Women´s experiences of menopause: A qualitative study among women in Soweto, South Africa

ABSTRACT

Women today are experiencing menopause for decades more than in previous generations. This ‘change of life’ is defined by an entire stage of physical, hormonal, and emotional changes that accompany menstrual irregularity and the cessation of fertility, although limited medical research has focused on it. Yet, the inevitability of menopause is universal for all human females around 50 years old. In this article, we conducted twenty-five 20–60 min semi-structured qualitative interviews. Most women marked menopause by fertility cessation and social transition to old age, pushing back against a medical framework of menopause that emphasises hormonal deficiency and becoming disordered. In contrast, women frame menopause as a natural process that contributes to a critical social role transition, which they perceive as deeply private in part because it is associated with a reduction in femininity, sexuality, and power. On the other hand, menopause was also described as a liberating process through which women no longer needed to purchase pads or manage blood loss. Recognising how women may perceive menopause not as a deficit or disorder but as a social role transition that has both costs and benefits is useful for medical practitioners when discussing clinical options.

KEYWORDS:

• Menopause
• aging
• postmenopause
• culture
• medicalisation

Introduction

Today, women live longer, often healthier lives than the generation before them. These decades involve the experience of menopause or a ‘change of life’ that is defined by an entire stage of menstrual irregularity and the cessation of fertility. As a physical life history of menopause, the experience is universal: it occurs midway through the lifespan of human females and consistently occurs around age 50 around the world (Ebong et al., 2014; El Khoudary, 2020; Xu et al., 2020). For centuries, biomedicine has framed menopause as pathological, characterised by an oestrogen deficit, or as a metabolic and biochemical disturbance (Brincat & Studd, 1988; Lock & Nguyen, 2018). In 1777, John Leake published a book, Chronic or Slow Diseases Peculiar to Women, describing the various chronic diseases that appeared in women at this critical time in life and blaming the ‘disorders’ on women’s ‘irregularities of passions’ (Leake, 1777), cited in (Pavelka & Fedigan, 1991). Within the purview of biomedicine, understanding menopause simply as a deficit of the physical body, provides opportunities to standardise this physical process of the aging female body without considering how different cultures and beliefs may mediate experiences in menopause and bodily experiences through these biosocial changes (Crews, 1993; Lock & Nguyen, 2018). Moreover, the biomedical view of menopause requires pharmaceutical intervention, such as hormone replacement therapy (HRT), to ‘fix’ the female deficits to sustain a pre-menopausal physical state.

Yet, as Margaret Lock (1995) argued in her pathbreaking book Encounters with Aging, ‘menopause is not a “fact,” and hence it cannot be neatly packaged or contained in a single precise term that transcends time and space, history and culture’ (xviii). In many cultures, people view menopause as a social status of esteem and wisdom, thereby elevating their social role in society at large (Alidou & Verpoorten, 2019). Understanding this dissonance between how people think about menopause – as positive, negative, or normative, is imperative in part because, in biomedical contexts, there is a stigma surrounding menopause through a negative or deficit view (Christensen & Pike, 2015; Cross & Lovett, 1994; Georgakis et al., 2016; Heidari et al., 2019; Lobo et al., 2014; Rossouw et al., 2007; Sheehy, 1992).

Much of the research on menopause has been conducted in western contexts and in relation to contexts that rely on biomedical care and frames for thinking about aging and disorder (O’Connor et al., 2009; Schoenaker et al., 2014). Historically, western biomedicine has been influenced by cultural norms about women’s demise of fertility, often regarded as ‘an illness that disturbed the body and deranged the mind’ (Cleghorn, 2022, p. 179). In some sense, women’s social purpose (e.g. of reproduction, and mothering) was perceived to end, and therefore they were perceived to become somewhat dangerous or deranged – and nearly every physical or mental disturbance observed among older women was tied to their diminishing fertility (Ibid). This dominant Western cultural belief permeated medicine’s priority of treating menopause as a disorder needing HRT in part because menopause was framed as an unattractive and emotional period women should want to delay (Ballard & Elston, 2005; McCrea, 1983). This frame was embedded in a cultural prominence of youth as the definition of beauty (Ballard & Elston, 2005; Cleghorn, 2022; Perez, 2019).

