Identifying Variables Associated with Menopause-Related Shame and Stigma: Results from a National Survey Study

Abstract

Background:

Despite the significance of menopause as a natural biological milestone experienced by approximately half the population, few studies have evaluated factors associated with menopause-related shame and stigma. Given previous research indicating increased shame and stigma are associated with negative outcomes that directly impact health (e.g., reduced access to health care), it is critical to identify variables associated with menopause-related shame and stigma.

Materials and Methods:

As part of a larger, national survey, 214 perimenopausal (n = 111) and postmenopausal (n = 103) individuals completed self-report questionnaires assessing demographics and menopause-related symptoms, shame, and stigma. Regression analyses examined variables associated with shame and stigma.

Results:

Over a third of respondents reported feeling shame related to their menopause-related symptoms (37.4%), while the majority of respondents reported feeling stigma associated with symptoms (82.7%). In addition, most respondents endorsed talking about their symptoms with friends, family, partners, or doctors (80.8%), and felt that their peers might experience the same symptoms (93.9%). Regression analyses identified several significant predictor variables; in particular, more severe psychosocial and urogenital symptoms, higher education level, and younger age were significantly associated with greater odds of reporting shame and stigma.

Conclusions:

Overall, findings suggest that even though menopausal individuals report feeling their symptoms are similar to their peers, shame and stigma are significantly associated with these symptoms, which may be impacted by symptom severity and socioeconomic factors. Results suggest that younger individuals (i.e., those just entering perimenopause) with more education may be more likely to feel shame and stigma, which could inform interventional strategies and improve clinical outcomes.

Introduction

Menopause is the permanent cessation of menstruation and reproductive capability, with individuals retroactively designated as postmenopausal following 12 consecutive months without a period, and perimenopause is the transitional time toward menopause characterized by irregularity of menstrual cycling evolving to amenorrhea.¹ During both peri- and postmenopause, individuals can experience a variety of bothersome symptoms, including hot flashes, trouble sleeping, depression, anxiety, and sexual dysfunction,² which are associated with significant psychosocial and economic burden, with more severe symptoms associated with increased shame, loss of productivity, and lower quality of life.^3,4

Importantly, menstruation and menopause are normal aspects of physiology that are often impacted by social and cultural influences, which can greatly impact the perception and management of menstrual and menopausal symptoms; these sociocultural factors help provide the context for how each individual experiences these basic biological functions.^5,6 Stigma is the term used when external factors (i.e., stereotypes, cultural attitudes) alter others' perceptions, usually in a negative way, whereas shame is the term for internalized feelings a stigmatized individual may endure such as embarrassment, indignity, and isolation.

Research has demonstrated numerous detrimental effects of shame and stigma including increased stress, poorer physical and mental health, reduced access to health care and other resources, and more; these factors directly impact health and result in poorer outcomes.⁷

Shame and stigma are commonly reported for concerns related to “women's health.” While menstruation is often associated with cultural stereotypes such as dirtiness or uncleanliness, menopause and the cessation of menstruation are often associated with aging and perceived loss of vitality.^8,9 In particular, menopause involves significant physical and emotional changes, often necessitating role and status shifts in society, which can cause feelings of uncertainty, emotional strain, and loss of identity.^10,11

Further, shame and stigma can make discussing topics related to menstruation and menopause uncomfortable due to cultural taboos, which can reduce educational efforts and sharing of reliable, accurate information about these functions.¹² In fact, a recent survey in the United Kingdom found that >90.2% of perimenopausal individuals reported they had never learned about menopause in school, and 60.8% reported that they did not feel informed at all about menopause.¹³ Given the significant impact of sociocultural attitudes on the experience of menopause, there is a critical need for normalization of this natural biological event as well as the identification of variables associated with shame and stigma.

Despite the significance of menopause as a natural biological milestone experienced by approximately half the population, few studies have evaluated factors associated with shame arising from menopause-related symptoms. Research suggests that experiencing shame and stigma during peri- and postmenopause is quite common and distressing,¹⁴ with increased shame associated with poorer psychological well-being.¹⁵ In addition, more negative attitudes about menopause (e.g., feelings of loss of identity, uncertainty, anxiety, etc.) have been associated with increased severity of menopause-related symptoms, suggesting that increased shame impacts symptomatology.¹⁶

