Podcast Episode 14: Navigating the perimenopause and menopause within South Asian communities with Dr Devika Patel

Though we may increasingly appreciate that the perimenopause and menopause will afflict over half of the global population, attention is rarely paid to the manner in which different cultural practices will inform a person’s navigation of treatment. Joining podcast host Lauren Redfern to discuss the ways in which the perimenopause and menopause may be experienced uniquely amongst South Asian communities, is psychiatric doctor and host of the podcast “Our Extraordinary Stories” Dr Devika Patel. Discussing everything from the institutionalised racism exhibited in the diagnosis of Begum Syndrome, to the importance of being activists in our own communities, Lauren and Devika dive into the importance of adopting cultural sensitivity and awareness in our daily practice.

Dr Devika Patel is a General Adult Psychiatry Higher Trainee, currently working in the West Midlands. Being from a South Asian background herself, Devika strives to reduce stigma around discussing menopause and improving access to HRT. She does so by improving knowledge and awareness and adopting an advocacy position in her daily practice. Devika’s podcast “Our Extraordinary Stories” provides a platform for people to share stories of mental illness recovery and human flourishing, with an aim of reducing stigma. Menopause and hormonal health has already featured as an important topic in the series. You can listen to the podcast here and can learn more about Devika’s work by following her on Instagram and Twitter.

Episode Transcript:

Lauren Redfern [00:00:06] Welcome to the podcast for the Newson Health Menopause Society, a multi-disciplinary collective of interested professionals passionate about improving hormone health across the world. The society exists to educate and inspire others to raise the standard of menopause care and access to treatment, to facilitate research, collaborations across specialities and countries, and to provide expert advice and guidance to our associates. The ultimate aim of the Newson Health Menopause Society is to improve the lives and future health of women and all who experience the perimenopause and menopause. I’m Lauren Redfern. I’m a medical anthropologist and I’ve been exploring the experiences of those using testosterone as part of their HRT treatment. In this podcast series, I’m going to be talking to guests from a variety of different disciplines in order to share knowledge and ultimately improve our understanding of the perimenopause and menopause.

Lauren Redfern [00:01:05] There is a particular narrative which argues that menopausal symptoms are a peculiarly western phenomenon. That is to say, they are not routinely experienced by women from other regions, and particularly not experienced by women from Asian regions, where it has been claimed that dietary, social and cultural factors combine to mean women are not afflicted by menopausal symptoms in the same way. Recent studies, however, conducted in multi-ethnic communities, have actually demonstrated that the menopause and its symptomatic consequences are in fact similar worldwide. So why does this narrative, the one where the perimenopause and menopause is an exclusively white Western issue, persist? One factor to consider is how talking about the menopause simply doesn’t translate universally in the same way. To use the South Asian context as an example, which will be the focus of today’s episode, there simply isn’t a word for menopause in Punjabi or Gujarati which can make both talking about the menopause and seeking care and treatment more complex. We are increasingly appreciating the long term implications that can occur as a result of poorly managed menopause, including cardiovascular disease, osteoporosis and cognitive function. And consequently, it’s important we start discussing the often misunderstood cultural barriers that can impact a women’s ability to seek support and treatment. Here to help me dive into this topic a little deeper is psychiatric doctor and the host of the brilliant podcast, Our Extraordinary Stories, Dr. Devika Patel. Hi, Devika, thank you so much for joining me on the podcast and chatting with me today about this really important topic. I wonder if we might just start with you introducing yourself to those listening and telling us a little bit more about the work that you do.

Dr Devika Patel [00:02:56] Of course. Thank you for having me on the podcast, Lauren. So my name is Dr Devika Patel and I’m a junior doctor specialising in psychiatry. I’m an ST4 at a level of my training, which means in two years time, I’ll be a consultant. Some people get a bit confused between psychiatrists and psychologists, so just to make that clear, so I’m a medically qualified doctor who has then decided that this specialist area is going to be mental health. As you can probably tell by my name, I’m Indian by background, and although I’m not a specialist in menopause, I do think that everyone needs to have understanding and knowledge of menopause. It’s been an area that I’ve been particularly interested in after seeing Dr Louise Newson’s work and there’s so many links with mental health and menopause, so I’ve been particularly interested in this area and then bringing my experiences of being from a South Asian background to the idea of menopause and how it’s translated. So I thought it’d be really useful and also important to have this discussion just to kind of see where our discussion takes us, not necessarily making any statements, just about sharing opinions and exploring the topic. Because when I was doing some research for the conversation, I couldn’t find much on it at all. So this might be the first of many conversations to come.