This deficit view, however, is not maintained globally among women or in healing systems (see Sievert, 2006). Women navigate their social worlds differently across contexts, and this might be understood generally to relate to the power women hold in society, the sociality maintained among women, and in relation to institutional powers, especially the influence of healing frameworks, from Western biomedicine to eastern medicines and traditional healing systems (see Sievert, 2006; Sievert & Obermeyer, 2012). There are three major distinctions that one must consider to understand how an individual or group might perceive menopause: first, how people mark menopause (from rituals to social positionality); second, how women conceive of menopause (as a distinguishing marker of a life lived, or a loss of reproductive power); and third, how women experience and respond to changes in the body associated with menopause (as a natural process, or a medical irregularity). These three distinctions differ meaningfully from place to place and through time.

We set out to investigate women’s perceptions and experiences with menopause in Soweto, a township of Johannesburg in the midst of South Africa’s first year of the COVID-19 pandemic. During this time, most people were in forced or voluntary quarantine and unable to work; therefore, we had ample access to conversation via phone. The 25 women we recruited for this study were already enrolled in a larger parent study (see Mendenhall et al., 2022). In these follow-up interviews, we sought to investigate women’s awareness of menopause, how menopause is felt physically, and what this life transition means personally as well as socially.

Materials and methods

Study setting

This study was conducted in Soweto (SOuthWEst TOwnships), a region that was formally designated by the South African government to accommodate black residents who were working in gold mines in Johannesburg and had been forcedly removed from ‘white designated areas’. The region has grown substantially over the past century, with nearly two million residents today, a growing economy, and a large number of intergenerational middle-class homes, where families have now lived for three generations. Most people have piped water, electricity, completion of some or all secondary education, and is relatively wealthier than other ‘townships’ in Johannesburg (Zuern, 2011). Soweto is characterised by vibrant cultural diversity, with families often speaking one or more languages, from isiZulu, Setswana, Sesotho, isiXhosa, and Xitsonga, mixed with English, and Afrikaans. Yet, like many other South African contexts, a history of systemic racism that was intensified during the apartheid period has led to systematic and reinforcing social, economic, and health inequalities among many residents see (Coovadia et al., 2009).

This study was conducted as a sub-study of the broader Soweto Syndemics Study (SSS) (Mendenhall et al., 2022). The first phase was a surveillance study, and we recruited (n = 957); of whom 626 participants were women. Then, three follow-ups for data collection were completed during the COVID-19 pandemic from 2019 to 2020, including a study of in-depth interviews about living with multiple chronic illnesses (see Mendenhall et al., 2022), an interview about mental health, perceived risk, and COVID-19 (see Kim et al., 2022), and a study of flourishing amidst multimorbidity (Cele et al., 2021). This current study (Phase 5) was conducted in 2021 and focused questions associated with menopause and COVID-19. We invited women who had participated in phases 2 and 4 of the study, and 25 were agreeable and available to participate in this follow up study from May to August in 2021. We conducted the study mostly over the phone because we were in lockdown due to high transmission rates of COVID-19 in Soweto. The SSS was approved by the Wits Human Research Ethics Committee (medial) (HREC) on 03/08/2018 with the ethics number (M180544). Phase 5 was also approved by Wits HREC on 29/03/2021 with the ethics number (M210101).