Evidence from one U.K. survey study (n = 270 middle-aged women) indicated a relationship between higher ratings of body dissatisfaction and greater negative attitudes toward menopause such as concerns about aging and changes in appearance.¹⁷ An American survey study (n = 74 middle-aged women) demonstrated that body-related shame may moderate the relationship between appearance-related menopausal attitudes and body esteem.¹⁸ This study found that for individuals with greater body-related shame, more negative appearance-related menopausal attitudes were associated with lower body esteem; importantly this relationship was not observed in individuals with lower body-related shame. In addition, self-compassion has been associated with higher levels of body appreciation and lower levels of body preoccupation during perimenopause, with greater mental distress reducing the impact of self-compassion.¹⁹

Most research thus far has focused on the relationship between attitudes about menopause and feelings of shame. In addition, previous studies have demonstrated that sociocultural factors (e.g., geographic location, socioeconomic status, employment status, education level) and stress can impact the prevalence and severity of menopause-related symptoms across the menopausal transition period.^2,20
–22 However, since increased menopause-related shame is associated with more negative outcomes (e.g., poorer well-being), it is critical to identify variables associated with shame. While previous work has demonstrated that more negative attitudes are associated with greater symptom severity, more complex modeling of factors associated with menopause-related shame and stigma could provide additional insight.

For this report, we utilized data collected as part of a recent national survey of peri- and postmenopausal individuals; the primary research goal was to conduct regression modeling to examine demographic and clinical variables associated with menopause-related shame and stigma. We hypothesized that both demographic (specifically sociocultural factors) and severity of menopause-related symptoms would be associated with menopause-related shame and stigma. In addition, given previous research indicating dynamic changes in menopause-related symptomatology throughout the time frame from peri- to postmenopause, between-group analyses (peri- vs. postmenopause) were performed to assist with interpretation of findings from the primary regression analyses.

Materials and Methods

Data utilized in the current analyses were collected as part of a large, national survey designed to assess cannabis use in peri- and postmenopausal individuals in the United States; results regarding cannabis use have previously been reported.²³ This study was approved by the Mass General Brigham (MGB) Institutional Review Board and conducted in accordance with the Declaration of Helsinki. Before starting the survey, study procedures, including risks and benefits, were presented to all respondents, and voluntary consent to participate was required from all respondents. Total time to complete the entire study was ∼10–20 minutes (average time was ∼16 minutes). Compensation was not provided for participation.

Participants

Perimenopausal and postmenopausal respondents were recruited through targeted online postings on social media platforms (e.g., Facebook) as well as Rally, the MGB online recruitment platform. Study enrollment was conducted between March 3, 2020 and April 16, 2021 using voluntary response sampling to generate a nonprobability sample. Eligible respondents were individuals aged ≥18 years, assigned female at birth, and reported current perimenopausal or postmenopausal status.

Menopause status was assessed initially through a categorical question about respondents' current menstrual status, which was cross-verified with questions about their menstrual cycle (e.g., last period); eligible respondents selected either “perimenopausal/menopausal transition (changes in periods but haven't gone 12 months in a row without a period)” or “postmenopausal.” A total of 214 respondents (perimenopausal = 111, postmenopausal = 103) completed questions about menopause-related shame and stigma, and were included in the current analyses.

Survey content

After a series of initial screening questions to determine eligibility, consenting respondents were directed to a survey consisting of several self-report questionnaires administered through Research Electronic Data Capture (REDCap).^24,25 In addition to other questions, respondents completed several well-validated clinical scales assessing menopause and sexual health as well as general questions regarding menstrual history and menopause-related shame and stigma.

The specific clinical scales completed by respondents were the Day-to-Day Impact of Vaginal Aging Questionnaire (DIVA) to assess common urogenital symptoms, and their effect on daily functioning and well-being²⁶; the Menopause-Specific Quality of Life Questionnaire (MENQOL) Vasomotor (e.g., hot flashes, night sweats) and Psychosocial (e.g., anxiety, mood) subscales to assess the presence and bothersomeness of past month menopause-related symptoms²⁷; and the Arizona Sexual Experiences Scale (ASEX) to assess sexual health and dysfunction.²⁸ For all scales, higher scores indicate more severe symptomatology and greater dysfunction.

Respondents also completed four binary (yes/no) questions designed to assess the frequency of endorsing different aspects of menopause-related shame and stigma. Specifically, these were as follows: (1) feeling shame related to menopause-related symptoms; (2) feeling there is stigma associated with menopause-related symptoms; (3) talking about menopause-related symptoms with friends, family, partners, or doctors; and (4) feeling that peers might experience the same menopause-related symptoms.

