The Soulful GP Perimenopause Series | Part Three
When Priya came to see me, she apologised before she had even sat down.
“I’m sorry,” she said. “I know I’m probably wasting your time. It’s probably just stress.”
She was 44. She had been waking at 3am with a racing heart for eight months. She had joint pain so severe she had stopped going to the gym. She had cried in her car before work three times that week and could not explain why. Her periods had become unpredictable. She had seen two other doctors. Neither had mentioned perimenopause.
Priya is not unusual. She is, in my experience, entirely typical - of what happens when a woman of colour navigates a healthcare system that was not designed with her in mind.
This post is about a disparity so stark it should be making headlines - and isn’t. It is about a treatment that is changing lives, and the women who are not being offered access to it. It is about the myths, the biases, the cultural barriers, and the systemic gaps that have kept women of colour out of the HRT conversation for far too long.
And it is about what we do about it. Together. Starting now.
The numbers that should shock you
Let’s start with the data, because the data tell a consistent and striking story.
A major analysis of English primary care prescribing records - covering 1.85 million women aged 45 to 55 between 2016 and 2023 - found the following:
- 23.3% of White women in that age group were prescribed HRT.
- 6.2% of Asian women were prescribed HRT.
- Women of Black African backgrounds were 79% less likely to receive HRT than White women.
- Women from minoritised ethnic backgrounds were 45% more likely to experience delayed diagnosis of perimenopause, compared to 31% for White women.
- Overall HRT uptake: 15% for White women, 8% for women from minoritised backgrounds.
Read those numbers again. Not because they are surprising - if you are a woman of colour navigating the healthcare system, they may feel painfully familiar - but because they need to be named. Clearly. Loudly. Without softening.
This is not a gap. This is a chasm. And it has consequences that extend far beyond a hot flush.
Why this is a health crisis, not just a statistic
HRT is not simply a comfort measure. It is a health-protective intervention with evidence-based benefits for the heart, bones, brain, and metabolism. When women are denied access to it - or never offered it in the first place - the long-term consequences are serious.
For Black and Afro-Caribbean women, who already experience perimenopause earlier, with greater severity, and with a higher burden of cardiovascular risk factors, the gap in HRT access is a serious concern. Observational evidence suggests that HRT started within ten years of menopause onset is associated with meaningful cardiovascular benefits - and Black women, who already carry higher rates of hypertension and heart disease, may stand to benefit significantly from this protection. Individual risk should always be assessed with a clinician. And yet they are being prescribed HRT at a fraction of the rate of White women.
For South Asian women, who reach menopause four to five years earlier than the Western average and carry a genetically higher risk of insulin resistance, type 2 diabetes, and osteoporosis, prolonged oestrogen deficiency is likely to increase long-term risk across multiple systems. Every year without an informed conversation about hormonal support may contribute to accelerated bone loss, worsening metabolic risk, and cardiovascular vulnerability. And yet only 6.2% are receiving HRT.
This is not a minor administrative oversight. The data point to a significant public health concern with a clear racial dimension - one that demands honest examination and urgent action.
How did we get here? The layers of the problem
The disparity in HRT access for women of colour is not caused by one thing. It is the result of multiple overlapping failures - cultural, systemic, and historical. Understanding them is the first step to dismantling them.
Layer one: the WHI hangover
In 2002, the Women’s Health Initiative study published findings that were widely reported as proof that HRT caused breast cancer and heart disease. Women stopped their prescriptions. Doctors stopped prescribing. A generation of women - of all ethnicities - lost access to a treatment that could have protected them.
The early reporting of the WHI created long-lasting fear, and many women were left undertreated as a result. The women in the study were, on average, 63 years old and were given older, synthetic hormones. The absolute risk increase for breast cancer was smaller than the risk of drinking two glasses of wine a day. The findings were later substantially reanalysed and recontextualised.
But the fear stuck. And it stuck hardest in communities where medical mistrust already ran deep - communities where the healthcare system has a documented history of failing, dismissing, and in some cases actively harming Black and Brown patients. The WHI story landed on fertile ground of existing mistrust, and it took root.
Layer two: medical mistrust - earned, not irrational
When we talk about why women of colour are less likely to seek or accept HRT, we cannot ignore the context in which that reluctance exists.
Black women in particular have historical and contemporary reasons to be cautious about medical institutions. From the unethical experiments conducted on enslaved Black women in the 19th century to modern documented disparities in pain management - where Black patients are approximately half as likely to be prescribed adequate pain relief as White patients in emergency settings - the relationship between Black communities and Western medicine is complicated by a long and painful history.
