MENOPAUSE and INDIGENOUS WOMEN in CANADA: the State of Current Research

MENOPAUSE AND INDIGENOUS WOMEN IN CANADA: The state of current research

Regine Halseth, Dr. Charlotte Loppie and Nicole Robinson

CHILD, YOUTH & FAMILY HEALTH © 2018 National Collaborating Centre This publication is available for Citation: Halseth, R., Loppie, C., for Aboriginal Health (NCCAH). This download at: nccah.ca. All NCCAH and Robinson, N. (2018). Menopause publication was funded by the NCCAH materials are available free and can and Indigenous women in Canada: and made possible through a financial be reproduced in whole or in part The state of current research. Prince contribution from the Public Health with appropriate attribution and George, BC: National Collaborating Agency of Canada. The views expressed citation. All NCCAH materials Centre for Aboriginal Health. herein do not necessarily represent the views are to be used solely for non- of the Public Health Agency of Canada. commercial purposes. To measure For further information or to obtain the impact of these materials, additional copies, please contact: Acknowledgements please inform us of their use. National Collaborating Centre for The NCCAH uses an external blind Une version française est Aboriginal Health (NCCAH) review process for documents that également publiée sur le site ccnsa. 3333 University Way are research based, involve literature ca, sous le titre : La ménopause et Prince George, BC, V2N 4Z9 reviews or knowledge synthesis, les femmes autochtones au Canada : Tel: 250 960 5250 or undertake an assessment of l’état actuel de la recherche. Fax: 250 960 5644 knowledge gaps. We would like Email: [email protected] to acknowledge our reviewers for Web: nccah.ca their generous contributions of time and expertise to this manuscript. ISBN (Print): 978-1-77368-171-9 ISBN (Online): 978-1-77368-172-6

Outer Cover Photo © Credit: iStockPhoto.com, ID 859972042 Inner Cover Photo © Credit: iStockPhoto.com, ID 476777746 CONTENTS

1.0 INTRODUCTION ------7 1.1 Methods ------8 1.2 Results ------8

2.0 KNOWLEDGE, PERCEPTIONS AND EXPERIENCES OF MENOPAUSE ------9 2.1 Knowledge ------9 2.2 Perceptions ------10 2.3 Experiences ------12

Download publications at nccah.ca/34/Publication_Search 3.0 PHYSICAL HEALTH CHALLENGES ASSOCIATED WITH MENOPAUSE ------15 3.1 Bone density, fractures and osteoporosis ------15 3.2 Cancer among post-menopausal Indigenous women ------18 3.3 Other health outcomes ------18

4.0 STRATEGIES FOR ADDRESSING CHALLENGES

Télécharger des publications à ASSOCIATED WITH MENOPAUSE ------19 ccnsa.ca/524/Recherche_de_publication 4.1 Hormone replacement therapy ------20 4.2 Alternatives to HRT ------20 4.3 Other strategies ------21 4.4 Culturally Safe Menopause Care ------22 issuu.com/nccah-ccnsa/stacks 5.0 CONCLUSIONS ------23 5.1 Recommendations ------24

REFERENCES ------26

APPENDIX 1 ------30 ABSTRACT

Objective

This study aims to: 1) identify and summarize the state of research on menopause and Indigenous women in Canada, 2) suggest how this existing knowledge can be applied in practice, and 3) identify where further research is required.

Data Sources

The review draws on research (peer and non peer-reviewed) published between 1990 and December 2016, identified through multidisciplinary general and health sciences indexes, including Academic Search Premier, EBSCOIHost, Sage Premier, Science Direct, Web of Science, Google Scholar, PubMed, and Medline.

Study Selection

Selection criteria included a significant focus on the characteristics of menopause among Indigenous (First Nations, Inuit and Métis) women in Canada; their perceptions of, and experiences with changes associated with menopause; methods of addressing challenges related to menopause; and the health outcomes associated with menopause. The review identified 22 publications with a focus on Indigenous women in Canada. However, to highlight gaps in knowledge, research on Indigenous women in other countries has also been included where appropriate.

Data Extraction/Data Synthesis

The literature search revealed very limited published research on menopause among Indigenous women in Canada, with the bulk of it focused on their perceptions of, and experiences with, menopause and on bone density loss associated with menopause.

Conclusion

Further research is required on how menopause manifests physically, mentally, emotionally, spiritually and socially among Indigenous women across Canada; how they experience and perceive it; how they address related changes; how menopause impacts health outcomes like cancer, cardiovascular disease, hypertension, and diabetes mellitus; and how best

Menopause

The cessation of menstrual periods and the end of female reproduction. A woman is said to have experienced menopause when she has had no menstrual periods for 12 consecutive months (Mayo Clinic Staff, 2016a).

Peri-menopause

The period of time (typically a few years), prior to menopause, during which a woman’s body is naturally transitioning towards permanent infertility (menopause) (Mayo Clinic Staff, 2016b).

Post-menopause

The period of time after menopause.

Estrogen

A hormone produced in women’s ovaries that “influences the course of ovulation during the monthly menstrual cycle, lactation after pregnancy, aspects of mood, and the aging process.” After menopause, the production of estrogen is drastically reduced (MedicineNet, 2016a).

Progesterone

A hormone that prepares the uterus to receive and sustain fertilized eggs (MedicineNet, 2016b).

Menopause and Indigenous women in Canada: The state of current research 5 Understanding how Indigenous women experience the menopausal transition and address associated changes and health outcomes should be viewed as an emerging priority for this population.