For this phase of the study, the first author conducted 25 in-depth (semi-structured) qualitative interviews over the phone that lasted between 20 and 60 min. Women gave verbal permission to record the interviews. We began the interviews by asking women to define what they think health is (this was the same question asked to the same women in 2020 in the SSS). Then we inquired about age, perceptions of aging, definitions for and perceptions of the word menopause, feelings about aging, and how women conceived aging and menopausal symptoms amidst other chronic health conditions. We also asked pointed questions about COVID-19, as we were still in the midst of the emergency period in lockdown. We asked women specifically for words they used to describe menopausal transition: ‘What words do you use to describe what happens when a woman gets older and stops having her period?’ We followed with questions like: What is menopause? What words do you use to describe this? Can you tell me about your experiences with this? Do you know anyone who has gone through it?

Data analysis

All interviews were audio-recorded and transcribed directly into English. However, some vernacular terms were not translated for the interest of the study, such as different definitions of ‘menopause’, because we wanted to identify the vernacular terms women used for menopause. We used the inductive thematic analysis to identify recurring themes from the in-depth interviews following Braun and Clarke’s 6-phase guide (Braun & Clarke, 2019). We used codes to identify common and recurring themes. Another reviewer coded five transcripts, which were then coded by the first author and later reviewed to reach a consensus. The first author proposed codes, provided definitions, and then reviewed and revised codes based on mutual agreement with the additional reviewer. Together we synthesised these data and organised themes, quotations, and interpretation of these emergent themes.

Results

The mean age for women in the study was 49.6 years and 20 women reported being postmenopausal while five were pre-menopausal. From the 20 women who were postmenopausal only 16 recalled their age at final menopause. The mean average age for age at final menstruation period reported was 47.6 years. Nine women had type 2 diabetes, 11 were hypertensive and 8 women had a comorbidity of hypertension and type two diabetes. Seventeen women had finished primary school, five had secondary education and only three had tertiary education.

Understandings of menopause transitions

In what follows, we discuss how women defined health and knowledge they shared about menopause, which was both biomedical and cultural. Women often defined health and disease through their descriptions of chronic conditions, living and dying, as well as aging. A woman in her fifties stated, ‘When I’m thinking about my health, I’m always saying I’m healthy, that state because I do not have those “chronics” my dear, you understand, I don’t have high blood, diabetes, you know, I tell myself that I am healthy.’ While many people described lack of health in relation to chronic conditions, many others related it to fear around living and dying, such as a middle-aged woman who said, ‘I think of dying, losing my life and leaving my child alone’, leaving her child alone was her greatest fear. A woman only slightly older explained how chronic diseases (in her case, diabetes) were entangled with stress or ‘disagreements in the household’.

Women used several idioms for menopause, often referring to the social and natural ageing transition. Table 1 shows that terms women used to refer to menopause mostly looked at menopause as the ageing process. Six women reported that they did not know any term used to describe the symptoms associated with menopause; however, when a follow up question was asked about how the community say about a woman who is menopausal, the women said that to indicate that life transition, they simply used the term ‘old age’. In addition, the term amahot flashes was used by women as a synonym for menopause although hotflashes are a symptom of flashes. Using the terms women use for menopause enabled us to try to understand their own personal view of menopause.

Table 1. Words used to refer to menopause (n = 25).

	Word used for menopause	Language
1.	Ugugile/Ukukhula/ukhulile (Growing older)	isiZulu
2.	Sekhulile (Grown)	isiZulu
3.	Uyekile ukuya exhesheni (No longer having periods)	isiXhosa
4.	‘amaHot flashes’ (hot flashes)	(Taken from English)
5.	Getting old	English
6	Menopause	English
7.	Izinto zamantombazana (things for women)	IsiZulu
8.	Into zabogogo (Grannies´stuff)	IsiZulu
9.	The person has grown up, they are no longer fit to share the bedroom with the husband

Many recognised that menopause experiences vary among women. One woman in her late forties stated, ‘I wouldn’t know [what menopause is] as we do not have the same bodies, some are slow, and some are fast.’ Another woman in her late sixties stated, ‘Isn’t menopause like pregnancy its different, women get pregnant at different ages and experience it different.’ A 50-year-old woman explained about menopause, ‘It just happens; one gets it after some time’. A postmenopausal grandmother around 60 years of age, stated, ‘Eish, you are asking me questions that I do not know, that I do not understand, I do not want to lie to you.’