Lauren Redfern [00:04:08] Yeah. I mean, we started talking really when we connected about this, we started off talking about your background in psychiatric medicine, which you’ll be joining me to do another podcast to chat about and sort of led us to this conversation really about how when we talk about the experience of perimenopause and menopause, we do sort of tend to think about it in universal terms. But actually, there are many different barriers in place for women navigating treatment and care for the perimenopause and menopause, depending on their background, their cultural background as well. And that’s where we sort of started talking about how that was for women in South Asian communities. And I wondered if you might want to talk a bit about that.

Dr Devika Patel [00:04:48] Yeah, well, I was trying to think like, where does this start? And I guess it comes down to, well, issues like periods, sex, fertility issues that is not openly discussed within South Asian cultures. I would say it’s a taboo in many cultures, not just for South Asians, but particularly we’re still a community that will not openly kind of say ‘I’m on my period’, or talk about if they’re having problems with their sex life or having difficulties with fertility, because it can be seen as quite a shameful thing. A women’s role can be seen within a family to reproduce and be a mother. So within that it is almost natural that menopause is not spoken about as well. If you’re not going to speak about when you start your periods, you’re definitely not going to even bother talking about when you’ve finished periods. So I think that’s really where it begins. And if you don’t talk about it, then you either think that it’s not happening, you don’t connect the dots and think this is actually due to a hormone deficiency, and you can easily just put down everything that happens in menopause to old age and accept that as your reality. And you can be like, ‘well, my mum felt this way’. ‘My grandma, I saw her, she was this way’. So this is just life. And after the age of 50, we just become less mobile, less able to do things. We get anxiety. We feel like we have lots of low energy, we get aches and pains and that’s just life. So I do think that women just accepted it as their state. So even if there’s research done in the area, if you asked a woman in a village in India or even here, they might not even be able to draw it together and be like, ‘Oh yes, that was the perimenopause or the menopause’. They’ll just brush aside be like ‘No, I have not experienced that entity that you call menopause’ until it’s actually spelt out to them, and they get the education on it.

Lauren Redfern [00:06:40] And I think you kind of alluded to this, and it’s important and we talked about this before we started the episode, it is really important not to kind of take that place as a spokesperson for an entire community, right? And generalise or assume that, you know, everything that goes on for, say, the South Asian community. However, that being said, we did sort of chat about, and I think you used your mum as an example when we were talking, saying that you really noticed during that time not only her but also others around her really struggling with exactly that. The conversations you were saying to talk about it and you know, you were mentioning really noticing for yourself a difference in your mum and how you knew her, but that it was almost quite challenging for you to have to bring that conversation up with her. And I wondered if you wanted to talk a bit about that.