Menopause marks the end of a After menopause, the production Although the Indigenous 1 woman’s reproductive potential. of the sex hormones, estrogen and population in Canada is a relatively Menopause is not a disease with progesterone, substantially decreases, young one compared to the non- symptoms; rather, it is a natural which may result in permanent Indigenous population, Wilson, biological process, which can also or temporary physical, mental, Rosenberg, and Abonyi (2011) be induced through the surgical emotional and/or sexual changes. note that “[o]lder cohorts of removal of a woman’s ovaries to Women who experience early the [Indigenous] population are treat cancer and noncancerous menopause (before age 40) may be increasing at a faster rate than conditions (through a procedure at greater risk for heart disease and younger cohorts” (p. 355). Over called an oophorectomy), or osteoporosis, as estrogen provides the period 2006 to 2016, the through medical treatments such as some protection against age-related proportion of the population who chemotherapy or pelvic radiation changes in blood vessels and bone was female and aged 45-54 grew therapy, which can damage the density (MedicineNet, 2016c). for all Indigenous populations ovaries (MedicineNet, 2016c). with the exception of Métis, while the proportion of the non- Indigenous female population in TABLE 1: PROPORTION OF THE POPULATION, WHICH IS FEMALE this age range declined over this AND AGED 45-54 YEARS period (Table 1).2 Yet, research on the health of older Indigenous populations remains limited. Population 2006 2011 2016 Understanding how Indigenous women experience the menopausal Indigenous 6.5% 7.0% 6.7% transition and address associated changes and health outcomes First Nations 6.0% 6.7% 6.5% should be viewed as an emerging Inuit 4.5% 5.0% 5.5% priority for this population.

Métis 7.3% 7.8% 7.2%

Non-indigenous 8.2% 8.3% 7.4%

Source: Statistics Canada, 2006, 2017a, and 2017b.

1 The terms ‘Indigenous’ or ‘Indigenous peoples’ are used throughout this paper to refer inclusively to the original inhabitants of Canada and their descendants, including First Nations, Inuit and Métis (Aboriginal) peoples as defined in Section 35 of theCanadian Constitution of 1982. The terms ‘Aboriginal’ or ‘Aboriginal peoples’ are used when reflected in the literature under discussion. Whenever possible, culturally specific names are used. 2 It is important to note that due to a change in the way the 2011 National Household Survey (NHS) was conducted, compared to the 2006 Census (from a mandatory survey in 2006 to a voluntary one in 2011), there are issues associated with data quality resulting from a significantly lower response rate (the 2011 NHS had a weighted response rate of 68.6% compared to the 93.8% response rate in the 2006 Census (Smith, 2015).

Menopause and Indigenous women in Canada: The state of current research 7 This paper aims to: Inuit/Native American/Indigenous 1.2 Results + menopause/aging/midlife + 1) identify and summarize women. In addition, several journals The search revealed very limited the state of research on were hand-searched including published research on menopause menopause and Indigenous Menopause and BMC Women’s Health, among Indigenous women in women in Canada, and the bibliographies of relevant Canada. While there is a considerable 2) suggest how the existing publications were checked to body of research published on knowledge can be applied identify additional publications. menopause among Indigenous in practice, and Studies were deemed relevant if women in other countries, only 22 3 3) identify where further research they: included a significant focus publications could be identified with is required. Specifically, it on Indigenous (including one a focus on Indigenous women in identifies and summarizes or all of First Nations, Inuit or Canada (Appendix 1). Of these, nine published research on the Métis) women in Canada with were focused specifically on First characteristics of menopause respect to the onset of menopause; Nations women, eight were focused (including age of onset; perceptions of and experiences with on Indigenous women in general, physical, mental, emotional, menopause; changes associated five were focused on Inuit women, spiritual and social experiences with menopause; strategies for with none focused specifically of menopause); Indigenous addressing changes associated with on Métis women. Most of this women’s perceptions of menopause; or health outcomes research was focused on Indigenous menopause; approaches to associated with menopause. women’s perceptions of menopause addressing changes during or on bone density loss during peri- and post-menopause; and It is important to note that as menopause and its implications health outcomes associated one objective of this paper is to for fractures and osteoporosis. with menopause among determine areas where further Indigenous women in Canada. research is required, the literature search was not restricted to freely 1.1 Methods accessible publications. Some of the publications may be available only through purchase, while others Published research on menopause may be available only in select among Indigenous women in libraries. Information obtained Canada was identified through through publications that are not both multidisciplinary general freely accessible was derived from and health sciences indexes, either the abstract or secondary including Academic Search Premier, sources. Further, to highlight EBSCOHost, Sage Premier, knowledge gaps in the context of Science Direct, Web of Science and Indigenous women’s experiences Google Scholar, as well as PubMed with menopause in Canada, and Medline. Peer reviewed and wherever relevant, this paper also grey literature published between includes research with Indigenous 1990 and December 31, 2016 was women in other countries. considered. Combinations of the following search terms were used: Aboriginal/First Nation/Métis/

3 The publication focused entirely on, or at a minimum had one section devoted to, Indigenous women.

8 2.0 KNOWLEDGE, PERCEPTIONS AND EXPERIENCES OF MENOPAUSE

Close to half of the publications identified in this literature review focused on knowledge of, experiences with, and perceptions of menopause among Indigenous women in Canada. There is overwhelming evidence that the menopausal transition is as diverse an experience as menstruation or birth. The research also highlights the influence that psychological factors, as well as social and cultural context, play in women’s conceptualization of and experiences with menopause (Loppie, 1997, 2004). Similar findings regarding the psychosocial and cultural contexts of Indigenous women’s knowledge, perceptions, and attitudes about menopause were found in the international literature (Castelo-Branco, Palacios, Mostajo, Tobar, & von Held, 2005; Jones, Jurgenson, Katzenellenbogen, & Thompson. 2012; Michel, Mahady, Veliz, Soejarto, & Caceres, 2006).

