Menopause in Nigeria: Evidence Gaps and the Case for Research

IN A NUTSHELL
Author's Note



This review summarises what Nigerian studies have established about menopause in Nigeria, identifies where the evidence is thin or missing, and proposes a research agenda. It gives particular attention to two areas that matter for service and labour planning but have received little study: the readiness of the clinicians who see menopausal women, and the experience of women who work

By Dr Hadiza Magaji Mahmoud

MBBS BUK, MRH BUK, MSc Public Health LSHTM, FRSPH

Nigeria

 Menopause in Nigeria

Evidence Gaps and the Case for Research

 

 

Introduction

Natural menopause is deemed to have occurred after 12 consecutive months without menstruation for which there is no other obvious physiological or pathological cause and in the absence of clinical intervention. [1]. Most women experience menopause between the ages of 45 and 55 years as a natural part of biological ageing. [1] Menopause can also be a consequence of surgical or medical procedures and is caused by the loss of ovarian follicular function and a decline in circulating blood oestrogen levels. [1] Menopausal transition can be gradual, usually beginning with changes in the menstrual cycle. [1]

Perimenopause refers to the period from when these signs are first observed and ends one year after the final menstrual period. Perimenopause can last several years and can affect physical, emotional, mental and social well-being. [1] A variety of non-hormonal and hormonal interventions can help alleviate perimenopausal symptoms. [1]

The regularity and length of the menstrual cycle varies across a woman’s reproductive life span, but the age at which natural menopause occurs is generally between 45 and 55 years for women worldwide. [1] Some women experience menopause earlier (before 40 years of age). This premature menopause may be because of certain chromosomal abnormalities, autoimmune disorders or other unknown causes. [1]

Demographic projections suggest that by 2030 the world population of menopausal and postmenopausal women will reach 1.2 billion, with 47 million new entrants each year [2]. Many are in paid work: of the 657 million women aged 45 to 59 worldwide, around half contribute to the labour force during their menopausal years, and their experience is shaped by the workplace environment as well as by symptoms [3]. The World Health Organization notes that menopause is often not discussed within families, communities, workplaces or health-care settings [1].

Menopause affects every woman who lives long enough to reach it, yet in Nigeria it receives little attention in research, clinical training and workplace policy. Women pass through menopause during years that are often professionally productive, and the clinicians they first consult may be insufficiently prepared to help.

The evidence base for Nigeria is thin. A national survey of gynaecologists published in 2009 described a dearth of information on menopause in the country, and noted that because few women presented to hospital with menopausal symptoms it had long been assumed that Nigerian women did not develop them or that they were mild [4]. In 2026, advocates meeting at Menopause Matters Nigeria in Abuja described menopause as largely absent from public discourse and workplace policy, with limited attention in healthcare training, and called for expanded training of health workers, supportive workplace policies and increased research funding [5].

This review summarises what Nigerian studies have established, identifies where the evidence is thin or missing, and proposes a research agenda. It gives particular attention to two areas that matter for service and labour planning but have received little study: the readiness of the clinicians who see menopausal women, and the experience of women who work.

Age at menopause

Clinic-based studies report mean ages at menopause of about 48 to 49 years. A survey of menopausal women in Enugu and neighbouring south-eastern cities found a mean of 49.4 years (SD 3) and a median of 49 years [6]. A survey of 400 postmenopausal women at a private specialist clinic in Enugu reported a mean of 48.4 years (SD 5.2), with a range of 38 to 52 years [7]. Both samples were drawn from women attending health facilities, so they may not represent the general population, and age at menopause was established by recall.

Symptom burden

Symptoms are common. In a community-based survey of 1,189 women aged 40 to 60 years in an urban area of Ibadan, 84.5% reported at least one menopausal symptom in the preceding four weeks, measured with a standardised Menopause Rating Scale. Joint and muscular discomfort was the most frequent (59.0%), followed by physical and mental exhaustion (43.0%), sexual problems (40.4%) and hot flushes (39.0%); occupation was the only predictor of the psychological subscale score [8]. In 385 women with natural menopause in Ilorin, Kwara State, the mean total Menopause Rating Scale score was 14.02 out of a maximum of 44, which the authors interpreted as a generally mild perception. Joint pain was the most perceived symptom and social support was the only independent determinant of severity [9]. In a general outpatient department in Port Harcourt, severe, moderate and mild symptoms were reported by 28.25%, 49.84% and 21.9% of menopausal women respectively, with loss of libido, muscle pain, joint pain and tiredness the most prevalent complaints [10].

