with a population-based,
Obstetrics & Gynecology &
cross-sectional screening survey administered
Women’s Health, 1300 Morris
to 16,065 women upon which eligibility for Park Avenue, Mazer 316, Bronx,
the longitudinal study was based. A total of NY 10461, USA
3302 women completed the baseline assess- Tel.: +1 718 430 3152
ment for the longitudinal study. Annual assess- Fax: +1 718 430 8586
ments in SWAN are fairly comprehensive and glicktoro@aol.com
include physical measurements, blood draws,
urine sampling and bone density measurements
Keywords
at some but not all sites, and a detailed bat-
tery of survey measures, details of which have ethnicity • Hispanic
been previously published [5] . Since the intent • hot flashes • menopause
was to track the menopausal process as fully as • vasomotor symptoms
possible, women were not eligible to be in the
study if they had less than one menstrual period
within the preceding 3 months. This is an part of
accepted epidemiological definition of the ‘early
transition’ [6] . SWAN is being conducted at the

10.2217/17455057.5.2.127 © 2009 Future Medicine Ltd Women's Health (2009) 5(2), 127–133 ISSN 1745-5057 127
SPECIAL REPORT – Green & Santoro
seven sites, each of which recruits non-Hispanic
Caucasian women and women from one other
race–ethnic background: (African–American,
Hispanic, Japanese or Chinese) Boston (MA,
USA), Chicago (IL, USA), Detroit (MI, USA),
Los Angeles (CA, USA), Newark (NJ, USA),
Pittsburgh (PA, USA) and Oakland (CA,
USA). At enrolment, women were required to
have an intact uterus and at least one ovary (to
allow bleeding patterns to be tracked), were not
pregnant or breastfeeding and were between 42
and 52 years of age. All participants were still
menstruating, and women using oral contracep-
tives or HRT within the previous 3 months were
excluded. A total of 420 women (278 Hispanic,
and 142 non-Hispanic Caucasian) were
enrolled from Hudson County, NJ, USA. The
278 Hispanic women were from five subethnic
groups; Central American, South American,
Cuban, Puerto Rican and Dominican, all
drawn from the same geographic area, as were
non-Hispanic Caucasians.
The initial sampling strategy of SWAN was
to include a non-Hispanic Caucasian group at
each site, assuming that these non-Hispanic
Caucasian women would be sufficiently simi-
lar to each other in order to allow comparisons
both across and within sites. Since sites differ
geographically as well as by the overall socio-
economic status of their particular sample, this
strategy has assisted in disentangling some of
the covariates mentioned previously, and allows
us to begin to answer questions about different
symptoms across ethnic groupings.
Basic menopausal physiology
& ethnic variation
Ethnic differences were observed in the onset
of premature and early menopause, defined as
the cessation of menstruation before the ages
of 40 and 45 years, respectively. The cross-
sectional survey used by SWAN to determine
eligibility for the longitudinal cohort study
included questions about the untimely cessa-
tion of menses. Highly statistically significant
differences were observed in the prevalence
of premature and early menopause across the
ethnic groups in SWAN. Although previous
reports estimated the prevalence of prema-
ture menopause at 1% [7] , there was variation
around this number in SWAN. In Hispanic
women, 1.4% reported menopause prior to
the age of 40 years; for African–Americans
the prevalence was 1.4%, for Caucasian (non-
Hispanic) 1%, for Chinese 0.5% and for
Japanese 0.1% [8] . Early menopause displayed
128 www.futuremedicine.com
even more striking differences, with 4.1% of
Hispanic, 3.7% of African–American, 2.9%
non-Hispanic Caucasian, 2.2% Chinese and
0.8% of Japanese women reporting cessation
of menses prior to 45 years of age [8] .
Hysterectomy confounds the assessment
of menopause because it interrupts bleeding
patterns and, thus, the cessation of ovarian
function can no longer be observed. Ethnic
differences in the indications for hysterectomy
have long been reported in the literature [9] .
The SWAN cross-sectional screening survey
(n = 15,160) sampled 49.9% Caucasian,
28.1% African–Americans, 12.3% Hispanic
and 9.8% Asian–American women. Ethnicity
was found to be associated with past hys-
terectomy [10] . The odds ratios (ORs) were:
Caucasian = 1.0, African–American = 1.66
(95% CI: 1.46–1.88), Hispanic = 1.64 (95%
CI: 1.29–2.07) and Asian–American = 0.44
(95% CI: 0.34–0.56). These results indicate
that for benign conditions, such as uterine
fibroids, abnormal bleeding, endometriosis and
pelvic organ prolapse, the highest rates of hys-
terectomy occurred in African–American and
Hispanic subgroups. These ORs were adjusted
for age, education, a diagnosis of fibroids, BMI,
marital status, smoking, geographic site and
country of education, all of which are believed
to affect the likelihood of hysterectomy. The
authors concluded that disparity in the form of
overuse in disadvantaged minority groups may
exist [10] . Previous studies that have attempted
to elucidate the reasons for higher hysterec-
tomy rates in African–American women have
found earlier onset of large, symptomatic
fibroids in this population group [11] , which
may account for their tendency to have hyster-
ectomies at an earlier age compared with other
ethnic groups.
It is important to recognize that there are
ethnic differences in the prevalence of prema-
ture menopause and hysterectomy because both
of these conditions are associated with worse
menopausal symptoms [1] .
Other possible modifiers may differ by eth-
nicity and be owing to a different genetic back-
ground, such as sex steroid-synthesizing enzymes
and metabolism-regulating genes [12] . Although
not observed in SWAN, in the Seattle Midlife
Women’s Health Study, the CYP19 11r poly-
morphism for the aromatase gene was associated
with worse vasomotor symptoms (VMS) [13] .
Genetic variations are tempting explanations for
symptoms that might be based upon hormone
synthesis pathways.
future science group