Dr Devika Patel [00:07:26] Yeah, 100%. I think you’re absolutely right. And talking about my own experience is the best way, because that’s why I can be an expert. And like I said, I can’t pretend to know about all the different nuances within the South Asian community in the UK or abroad. But what I do know is about my mum’s experience. So and this is really a revelation I’ve had in the last 12 months. So my mum went through the menopause around about 48, 49. She had really dysfunctional uterine bleeding before that. So that’s when you get really heavy periods before your periods stop. And that was associated with lots of mood changes. So she would become anxious and this was my mum, very high functioning before that, she would be up at 6am. All the cooking is done for the whole day, our lunches, our dinner, and then she would get on it and get everything so there’d be nothing that would be missed. And suddenly she was there fumbling at the checkout, trying to remember her pin or trying to kind of get her card out, get the right one out, and getting really anxious over the smallest things. And I thought, this is not right. But even at the time, I kind of just brushed it off and thought, you know what? She just must be stressed and there must be something else going on. I didn’t really pay attention. And that’s the thing. These signs are so slow and insidious. And then I started to just understand my mum as this person that gets anxious quite easily, can get stressed or can be irritable or can become tearful over something small. That was not my mum before, or can become quite angry, and it was like walking on eggshells. And I just thought, you know what? Maybe there is a lot going on in her life. She’s got three teenage girls to look after. Must be a difficult time, but only when I started reading about the menopause in depth. And that was a year ago. Even though I’ve been through med school, medical school, there wasn’t much teaching on it. I was able to connect those dots and be like, ‘Wait, that was her experiencing the perimenopause! And then when periods did stop, that was the menopause’, and that was ten years ago. And she actually was kind of offered HRT. And I asked her about this just a week ago. I was like, ‘What happened in that consultation? Why did you not go for it?’. She goes, ‘Well, I was asked if I wanted to go on it and the GP was brilliant and they said, ‘You know what, you should really give it a go. Your periods have now stopped, so go for it. It’s going to be life changing’. But she kind of just said, ‘you know, I’m not too sure about it and I’ll speak to my husband’. But she goes, ‘at that point, I really would have wanted the doctor to sit down with me and say, okay, these are the benefits of having it. And if you don’t have it, these are the risks of not having it.’

Lauren Redfern [00:09:54] Yeah.

Dr Devika Patel [00:09:55] Whereas she was kind of just told ‘have this, it’s recommended’ and when she said no it wasn’t really challenged. And I know that is a lot to ask for a GP in this day and age, when they have a set time limit to do a consultation. But that’s where her information, education of HRT started and ended. And at that time the news about breast cancer risks, that was all over the papers. I remember it quite vividly as well. So my dad’s reaction was ‘I’ve heard some of my colleagues talking about this and HRT is a no no’. So from that point forward, there wasn’t much discussion about it. It was just how to put aside. And even then it wasn’t like, ‘Oh, you’ve got menopausal symptoms, take HRT’. It was just the doctor recommended her HRT so take it. But there wasn’t that ‘you may be feeling this way, and that’s why HRT may be useful’. And again, just kind of drawing on like differences in culture and again not speaking for everyone. But I do feel that South Asians still follow quite a paternalistic style of medicine. So when the doctor says something, they will listen to them. So even though my mum said ‘no’ in that instance, because she was kind of like not too sure, sounds a bit experimental, risks sound a bit scary. She said no, but if your doctor is not proactive, then you’re not really going to challenge it. So I was thinking on the other side if my mum will actually – let me tell you the story now – so ten years on, I’ve said to my mum, I was like, ‘okay, you still have a lot of those menopausal symptoms and I’ve read all the stuff that Dr Newson has put out and it is worth considering if HRT is for you now and thinking about the risks and benefits’. Still has mood swings, sleep is poor, hot flushes still there. She’s tried to use lots of ways like diet and exercise, but still those things are still impacting her quality of life. Now she’s worried that it’s not bad enough to justify treatments or like.

Lauren Redfern [00:11:37]  Wow, interesting. Yeah.

Dr Devika Patel [00:11:38]  ‘I can cope. I can manage’. She’s like, ‘People don’t go to the doctor for this, do they?’. They do Mum. So it’s both about kind of empowering women to have that conversation. I’m feeling kind of like if they are told by the doctor it’s nothing, then they’re definitely not going to do anything. But it’s just feeling empowered by the medical system and taking it from there.

Lauren Redfern [00:12:01] Yeah. And I suppose also in the context of your mum there with that examples of appreciating that medical decision making also tends to maybe involve other people as well, whether that’s family members or a husband and her partner. You know, to know that there is still a level of sort of paternal hierarchy, as you said. So it doesn’t necessarily come down to the decision of one individual in that context and that maybe it’s important for medical professionals to recognise that in consults, that it’s not that straightforward for women to, in that instance, make that decision.