2.1 Knowledge

Knowledge about menopause varies widely among Indigenous women (Chadha, Chadha, Ross, & Sydora, 2016). Indigenous women do not always have access to useful information about menopausal changes and challenges, or how best to address them (Banister, 2000; Loppie, 2004, 2005; Stern & Condon, 1995). This may result from a lack of access to health information that is non-medical, straightforward, and balanced (Loppie, 2004). Jurgenson, Jones, Haynes, Green and Thompson (2014) and Loppie (2004) note that a lack of knowledge about menopause among Indigenous women contributed to feelings of stress and fear. © Credit: iStockPhoto.com, ID 145921567 © Credit: iStockPhoto.com,

Menopause and Indigenous women in Canada: The state of current research 9 Colonial religious oppression of Indigenous peoples’ historic comfort with sexual and reproductive matters, in addition to experiences of sexual repression and/ or sexual abuse in Residential Schools (MacDonald & Hudson, 2012), has likely resulted in Indigenous women not always feeling comfortable talking about their sexual and reproductive health. © Credit: iStockPhoto.com, ID 53683730 © Credit: iStockPhoto.com,

Several studies have found that through other women who had Loppie, 1997, 2004). For example, Indigenous women often report experienced them, while younger Buck and Gottlieb (1991) situated feeling uncomfortable discussing women primarily accessed medical menopause within the context of menopause (Davis et al., 2003; information about midlife changes other life experiences and found Jurgenson et al., 2014; Michel et from western medical sources. that Mohawk women who felt in al., 2006) or “women’s issues” ‘synchrony’ also tended to feel that in general (Madden et al., 2010; 2.2 Perceptions they were ‘where they should be’ Stern & Condon, 1995), which may at this stage of life, while those prevent them from seeking care Indigenous worldviews who felt ‘out of synchrony’ were and support. Colonial religious conceptualize health holistically, often more uncomfortable or oppression of Indigenous peoples’ including mental, physical, spiritual, unhappy with this stage of life. historic comfort with sexual and and emotional dimensions (Reading reproductive matters, in addition & Wien, 2013), so that menopause is Some researchers have reported to experiences of sexual repression not viewed as simply a physiological dramatic improvements in and/or sexual abuse in Residential transition. The socio-political, Indigenous women’s lives at middle Schools (MacDonald & Hudson, historical, cultural and medical age. For instance, Maori women 2012), has likely resulted in contexts within which Indigenous experienced increased prestige Indigenous women not always women experience midlife and influence, participated more feeling comfortable talking about change, including the context and fully in rituals and ceremonies, and their sexual and reproductive substance of their relationships became the arbiters of community health. In 1995, Stern and Condon with partners, family, community standards (Sinclair, 1992); and 4 found that older Inuit women (who and kinship networks, also affects among Koori women, where age would have been born in the 1940s the degree to which they are able is equated with wisdom, women – before large-scale colonization to maintain balance during this attained high community status of the North) generally acquired transition (Banister, 2000, Buck & during this stage of their lives information about midlife changes Gottlieb, 1991; Chadha et al., 2016; (Thomson, 1992). Menopause may

4 Koori women are Indigenous Australians from New South Wales and Victoria.

10 also mark the transition to becoming al., 2004). These measures often more positively). Indeed, within a a grandmother and prioritizing contributed to women healing from holistic, naturalistic perspective, time for grandchildren, as well past traumatic and discriminatory Indigenous women can be protected as an evolution from learning experiences and helped enhance from pathologizing their experience to teaching cultural ways, and a their self-confidence. This, in turn, or fearing old age (Loppie, 2004). time when women gained greater becomes a resource for building respect within the community local capacity and strengthening Understanding this context can (Jurgenson et al., 2014). existing social capital within their lead to improved strategies for communities (Meadows et al., 2004). communicating menopause-related In some studies, freedom, self- information to Indigenous women, discovery and self-reflection were For other Indigenous women, and recommending appropriate the dominant themes of Indigenous however, fear and apprehension and acceptable mechanisms for women’s perceptions of menopause dominated their perceptions of managing menopausal discomforts. (Buck & Gottlieb, 1991; Loppie, midlife changes (Jurgenson et al., Yet, few studies identified in 2005; Meadows, Thurston, & 2014; Loppie, 2004). For example, this review focused exclusively Lagendyk, 2004; Webster, 2002). some of the Indigenous women from on cultural context, though This reflection often translated into Western Australia who participated several highlighted aspects of active steps to enhance women’s in a study by Jurgenson et al. (2014), Indigenous women’s experiences wellness, including seeking reported negative attitudes about and perceptions. Some publications further educational opportunities, menopause. Banister (2000) asserts highlighted the need for culturally reconnecting with traditional that this might stem from negative appropriate communication of knowledge and ways, sharing life attitudes about female aging within health information and suggested experiences and wisdom with other Western social and cultural contexts, that health care providers not community members, and playing which can challenge women’s convey any rigid meanings to the stronger roles within their families self-esteem (in contrast to many menopause experience so that and communities (Meadows et Indigenous cultures that view aging Indigenous women can make

Menopause may also mark the transition to becoming a grandmother and prioritizing time for grandchildren, as well as an evolution from learning to teaching cultural ways, and a time when women gained greater respect within the community (Jurgenson et al., 2014). © Credit: iStockPhoto.com, ID 137142511 © Credit: iStockPhoto.com,