Most women suggested menopause was not a term they thought about, had learned much about, and hardly talk about. Another elderly woman mentioned,

You know I don’t know menopause properly, I don’t understand it properly, other people say that when you stop going on your period, you’re in menopause, but I don’t understand menopause. […] I don’t understand it because sometimes people speak in such big English, so you don’t understand it, unless someone explains it to you.

A young woman who was breastfeeding at the time of data collection stated, ‘No sister, I don’t know, I have never received any health education about menopause.’ A few women opted out of the interviews, explaining that they did not know much about menopause.

Many women conveyed the belief that talking about menopause, or women’s aging bodies, was somewhat taboo. Only two women reported that they could talk freely about menopause. Three mentioned that they talk to friends about these changes. Most believed such bodily transitions are private and should not be discussed with anyone, with the exception of one’s mother or daughters. For instance, one woman said, ‘I think that it is a private thing; you should not go around telling people that you are in menopause because some people don’t even know what menopause is right.’ Another participant stated, ‘Because we as women think that period matters are private. We do not like to talk about them usually.’ A young woman said, ‘I think us as black people, our background of talking about other things is limited. And the fact that maybe the lack of knowledge of certain things you know, makes it even more difficult for you to engage with other people.’

Premenopausal women´s perceptions of menopausal women

We asked women who identified as premenopausal on their perceptions of menopausal and postmenopausal women. Some premenopausal women suggested that menopausal women isolate themselves from younger women. A woman in her thirties said, ‘So I think they isolate themselves and relate with older people.’ One premenopausal woman in her forties indicated that menopausal women should pass down their knowledge, ‘I think they must share with other people. Remember most of us women do not share such information.’ Another premenopausal woman reported, ‘I think that they throw tantrums easily, they are stressed people, they are miserable, it is just negative things around them when you go through that period.’ A 60 year old woman living with HIV, hypertension, and diabetes, described how she went through menopause at 40 and worried because her mother passed away: ‘It worried me because my mom died a while ago so I was going to ask her why I menopaused so early, like what happened.’ The first author asked, ‘Did you go to the clinic to ask?’ The woman described how she felt uncomfortable discussing such intimate experiences in the clinic, saying, ‘No, I didn’t think to do that, isn’t it the nurses like shouting at people?’

Postmenopausal women attitudes on menopause

Postmenopausal women were more positive about menopause compared to premenopausal women. They saw menopause as liberating and a cost-effective period where they did not have to buy pads and could wear anything. One postmenopausal woman stated that,

The Good thing is no longer having to stress about buying pads and the stress of washing now and again. Going through this on a monthly basis. The protection process that comes with it, you know that you are free now and no longer need to put on pads.

In contrast, premenopausal women worried about losing their sexual desire when they reached menopause.

The physical experience of menopause

Women were asked about the symptoms they experienced during menopause and for premonopausal women what they thought happens to their bodies during menopause. Most women described how their periods stopping was a sign of aging. Few women associated chronic conditions with menopause: one had diabetes before menopause and eight developed diabetes after menopause. However, only one participant stated that she blamed menopause for having diabetes, ‘I think that menopause made me become diabetic, I think that because of since I started taking the high blood medication, I never had diabetes; so I think that now that I’ve menopaused and it came after that, it’s because of it you know.’