Dr Devika Patel [00:12:33] Yeah, definitely. Yeah, it is different… It’s a different cultural background. And what we can’t try to do is teach every doctor about every culture. But what you need to have is that cultural humility. Or if you see something, you’re like, I’m not too sure I communicated that so well, or the patient might not have understood what I was saying. Maybe I can do a reappointment and say, ‘Let’s just talk about it again. Why don’t you bring a family member along with you and we can discuss again’. Yeah so that’s a bit of a reflection on my mum’s kind of journey with the menopause and some of the things that I’ve learnt from it.

Lauren Redfern [00:13:05] Yeah, I was curious to hear your thoughts. I was reading an article recently that the author really spoke about the highly taboo nature of talking about mental health issues within South Asian community. And I mean, that’s interesting for yourself with your background in working in psychiatry, but they were specifically talking how in the time of perimenopause and menopause for South Asian women, if changes to mood are experienced, these will often be downplayed or ignored out of a fear of stigma. And really what the author was alluding to is that if the idea of menopause was discussed at all, be that with friends or family or partners or even a doctor, it would more often than not be a discussion focused on physical discomfort. So, you know, if you’re experiencing pain, if you’re experiencing hot flushes, those types of physical symptoms as opposed to psychological suffering. And what they’re saying is this is interesting because it can actually lead to mismanagement of menopause, where those psychological symptoms are not being checked in with or looked at or thought about in management. It’s just kind of being pertaining to the physical. And I just wondered, you know, what your thoughts are on that and how we can feel more at ease to discuss those changes that you might be struggling with psychologically and reduce that stigma.

Dr Devika Patel [00:14:19] Yeah, it’s a really hard one. So in my work I try to reduce the stigma of mental health. So the podcast is one of the ways I do that. I also go into communities and temples and do talks about mental health just so that I can start the conversation and kind of say, ‘Look, I’m a psychiatrist and when you go to your appointment, you will see someone like me that’s friendly, empathetic, compassionate, and who’s there to kind of listen to your problems’. So that’s one of the ways I’m trying to reduce the barriers for people to seek help. I actually think that if we gave the information about menopause and people started to understand that mental health can be one of those symptoms, they might actually feel safer talking about it because they’ll be like ‘Oh wait is this because of a estrogen deficiency?’. And the truth is, it might actually be depression, but at least it’s given them the opportunity to talk about it with their practitioner rather than not. And we know that kind of in the perimenopause or even kind of if they’ve not experience perimenopause and so just early menopause, it’s the mood symptoms and the mental health issues are the first ones to come out. So I really think it comes down to conversations and education, but those conversations need to be from within the community, with the community, rather than kind of going from the outside. And we’re saying this is the menopause but people from within. Because the truth is, I could go into a temple and temples are a hub for you’ve got your young families and then you’ve got your older generation. So I will find all my menopausal women there. So it’s just about asking the question, have you been through this? Well, tell them a little about it and getting them to start the conversation and talking amongst themselves. So after I’ve kind of spoken to everything, if I learn anything about mental health or anything to do with women’s health and relate to my mum’s age, I always make sure I have a conversation with her about it, really teach her about it. Cause I’m like, ‘Listen, when you go and meet up with your friends, it’s your responsibility now to share and spread that knowledge’. Because if I can tell you and you go and tell five of your friends, and then they will tell five more of the friends. It’s just this beautiful ripple of education which gets people talking. And I was like, ‘Do you know what? Your friends are probably going through the same thing, but everyone’s suffering silently. They just don’t know that the other person is going through it’. I was like, ‘You can talk to me and I can help you from medical point of view, but talk to your friends, the people that might actually be going through the same things. And then you can see what’s worked for each other and tell them about the HRT and tell them about the risks aren’t what they used to be and what they were kind of told that they were meant to be so bad’. So, I do think this reduction in stigma like with everything comes from conversations and those conversations help with education. Just on that point while we’re talking about that, the other thing I wanted to bring about was how a woman’s sex life is majorly impacted through the menopause. You are not really going to get a South Asian woman kind of having an appointment with their GP to discuss their sex life. Like I can just not imagine that happening. They like I would say maybe, maybe there’s like 10% of women that will feel empowered to go and do it, but they would just think like sex life, that’s a low priority for them. And again, I think then it becomes maybe the response of the clinician just to be a bit more proactive with the questioning to allow that question to happen and to make it comfortable. Like ‘we talk about this with all our patients. I just want to ask you, what is your sex life like?’ because there’d be so many things that could happen. A relationship breakdown could lead to low self-esteem. It could cause problems within the marriage, even if there isn’t a divorce or a separation. And that’s really, really difficult for women in their fifties. And she might live till 80, 90. It’s like half her marriage is still going to be kind of difficult. So, I just want to drop that in there.