Menopause and Indigenous women in Canada: The state of current research 11 © Credit: iStockPhoto.com, ID 115192290 in their lives. Loppie (2004) (2004) Loppie lives. their in directions meaningful and active more assume menopause and of meanings personal their to articulate clients encourage which toneed employ strategies for the She argues clients. their with interact to and relate they how in particularly experiences, women’sIndigenous midlife consciousbe of view how they to need practitioners health that argues (2000) women. Banister Indigenous for midlife delivery service and programs for improving suggestions offered Two publications 331). stop” (p. when periods time to “that by referring discussions initiate should practitioners health so languages, Indigenous all in meaning same or have the exist word ‘menopause’ the may notthat (2010) noted colleagues and Madden For decisions. instance, informed 12 and wellness during this stage of life. stage this during wellness and women’s Indigenous health optimize development of that supports to the lead could research Such alleviated. be menopause can about possible anxieties so that appropriately more communicated be can information which in ways the women, and Indigenous of menopauseperceptions among influence might that circumstances of exploration for need further the to point literature international and fromCanadian findings Collectively, necessary. if healing and wellness mid-life towards strategies diverse in to engage opportunities incorporate and building, capacity values, focus on intergenerational on Indigenous based be broadly) women more (and Indigenous women for Mi’kmaq services and programs that suggests further than original research. One focused One focused research. original than rather databases non-medical and medical from of literature review involved a both and identified, be could publications two only fact, In Canada. women in Indigenous among of menopause manifestation) (e.g. of onset age and characteristics about the of information dearth aparticular is There lives. their post-menopausal of phase the or during peri-menopause through womenIndigenous transitioning of experiences self-reported to the relates internationally, and Canada within attention, limited received has that of research area Another Experiences2.3 Monterrosa, Blümel, Escobar- Escobar- Blümel, Monterrosa, 2010; Ojeda, Tan, &Villaseca, Siseles, Henderson, 2013; Palacios, 2009, al., et Monterrosa-Castro 2001; 2012; Johnston, &Najman, Sina, Williams, Clavarino, Hayatbakhsh, 2016; al., et Chadha 2005; al., et on tobacco (Castelo-Branco use as well as region, geographical status), composition and body (e.g. factors socio-economic social dependentwere to upon be found changes of associated discomfort of onset age of the menopause and the studies, these Within States. United the and Zealand, New Central/South Australia, America, Latin/ women in Indigenous among conceived, bio-medically and narrowly experiences, menopausal on focused ofbody literature however is asubstantial There 2016). al., et world (Chadha the women around from Indigenous on focused other the while 2002), (Webster, well as included were America women North from Indigenous other though Canada, women in on Indigenous primarily López, & Chedraui, 2011; Schindler, dryness and/or painful intercourse, 2006). For example, in one study of sleep disturbances, dizziness, Blackfoot women, the average age depression, fatigue, memory loss, of menopause was 51.2 years and incontinence, and reduced energy was found to be associated with: (Loppie, 2004). The gradation and age at menarche, ever having used variation in reported experiences birth control, ever having used oral is best viewed on many continua, contraceptives, and having been related to the frequency, duration, breastfed (Johnston, 2001, 2003). and intensity of these experiences A systematic review of literature which are similarly reported by on the experiences of menopause non-Indigenous women in North among Indigenous women around America (Freeman, & Sherif, 2007). the world found that the average onset of menopause appeared to Globally, when compared to reports be earlier among most Indigenous among non-Indigenous women, groups, which was often attributed some researchers found that rural to malnutrition and harsher Navajo women (Mingo, Herman, lifestyle (Chadha et al., 2016) & Jasperse, 2000), Yucatan Mayan

women (Carranza-Kira, Quiroz, ID 487123353 © Credit: iStockPhoto.com, Evidence with respect to the González, Alfaro Godinez, & May characteristics and severity of Can, 2012), Australian Aboriginal osteoarthritis. They also found that discomforts associated with women (Thomson, 1992), and American Indian/Alaskan Native menopause among Indigenous rural Mayan Indian women postmenopausal women reported women is mixed. Webster (2002) (Martin, Block, Sanchez, Arnaud, moderate/severe pain (including indicated fewer vasomotor & Beyene, 1993) reported fewer generalized aches or pains, low changes (i.e. hot flashes and/or or no menopausal discomforts, back pain, neck pain, or joint pain sweats) among Indigenous women while others like Monterrosa et or stiffness) more frequently than compared to non-Indigenous North al. (2009) and Ojeda et al. (2011), the other ethnic groups, and that American women. In contrast, in their studies of Indigenous they were also more likely to report Madden et al. (2010) reported that women in South America, found a history of mood disorder and six of the First Nations women they had more severe discomforts 5 more than five negative life events. in their study (n=18) reported no associated with menopause, which Monterrosa-Castro and colleagues hot flashes at all, while six others increased the potential for them (2009, 2013) also noted the role that described hot flashes as a main to report lower quality of life. smoking played in insomnia and the component of their menopausal severity of somatic and psychological experience. Among Mi’kmaq Lynch and colleagues (2010) menopausal discomforts. Research women, some women reported no explored weight and health- specifically exploring the impacts mood swings, no hot flashes, and no related quality of life among post- of menopause on mental health memory disturbances, while others menopausal women across five and wellness, as well as its experienced changes in mood and ethnic groups in the United States associated manifestations and eating habits, hot flashes, weight and found that the most common health outcomes among Indigenous gain, heart palpitations, hot or cold health issues were obesity-related women, is virtually absent. sweats, changes in libido, vaginal conditions, hypertension and

5 The severity of discomforts was measured with the Menopause Rating Scale, grouped into three subscales: somatic, psychological, and urogenital. Each type of discomfort was graded on a scale of 0 (not present) to 4 (very severe). Values above 8 (somatic), 6 (psychological), and 3 (urogenital) and 16 (total) were used to define severe ‘symptoms’.

Menopause and Indigenous women in Canada: The state of current research 13 ...forced transition to a Western diet, coupled with living in northern and remote locales and lower socio- economic circumstances, has resulted in a number of nutrient deficiencies among many Indigenous people in Canada, especially Vitamin D and calcium (Kuhnlein & Receveur, 2007; Halseth, 2015).

While there is a plethora of (Perry, et al., 1998a/b). Nine studies Four Canadian studies have explored research on health challenges in this review explored bone density the role of nutrition in bone density associated with menopause among among Indigenous (mostly First among Indigenous women, including non-Indigenous women, studies Nations) women in Canada (El saturated and monounsaturated involving Indigenous women in Hayek, Pronovost, Morin, Egeland, fatty acids (Paunescu, Ayotte, Canada are extremely limited. The & Weiler, 2012; Evers, Orchard, & Dewaily, & Dodin, 2014), Vitamin available literature focuses primarily Haddad, 1985; Leslie et al., 2004, D (El Hayek et al., 2012; Weiler, on bone density, osteoporosis and 2005, 2006a/b, 2008; Paunescu Leslie, & Bernstein, 2008), and fractures, with no research on et al., 2013a/b). These studies calcium (Evers et al., 1985). health outcomes such as cancer tended to focus on the Indigenous or cardiovascular disease, and one population in general or on Traditional Indigenous food sources, article focusing on the prevalence Indigenous women of all ages, rather especially fish and marine mammals, of unexplained anaemia. than on post-menopausal women are important sources of fatty acids in particular. While the results of and vitamin D (El Hayek, Egeland, 3.1 Bone density, fractures these studies are somewhat mixed & Weiler, 2011; Lock, Waagbo, (with Indigenous women having Wendelaar Bonga, & Flik, 2010), and osteoporosis relatively lower bone density in some while beans, fish bones, nuts, and body locations and higher bone some greens are good sources of With some variations related density in others), they highlight calcium (Phillips, 2009). However, to ethnicity, women generally the need for further research on forced transition to a Western diet, experience a relatively rapid decrease factors that might put Indigenous coupled with living in northern in bone density during the post- women at risk for post-menopausal and remote locales and lower menopausal period which can be fractures, such as exposure to socio-economic circumstances, has a risk factor for osteoporosis and environmental contaminants and resulted in a number of nutrient bone fractures, and is thus an the prevalence of obesity, diabetes, deficiencies among many Indigenous important health issue for aging comorbidity and substance abuse. people in Canada, especially women (Ohta et al., 1992; Paunescu, Vitamin D and calcium (Kuhnlein Dewailly, Dodin, Nieboer, & Ayotte, Research has demonstrated that & Receveur, 2007; Halseth, 2015). 2013a). Some research suggests that Vitamin D, calcium, and fatty acids Indigenous women in the United are important for the maintenance Surprisingly, Evers and colleagues States have higher bone mass before of bone strength (Côté et al., 2004; (1985) found that, after controlling menopause than Euro-American El Hayek et al., 2012; Paunescu for number of years since women but lose it more rapidly et al., 2013c, 2014; Weiler, Leslie, menopause, diminished calcium during the post-menopausal years Krahn, Steiman, & Metge, 2007). intake was not a predictor of bone