Ethnicity as a covariate influencing
symptom vulnerability
Diet, methods of coping and sociopolitical
factors may play a role in symptom sensitivity
as well as in symptom reporting. It is impor-
tant to keep in mind that there may be ethnic
differences in how some of the SWAN survey
measures are processed by women of different
backgrounds and literacy.
Vasomotor symptoms
The hot flash is viewed as the cardinal symptom
of menopause. Hot fl ashes affect up to 75%
of women at some point in the menopausal
transition [1] . However, a minority of women
report being severely affected. Their preva-
lence peaks less than 2 years to 1 year before or
after the fi nal menstrual period and returns to
near premenopausal levels 8 years later, based
on a recent meta-ana lysis [14] . In the SWAN
baseline, 46.5% African–American, 49.4%
Hispanic, 36.6% Chinese, 34.3% Japanese and
28.9% Caucasian women reported hot flashes
and/or night sweats [2] . Hispanic women
report more negative associations (embarrass-
ment) with VMS than do other ethnic groups
in SWAN [15] . Hispanic women also reported
more baseline anxiety and depressive symptoms
related to VMS. However, Chinese women had
the fewest VMS overall.
These early findings from SWAN chal-
lenged the current thinking about the genesis
of VMS and have led to new hypotheses. It has
long been believed that increased adiposity is
associated with decreased menopausal VMS
because of the known conversion of andro-
gens to estrogens in body fat [16] . However,
increased adipose tissue may be associated
with a greater likelihood of VMS because of its
insulating properties. This thermoregulatory
model of the pathophysiology of VMS is sup-
ported by SWAN. In a sample of 1776 women,
a higher percentage of body fat was associated
with increased odds of reporting VMS (per
standard deviation increase in percent body
fat; OR: 1.27; 95% CI: 1.14, 1.42) in both
age and site-adjusted models [17] . It is impor-
tant to recognize the role of adiposity in pre-
dicting VMS, because BMI varies consider-
ably in SWAN with respect to ethnicity [18] .
African–American and Hispanic women have
the highest BMIs in SWAN. Combined with
their higher risk for hysterectomy, African–
American women are at greatest risk for VMS
than the ORs suggest, because the various
studies adjust for these additive factors.
future science group Women's Health (2009) 5(2)
Menopausal symptoms & ethnicity: SWAN – SPECIAL REPORT
Vaginal symptoms
Approximately 30–40% of women experience
dyspareunia or vaginal dryness apart from
during intercourse, and symptoms p ersist
long after menopause in at least 26% of
women [19,20] .
In SWAN, Hispanic women complain of
more vaginal symptoms than the other ethnic
groups [15] . These findings are similar to those
from the Women’s Health Study, in which
postmenopausal Hispanic women reported the
highest rates of vaginal irritation [19] .
Menopause & mood
Hispanic and African–American women are
more likely to report depressive symptoms and
Chinese and Japanese women are the least likely
to report depressive symptoms in SWAN [21] .
Irritability and nervousness, associated with the
early transition, appears to be linked to fluctuat-
ing hormones. The late menopausal transition is
associated with increased depressive symptoms
(OR: 1.3–1.71) in SWAN [22] and other studies
as compared with premenopause [23,24] . Prior
history of depression is predictive of increased
body pain, poor social functioning, negative
mood (not clinical depression) and treatment
for back pain [21,22,25] .
Sleep disturbances
Sleep complaints begin to appear in women
above 35 years of age. A total of 23.6% of
women and 14.4% of men report sleep diffi-
culties between 45–49 years of age and 39.7%
women and 15.3% of men report not sleeping
well by their early 50s [26] . Whether the large
midlife increase in sleep problems in women is
due to aging, stress, psychosocial and physical
problems or the effects of hormonal changes
associated with menopause is still unclear.
Among ethnic groups, poor sleep increases
with menopausal stage [26] . In SWAN, longi-
tudinal data revealed that African–American
and Hispanic women reported the highest
p ercentage of diffi culty in sleeping, mani-
fested as staying asleep, and early morning
awakenings. Progression through the meno-
pausal transition as indicated by three meno-
pausal characteristics – symptoms, bleeding-
def ined stages and endogenous hormone
levels – is associated with self-reported sleep
disturbances [26,27] . These findings are the first
to describe ethnic-specific changes in perceived
sleep efficiency in middle-aged women.
TABLE 1 displays major menopausal symptoms
and their associations with ethnicity.
129
SPECIAL REPORT – Green & Santoro