These four outcome variables were designed to probe several features of menopause-related shame and stigma such as those discussed in Nosek et al.,¹⁴ which included feelings of shame (internalized source), feelings of stigma (externalized source), feelings of silence/isolation (e.g., discussing symptoms with others), and feelings of otherness versus menopause as a common experience (e.g., whether peers have similar experiences).

Statistical analyses

Pearson's chi-square tests (for frequency data) and one-way analyses of variance (ANOVAs; for scalar data) were conducted to assess differences between peri- and postmenopausal respondents. Binary logistic regression analyses examined the four different binary outcome variables assessing menopause-related shame and stigma through backward stepwise models calculated using removal testing based on the probability of the likelihood ratios (p(Out) = 0.05).

Multicollinearity diagnostic assessments were performed for predictor variables including variance inflation factor (VIF) assessments as well as eigenvector linear transformations of the variance to calculate proportions of variance uniquely attributable for each predictor.

After controlling for multicollinearity, the predictor variables included in the regression analyses were demographic variables: age, race (binary coded: White vs. non-White), education level (ordinal coded: 4 ranks), and number of medical conditions as well as menopause-related variables: DIVA total score, MENQOL Vasomotor and Psychosocial subscale scores, and ASEX total score (Supplementary Table S1). Candidate predictor variables excluded from the regression analyses due to issues of multicollinearity were menopause status, ethnicity, income level, marital status, employment status, number of medical conditions, and age of 1st period. All analyses were two tailed (α = 0.05) and were conducted using SPSS version 28 (IBM Corp., Armonk, NY).

Results

Demographic data and menopause symptoms

Respondents were primarily White, non-Hispanic, middle-aged, cisgender women who reported an annual income reflecting middle-class status or above, completed an undergraduate degree or higher, were married or in a relationship, and were employed at least part-time (Table 1). Spontaneous, natural cessation of menses was not a requirement for this study, and 14.6% of respondents reported nonspontaneous, induced menopause (e.g., surgical).

Table 1.

Demographic Comparison of Perimenopausal and Postmenopausal Survey Respondents (Two Tailed)

