What are the similarities and differences in hot flashes in women in different countries and cultures?

Have you ever wondered if women around the world experience menopause and hot flashes the same way we do? We talked to biological anthropologist Dr. Lynnette Leidy Sievert about the similarities and differences among women in a variety of countries and cultures. Author of “Menopause: A Biocultural Perspective,” Dr. Sievert has been traveling all over the world since the 1980s, studying the menopausal experience and hot flashes in women in different countries and ethnic groups, with research including Hawaii, Slovenia, Bangladesh, and Mexico. She shared with us some of her fascinating findings. Read on for Part I of our discussion.

You just got back from India. Was your trip related to your menopause research?

Yes, it was. In 2007 we interviewed women in Bangladesh, which is 80 percent Muslim and 20 percent Hindu1. We found that religion was pretty important to understanding cultural patterns of hot flashes in women. So this time we went to India, where the religious demographics are just the opposite of Bangladesh. India is about 80 percent Hindu and 20 percent Muslim. We wanted to study the different religious demographics to see whether the attitudes and relationship between hot flashes and hormones were the same or if they shifted also.

How did you first become interested in studying menopause?

I wanted to be a biological anthropologist. In the ‘80s, a lot of people were interested in growth and development and age of menarche [the first menstrual period], which can vary from 8 or 9 to 17 or 18, a big difference. But when you look at the variation in age at menopause, it can range from 40 to 58. That’s a much bigger difference than the age of menarche. It’s interesting that it’s clinically normal for one woman to stop menstruating at 44 and another to stop at 55. I started my research by studying the age of women when they reach menopause, mostly because trying to explain symptoms of menopause is so much more complicated. When researching symptoms, it’s not enough to find out whether a woman has a symptom or not. We also need to find out how she perceives it, and whether she labels it and reports it. The many cultural filters are separate from knowing whether a woman is menstruating. She either is, or she isn’t. So I started to focus on age at menopause, and then moved on to focus on hot flashes as well.

You’ve traveled the world collecting data on women and menopause. What were some of the similarities and differences between hot flashes in women in different countries?

The most important outcome of my work is finding out how similar hot flashes are across the world. People make erroneous comments to me like, “In Bangladesh they have so many problems. They have such poverty, and they probably don’t even think about hot flashes.” That’s completely not true, because women there are struggling to take care of their families, and have to deal with hot flashes on top of it.

I asked women in Bangladesh, “What do you do for your hot flashes?” We were studying middle class women who had electric fans, and they said, “I take off all of my clothes and stand under the fan.” I’m sure that’s what a lot of women would like to do, no matter where they are!

In Campeche, Mexico, I talked to Mayan women in tiny little villages, and asked, “What do you do for hot flashes?” They told me, “I bathe myself with water that has orange leaves in it.” They may do that because the orange leaves have a chemical compound that’s helpful, but the custom could also be related to their ideas of hot and cold, and citrus is always cold. But taking a cold shower helps cool you down. It’s the best way to stop or prevent hot flashes without hormones. It resets your internal thermometer for a while.

In Hawaii, we surveyed Japanese women who reported on how many hot flashes they had. The number was lower than other groups of women. However, although they said they had fewer hot flashes2, when we put monitors on them, and followed them intensely for a period of time, we discovered they have exactly the same number of hot flashes as their non-Japanese neighbors. They just don’t report them.

Why do you think that is?

They also don’t report many other symptoms to the same degree as the non-Japanese, such as irritability, depression and other problems. It’s hard for me to believe they don’t experience any of these symptoms, because we monitored them for hot flashes and saw that they have them. They’re either not labeling them, or it doesn’t bother them, or they just don’t think it’s appropriate to report. We weren’t able to separate these three possibilities to come to a final conclusion about that. We’re trying to do a better job among the Maya in Mexico. We’re trying to separate what they feel, what they label and what they report.

Were there any other populations you studied that had a lower incidence of reporting hot flashes?

I went to Slovenia because a friend of mine invited me by saying, “Come to Slovenia! We have no hot flashes here.” So I went. She and I visited one house after another in very small villages in the Julian Alps to talk to all of the women who were 35 or older. We found a rate of hot flashes that wasn’t much different from the United States. But unlike American women, they don’t talk about them to their husbands or other women or doctors. Actually, it was obvious they hated talking to us. When they were done answering our questions, they’d relax and bring out the schnapps. It was really pleasant to chat with them, but when we were actually going through the symptom list, I could see they were very uncomfortable. They just didn’t think it was right to talk about their symptoms.

Before you started doing your research, did you have expectations about what you might find? If so, how did the reality match up with what you expected?

Back in the ‘80s, when I started to research menopause, a couple of studies had been done: one in India, and another one in Yucatan. This research showed that there were populations without hot flashes. There was also a lot of research that suggested that women in developed and Western countries such as the United States, Europe and Australia had hot flashes because they had more time on their hands, and so they could think more about things and complain. And so I expected that indigenous people, or non-Western populations, would report fewer hot flashes. But when I did my work in Puebla, Mexico, the first place I worked outside the US, my team talked to 755 women and discovered that they had a higher rate of hot flashes than I had found in the United States. I kept double-checking everything because these findings were so unexpected! That first study really challenged my preconceptions about hot flashes. The conventional wisdom about hot flashes in developing countries was that women experienced menopause at earlier ages than in developed countries. But I discovered that the statistics were different because the research methods were different. A lot of the difference in ages might be due to the methods used to calculate the averages, rather than different averages. However, it is still true that women experience menopause at later ages in the United States than in Mexico.

Why do you think that is?

I think it has to do with childhood nutrition and childhood infections. Gillian Bentley, who worked with me in Bangladesh, conducted a study published in 2013 of women in different ethnic groups in the United States. The results showed no difference in the age at menopause between different ethnic groups. I think that’s because these women all grew up in the United States, even though they’re Japanese or Chinese or Puerto Rican. They had relatively the same health care and nutrition, and were the same age at menopause. Compare women in Bangladesh, whose age at menopause is 47 or 48, with Bangladeshi immigrants in London3, whose age at menopause is very similar, at 48 or 49. These immigrants were born in Bangladesh. But their London neighbors’ average age of menopause is 52. After a couple of generations, I believe Bangladeshi women in London will have ages at menopause very similar to their non-Bangladeshi neighbors. Irene Perez-Alcala studied Latin-American immigrants in Madrid, and she also found differences in symptom experiences between them and their Spanish neighbors.4

Part II of our interview with Dr. Lynnette Leidy Sievert will be published on March 15, 2017.

1. Sievert LL, Begum K, Sharmeen T, Chowdhury O, Muttukrishna S, Bentley G.— Patterns of Occurrence and Concordance Between Subjective and Objective Hot Flashes Among Muslim and Hindu Women in Sylhet, Bangladesh. American Journal of Human Biology 20:598–604 (2008)

2. Brown DE1, Sievert LL, Morrison LA, Reza AM, Mills PS. — Do Japanese American women really have fewer hot flashes than European Americans? The Hilo Women’s Health Study. Menopause. 2009 Sep-Oct;16 (5):870-6

3. Murphy L, Sievert L, Begum K, Sharmeen T, Puleo E, Chowdhury O, Muttukrishna S, Bentley G.— Life course effects on age at menopause among Bangladeshi sedentees and migrants to the UK. American Journal of Human Biology 25:83–93 (2013)

4. Pérez-Alcalá I, Sievert LL, Obermeyer CM, Reher DS.— Cross-cultural analysis of determinants of hot flashes and night sweats: Latin-American immigrants to Madrid and their Spanish neighbors. Menopause 2013 Nov;20 (11):1111-9

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