Table 1. Relationship of common menopausal symptoms to ethnicity in the Study

of Women’s Health Across the Nation.
Symptom or condition Most (%) Fewest (%) Ref.
Early/premature menopause Hispanic (3.7) Japanese (0.8) [8]

Benign hysterectomy African–American Chinese/Japanese [10]

(OR: 1.66; 95% CI: 1.46–1.88) (OR: 0.44; 95% CI: 0.34–0.56)
Vasomotor symptoms African–American* (46.5) Caucasian (28.9) [2]

Vaginal symptoms Hispanic (17.9–58.6) Caucasian (21.2) ‡ [15]

Depressive symptoms Japanese Chinese [22]

(OR: 1.39; 95% CI: 0.93–2.17) (OR: 0.51; 95% CI: 0.33–0.79)
Trouble falling asleep Hispanic (14.4) Japanese (6.5) [27]

Data are shown as the percentage of women experiencing the symptom or condition, or as an OR, with Caucasian
women = 1.0 and appropriate 95% CI.
*Hispanic women reported more embarrassment or discomfort associated with hot flashes.
‡
Other ethnic groups not compared.
CI: Confidence interval; OR: Odds ratio.

Discrimination, ’othering’ Thus, acculturation may not bring about

& acculturation
As new immigrants become accustomed to
the dominant culture of their newly adopted
county, there is an expectation of assimila-
tion and acceptance. In an ideal scenario, the
USA is viewed as a benign ‘melting pot’ into
which immigrants are welcomed and prosper.
According to this logic, the more assimilation
that takes place, the better the lot of the immi-
grant. In this model, assimilation is viewed
as entirely beneficial. This phenomenon has
been observed among the Hispanic women in
SWAN [28] inasmuch as increased self-reported
language acculturation is related to improved
overall quality of life (QoL).
However, increased acculturation has the
potential to erode the QoL for immigrants. As
individuals assimilate, they have more inter-
action with the dominant culture and more
chances for discrimination [29] . Acculturation
may erode immigrant family values. Increased
acculturation has been hypothesized to lead to
worsening health outcomes in Hispanic popu-
lations, another so-called Hispanic paradox
attributed to acculturation stress [30] . In this
scenario, increased time since immigration
results in a loss of healthy behaviors, resulting
in an adverse influence on a variety of health
outcomes. For example, Central American
immigrants who are less acculturated are more
likely to be married, and less likely to engage in
unhealthy habits, such as cigarette smoking [31] .
Adverse effects of migration include a loss of
family and social structure, and exposure to
street drugs and unmarried pregnancy. These
factors result in a deterioration of the nativity
advantage in perinatal outcomes [32] .
health benefits if there is a significant increase
in exposures that are unhealthy or that lead
to the perception of ‘othering’ or frank dis-
crimination. There is evidence that relatively
highly acculturated, Hispanic women from
the Bronx, NY, USA, who are exposed to high
rates of poverty, drug use and HIV infection are
especially vulnerable to menopausal symptoms
of all kinds [3] . The data suggest that symptom
vulnerability cannot be reliably predicted by
acculturation alone. Specific studies examin-
ing these issues in the context of menopause
are sparse.
SWAN: the trouble with generalizing
SWAN Hispanic women & acculturation
Despite the similarity of their geographic sites
and low overall socioeconomic status, there are
large differences between the Hispanic women
in SWAN with respect to acculturation and a
number of other factors that are typically related
to acculturation, such as education, fi nancial
strain (difficulty paying for the basic neces-
sities of life) and health habits (e.g., cigarette
smoking). Puerto Rican women are the most
acculturated, based upon their response to a
language variable ascertained from four ques-
tions regarding the language women usually
think, read and speak in, talk with their friends
in and listen to the radio or watch television
in. The acculturation scale allows researchers
to quickly identify Hispanics who are low and
high in mostly language acculturation. The scale
has been referenced with a variety of Hispanic
subgroups, including Mexican–Americans,
Cuban–Americans, Puerto Ricans, Dominicans
and Central and South Americans [33] .

130 www.futuremedicine.com future science group


Despite their greater acculturation, Puerto Rican
women are not better educated than other
Hispanic women in SWAN. They also report
relatively more menopausal symptoms and more
anxiety symptoms among the Hispanic women
of SWAN. The Cuban women have the highest