Demographic variables	All respondents n = 214	Perimenopausal n = 111	Postmenopausal n = 103	Peri vs. Post
Gender identity	n (%)	n (%)	n (%)	Χ² = 2.006, p- = 0.367
Female	212 (99.1%)	110 (99.1%)	102 (99.0%)
Male	1 (0.5%)	0 (0.0%)	1 (1.0%)
Non-Binary	1 (0.5%)	1 (0.9%)	0 (0.0%)
	Mean ± SD	Mean ± SD	Mean ± SD	ANOVA
Current age	51.71 ± 5.67	49.14 ± 4.40	54.49 ± 5.60	F = 60.722, p < 0.001
Years since last period	—	—	5.88 ± 5.38	—
Race^a	n (%)	n (%)	n (%)	Χ² (p)
American Indian	4 (1.9%)	2 (1.8%)	2 (1.9%)	0.006 (0.939)
Asian	4 (1.9%)	3 (2.7%)	1 (1.0%)	0.872 (0.350)
Black/African American	3 (1.4%)	0 (0.0%)	3 (2.9%)	3.282 (0.070)
White	206 (96.3%)	108 (97.2%)	98 (95.2%)	0.851 (0.356)
No response	2 (0.9%)	1 (0.9%)	1 (1.0%)	0.003 (0.958)
Ethnicity	n (%)	n (%)	n (%)	Χ² = 0.037, p = 0.982
Hispanic	12 (5.6%)	6 (5.4%)	6 (5.8%)	—
Non-Hispanic	189 (88.3%)	98 (88.3%)	91 (88.3%)	—
No response	13 (6.1%)	7 (6.3%)	6 (5.8%)	—
Income level (US$)	n (%)	n (%)	n (%)	Χ² = 1.984, p = 0.739
0–49,999	39 (18.2%)	17 (15.3%)	22 (21.4%)	—
50,000–99,999	72 (33.6%)	39 (35.1%)	33 (32.0%)	—
100,000–149,999	43 (20.1%)	25 (22.5%)	18 (17.5%)	—
≥150,000	38 (17.8%)	19 (17.1%)	19 (18.4%)	—
No response	22 (10.3%)	11 (9.9%)	11 (10.7%)	—
Education level	n (%)	n (%)	n (%)	Χ² = 6.071, p = 0.108
GED/high school diploma	16 (7.5%)	7 (6.3%)	9 (8.7%)	—
Some college/Training/Associate's	60 (28.0%)	25 (22.5%)	35 (34.0%)	—
Bachelor's	90 (42.1%)	55 (49.5%)	35 (34.0%)	—
Master's/Doctoral	48 (22.4%)	24 (21.6%)	24 (23.3%)	—
No response	0 (0.0%)	0 (0.0%)	0 (0.0%)	—
Marital status	n (%)	n (%)	n (%)	Χ² = 5.894, p = 0.117
Single	31 (14.5%)	13 (11.7%)	18 (17.5%)	—
In a relationship	41 (19.2%)	18 (16.2%)	23 (22.3%)	—
Married	118 (55.1%)	70 (63.1%)	48 (46.6%)	—
Divorced/Widowed	24 (11.2%)	10 (9.0%)	14 (13.6%)	—
No response	0 (0.0%)	0 (0.0%)	0 (0.0%)	—
Employment status	n (%)	n (%)	n (%)	Χ² = 0.274, p = 0.600
Employed (at least part-time)	145 (67.8%)	77 (69.4%)	68 (46.9%)	—
Unemployed/Retired/Disabled	69 (32.2%)	34 (30.6%)	35 (34.0%)	—
No response	0 (0.0%)	0 (0.0%)	0 (0.0%)	—
Self-reported medical conditions^a	n (%)	n (%)	n (%)	Χ² (p)
Psychiatric	125 (58.4%)	75 (67.6%)	50 (48.5%)	7.959 (0.005)
Pain	90 (42.1%)	43 (38.7%0	47 (52.2%)	1.041 (0.307)
Uterine/Vaginal	85 (39.7%)	48 (43.2%)	37 (35.9%)	1.196 (0.274)
Sleep	51 (23.8%)	26 (23.4%)	25 (24.3%)	0.021 (0.884)
Cardiovascular/Hematological	43 (20.1%)	21 (18.9%)	22 (21.4%)	0.198 (0.656)
Endocrine	24 (11.2%)	16 (14.4%)	8 (7.8%)	2.371 (0.124)
Oncological	11 (5.1%)	6 (5.4%)	5 (4.9%)	0.033 (0.855)
Gastrointestinal	11 (5.1%)	6 (5.4%)	5 (4.9%)	0.033 (0.855)
Dermatological	7 (3.3%)	4 (3.6%)	3 (2.9%)	0.081 (0.776)
Neurological/Neurodegenerative	7 (3.3%)	0 (0.0%)	7 (6.8%)	7.799 (0.005)
Other	11 (5.1%)	5 (4.5%)	6 (5.8%)	0.191 (0.662)
No reported medical conditions	24 (11.2%)	12 (10.8%)	12 (11.7%)	0.038 (0.846)
Number of medical conditions	Median (IQR)	Median (IQR)	Median (IQR)	Mann–Whitney
Number of medical conditions	2 (2)	2 (2)	2 (2)	Z = −0.714, p = 0.475

Bold numbers are significant at p ≤ 0.050; italicized numbers are trends toward significance at p < 0.100

Respondents were instructed to select all items that applied.

IQR, interquartile range.

Respondents were well-matched for almost all demographic variables regardless of menopause status, with few significant differences between peri- and postmenopausal respondents. As expected, perimenopausal respondents were significantly younger than postmenopausal respondents (p < 0.001). In addition, with regard to self-reported medical conditions, perimenopausal respondents reported significantly greater frequency of psychiatric conditions (e.g., anxiety and depression) than postmenopausal respondents (p = 0.005), and postmenopausal respondents reported significantly greater frequency of neurological/neurodegenerative conditions (i.e., glaucoma, Parkinson's disease) than perimenopausal respondents (p = 0.005).

With regard to menopause symptoms (Table 2), perimenopausal respondents reported significantly worse psychosocial (p = 0.038) and a trend for worse vasomotor (p = 0.057) menopause-related symptoms on the MENQOL relative to postmenopausal respondents. In addition, postmenopausal respondents reported significantly worse sexual dysfunction measured by ASEX total score compared with perimenopausal respondents (p = 0.027). Perimenopausal and postmenopausal respondents reported similar total scores on the DIVA.

Table 2.