These studies show that the experience is not confined to vasomotor symptoms, and that musculoskeletal, psychological and sexual complaints are prominent. They also show that symptom definitions, instruments and sampling frames differ, which limits comparison between sites.

Awareness, help-seeking and access to treatment

Awareness of menopause is high but anticipation of its effects and knowledge of treatment appear limited. In a family medicine clinic at University College Hospital, Ibadan, 86.4% of 352 women over 40 who had not yet reached menopause had heard of it, but only 36.1% anticipated associated symptoms [11]. In Enugu, about half of 400 postmenopausal women had heard of hormone treatment and 37% had sought treatment in hospital, which the authors read as a trend towards greater awareness [7].

Help is often sought outside the formal health system. In the Port Harcourt outpatient clinic, women with menopausal symptoms most often consulted patent medicine dealers (51.4%), followed by health workers (44.7%), while traditional healers were little used [10]. In Ibadan, friends and peers (45.7%) were the most common source of information about menopause and health care providers accounted for 17.0%; only 17 of the 352 women (4.8%) reported having been offered treatment options by a health care provider [11].

Clinician readiness

The only national evidence on clinician practice is a survey of 126 gynaecologists drawn from the six health zones of Nigeria [4]. They reported seeing, on average, one patient with menopausal symptoms every three months. The symptoms most often encountered were hot flushes (88%), insomnia (75.4%), depression (58.0%), irritability (56.3%) and night sweats (55.6%). The treatments ever offered for severe symptoms were reassurance (90.5%), anxiolytics (68.3%), analgesics (14.3%), hormone replacement therapy (7.9%), vitamins (4%), beta-blockers (3.2%) and danazol (2.4%). The author concluded that treatments reflected institutional tradition rather than evidence, and recommended mandatory continuing medical education for physicians. The paper also notes that results of the Women’s Health Initiative, which linked long-term hormone therapy with increased risks of breast cancer, stroke and pulmonary embolism, shaped attitudes to hormone therapy [4].

This study is important but limited. It surveyed specialists rather than the general clinicians who may be the first point of contact in outpatient departments, and it recorded reported treatments rather than testing knowledge or clinical reasoning. Patient-side findings from general outpatient settings are consistent with a care gap, since few women reported being offered treatment [11] and many consulted patent medicine dealers first [10]. In the sources retrieved, however, no study measured knowledge, vignette-based diagnostic competence and reported practice among general outpatient clinicians themselves.

Menopause and work

Research on menopause in the Nigerian workplace is very limited. Hence, the need for more research.

A descriptive cross-sectional study of working women aged 45 to 60 years at Ekiti State University used a questionnaire adapted from the Greene Climacteric Scale and the Work Ability Index to examine perceived work ability, and its authors noted a paucity of data on the question. Most women reported at least one symptom, and the abstract concluded that symptoms did not negatively influence perceived work ability, although it also describes a positive correlation between symptom and work-ability scores [12].

Two further sources are indirect. In the Ibadan community survey, occupation was the only predictor of psychological symptom scores [8], which suggests that work context matters. In a survey of 466 menopausal women in Kwara State, adjustment strategies did not differ significantly by religion or job type [13].

International studies show what Nigerian research could measure. Among 94 Italian nurses, menopausal symptoms were significantly associated with emotional exhaustion, and depersonalisation was affected only in nurses reporting low social support, optimism and resilience [14]. No comparable Nigerian data on nurses or other health workers were identified. At the policy level, advocates in Abuja urged employers to recognise menopause as a workplace issue rather than a private matter [5], and an international consensus statement recommends that workplace health policies incorporate menopausal health and create an open, supportive culture [3].

Evidence gaps

The Article points to nine main gaps.