socioeconomic status and fewer symptoms than
the other Hispanic subgroups, despite being less
acculturated. Central American women tend
to have the worst overall menopausal sympto-
matology (VMS and vaginal dryness) [15] and
less acculturation.
Thus, for the Central American women, who
were more likely to be the more recent immi-
grants, less acculturation appeared to help explain
some of their increased symptoms. However, the
Puerto Rican women, who were most accultur-
ated, appear to be suffering from the phenomenon
of acculturation stress and did not experience
better health as a result of being more assimilated
into the US mainstream culture.
Quality of life & race/ethnicity
The question of whether menopausal status is
associated with global QoL among multiethnic
(Caucasian, African–American, Chinese,
Japanese and Hispanic) women aged 40–55 years
and whether this association varies by race/
ethnicity in SWAN analyses suggests that in
this population-based sample of women, early
perimenopausal women reported lower QoL
compared with premenopausal in unadjusted
analyses, but menopausal status was no longer
associated with QoL when analyses were adjusted
for other variables. This difference was largely
explained by perceived stress, which was high-
est among the early perimenopausal women.
Whether this is directly related to menopausal
status or explained by a third variable (e.g., life
changes) needs further exploration. In multivari-
ate models, being married and having low levels
of perceived stress were associated with better
QoL across all racial/ethnic groups [28] .
Attitudes towards menopause & aging
Attitudes vary across ethnic groups and meno-
pausal status (i.e., premenopausal through to
postmenopausal). African–American women
were significantly more positive in their attitude
towards menopause. The least positive groups
were the less acculturated Chinese–American
and Japanese–American women. The general
finding that attitudes toward menopause ranged
from neutral to positive is consistent with find-
ings of previous research. The finding that
more African–American women and Caucasian
future science group Women's Health (2009) 5(2)
Menopausal symptoms & ethnicity: SWAN – SPECIAL REPORT
women agreed with the perception of menopause
signaling freedom and independence may reflect
a higher value of these qualities than is the case
in the Asian and Hispanic cultures, which are
generally thought of as more communal. The
SWAN data have the advantage of comparing
responses of presumably more and less accultur-
ated women to the same questions and do not
support the conclusion that exposure to Western
ideas is the source of negative attitudes towards
menopause [34] .
Conclusion & future perspective
In summary, examination of epidemiologi-
cal data on menopausal symptoms indicates
clear-cut differences in symptom reporting by
ethnicity. Much caution needs to be exercised
in interpreting these data since the reasons
are unlikely to be innate ethnic-related issues.
Genetic hypotheses are under exploration but
to date the data have not been explicatory of
these relationships. The role of discrimina-
tion and ‘othering’ in increasing vulnerability
to symptoms needs to be taken into account;
clearly further research is needed. As immi-
grant populations on the whole are targeted
to exceed the ‘majority’ of Caucasians over
the next several decades, much more attention
needs to be focused on the differences in report-
ing of menopausal symptoms, their treatment
and their long-term consequences in women of
varying ethnic backgrounds.
Acknowledgements
The Study of Women’s Health Across the Nation (SWAN)
has grant support from the National Institutes of Health
(NIH), Department of Health and Human Services,
through the National Institute on Aging (NIA), the
National Institute of Nursing Research (NINR) and the
NIH Office of Research on Women’s Health (ORWH);
grants NR004061; AG012505, AG012535, AG012531,
AG012539, AG012546, AG012553, AG012554 and
AG012495. The content of this article is solely the respon-
sibility of the authors and does not necessarily represent the
official views of the NIA, NINR, ORWH or the NIH.
Financial & competing interests disclosure
The authors have no relevant affi liations or fi nancial
involvement with any organization or entity with a finan-
cial interest in or financial conflict with the subject matter
or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or
pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.
131
SPECIAL REPORT – Green & Santoro