Menopause-Related Clinical Scales and Assessments (Two Tailed)

Menstrual history variables	All respondents n = 214	Perimenopausal n = 111	Postmenopausal n = 103	Peri vs. Post
Menstrual history variables	n (%) or Mean ± SD	n (%) or Mean ± SD	n (%) or Mean ± SD	Χ² or F (p)
Age of first period	12.52 ± 1.65	12.50 ± 1.62	12.54 ± 1.70	0.045 (0.831)
Age of last period	—	—	48.60 ± 4.85	—
Menopause-related clinical scales
DIVA
Total	3.90 ± 3.40	3.68 ± 3.38	4.15 ± 3.42	1.039 (0.309)
MENQOL
Vasomotor	4.29 ± 2.31	4.58 ± 2.15	3.98 ± 2.45	3.677 (0.057)
Psychosocial	4.15 ± 1.81	4.39 ± 1.76	3.88 ± 1.84	4.344 (0.038)
ASEX
Total	17.81 ± 5.00	17.08 ± 5.04	18.59 ± 4.85	4.979 (0.027)
Menopause-related shame and stigma questions
Do you feel shame related to menopause-related symptoms?				0.020 (0.887)
No	134 (62.6%)	69 (62.2%)	65 (63.1%)	—
Yes	80 (37.4%)	42 (37.8%)	38 (36.9%)	—
Do you feel there is a stigma associated with menopause-related symptoms?				11.058 (<0.001)
No	37 (17.3%)	10 (9.0%)	27 (26.2%)	—
Yes	177 (82.7%)	101 (91.0%)	76 (73.8%)	—
Do you talk about menopause-related symptoms with friends, family, partners, or doctors?				6.381 (0.012)
No	41 (19.2%)	14 (12.6%)	27 (26.2%)	—
Yes	173 (80.8%)	97 (87.4%)	76 (73.8%)	—
Do you feel your peers might experience the same menopause-related symptoms?				0.997 (0.318)
No	13 (6.1%)	5 (4.5%)	8 (7.8%)	—
Yes	201 (93.9%)	106 (95.5%)	95 (92.2%)	—

Bold numbers are significant at p ≤ 0.050; italicized numbers are trends toward significance at p < 0.100.

ASEX, Arizona sexual experience scale; DIVA, day-to-day impact of vaginal aging scale; MENQOL, menopause-specific quality of life scale.

Results from the 4 binary questions about shame and stigma indicated over a third of all respondents reported feeling shame related to their menopause-related symptoms (37.4%), and the majority of respondents reported feeling there is stigma associated with menopause-related symptoms (82.7%). In addition, most respondents endorsed talking about their menopause-related symptoms with friends, family, partners, or doctors (80.8%), and that they felt their peers might experience the same symptoms (93.9%). Interestingly, more perimenopausal respondents reported feeling shame related to menopause-related symptoms relative to postmenopausal respondents (p < 0.001), but more perimenopausal respondents reported talking about these symptoms with others (p = 0.012). No between-group differences were noted for those who reported feeling shame related to symptoms or feeling their peers might experience the same symptoms.

Regression analyses

Backward stepwise regression analyses indicated several predictor variables associated with endorsing menopause-related shame and stigma (Table 3).

Table 3.

Backward Logistic Regression Analyses Assessing Predictors of Endorsing Variables Assessing Menopause-Related Shame and Stigma (Two Tailed)

	B	SE	Wald	p	Exp(B)	Exp(B) 95% CI
	B	SE	Wald	p	Exp(B)	LB	UB
Do you feel shame related to menopause-related symptoms?Model summary: Χ² (5, N = 212) = 57.565, p < 0.001
Education level	0.569	0.202	7.933	0.005	1.767	1.189	2.627
DIVA total	0.229	0.061	14.141	<0.001	1.258	1.116	1.417
MENQOL vasomotor	−0.171	0.081	4.527	0.033	0.843	0.720	0.987
MENQOL psychosocial	0.517	0.116	19.899	<0.001	1.677	1.336	2.105
ASEX total	−0.087	0.042	4.407	0.036	0.916	0.844	0.994
Do you feel there is a stigma associated with menopause-related symptoms?Model summary: Χ² (3, N = 212) = 21.728, p < 0.001
Education level	0.631	0.225	7.861	0.005	1.880	1.209	2.923
MENQOL psychosocial	0.445	0.129	11.965	0.001	1.560	1.213	2.007
ASEX total	−0.094	0.041	5.280	0.022	0.910	0.839	0.986
Do you talk about menopause-related symptoms with friends, family, partners, or doctors?Model summary: Χ² (1, N = 212) = 7.012, p = 0.008
Age	−0.082	0.032	6.749	0.008	0.921	0.865	0.980
Do you feel your peers might experience the same menopause-related symptoms?Model summary: Χ² (2, N = 212) = 19.837, p < 0.001
Age	0.214	0.058	13.512	<0.001	1.238	1.105	1.387
ASEX total	−0.155	0.067	5.416	<0.001	0.857	0.752	0.976