Lauren Redfern [00:18:13] Yeah. And I think that really comes back to your first point in saying, I think generally we can say universally we’re becoming really aware that this isn’t an easy topic for anyone to talk about and for, you know, all women struggling or person experiencing perimenopausal or menopausal symptoms, it’s challenging to talk about these things with anyone, let alone a medical professional. And in my own research, I really noticed how those conversations actually happened when probing occurred. You know, it was often a conversation about mental health first or somebody presenting with anxiety. And then when asked about, you know, vaginal dryness or difficulty engaging in intimate relationships, that’s when that came about. But I think really kind of what you’re bringing out within that is that culturally that just isn’t the same. You know, you mentioning when we first start the conversation that there is no space to discuss periods or sex and menopause falls within that, so there’s that added barrier when it comes to having those conversations. And I think, you know, what I’m picking up on from our conversation today is sort of the issue of silence. And I think it really illustrates how damaging silence can be. And again, you know, coming back to this article that I read recently, that one of the things they were talking about is how South Asian women are actually, what we’re seeing is that there is an increasing prevalence of osteoporosis, diabetes and heart disease. And one of the arguments that the author was making in this is saying it’s rising because we’re tending not to talk about these things. And so a quote from that was, ‘whether it’s miscarriages or periods, you’re just meant to get on with it and not talk about it’. And I’m curious what your thoughts are on how we can address this silence and actually empower South Asian women to feel more confident and comfortable, not only talking about their experience, but feeling able to seek treatment. You know, moving that silence from talking about it within the communities of friends, but also feeling confident to go to their healthcare professional.

Dr Devika Patel [00:20:09] I think, again, because I’ve thought about this in terms of mental health and the stigma, and I think the same principles can be applied to the menopause. It’s about people having the conversations within their communities, the communities making space for that. So number one, the community needs to prioritise that women’s health is important, women’s mental health is important. And they are such valuable members of this society and this community that we need to make sure they have a protected, safe space where they can have these discussions. Then it needs individuals like myself to take responsibility and say, ‘I’m a member of this community. I know this knowledge’, okay I’m not a menopause expert, but I know enough to inform these women about what menopause is and what treatments are available and show them things like the balance app, like Dr Newson has created everything. Now it’s about us using those tools and everyone that has any interest in the menopause going to our own communities, whatever that may be, whether you’re going to your church and it’s an Afro-Caribbean community or you’re going to the temple and I’m going to South Asian women. We need to tap into these places. And I can keep saying, ‘Oh, change needs to happen’. Really, a change starts for me from people, from the community. I need to say that actually this isn’t happening and I can see it because I’ve seen in my mum’s own experience, I need to now stand up and make a change.

Lauren Redfern [00:21:30] Yeah. And I mean, I think, you know, I liked actually in the example of your mum that what you noticed is, you know, your background is working in psychiatric medicine and you know, you’re talking about is maybe it is depression, anxiety, but what you really noticed for your mum was it was a stark difference and a stark change that wasn’t picked up on. And I think, you know, prior to us speaking today, one of the things you were saying is there’s often maybe a confusion with what women are going through at that time, being thought of as empty nest syndrome as opposed to this is perimenopause or menopause. So almost elevating one cultural phenomenon over another. Yeah. And I wondered if you might want to talk a bit about that.