Executive summary
The Study of Women’s Health Across the Nation story
• The Study of Women’s Health Across the Nation (SWAN) is a multiethnic, longitudinal, cohort study of mid-life women – the first NIH
observational study of its kind that sought to include women from a variety of ethnic backgrounds in order to encompass the
menopausal experience of as many women as possible and, thus, to fully characterize the menopause of American women.
Basic menopausal physiology & ethnic variation
• Hispanic and African–American women were most likely to have premature or early menopause.
• For benign conditions, such as uterine fibroids, abnormal bleeding, endometriosis and pelvic organ prolapse, the highest rates of
hysterectomy were observed in African–American and Hispanic subgroups.
Ethnicity as a covariate influencing symptom vulnerability
• Interactions of adiposity, higher rates of hysterectomy and earlier menopause favor increased vasomotor symptoms in African–
American women and may help to explain their almost twofold increased risk of this common menopausal symptom.
• Vaginal dryness is a prevalent menopausal symptom and was reported by up to 40% of women in SWAN, most commonly
by Hispanics.
• Depressive symptoms and major depression are increased over the menopausal transition. Hispanic and African–American women
appear to be the most vulnerable.
• Sleep disturbances increase during the perimenopause and are worst in African–American and Hispanic women.
Discrimination, acculturation & ‘othering’
• Assimilation into the mainstream culture is often associated with improved symptoms, but in the SWAN study, midlife Hispanic women
who are more acculturated may not enjoy a reduction in symptoms.
The trouble with generalizing
• Symptoms differ within and among Hispanic women based upon their country of origin, indicating an ability to resolve the
relationships of culture to symptoms at a very fine level.
• Appreciation of the role of ethnicity in the expectations, onset and duration of menopausal symptoms is expanding.
Future perspective
• Cultural, biological and genetic factors that influence vulnerability to symptoms can be identified by detailed study.
• The role of othering or discrimination in predicting symptoms will be best resolved by using a correlative biological marker for
acculturation stress.
• The definition of Hispanic ethnicity as a single subgroup is a concept that warrants reconsideration, since differences among women
who self-identify as Hispanic have been shown to exist based upon their country of origin.

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Affiliations
• Nanette Santoro
Albert Einstein College of Medicine,
Department of Obstetrics & Gynecology
& Women’s Health, 1300 Morris Park
Avenue, Mazer 316, Bronx, NY 10461, USA
Tel.: +1 718 430 3152
Fax: +1 718 430 8586
glicktoro@aol.com
• Robin Green
Albert Einstein College of Medicine,
Department of Obstetrics & Gynecology
& Women’s Health, 1300 Morris Park
Avenue, Mazer 316, Bronx, NY 10461, USA
Tel.: +1 718 430 3152
Fax: +1 718 430 8586
rrgpsyd@aol.com
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