A few women stated that obesity caused blood to stop flowing in the body and might result to menopause. A young woman in her thirties stated, ‘It blocks you from having your normal period.’ Another elderly woman in her sixties suggested, ‘Isn’t it your knees are suffering because of the extra weight, so even your womb starts getting painful as well?’ Other women saw periods as a way of the body cleaning itself, such as a woman in her sixties who stated, ‘Your blood is usually fresh if you see your period regularly. You do not pick up issues with anything but if you do not see your period, your body also suffers.’ Women also associated abortion, giving birth, and miscarriages with menopause, linking blood loss with becoming menopausal,

I saw myself with a firstborn boy, and then I tried after, and it was a girl, the third one was a girl as well, we were trying for a boy … I do not want anything anymore, my blood is running out, that is what I was telling myself, that my blood is running out.

Another woman in her forties stated, ‘early menopause happens maybe if someone has numerous abortions and even the issue of miscarriage, blood runs out.’

We asked women to define the physical experiences they experienced, and thought were menopause related. Hot flashes were described as the most severe symptoms experienced, as a grandmother in her sixties stated, ‘It did happen to me maybe for three days and I was feeling like, if only I could go inside a bathtub, that’s ice cold, I was so hot, I was literally burning.’ Other women described cramps, swollen feet, and headaches (see Table 2). A woman in her sixties said, ‘At first, my womb was sore, and I had lower back pains and headaches. I figured that was the reason I stopped seeing my period.’

Table 2. Menopause symptoms.

	Menopause symptoms
1.	Bulging belly (80%)
2.	Lower back pain (71%)
3.	Cramps (70%)
4.	Headaches (60%)
5.	Skin change (50%)
6.	Cravings (45%)
7.	Swollen and painful feet (40%)
8.	Wounds (30%)

A sign of disorder

Women were asked their perceptions on the age of menopause. Late menopause was conceived as a sign of disorder. Most women stated that when they first reached menopause, they panicked as they associated the phase with cancer or pregnancy. For example, a woman in her sixties stated that; ‘When I stopped my period, I was scared as that usually meant you would be pregnant or have cancer.’ A woman in her late fifties stated that,

Uh, sometimes we chat with friends and other women that when such a time comes you no longer go on your periods, but it’s natural; like if you were to go on your periods at maybe 50, maybe you may have cancer in that case, so it’s not something that one must be happy about being on their periods when they’re older, you’ll think things are okay when in fact something is going wrong somewhere.

Menopause and sex

Aging, sex, and menopause were tightly connected: many women relayed how menopause was a period where most of their relationships with their partners come to an end. A woman explained how, during this stage, women would not be sexually active: ‘An older woman should not sleep with her husband because she will have a bulging stomach.’ Women explained that according to their tradition, sex with men would lead to them having bulging stomachs where dirt accumulates, causing sickness or for them to become impure. For instance, another woman in her fifties stated, ‘When you are in menopause, you need to use a condom because you will get your partner sick.’ Others believed that having sex makes them sick, ‘Isn’t it when you no longer go on your periods you find that when you have sex you have stomach cramps or what, ja that’s what you’ll find.’

Health system care and treatment

Most women were unaware of HRT. When we asked about HRT, many women dismissed the idea that menopause should be medicated because it is a natural, as opposed to a medical, condition. A woman said, ‘It’s natural, there’s no treatment,’ and another stated, ‘It is normal, it is not a sickness. It is a stage you must reach at some point.’ One woman mentioned she used ‘tea’ from her church, which helped her from experiencing menopausal symptoms. ‘I no longer feel any symptoms in my body as the tea is working well.’

Women also perceived nurses to have minimal information about menopause. One woman in her fifties stated,

So some of the answers, even though we are not well informed, we can tell that it’s just assumptions, you know … Well, they’re nurses so you need to listen to whatever they’re saying; when you look at it, you can see that they are wrong.

Women stated that, at their local clinic, they were not given much information about menopause. An elderly woman in her late sixties stated, ‘They said that this process stops when you are older to indicate that you can no longer bear children, and everything is closed.’ Another woman in her fifties stated that; ‘They only suggested that I come regularly for a Pap smear check-up.’ Another woman again showed her frustration with the health system by giving an example of her chronic condition;

I have more than 15 years having diabetes, and every time, they tell me that my sugar levels are high … they ask what I ate? I ask them what it is that I’m supposed to eat, but they won’t tell me.