Dr Devika Patel [00:22:09] Yeah. That’s really, really important thing to talk about because there’s also something else that I picked up during my training and actually looking back on it, it leads to lots of health inequalities and is a very racist stereotype. So there is a ‘syndrome’ called Begum Syndrome or Bibi syndrome. And if you’re in the medical profession, you would have heard of it. It’s not something that’s ever written on records. It’s not an official diagnosis, but it’s given to… So Begum or Bibi is a traditional surname given for a Bangladeshi or Pakistani woman. But actually this syndrome can be given to anyone that looks vaguely Asian. And basically it would be when someone presents with non-specific pain, all their blood tests are normal, on examination, can’t really find anything. They might have headaches, might be tired, might have some memory issues. So lots of vague, non-specific symptoms, a bit like what you see in menopause and then they’re always kind of aged like 40/50 and there may be a language barrier and they might turn up even to A&E because they feel so dreadful with it. And your doctors will be like, ‘Oh, we’ve just got another Begum Syndrome in cubicle eight, so I’m just going to send them on the way with some pain relief. And -.

Lauren Redfern [00:23:19] Wow.

Dr Devika Patel [00:23:19] That just means that that person… no one’s really.. I’m thinking about all those patients that I’ve heard that term being used for and I’m like, number one, it could have been anything else. We haven’t really treated that patient properly because you’ve just put her into that stereotype by literally looking at the first sign of her history, you would have stereotyped that person automatically and put her aside. And that could easily be the menopause because it just ticks all the boxes. And the reason why they kind of go to that is because they say it’s a psychosomatic illness, because women at that age, they might feel a lack of identity and purpose because their children have moved on and things like that. So the truth is, yes, mental health problems do manifest when there is changes in roles because it’s almost like a grief reaction. But these changes are happening at the same time as menopause and people are not having their periods in the perimenopause. So you cannot just decide which one it’s going to be. And like you said, you can’t put so much emphasis on one, but as medical professionals we need to be holistic. So yes, we need to look at the psychological problems that may be causing a person to have psychosomatic pain. You also need to look at whether this is an estrogen deficiency and they’ve stopped having their periods. Did anyone ask her that? Probably not.

Lauren Redfern [00:24:35] I mean, I think this also just demonstrates generally the sort of prejudicial space that we live within where we’ve created an entire different syndrome, right, as well, that we might be more willing to consider that if it’s somebody that looks like what we see and I think it’s getting better but generally, you know, when we think about this idea of perimenopause or menopause being a white Western issue, everything we see to do with menopause is generally white and western. So it doesn’t lend itself to saying this affects all communities. And I think that’s kind of what I’m really trying to pull out from today is that, yes, there are barriers involved, but we also need to look within our own cultural representations to say, how are we actually demonstrating this to be a universal issue for all persons of that age group and demographic as opposed to a specific cohort. And I think it really brings attention to that in saying we have a completely different, you know, something that generally is presenting, exactly as you say, as perimenopausal or menopausal symptoms, and it’s just being missed completely. And I did a podcast with Sarah Ball about this where she was saying it’s not uncommon for people to present actually in A&E with symptoms of perimenopause and menopause. So, you know, what you’re saying isn’t an anomaly that happens quite often, but the fact that we sort of have this separate category for women. Yeah, is really quite shocking. So we’ve talked a bit about stigma and we’ve talked a bit about language within that and being able to talk about these things within the community. But I wondered if there were any other major barriers that you think are important for us to discuss when it comes to really seeking treatment and care for perimenopause and menopause, if you are, you know, from South Asian community.

Dr Devika Patel [00:26:09] I think one of the other things is what really struck me when you were reading your introduction, when you spoke about that actually is women may not suffer as bad symptoms because of their diet and their social situation, their cultural backgrounds. I actually think that there may be some truth in that because when you look at the lifestyle kind of solutions to the menopause, you’re not looking for HRT. All of that is to do with having a good, healthy lifestyle. And when you go back to the root of things like  ayurveda, which is an Indian ancient practice, they all look like that. Make sure you’re getting exercise, you’re doing mindfulness and breathing, exercising, you’re doing some weight-bearing training, you’re eating well, you could say all those things are in there. So actually, I think maybe this is just me just hypothesizing, hundreds and thousands years ago, women would have been able to manage the menopause much better. So there’s probably this myth in their minds that, ‘Oh, look, my ancestors did okay, we’re okay’. But we have to appreciate that we’re now living in a Western, we’re living a Western lifestyle. Like my great grandma would have made the food that she picked in the field that day. That’s how fresh it would have been. But that’s lost by two generations. That’s lost now. I buy my food from the supermarket and I cook it.