  1. No representative national data. All nine studies are single-site or regional. Age at menopause, symptom prevalence, premature and surgical menopause and care-seeking have not been estimated at national or zonal level.
  2. Non-standardised measurement. Studies used the Menopause Rating Scale [8,9], a modified version of it [10], the Greene Climacteric Scale with the Work Ability Index [12] and locally designed questionnaires. Results cannot be pooled or compared reliably.
  3. Under-representation of northern Nigeria. Apart from the national gynaecologist survey [4], none of the studies was set in the north-west or north-east, and Hausa women were 3 of 385 participants (0.8%) in the Ilorin sample [9]. How menopause is understood, discussed and treated in northern settings is largely undocumented.
  4. Clinician competence in general outpatient care. The only clinician survey covers gynaecologists [4]. Knowledge, diagnostic reasoning and practice among general outpatient and primary-care clinicians have not been measured, although patient-side data point to a care gap [10,11].
  5. Treatment access and use. Hormone therapy was offered by few gynaecologists [4], but there is little current information on availability, cost, prescribing barriers, non-hormonal options or the use of traditional remedies.
  6. Workplace impact. The available findings are inconclusive [3,12]. There are no data on absenteeism, presenteeism or career decisions, on employer awareness and policy, or on occupational groups such as nurses, teachers, civil servants and informal-sector workers.
  7. Modifiable determinants. Social support [9] and occupation [8] were associated with symptom severity, but whether support at home, in the community or at work can be strengthened to reduce burden has not been tested.
  8. Evaluated interventions. No trial or pre-post evaluation of clinician training, patient education or workplace programmes was identified, so calls for training and policy [4,5] cannot yet be translated into tested models.
  9. Economic cost. No Nigerian estimate of the productivity or health-system cost of unmanaged menopause was identified.

A research agenda

The priorities below build on each other, from describing the problem to testing solutions.

Priority Suggested approach Key outcomes
Population burden Multi-zone community surveys with a validated symptom scale and common definitions Age at menopause, symptom prevalence and severity, premature and surgical menopause, care-seeking
Clinician readiness Cross-sectional studies of general outpatient, primary-care and specialist clinicians using knowledge tests and clinical vignettes Knowledge, diagnostic competence, reported prescribing and referral practice, training needs
Workplace impact Surveys and mixed-methods studies in health care, education, civil service and informal work Work ability, absenteeism, presenteeism, career decisions, stigma, employer policy
Northern and rural contexts Qualitative and mixed-methods work in Hausa-speaking and other northern settings Local concepts and language, religious and family influences, preferred sources of help
Intervention evidence Pilot and quasi-experimental evaluations of training, toolkits and workplace programmes Change in knowledge and practice, patient-reported outcomes, feasibility and cost
Economic evaluation Cost studies linked to the surveys above Productivity loss, out-of-pocket cost, cost-effectiveness of care models

Studies should use common definitions and validated instruments, report symptoms by severity, include women outside tertiary hospitals, and involve policymakers and employers from the outset so that findings feed into practice.

Implications for policy and practice

Continuing professional development for physicians should include menopause, as recommended for gynaecologists in 2009 [4]. Outpatient services need simple assessment tools and referral pathways. Employers, particularly in health care, education and the public service, should be encouraged to treat menopause as a workplace health issue, consistent with international consensus guidance [3] and the recommendations made in Abuja [5]. Because many women turn first to friends, peers and patent medicine dealers [10,11], public education and service design should aim to reach these sources of advice as well as clinicians.

Strengths and limitations

The strengths of this article are its focus on clinician readiness and the workplace, two areas central to health-system and labour planning, and its restriction to sources whose bibliographic details and findings could be verified. Most included studies are cross-sectional, hospital-based and from southern Nigeria, which limits generalisability to overall Nigerian context.

Conclusion

Menopause affects every Nigerian woman who lives long enough to experience it, yet the evidence needed to plan care is fragmentary, largely hospital-based and doesn’t include other community members. Clinician readiness in general outpatient care and the workplace experience of menopausal women are almost unstudied. A coordinated agenda of population surveys, clinician assessment, workplace studies and evaluated interventions, with deliberate inclusion of northern Nigeria, would provide the evidence on which training, services and policy can be built.

 

References

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  2. Hill, K. (1996) The Demography of Menopause. Maturitas, 23, 113-127.
    http://dx.doi.org/10.1016/0378-5122(95)00968-X
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