Women also indicated that the clinics were sometimes noisy, and it was difficult to hear the nurses’ advice. These experiences at public medical clinics also led women to conclude that there was no medication for menopause symptoms available.

Discussion

This is one of few studies that has addressed the perceptions and experiences of living through menopause in sub-Saharan Africa. We found three major findings: first, women marked menopause by the cessation of fertility and the transition to old age; in many ways our interlocutors resisted or pushed back against a medical framework of menopause that emphasises hormonal deficiency and ill-health. Second, women conceive menopause to be a natural process that diminishes their social roles in some ways leading them to see menopause as a private affair, which is amplified by a reduction in femininity, sexuality, or power, and amplifies their social roles in other ways, such as through a liberation from buying pads and managing monthly blood loss. Third, most women in our study reported that they had diabetes after menopause. We discuss major findings around perceptions and experience of menopause, in turn.

First, we found that many women were not familiar with the word menopause and were resistant to discuss it in a medical way. In many cases, women were adamant that menopause should not be medicalised, pushing back against the idea that it was a disease, illness, or non-natural event (Ballard & Elston, 2005; McCrea, 1983). The conceptualisation of menopause as an accompaniment to aging has been found broadly throughout studies across the African continent, including other studies in southern and West Africa (Adanikin, 2013; Alidou & Verpoorten, 2019). These juxtapositions of the body’s heat, openness, and wetness illuminate how women conceive of the physical body as fundamentally transformed. Hence, as opposed to conceiving menopause as a ‘loss’ of fertility (Lebese et al., 2014), it is perceived, at least among the women we interviewed, as a physical transition toward a calmer and quieter physical experience that is ‘normal’ where your ‘blood is running out’ and ‘everything is closed’.

Like a small body of research on menopause in Africa, we found most women perceive menopause through a social, rather than a biomedical, lens (Adewuyi & Akinade, 2010; Anolue et al., 2012; Faye et al., 2014; Jaff et al., 2020; Makuwa et al., 2015; N. Ramakuela, 2015; N. Ramakuela et al., 2015; N. J. Ramakuela et al., 2014). For example, some women in Nigeria consider menopausal symptoms a ‘natural’ process (Adanikin, 2013; Alidou & Verpoorten, 2019) and few people recognise biomedically defined menopause and HRT (of the need for it) (Anolue et al., 2012; Faye et al., 2014), and this was true across ethnicities and generations (Adewuyi & Akinade, 2010). These may be the driving reasons for such low use of HRT in Nigeria; it may also be that women resist a lifetime of medications, or they are not a target for pharmaceutical markets. Few studies have investigated how South African women perceive and experience menopause or related symptoms, although one study suggested people perceive it to be a punishment from God (Adanikin, 2013). One study in rural Limpopo found women linked menopause primarily to normal aging, such as one woman who said,

Old age is bad, look at my skin is becoming wrinkled and no longer shiny and firm. You know I used to be very big and fresh and now I have lost weight I look wasted. My breasts were so big and nice, my children would get enough milk from one breast, but now they are so thin with no flesh. My big curves and bums are gone with old age [uttered by a frustrated post-menopausal participant]. (N. J. Ramakuela et al., 2014)

Women´s experiences at the clinics might play a role in many women’s pushback on the medicalisation of menopause. Many women were lower income and may rely on public health care, which results in longer waiting times to see a primary care provider with shorter consultations (MacMahon et al., 2018; Mercer et al., 2016).