This is not paranoia. This is a rational response to a documented pattern. And any healthcare provider who dismisses this context as an obstacle to overcome, rather than a reality to acknowledge and address, is not providing culturally competent care.
Layer three: cultural silence and shame
As we explored in Part One, menopause is not discussed in many South Asian and Afro-Caribbean communities. The silence is generational. The shame is real. And HRT - a treatment that involves hormones, that touches on fertility and femininity and the body - sits squarely in the territory of things that are not spoken about.
In some South Asian communities, there is a persistent myth that HRT is derived from horse urine and is therefore impure, unsuitable, or dangerous. This belief has its roots in older formulations of conjugated equine oestrogen - horse-derived hormones that were indeed used historically. Modern body-identical HRT is derived from plants and is structurally identical to human hormones. But the myth persists, and it persists in communities where there is no counter-narrative, no trusted voice saying: that is not true anymore, and here is what you need to know.
In Afro-Caribbean communities, the expectation that women are strong, that they endure, that they do not make a fuss - this cultural framework actively discourages women from seeking treatment. Asking for HRT requires first admitting that you are struggling. For women who have been told their whole lives that struggling is not an option, that admission can feel impossible.
Layer four: clinician bias and knowledge gaps
Let us be honest about something that is uncomfortable but necessary.
Clinician bias - both conscious and unconscious - plays a role in this disparity. Studies have shown that Black patients are less likely to be believed when they report pain. They are more likely to have their symptoms attributed to psychological causes. They are less likely to be referred to specialists. These patterns are not confined to emergency medicine. They extend to primary care, and they extend to menopause care.
There is also a knowledge gap. Many GPs have received minimal training in menopause - one survey found that UK medical students received an average of just one hour of menopause education during their entire training. When that limited training is also not culturally informed - when it does not account for the earlier onset of menopause in South Asian women, or the higher symptom burden in Black women, or the cultural barriers that affect help-seeking - the result is a system that is structurally unable to serve these communities well.
Layer five: representation in research
The women who have been studied in menopause research have been, overwhelmingly, White. The clinical benchmarks - the average age of menopause, the typical symptom profile, the standard treatment protocols - have been built on data that does not represent the diversity of women’s experiences.
When a South Asian woman presents to her GP at 42 with perimenopausal symptoms, her GP may not recognise them as such - because the guidelines say menopause happens at 51, and those guidelines were built on studies of White women. The data gap is not just an academic problem. It translates directly into missed diagnoses and withheld treatment.
The myths, dismantled
Let us address the most common beliefs that keep women of colour away from HRT - clearly, and directly.
Myth: HRT causes breast cancer.
Reality: The risk is more nuanced than the headlines suggested. For most women, the absolute risk increase associated with combined HRT is small - comparable to the risk of drinking one to two units of alcohol daily, or being overweight. Modern body-identical HRT, particularly when micronised progesterone is used rather than synthetic progestins, carries a more favourable risk profile than older formulations, with observational evidence suggesting a lower breast cancer risk than some synthetic alternatives. The 2024 NICE guidelines are clear: for most women with bothersome symptoms, the benefits are likely to outweigh the risks - explored through an individualised conversation with a clinician, not dismissed as a blanket prohibition.
Myth: HRT is made from horse urine.
Reality: Older conjugated equine oestrogen (Premarin) was derived from pregnant mares’ urine. Modern body-identical HRT - oestradiol and micronised progesterone - is derived from plant sources (typically yams) and is structurally identical to the hormones your body produces. This is not the same product. The distinction matters.
Myth: I am too young for HRT.
Reality: Perimenopause can begin in the late 30s. South Asian women may be entering it in their early 40s. There is no minimum age for HRT - the decision is based on symptoms and individual risk assessment, not age alone. If your symptoms are affecting your quality of life, you are not too young to have the conversation.
Myth: Natural is better - I should just manage without.
Reality: Perimenopause is natural. So is the cardiovascular disease, osteoporosis, and cognitive decline that prolonged oestrogen deficiency may contribute to over time. “Natural” does not mean “without consequence.” We do not tell a woman with an underactive thyroid to simply endure it. The same principle applies here.
Myth: HRT is only for hot flushes.
Reality: HRT addresses the full spectrum of perimenopausal symptoms - brain fog, joint pain, anxiety, insomnia, vaginal dryness, low mood, palpitations - and is associated with long-term protective benefits for the heart, bones, and brain. It is not a luxury treatment for one symptom. It is a comprehensive hormonal support for a whole-body transition.