Higher MENQOL Psychosocial score (p < 0.001), DIVA total score (p < 0.001), and education level (p = 0.005) as well as lower MENQOL Vasomotor score (p = 0.033) and ASEX score (p = 0.036) were all significantly associated with increased odds of feeling shame from menopause-related symptoms. Higher MENQOL Psychosocial score (p = 0.001), education level (p = 0.005), and lower ASEX total score (p = 0.022) were significantly associated with increased odds of feeling stigma from menopause-related symptoms. Younger age (p = 0.001) was significantly associated with increased odds of talking about menopause-related symptoms with others. Older age (p < 0.001) and lower ASEX scores (p < 0.001) were significantly associated with increased odds of feeling peers might experience the same menopause-related symptoms.

Discussion

In this study, more than a third of respondents reported feeling shame related to their menopause-related symptoms. In addition, the majority of respondents (≥80%) reported feeling stigma associated with menopause-related symptoms; endorsed talking about their menopause-related symptoms with friends, family, partners, or doctors; and felt their peers might experience the same symptoms. Menopausal status significantly impacted several of these frequencies, with more perimenopausal respondents endorsing feelings of shame associated with menopause-related symptoms and talking about these symptoms with others relative to postmenopausal respondents.

Previous research has demonstrated associations between increased menopause-related shame and poorer well-being, higher ratings of body dissatisfaction, and greater negative attitudes toward menopause.^14,17 This study expanded upon prior research by utilizing regression analyses to identify demographic and clinical predictors of menopause-related shame and stigma.

In particular, more severe psychosocial symptoms on the MENQOL and urogenital symptoms on the DIVA (including the impact of urogenital symptoms on daily functioning and well-being) were significantly associated with greater odds of feeling shame from menopause-related symptoms. Interestingly, less severe vasomotor symptoms on the MENQOL and sexual dysfunction symptoms on the ASEX were also associated with greater odds of feeling shame from menopause-related symptoms. Notably, a similar pattern was observed for other measures of menopause-related shame and stigma, with more severe psychosocial symptoms and less severe sexual dysfunction significantly associated with increased odds of feeling stigma associated with menopause-related symptoms, and feeling that peers might experience the same menopause-related symptoms.

However, it is important to note that ASEX scores range from 5 to 30, and the average ASEX scores in the current sample (M = 17.81) fell below the clinical threshold score of ≥19 indicating sexual dysfunction.²⁸ Therefore, the current findings may not be generalizable to individuals experiencing clinical levels of sexual dysfunction. Conversely, severe psychosocial symptoms were reported in the current sample, and the regression modeling results indicate a strong relationship between these symptoms and variables associated with menopause-related shame and stigma.

Results from this survey study also indicated that perimenopausal respondents reported greater frequency of psychiatric medical conditions (e.g., anxiety and depression), more severe psychosocial symptoms, as well as a trend for more severe vasomotor symptoms relative to postmenopausal respondents, whereas postmenopausal respondents reported more severe sexual dysfunction symptoms relative to perimenopausal respondents. Previous research suggests that vasomotor and psychosocial symptoms are typically more severe during the transition from peri- to postmenopausal with urogenital and sexual dysfunction symptoms (e.g., vaginal dryness and discomfort, decreased sexual desire) tending to persist during the postmenopausal period²; similar patterns of menopause-related symptomatology were observed in this study.

Presentation of different symptomatology over the course of menopause is considered the result of dynamic biological changes as an individual ages (e.g., hormonal fluctuations) as well as the psychological and sociocultural impact of these changes, which can significantly affect the perception and management of symptoms.^5,6 Importantly, given that menopause is significantly associated with aging, it is difficult to differentiate the unique impact of these biological milestones.