Menopause and Indigenous women in Canada: The state of current research 15 El Hayek and colleagues (2012) found that Inuit women 50 years or older had more nutrient dense diets and higher concentrations of Vitamin D than younger women (40-49 years) because they consumed more traditional foods. © Credit: Alamy.com, ID CXJHBC © Credit: Alamy.com,

loss in North American Indian monounsaturated fatty acids were in Canada. In 2008, Leslie and (NAI) 6 women. Similarly, 25(OH) associated with bone strength colleagues found that First Nations D 7 was not found to be a significant among Inuit women in Nunavik. women had significantly lower predictor of bone density in This finding is supported by weight-adjusted bone mineral density samples of Inuit and First Nation other research with Inuit from (BMD) compared to Euro-Canadian populations, despite its importance Greenland (Côté et al., 2004; women at two body sites, which in the maintenance of bone density Stark et al., 2002; Paunescu et al., they largely attributed to a lower (El Hayek et al., 2012; Weiler et al., 2013c). One implication of this ratio of lean body mass to fat mass. 2008). This may be due to a plateau finding is that, as a result of the However, El Hayek et al. (2012) in the concentration of parathyroid nutrition transition, which has found that increased adiposity (fat) hormone (a hormone that is led to decreased traditional food predicted forearm bone mineral important in bone remodeling), consumption among younger Inuit density (fBMD) in both pre- and which occurs when a certain populations, their risk of future post-menopausal Inuit women. concentration of 25(OH)D is reached osteoporosis and bone fractures Likewise, Evers et al. (1985) found (Dawson-Hughes et al., 2005). may be increased. Promoting that obesity was positively associated the consumption of traditional with bone density among NAI El Hayek and colleagues (2012) food sources may therefore be an women and Paunescu et al. (2014) found that Inuit women 50 years important component of bone found no associations between or older had more nutrient dense health promotion strategies. anthropometric measures (the size, diets and higher concentrations shape and composition of the human of Vitamin D than younger Several studies have examined body) with the Stiffness Index 8 (SI) women (40-49 years) because they obesity and chronic health among a sample of Inuit women, consumed more traditional foods. conditions, such as diabetes, as despite a large proportion of these Paunescu et al. (2014) also found risk factors for osteoporosis and women being considered obese. that higher levels of saturated and fractures among Indigenous women They argued that although a high

6 The term used by the authors is “North American Indian”; however, they are referring to First Nations women from southwestern Ontario. 7 This acronym refers to “25-hydroxy vitamin D,” a biochemical substance that is produced in the liver through the conversion of vitamin D3; it is used to determine a patient’s vitamin D status (Wikipedia. Calcifediol. 2015; https://en.wikipedia.org/wiki/Calcifediol 8 The Stiffness Index is an expression of bone quality relating to density, structure and strength. Bone density is generally screened using dual energy x-ray absorptiometry or ultrasound, and scores are presented in two formats: the T-score compares your bone density to that expected for a healthy, young person and is used to determine fracture risk; and the Z-score which compares your bone density to the average bone density of a person your age, which is not used to determine fracture risk (Osteoporosis and Related Bone Diseases National Resource Center, n.d. Building Strong Bones for Life).

16 level of fat mass has been identified the development of osteoporosis fracture among Indigenous women, as a risk factor for osteoporosis among Indigenous women in including smoking, physical activity, and fragility fractures, among Inuit Canada (Paunescu et al., 2013a/b). and substance abuse. Paunescu et women obesity may not “reflect These studies found little evidence al. (2013a) found that smoking was the same degree of metabolic risk” that exposure to environmental negatively associated with bone as in other populations because contaminants was related to density status among Cree women oleic acid (a fatty acid in meat) osteoporosis in a sample of Cree from James Bay, while physical contributes to bone strength and Inuit women. The findings are activity was a positive predictor of in this population (p. 8). supported by a similar study with the radial (the long bone of the forearm) Greenland Inuit (Côté et al., 2006). bone density in this population. Two studies have examined the Though evidence that environmental In contrast, Evers and colleagues potential association between contaminants are associated with (1985), who sought to determine diabetes and bone loss and/or osteoporosis is at present limited,9 differences in risk factors for bone fracture, of which only one focused given the high rates of tobacco loss in Euro-American and NAI exclusively on post-menopausal smoking and the potential for high women, found that, after controlling Indigenous women. Evers and levels of exposure to environmental for number of years post-menopause, colleagues (1985) found no contaminants among Indigenous smoking was not a predictor of association between diabetes and people in Canada, further research bone loss in NAI women. One bone loss in NAI women, while in this area may be warranted. study found that substance abuse 10 Leslie et al. (2006a) found that was associated with osteoporotic a greater prevalence of diabetes Few studies in this review focused fractures in both Indigenous was associated with higher rates on identifying lifestyle risk factors and non-Indigenous adults in of osteoporotic fractures in the associated with loss of bone Manitoba (Leslie et al., 2006a). general First Nations population, density, osteoporosis and risk of including post-menopausal women. However, they also indicated that other risk factors, not explored in their study, could be contributing to high rates of osteoporotic fractures in this population.