Myth: My community does not use HRT.
Reality: Your community has not been given the information, the representation, or the culturally safe space to consider it. That is not a reflection of what is right for your body. It is a reflection of a gap in healthcare that we are working to close.
What good care looks like
You deserve a clinician who:
- Knows that South Asian women reach menopause earlier and adjusts their assessment accordingly.
- Understands that Black women carry a higher symptom burden and a higher cardiovascular risk - and factors this into the case for HRT.
- Does not dismiss your symptoms as stress, anxiety, or “just getting older.”
- Offers you a full, individualised risk-benefit discussion about HRT rather than a blanket refusal.
- Acknowledges the cultural context you bring to the appointment without using it as a reason to withhold treatment.
- Treats your medical mistrust as a legitimate response to a real history, not as an obstacle to manage.
If your current GP does not provide this, you are entitled to seek one who does. The British Menopause Society maintains a directory of accredited menopause specialists across the UK. You can ask for a referral. You can seek a second opinion. You can change GP practices. These are your rights.
How to have the conversation
Walking into a GP appointment as a woman of colour asking for HRT can feel like walking into a room where the odds are already stacked against you. Here is how to shift those odds.
Bring your symptom diary. Document every symptom - physical, psychological, sleep, menstrual - for at least two weeks before your appointment. Dates, severity, and impact on daily life. This is objective data. It is harder to dismiss than a verbal account.
Name what you want. Do not wait for your GP to offer. Say: “I believe I am in perimenopause. I have been experiencing [symptoms] for [duration] and they are significantly affecting my quality of life. I would like to discuss HRT as a treatment option.”
Cite the guidelines. The 2024 NICE guidelines (NG23) state that HRT should be offered to women with bothersome menopausal symptoms, with an individualised risk-benefit discussion. You can say: “I understand the current NICE guidance recommends an individualised discussion about HRT. I would like to have that conversation.”
If you are dismissed, push back. If you are told you are too young, too healthy, or that your symptoms do not warrant HRT, you can say: “I would like my symptoms and this discussion to be documented in my notes. I would also like a referral to a menopause specialist for a second opinion.”
Bring someone with you. Having a trusted person in the room - a partner, a friend, a family member - can make a significant difference to how you are treated and how you feel in the appointment.
Know that you are not alone. The disparity you may experience in that room is not a reflection of your worth, your intelligence, or the legitimacy of your symptoms. It is a systemic failure. And it is one that is being named, challenged, and slowly changed - by clinicians, by researchers, by advocates, and by women like you who refuse to accept inadequate care.
A word to the clinicians reading this
If you are a GP, a nurse practitioner, a pharmacist, or any other healthcare professional who has found this post - this section is for you.
The data on HRT prescribing disparities is not new. The SWAN study data on ethnic differences in menopausal experience is not new. The evidence on the earlier onset of menopause in South Asian women is not new. What is new - or what needs to become new - is the clinical response to this evidence.
Ask yourself honestly: are you applying the same standard of care to your Black and South Asian patients as to your White patients? Are you initiating the HRT conversation, or waiting for patients to raise it - knowing that cultural barriers make it less likely they will? Are you accounting for the earlier onset of perimenopause in South Asian women when a 42-year-old presents with symptoms? Are you addressing medical mistrust with empathy and evidence, rather than dismissal?
The women in your waiting room are not less deserving of protection for their hearts, their bones, and their brains because of their ethnicity. They are, in many cases, more vulnerable - and more in need of proactive, informed, culturally competent care.
The conversation starts with you too.
This is not the end of the story
The disparity in HRT access for women of colour is a problem that has been created by multiple forces - and it will be dismantled by multiple forces too. By researchers who include diverse women in their studies. By clinicians who update their knowledge and examine their biases. By healthcare systems that train their staff in cultural competence. By advocates and organisations who amplify these stories.
And by women. By you.
Every time you walk into a GP’s office and ask for the care you deserve, you are not just advocating for yourself. You are shifting the norm. You are making it slightly easier for the woman who comes after you. You are part of a movement that is slowly, determinedly, changing what it means to be a woman of colour navigating the healthcare system.
Your symptoms are real. Your health matters. Your access to treatment is not a privilege - it is a right.
Go and claim it.
Every woman deserves to see herself reflected in the science, recognised in the consultation room, and offered the same opportunity to thrive through menopause - regardless of the colour of her skin.
The Soulful GP | Mind · Body · Soul
Share this post with every woman of colour you know who is in her 40s. Share it with your GP. Share it with your daughter. The conversation starts here.