Lauren Redfern [00:27:27] And I mean, I think also and within that introduction, really the thing I’m trying to emphasise is that research isn’t suggesting that anymore. And where it comes from is also from a cultural research perspective. You know, there was this whole body of researchers, actually anthropologists, that were talking about how women in these contexts don’t experience the perimenopause or menopause. But actually kind of what we’re looking at now is saying, is that correct or is that actually that there isn’t the language to discuss it in the questions that you’re asking? And I think you’re right, there are all of those factors that make it easier to manage, but it doesn’t mean it’s nonexistent. And I think this sort of dichotomy of either experiencing or not experiencing just isn’t relevant. And it may be that and I think we talk about this a lot on the podcast, that there is no universal experience of perimenopause or menopause, but that doesn’t mean it doesn’t exist.

Dr Devika Patel [00:28:16] I’m kind of just picking up on that. It seems a bit unnatural to take a medication to help you with something that’s natural. So Asian women think menopause is natural like periods. You just have to just have them bear them, grin and bear, it is fine. Lots will not even seek help for endometriosis, they’ll just be like ‘Well periods are meant to be painful, it’s fine’. So similar with the menopause, they’ll be like, ‘They just stop? This is what God has created. Our bodies will stop menstruating and that’s fine. We just have to grin and bear it’. So I think some more education around it actually that might have been fine when we lived, life expectancy was lower, but now we’re number one in a western society, we’re living different ways, we live longer and there is the science to back it and we’re just putting estrogen back into our body. It’s not unnatural. This is what our body naturally produces, and that’s what we’re just giving it and treating it like a hormone deficiency rather than being like this is medical treatment. Because I almost feel that there’s a bit of it feels over medicalised, and South Asians kind of are still rooted in their ancient medical practices, which is everything is natural. But when I think about HRT, I think of it very much as a natural treatment for a hormone deficiency. So I think maybe if the language has changed, it’s not so medicalised. Then these women will be more open to the idea to even have the conversation. I’m worried if we just go in there with the information, HRT have it. This is good if you’re menopausal, I don’t think it’s going to hit right. Again going back to language, we’ve got to change your language so that it’s appropriate to the culture and what they’re understanding of medicine, illness, treatment is and then take it from there.

Lauren Redfern [00:29:49] And I think also appreciating that the two can co-exist. Right? And also for some people, you know, for some people, they may be able to manage their symptoms, but for others, for others that aren’t I always think there’s almost the frustration of going this emphasis on naturopathic techniques to manage our symptoms. You almost feel women can end up feeling very guilty and almost like, what’s wrong with me if I’m unable to get through this or deal with this without HRT? And actually, I think it’s going, you know, the two coinciding can be helpful.

Dr Devika Patel [00:30:17] Yeah. And just giving those options, making it possible for people to choose what they want to do.

Lauren Redfern [00:30:21] I wondered just sort of briefly what advice you would have for healthcare professionals when it comes to remaining cognisant of particular barriers facing South Asian patients, when it comes to talking about the perimenopause or menopause, what really healthcare professionals can do to support in overcoming these barriers, but also, you know, remaining aware of when they’re having appointments and consultations with patients.