Some researchers have hypothesized that environmental contaminants such as cadmium (a toxic metal) and organochlorine pollutants (pesticides) are risk factors for

osteoporosis in post-menopausal ID 182858916 © Credit: iStockPhoto.com, women (Alfvén et al., 2000; Järup & Åkesson, 2009; Rignell-Hydbom et al., 2009; Vahter, Berglund, & Akesson, 2004). Two studies have investigated the role of environmental contaminants in

9 While there has been some research indicating an association between cadmium and bone density (see for example, Vahter, et al., 2004), other research has found only weak or no associations between other environmental contaminants and bone density or osteoporosis. 10 Substance abuse was defined as any hospitalization or medical claim with a code for a relevant diagnosis (i.e. alcoholic psychoses, drug psychoses, alcohol dependence, drug dependence or nondependent abuse of drugs).

Menopause and Indigenous women in Canada: The state of current research 17 Although Indigenous peoples in of breast radiolucency (fat in the who generally had adequate stores of Canada (including post-menopausal breast, which is associated with iron. The authors highlight several women) have higher rates of an increased risk of breast cancer) factors beyond iron status that may osteoporosis than non-Indigenous included obesity, older age and/or be contributing to the prevalence people (Statistics Canada, 2009), post-menopausal status, and Native of anaemia among older Inuit, this review indicates that the American identity (Bartow et al., including inflammation, infections, findings of research about impact 1995; Eaton et al., 1994). Roubidoux and low socio-economic status, of substance use (licit and illicit), and colleagues (2003) found that and argue that the nutrient-rich physical activity, nutrition, obesity the relationship between breast traditional diets and lifestyle may and diabetes on bone density, density (containing less fatty tissue) be protecting Inuit from nutritional osteoporosis and fracture risk to diabetes varies with menopause anaemias but contributing to among post-menopausal Indigenous status in Native American women, lower hemoglobin values through women is inconsistent and not well with diabetes correlating with breast environmental exposures. understood. Future research focused density in pre-menopausal women on living conditions (which is an but not in post-menopausal women. important determinant of smoking, McKenzie et al. (2014) found that substance abuse, lack of physical post-menopausal Maori women with activity, obesity and diabetes) may scores in the top third of the healthy offer additional insights into the risk lifestyle index had significantly of fractures among this population. lower breast cancer risk compared than those in the bottom third. 3.2 Cancer among Finally, Slattery et al. (2006) found that physical activity was associated post-menopausal with reduced risk of breast cancer in Indigenous women American Indian women, especially in post-menopausal women and Breast cancer is an important health those not recently exposed to HRT. issue for women after menopause, especially among women who 3.3 Other health outcomes are using hormone replacement therapy (HRT). In fact, a number Only one additional article was of studies have suggested that HRT identified that explored associations is associated with an increased between menopause and other risk of breast cancer (Eaton et health outcomes among Indigenous al., 1994; Printz, 2014; Wise, women. This article examined 2016). Despite this, no studies and compared the prevalence of were found on breast cancer or unexplained anaemia in Inuit men its risks among post-menopausal and post-menopausal women from Indigenous women in Canada. northern Labrador (Jamieson, Weiler, Kuhnlein, & Egeland, Research in this area is also fairly 2016). The study’s findings indicate limited with respect to Indigenous relatively stable rates of anaemia women in other countries, with for Inuit women across age groups. most of it focused on NAI women However, while iron deficiency (Bartow, Pathak, Mettler, Key, & explained much of the anaemia Pike, 1995; Chlebowski et al., 2005; observed in pre-menopausal Inuit Eaton et al., 1994; McKenzie et women, it did not explain the al., 2014; Roubidoux et al., 2003; moderate rates of anaemia found Slattery et al., 2007). Predictors among post-menopausal women,

18 4.0 STRATEGIES FOR ADDRESSING CHALLENGES ASSOCIATED WITH MENOPAUSE

Multiple strategies exist for addressing challenges that sometimes occur during peri- and post-menopause. Some women use estrogen and progesterone-based HRT to reduce hot flashes and reduce bone loss; however, as a result of concerns about the safety of these non-human hormones, many women are turning to more natural alternatives which they believe to be safer (Rees, 2009; Wuttke et al., 2014). In addition, there is a small body of literature on other strategies, such as stress reduction and lifestyle changes, which might reduce potential discomforts and thereby improve quality of life.

A few studies explored strategies used by Indigenous women in Canada to address challenges during the peri-menopausal transition. However, there is limited information about the extent to which Indigenous women in Canada seek advice from health professionals about menopause and associated changes; their use of HRT, traditional approaches, and alternative strategies to manage symptoms; and the effectiveness or safety of various strategies used by this population. Similarly, sparse literature exists on the use of HRT, natural supplements, and other coping strategies among Indigenous women elsewhere.

