India's Menopause Challenge: Economic Case For Better Women's Healthcare

Menopause is a natural and inevitable phase that all women experience, yet its implications on women’s overall health are frequently overlooked. In India, where women constitute nearly half of the population, discussions surrounding menopause are conspicuously absent at both homes and workplaces, leaving many alone to navigate this transition in silence. 

In India, the average age of menopause is approximately 46 years—five years earlier than the global average of 51. This earlier onset not only extends the post-menopausal phase but also significantly increases their risk of chronic health conditions. While many associate menopause primarily with symptoms such as hot flashes and mood swings, the health implications are far broader and intersect with the prevalence of non-communicable diseases.

For instance, the risk of breast cancer seems to be higher with increasing age, and as hormonal changes occur during menopause the risk gets further pronounced. Also, close to 50% of postmenopausal women experience vaginal atrophy due to decreased oestrogen, and about 30-50% report urinary incontinence.

The Health Burden Of Menopause

The hormonal shifts during menopause can intensify risk factors associated with NCDs, including cardiovascular diseases, obesity, and osteoporosis. For instance, cardiovascular diseases (CVDs) are a leading cause of mortality among Indian women over the age of 45, accounting for nearly 30% of deaths.

Studies indicate that postmenopausal women have a 1.5 to 2 times higher risk of developing CVD compared to premenopausal women. Furthermore, the rising prevalence of obesity among Indian women can be exacerbated by hormonal shifts during menopause, leading to a cycle of health complications. The decline in estrogen levels post-menopause accelerates bone loss, increasing the likelihood of fractures and other skeletal issues.

Yet, despite the strong correlation between menopause and chronic diseases, menopause remains grossly underrepresented in India’s health strategies, policy frameworks and the mainstream discourse.

While natural menopause has long been overlooked in broader discussions on women's health, emerging findings on surgical menopause now highlight a dual challenge facing the country. Contrary to natural menopause, surgical menopause occurs when a woman undergoes a surgical procedure that removes her ovaries, typically during a hysterectomy. This procedure results in an abrupt cessation of ovarian hormone production, leading to menopause symptoms that can occur suddenly rather than gradually, as seen in natural menopause. 

According to recent studies, hysterectomy rates in India have been increasing significantly, with an estimated 3.5 million surgeries performed annually. The National Family Health Survey (NFHS-5) data reveals that certain regions such as parts of Tamil Nadu and Andhra Pradesh, reported hysterectomy rates as high as 60-70% among women aged 30 to 49. While natural menopause remains underrepresented in public discourse, the growing prevalence of surgical menopause adds another layer of complexity, underscoring the urgent need for a broader public health lens while viewing menopause. 

Mainstreaming Women’s Health in Policies and Programs

Many of these health challenges that women face are not only due to knowledge gaps but also stem from the limited scope of program design targeting women’s health. Current health programs often compartmentalise women's health into distinct areas, such as adolescent health and reproductive health, which neglect critical periods like midlife and post-menopause. This oversight exacerbates the unique challenges related to menopause today.

Women’s physiology and health needs are inherently dynamic, undergoing significant transformations approximately every 12 to 16 years from menarche to menopause. Each of these stages is critical for understanding women’s health across their lifespan. However, a fragmented approach not only limits the focus on comprehensive care but also fails to recognise the complex interplay of biological, psychological, and social factors that influence women’s health.

For instance, in present landscape, a thorough examination of factors contributing to early menarche, early menopause, and the rising prevalence of hormonal conditions such as PCOS/PCOD is essential. Additionally, the increasing rates of hysterectomies warrant a closer look to fully understand the state of women’s health in India today. Addressing these interconnected issues is vital for developing more effective and holistic healthcare strategies for women.

Adopting a Life Course Approach

At this juncture, India stands to gain significantly from adopting a women’s health strategy grounded in a life course approach. Life course health starts with genetic endowment and is then influenced by multiple external factors pre-birth, in early life, and through to end-of-life care. 

This framework acknowledges that women’s health is shaped by a multitude of (interrelated) factors throughout their lives, from adolescence to menopause and beyond. By employing a life course perspective, targeted interventions can be implemented at critical life stages—such as puberty, pregnancy, mid-life and menopause—specifically designed to address unique health risks and enhance overall well-being.

For instance, comprehensive Health Education and Awareness Programs can be designed that aim to inform women about health needs at various life stages, from adolescence through menopause and beyond.

Additionally, this shall help in designing integrated healthcare models that provide a continuum of care starting from pre-birth to post-menopausal care. Such an approach would not only address the immediate health needs but will also contribute to long-term health equity. If integrated with the existing non-communicable diseases programs it can help in the early recognition of risk factors, and allow for integration of services that can potentially facilitate early diagnosis and management of conditions. Perhaps, it can be a step towards proactive health-seeking behaviour from the currently predominant reactive one. 

Implementing similar comprehensive strategies would not only enhance women’s health outcomes but also address the broader implications of women’s health on public health systems. By recognizing and integrating the multifaceted nature of women’s health into national policies, we can better support women through their natural life transitions and improve overall health equity.

Authored by Dr Nalini Kaushik, an expert in policy advocacy and government affairs, specializing in health policy with a focus on women's health, menstrual health, and hormonal health. Views expressed by the author are their own.