Dr Devika Patel [00:30:45] Yeah, I would say the best thing to do is to assume your South Asian patient doesn’t have knowledge of menopause, perimenopause or HRT. Just go with that because there’s no way of doing too much. You’re just going to assume that their knowledge is non-existent because they may have some knowledge, but we don’t know where that has come from. And if it’s up to date, or if it’s just going to be HRT equals breast cancer. So it’s about re-educating and just assume that the knowledge isn’t there and then also get the family involved, get the husband involved, even get their children involved and see if they want to reattend the appointment with them or if it’s a telephone appointment, see if they want to reschedule it with another family member present. When there’s a language barrier, definitely get an interpreter. There’s even, because there’s no word for it 100% you need an interpreter to just go through the signs and symptoms and see if it relates and just be so aware of any biases that you have. And if you’re thinking Begum Syndrome, replace that with the menopause and just see, to see what happens and if you get anything out of it. And then finally, proactively ask about sex life, mental health symptoms because they are not going to be the ones. And I do find that South Asian women overall minimise their symptoms. My mum will be like ‘I don’t need to have that appointment for the HRT’. I’m like, ‘How bad’s your sleep?’ And she’s like ‘I haven’t slept five nights in a row out of seven’. I’m like, That’s pretty bad.

Lauren Redfern [00:32:09] Yeah.

Dr Devika Patel [00:32:09] So they’re going to minimise. So whatever they tell you it’s going to be worse. So just be really proactive with asking the questions upfront. Don’t expect them to tell you everything just because they don’t mention mental health. They might be some really debilitating anxiety or depression or even suicidal thoughts like no one’s going to come and accept that there is so much shame and stigma around mental health. They’re not going to come to the appointment, say, ‘I have suicidal thoughts’, so just need to bear in mind.

Lauren Redfern [00:32:35] Yeah. And I mean, I think it’s to be honest, I mean, your best practice tips are great for all patients and that is what it should be doing. I really do think that’s an interesting one to be aware of is also just really appreciating that for lots of people in different communities, decision making when it comes to our health is not based always on the individual and it does involve shared decision making within the family. And I think kind of reconditioning ourselves to understand that and appreciate it and not think of it as an inconvenience, but just an accommodation of somebody’s culture is really key.

Dr Devika Patel [00:33:04] Yeah, yeah. Like my mum will always ask me. Even my sisters will ask me obviously because I’m a medical professional, but generally we tend to make decisions as a family. We don’t do things on our own. We like to be involved in a supportive way and support each other. So see as that rather than, ‘Oh God, there’s another person I need to explain it to’. Because whatever’s happening, they can give you that collateral, they can give you more information is just much easier. That’s how I approach my patient’s mental health. The more the merrier. I know the GP practice isn’t able to do it as much, but just try to give the patients the option and see what you get from them.

Lauren Redfern [00:33:37] And I suppose it’s a case of also appreciating that if somebody is quiet or withdrawn or not really responding, it’s about really looking at your own way of communicating and thinking clearly something here isn’t working. So I need to really look at what that would be for that patient and talk to them about the needs that need to be accommodated in that.

Dr Devika Patel [00:33:53] Yeah, yeah, definitely.

Lauren Redfern [00:33:55] I think sadly Devika, that’s all we’ve got time to discuss today. And I really want to thank you for joining me and participating in what I’ve found, a really fascinating and interesting conversation. And I just wonder if we could end with, if you have any takeaway messages for those listening, any particular points you’d like to stress to our listeners?

Dr Devika Patel [00:34:11] So I hope there’s loads of South Asian women listening to this and hearing that menopause happens to everyone. It does not choose by skin colour, race, religion and those things do not protect us from the menopause. We are all vulnerable to it. So start having these conversations with whoever you feel comfortable with, whether it’s your daughter or whether it’s your friends, whether it’s your husband. Then get the app so you can download it, have a look at it, do some more reading, educate yourself, empower yourself, and if you need to, then book that appointment with your GP and get all the support you need from your friends and family to get yourself there. But remember that the more we talk about it, you’re not only helping yourself, but you’re helping the whole community around you.

Lauren Redfern [00:34:52] That’s great. Well, thank you so much Devika I look forward to chatting with you again soon, particularly when we talk about mental health in psychiatry.

Dr Devika Patel [00:34:59] Thanks so much.

Lauren Redfern [00:35:03] We would love for you to join our collective of professionals passionate about the menopause visit and each menopause society dot org to become an associate. You’ll receive regular webinars and advice from our experts as well as opportunities to network and connect with the latest research from around the world. You can follow us on Twitter @NHMenoSociety. And don’t forget to tell your colleagues about the Newson Health Menopause Society.

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