© Credit: iStockPhoto.com, Menopause and Indigenous women in Canada: The state of current research 19 ID 908629168 4.1 Hormone (2004) reported that Mi’kmaq 4.2 Alternatives to HRT replacement therapy women in Nova Scotia were wary of the health effects of HRT and many Alternatives to HRT include natural stopped using it after a short time. HRT has been reported in studies supplements, several of which are among Mi’kmaq women (Loppie, considered ‘traditional medicines’ HRT has been associated with an 2004), Maori women (Lawton, by some Indigenous populations, increased risk of breast cancer, Rose, Cormack, Stanley, & Dowell, including ‘black cohosh’, evening especially in obese post-menopausal 2008), Australian Indigenous women primrose oil, red clover blossoms, women (Eaton et al., 1994). This (Davis et al., 2003; Jurgenson et al., and soy isoflavone extracts, which may be an important concern for 2014), and American Indian women are primarily used to reduce hot Indigenous women in Canada (Cowan et al., 1997; Redwood, flashes and/or sweats. The literature who have higher rates of obesity Lanier, Johnston, Murphy, & search discovered no studies that compared to non-Indigenous women Murtaugh, 2012). In all but one of exclusively explored the use of such (NCCAH, 2012). Jurgenson et al. these studies, supplemental estrogen products by Indigenous women (2014) found that some Indigenous use was found to be quite low among in Canada, or their effectiveness women in Australia were fearful Indigenous women. These studies within this population. There has of seeking help for their symptoms suggest that Indigenous women may been more research on the use because of concerns that they were not be using, or continuing to use, of such products among other due to illnesses such as diabetes HRT for a variety of reasons. Mingo Indigenous women, including or a heart condition. Zhang and and colleagues (2000) found that those in the United States as well colleagues (2002) caution that some Native American women had as South and Central America. diabetes should be considered not heard about HRT and among There have also been several when deciding whether or not to those who had been prescribed studies assessing the safety and use estrogen. Given the high rates it, many expressed dissatisfaction effectiveness of these products of diabetes among First Nations with its side effects. Women may generally. Yet, the evidence has been women, further research in this also be apprehensive about using mostly inconclusive, resulting in area is required, as is research to HRT. For example, Jurgenson and some uncertainty about alternative determine the prevalence of HRT colleagues (2014) found that 20% of (to HRT) methods to reduce the use among Indigenous women, and the Australian Indigenous women discomforts of menopausal change. their perceptions of HRT use. in their sample were reluctant to use HRT for fear of health complications Most research evidence on the and wanted to go through the safety and effectiveness of natural process naturally. Similarly, Loppie therapies relates to the use of a

20 flashes, butflashes, tested has not been it to reduce tea hot on mugwort relied have of California Indians Chumash The therapies. of natural other safety and effectiveness on the undertaken been has research Less 2013). al., et (Rahal health general for beneficial are that effects shown to provide antioxidant been Cohosh Black has addition, In 2007). al., et (Chung metabolism lipid some to benefits depression, with to moderate mild Wort, to address John’s St. with combination in used when effective, to be appears also 2014). al., et Wuttke It 2003; al., Lupu et Papps, 2000; 2005; Dog, Low Huntley, 2007; 2004; al., et (Chung use for long-term its safety to assess required is research further however, durations; limited for taken hotif flashes reducing safe in and CohoshBlack may effective be that indicates available currently 2013). evidence al., et The Rahal 2005; Dog, Low 2004; (Huntley, explored been has its safety and hot flashes to alleviate populations by American used Native medicine atraditional is plant racemosa). This Cohosh Black (Cimicifuga as known plant perennial American North the interaction of such products interaction the may cause for be about concern there fact, in and, discomforts menopausal peri- alleviating in effective are therapies complementary’ and of use ‘alternative that showing trials randomized from robust evidence no is At there present, 2005). Dog, Low 2002; &Hammoud, Ansbacher, (Kang, uncertain is safety long-term and minimal to be appear extracts clover blossoms soy and isoflavone red oil, primrose benefits evening of The required. is study further and effect placebo adistinct had also it peri-menopause, with associated discomforts substantially-reduced it although that found colleagues women off of HRT. Meissner and supplements, to wean nutritional with conjunction in and, energy to boost balance, hormonal maintain to help discomforts, menopausal to relieve used been has plant This post-menopausal period. early the women during among Maca plant Andean of the effectiveness the at assessing aimed study pilot clinical placebo-corrected a double-blind conducted (2005) Lutomski and Mscisz, 2012). Meissner, Kapczynski, &Garg, Garcia, Adams, 2006; &Garcia, (Adams trials clinical in Menopause and Indigenous women in Canada: The state of current research current of state The Canada: in women Indigenous and Menopause cancer (McBride, 2015; 2009). Rees, (McBride, cancer like of illnesses treatment the with and further research is required. required. is research further and internationally and domestically both thin especially is research of area However,humour. this asense of adopting and family, visiting alcohol, music, consuming to listening exercising, weight, their watching for support, together sticking including: Australia in women Indigenous from suggestions al.’set (2014) offers several study Jurgenson Similarly, 2004). (Loppie, transition menopausal the during balance spiritual and emotional mental, physical, ways to maintain as practices spiritual traditional and humour, acceptance, socializing, busy, staying activity, physical using women report Mi’kmaq lifestyle. ahealthier adopting and activities, releasing stress in engaging of forms support, seeking included: globe have the women around Indigenous among menopause of peri- discomforts potential the for managing strategies Other 4.3 Other strategies 21

© Credit: iStockPhoto.com, ID 517798799 4.4 Culturally Safe According to Northrup (2012), persistent elevation of a hormone Menopause Care called DEA, which is produced in response to chronic stress, may In Canada, well-documented deplete the adrenal gland, which concerns have been raised is an important source of post- about the adequacy and cultural menopausal androstenedione, appropriateness of health services for which is converted to estrogen Indigenous peoples (see for example, (Larsen, Kronenberg, Melmed, & Macdonald, Rigillo, & Brassard, Polonsky, 2002). Women whose 2010; Browne & Fiske, 2001; & lives have been stressful or who Tang & Brown, 2008). Particularly suffer from chronic illness may in remote/northern regions of enter peri-menopause in a state Canada, challenges associated of adrenal exhaustion. The link with accessing health care and between adrenal function, historic appropriate informational resources trauma and hormone sensitivity can impact the ability of local may place some Indigenous women residents to make decisions about at increased risk of emotional and/ their health care options as well or physical discomforts during as prevent them from seeking out peri-menopausal change. Yet, care when they need it. Leipert and physicians are often insensitive Reutter (2005) note, for example, to the multiple and persistent that in the context of northern personal, family and community residents and their access to health responsibilities that can impact care services generally, options for adrenal function in Indigenous peri- diagnosis, treatment and health menopausal women (Loppie, 2004). promotion (including menopause and mental health resources), illness prevention services, and alternative therapies are very limited and that northern residents have developed strategies for coping with health challenges on their own. According to Loppie (2004), Mi’kmaq women who pursue traditional healing and/or herbal medicines often feel more empowered about menopause. However, jurisdictional issues related to accessing health services outside those covered by the federal government present barriers to First Nations women who wish to pursue alternatives to HRT and other medical treatment (e.g. anti-depressants) during this natural process of change.