In addition, the majority of respondents (58.4%) endorsed at least one psychiatric medical condition (e.g., anxiety, depression), which likely affected the results of this study and may have had an additive impact, strengthening the influence of the ratings of psychosocial symptoms on the MENQOL. Previous research has demonstrated that peri- and postmenopausal status is associated with increased risk of more severe symptoms of anxiety and depression relative to premenopausal individuals,²⁹ and previous studies employing regression modeling suggest that greater severity of depressed mood and anxiety are predictor variables for interference with work and relationships.³⁰

Evidence also suggests that anxiety and mood symptoms experienced by menopausal individuals are significantly impacted by other life stressors that typically co-occur during this time period (e.g., parental death, empty nest syndrome).^31,32 The current results support and extend previous findings, and indicate that psychosocial symptoms including increased symptoms of anxiety and depression are particularly problematic during perimenopause, and also appear to significantly impact shame and stigma. Future studies should continue to examine the intersectional relationship between these factors to better understand menopause-related shame and stigma, and explore factors that may alleviate psychosocial discomfort associated with menopause-related changes and other stressors.

The current analyses also demonstrated that two demographic variables, education and age, were significantly associated with outcomes associated with menopause-related shame and stigma. Specifically, higher education level was associated with increased odds of feeling menopause-related shame and stigma. Importantly, while previous work has demonstrated that lower socioeconomic status (e.g., lower income and less education) is associated with greater frequency and severity of menopause-related symptoms,^33,34 findings from this study indicate that higher education level is associated with increased odds of feeling shame from menopause-related symptoms.

Taken together, these findings suggest that individuals with lower socioeconomic status are more likely to experience more severe menopause-related symptomatology (or are not able to achieve adequate relief of symptomatology), while individuals with higher socioeconomic status are more likely to report the perception of shame and stigma. These results are likely related to complex sociocultural factors, which can impact the perception and management of menopause-related symptoms.^5,6 For example, one potential consideration is that individuals with lower socioeconomic status likely have other critical life stressors (e.g., financial hardship, limited access to health care) that take precedence over stressors related to shame and stigma. Future research should further assess the impact of socioeconomic factors on both symptom severity and menopause-related shame and stigma.

In addition, younger age was significantly associated with increased odds of talking about menopause-related symptoms with others, and chi-square analyses also indicated that significantly more perimenopausal respondents reported discussing menopause-related symptoms with others. These findings suggest that increased discussion of symptoms is more frequently sought out by perimenopausal individuals, who are younger than postmenopausal individuals and just beginning their experience with menopause.

Previous research indicates that most perimenopausal individuals report never learning about menopause in school and feel uninformed about menopause.¹³ Further, cultural taboos about menopause have significantly impacted education efforts by limiting the availability and sharing of accurate information and perpetuating negative stereotypes.¹² Interestingly, in this study, while older age was associated with increased odds of feeling peers might experience the same symptoms, it is important to note that an overwhelming majority of respondents (93.9%) felt their peers experienced the same symptoms. These findings suggest that even though menopausal individuals may feel like their symptoms are similar to their peers, there is still significant shame and stigma associated with these symptoms.

Clinical implications

Importantly, increased shame and stigma are associated with negative outcomes (e.g., increased stress, poorer physical and mental health, reduced access to health care, and other resources), which directly impact health.⁷ However, a narrative review of health-related discrimination across a broad variety of stigmatized medical conditions (e.g., psychiatric conditions, HIV/AIDS) suggests that individual- and community-level interventional strategies (e.g., education, advocacy) designed to reduce shame and stigma can be effective, especially patient-centered approaches that empower patients to actively participate in the development and implementation of these programs.³⁵ In particular, normalizing menopause and related symptoms and increasing the availability of resources to encourage discussion and education about menopause and related symptoms may provide comfort, and reduce the associated burden of shame and stigma.⁶

Further, interventions do not need to be exclusively focused on health care settings. For example, research suggests that workplace interventions designed to decrease shame and stigma and increase education about menopause can result in significant improvement of workers' physical and mental health, and benefit the company (e.g., improved productivity, capacity to work, and work experience).^36,37 The current research underscores the importance of reducing menopause-related shame and stigma as these factors are associated with increased psychosocial and urogenital symptom severity. In addition, current data suggest that individuals with higher education level as well as younger individuals (i.e., those just beginning perimenopause) may be at higher risk of feeling shame and stigma, which could help inform and improve future-targeted interventional strategies designed to reduce shame and stigma.

Limitations

In this study, respondents were predominantly White, upper/middle-class, cisgender women. However, several demographic and sociocultural factors including race,^33,38 socioeconomic status,^33,34 immigrant status,^39,40 generational group,⁴¹ and others may significantly impact menopause-related symptoms as well as the perception and management of these symptoms.^5,6 Given the homogeneity of respondents in the current survey, results may not be generalizable to more diverse samples of menopausal individuals. To ensure generalizability of our results, replication of assessments should be considered in a larger sample with greater socioeconomic, racial, and ethnic diversity.