Second, menopause was perceived to be a private affair that was shared with one’s most intimate female family members or friends, which they discussed with age (as opposed to with younger family members). Modigh (2020) states that in South Africa, a culture of silence is associated with menstruation and women partake in this journey in their own. This was partly because menopause was described as ‘clean blood and dirty blood’ and a private experience. Women in our study shared the same sentiments where menopause was seen as an individual experience that women might not share widely, although women shared information about menopause within their most trusted circles. Ramakuela (2015) found in Limpopo that women often described how crucial their female relations were during this physical and social transition, which these social networks also work to amplify taboos about menstruation, such as the belief that sex in old age would cause their bellies to grow and explode due to a build-up of dirt in the body (Drew et al., 2022; Lebese et al., 2014; Makuwa et al., 2015; N. Ramakuela et al., 2015). We also heard several of these taboos, and many of these fears affected women’s interest in sex, such as taboos around a fear of getting sick, going against their culture, and making their partners sick. Even so, many women we spoke to found menopause liberating and cost-effective, similar to other studies in similar contexts (Makuwa et al., 2015). A study conducted in Zimbabwe and South Africa cities found women largely linked menopause with aging, loss of sexuality, shame, and social role shifts, emphasising biosocial dimensions of aging, such as cessation of blood makes a woman’s vagina unclean and causes a husband’s infidelity (Drew et al., 2022). This demonstrated a radical acceptance by many older women who were unconcerned with the loss of sexuality and embraced their new social and physical status.

Third, most women in our study reported that they had diabetes after menopause, indicating that menopause is a natural process that occurs as women age and, unsurprisingly, is associated with the development of chronic health conditions. This creates a negative feedback loop, where hormonal changes associated with menopause may contribute to multimorbidity at a younger age, which may lead to early menopause (Ataguba, 2013; Calvet et al., 2015; Fantry et al., 2005; MacMahon et al., 2018; Mercer et al., 2016). More research is necessary to interrogate the dynamics of menopause-presenting people’s hormonal changes and metabolic shifts, particularly as surveillance data reveals Soweto residents develop diabetes at earlier ages than they did two decades ago and women are more likely to have a prevalence of comorbidities now compared to the previous generation (Crowther & Norris, 2012). These data track with broader studies elsewhere that suggest diabetes may lead to early menopause (Fu et al., 2016; Wellons et al., 2017) and that premature menopause was associated with a high prevalence of multimorbidity. On the other hand, late menopause (experiencing menopause at 50–55 years) was associated with having fewer chronic health conditions (Xu et al., 2020). Understanding these trends are only possible through longitudinal studies of health and well-being that address the dynamics among hormone and metabolic change as women age.

Finally, women described how they lacked biomedical information about menopause and what to expect during this transition in medical settings. This indicates the need for awareness and education on menopause perhaps not in how women might perceive menopause but instead in how women relate their physical changes to clinical spaces. Moreover, for the women we spoke to, it may be helpful to provide more education about why chronic conditions from diabetes to cancers are more prevalence after menstruation ceases.

There were important limitations to the study. While having been enrolled in the study for four previous waves, many women were eager to participate in the study, but others may have refused due to study fatigue, lack of finances, loss of phones due to economic distress, and lack of time due to caring for family members during a stressful time. Moreover, we were disappointed that we could not conduct these studies in person, which reduced the amount of time and interpersonal interaction possible during the interview. Some women might have been hesitant to discuss menopause because of stigma or the fact that many women perceive menopause to be a very personal matter.

Conclusion

In conclusion, how women perceive aging is often a social or personal experience as opposed to a medical one. In contexts like Soweto, where constructs of aging are less commonly associated with the culture of biomedicine, attributing natural changes to the body is not commonly associated with health or disease. In this way, women do not link their menopausal symptoms to one health condition or multiple, even though clinical providers might observe an increase in or worsening of chronic conditions when women’s hormones change with aging. These findings emphasise the need for cultural humility among physicians when speaking with patients who may have different perceptions of what menopause is and what related symptoms mean.

Acknowledgements

We wish to thank the MRC/WITS Developmental Pathways to Health Research (DPHRU) where this study was nested. We would further want to thank and acknowledge women from Soweto who agreed to be part of this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data are available on request from the authors.