22 5.0 CONCLUSIONS

This literature review indicates that Indigenous women’s perceptions are shaped by a number of cultural (both Western and Indigenous), socio-economic, historical, medical and political contexts, which also impact their physical and emotional balance during midlife. Some women have negative experiences and difficulties maintaining a balance, while others experience improved quality of life; a time to focus on themselves and enhance their relationships.

This review also reveals a number of knowledge gaps that require further research. Given the growing number of aging Indigenous women, it is clear that further research is required to provide an understanding of how menopause manifests in Indigenous women, how they experience and perceive it, how they cope with and ameliorate discomforts associated with it, and how it impacts their health and wellness. Moreover, there does not appear to be much information about Indigenous women’s informational needs and the best ways of communicating that information, or about the use and safety of HRT and other strategies within this population.

There is little research on the quality of midlife Indigenous women’s lives, beyond a focus on some of the health outcomes associated with menopause. The existing body of research focused on bone density, osteoporosis and fractures indicates that factors which may be placing Indigenous women at increased risk are not well understood, and there is virtually no research on how menopause affects existing conditions like hypertension, cancer and diabetes mellitus. This type of research is essential so that Indigenous women can experience an optimal menopausal experience, and so that health care providers and community supports can enhance Indigenous women’s transition through this life stage.

Given the findings of this literature review, several recommendations can be made to optimize the health and wellness of Indigenous women throughout the menopausal transition.

1. Equitable 2. Diverse 3. Local 4. Culturally research teams knowledge appropriate Provide equitable research Establish multi- Account for the local Implement culturally opportunities for relatively disciplinary teams of knowledge of the women appropriate public health small, qualitative studies researchers, health themselves in approaches initiatives aimed at that attempt to capture care professionals, aimed at informing fostering health equity, important nuances community organizations, Indigenous women especially by increasing of menopause among and Indigenous about the challenges opportunities for Indigenous women, the women to ensure that and opportunities of physical activity and the knowledge of which multiple perspectives menopause change. Health consumption of traditional creates a more balanced are represented in professionals, particularly foods, which have the perspective from which the development and those from outside potential to reduce bone to develop and implement implementation of communities, can enhance loss and, therefore, the culturally appropriate self-care and support educational approaches risk of osteoporosis and educational, instrumental programs. by incorporating bone fractures in post- and emotional supports. opportunities for menopausal Indigenous women to share their women. Such initiatives experiences with one may also help reduce another. This practice the risk of breast cancer not only acknowledges and adverse health the subjectivity of this issues associated with experience but also menopause, and improve honours the tradition of the quality of Indigenous story telling as a useful women’s lives. tool for learning.

© Credit: iStockPhoto.com, ID 470361150 5. Tailor 6. Screening 7. Traditional messaging supports approaches Tailor health promotion Put in place supports so Given the high prevalence initiatives and that post-menopausal of diabetes among interventions, and the Indigenous women can Indigenous women, ways in which they be routinely screened for a diabetes diagnosis are implemented, to bone mineral density as should be considered the specific needs of a preventive strategy for in physician’s decisions Indigenous women as osteoporosis and bone to prescribe HRT and they transition through fractures. there may be a need menopause. There is to advocate for more a need for culturally traditional approaches. appropriate health information about menopause, as well as options for addressing discomforts for Indigenous women.

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29 APPENDIX 1

Publication Menopause topic Methodology

Webster (2002) Characteristics of menopause; Literature review knowledge/experiences/perspectives

Banister (2000) Knowledge/experiences/perspectives Ethnographic study

Buck & Gottlieb (1991) Knowledge/experiences/perspectives Qualitative study – interviews

Chadha et al. (2016) Knowledge/experiences/perspectives Systematic review

Loppie (1997) Knowledge/experiences/perspectives Qualitative study – interviews/focus groups

Loppie (2004) Knowledge/experiences/Perspectives; Qualitative study – participatory model/focus groups Implications for programs/services

Loppie (2005) Knowledge/experiences/perspectives Qualitative study – participatory model/focus groups

Madden et al. (2010) Knowledge/experiences/perspectives Qualitative study - interviews

Meadows et al. (2004) Knowledge/experiences/perspectives Qualitative study – ethnography; group and individual interviews

Stern, & Condon (1995) Implications for programs/services Methodology uncertain – only abstract available

El Hayek et al. (2012) Associated health outcome Quantitative/qualitative – questionnaire, anthropometric measurements and laboratory testing of samples

Evers et al. (1985) Associated health outcome Quantitative and qualitative – interviews, physical measurements; statistical analysis techniques

Jamieson et al. (2016) Associated health outcome Cross-sectional survey, lab testing

Leslie et al. (2006a) Associated health outcome Quantitative/qualitative – questionnaires, physical measurements; statistical analysis techniques

Leslie et al. (2006b) Associated health outcome Retrospective, population-based matched cohort study using Manitoba administrative data

Leslie et al. (2004) Associated health outcome Quantitative using Manitoba administrative data

Leslie et al. (2005) Associated health outcome Retrospective, population-based matched cohort study using Manitoba administrative health data

Paunescu et al. (2013a) Associated health outcome Laboratory testing for concentrations of dioxins in blood plasma

Paunescu et al. (2013b) Associated health outcome Laboratory testing for concentrations of dioxins in blood plasma

Weiler, Leslie, & Bernstein (2008) Associated health outcomes Laboratory testing of serum biomarkers

Paunescu et al. (2014) Associated health outcome Cross-sectional descriptive study; multiple linear regression used to explore associations. Bone measures and qualitative survey techniques

Lix, Metge, & Leslie (2009) Associated health outcome Qualitative research methodology – questionnaire; confirmatory factor analysis techniques to test hypotheses sharing knowledge · making a difference partager les connaissances · faire une différence ᖃᐅᔨᒃᑲᐃᖃᑎᒌᓃᖅ · ᐱᕚᓪᓕᖅᑎᑦᑎᓂᖅ

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