In addition, this study utilized binary outcome variables to assess the frequency of different aspects of menopause-related shame and stigma. While these binary variables provided a first-level assessment of predictor variables associated with these outcomes, future research should expand these findings using scalar variables to examine how the severity and frequency of feeling menopause-related shame and stigma are impacted by these predictors.

It is also important to note that shame and stigma associated with menopause-related symptoms are highly intercorrelated with shame and stigma associated with general aging.^14,17,18 In addition, the peri- and postmenopausal period for many individuals often coincides with other stressful life events that can significantly impact quality of life, mental health, as well as menopause-related symptoms.^31,32

In this study, age was only a significant predictor variable in the model examining whether respondents discussed menopause-related symptoms with others; however, other factors associated with and aging and stressful life events that occur as individuals age (e.g., concern about health problems, death of loved ones, feelings of lost youth and vitality) were not directly assessed, and likely influence shame and stigma. For example, in this study, the number of medical conditions was not a significant predictor variable in any of the regression models; however, variables assessing the severity of these medical conditions and their impact on quality of life and mental health may have yielded different results.

In addition, this study found increased frequency of psychiatric conditions and greater severity of psychosocial symptoms in perimenopausal respondents relative to postmenopausal respondents but did not examine levels of anxiety and depression outside of the context of menopause symptoms. Future research should also examine anxiety and depression related to aging and stressful life events. Given the complex and interconnected relationship between aging and menopause-related symptoms, it is difficult to differentiate the specific impact each has on shame and stigma; however, results from this study suggest several potential future directions to continue to explore this important research question.

Conclusions

Despite the significance of menopause as a natural biological milestone experienced by approximately half the population, few studies have evaluated factors associated with menopause-related shame and stigma. The current investigation expands previous research by identifying several variables associated with menopause-related shame and stigma. In particular, more severe psychosocial and urogenital symptoms, higher education level, and younger age were significantly associated with greater odds of endorsing menopause-related shame and stigma.

Overall, findings suggest that even though menopausal individuals report feeling their symptoms are similar to their peers, there is still significant shame and stigma associated with these symptoms, which are likely impacted by symptom severity and socioeconomic factors. Given previous research indicating increased menopause-related shame is associated with negative clinical outcomes, future studies should continue to examine the relationship between demographic and sociocultural factors, measures of menopause-related symptom severity, and shame and stigma to better understand how these factors influence clinical outcomes and can be used to improve interventional strategies.

Authors' Contributions

S.G. conceptualized and designed the study. All authors contributed to the acquisition of data (primarily M.K.D., D.K., and C.E.). M.K.D. performed all the statistical analyses and drafted the article. R.S. provided administrative and regulatory support. M.K.D., S.G., and K.S. provided critical revision of the article for important intellectual content.

Data Sharing Statement

The datasets generated and/or analyzed in this study are available from the corresponding author upon reasonable request and completion of a data-sharing agreement with MGB starting immediately after publication and ending 3 years after publication.

Footnotes

Author Disclosure Statement

All authors report no biomedical financial interests or potential conflicts of interest.

Dr. Gruber reported grants from the National Institute on Drug Abuse, the Center for Medical Cannabis Research (UCSD), Foria/Praxis Ventures, and Charlotte's Web outside the submitted work. Over the last 5 years, he has reported receiving fees from the Coalition for Cannabis Policy, Education, and Regulation (CPEAR); Beth Israel Deaconess; Fenway Health; Greenwich Biosciences Cannabis Education Working Group; National Academy of Neuropsychology; McMaster University; Harvard Health Publications; University of Florida; and the Massachusetts College of Pharmacy and Health Services, all related to presentations outside the submitted work. Dr. Gruber is also a scientific advisor for Ajna Biosciences.

Dr. Dahlgren reported receiving the McLean Hospital Jonathan Edward Brooking Mental Health Research Fellowship outside the submitted work.

Dr. Sagar received the McLean Hospital Eleanor and Miles Shore Fellowship and the Charles Robert Broderick III Phytocannabinoid Research Fellowship, and reported personal fees from (CPEAR) outside the submitted work. No other disclosures were reported.

Funding Information

This study was supported by private donations to the Marijuana Investigations for Neuroscientific Discovery (MIND) Program at McLean Hospital, including generous support from Apothercare. No funding sources were involved in the design or conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article; or decision to submit the article for publication.

Supplementary Material

Supplementary Table S1

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