By Rachel Showstack
Earlier this year, a few weeks after my 47th birthday, somebody who I love very much woke me up in the middle of the night during a weekend retreat in Cottonwood Falls, Kansas. Our ensuing interaction made me angry; an anger that pulsated through my veins. I lost my temper and then later found myself lying awake with adrenaline in my veins and a feeling of remorse. Trying to calm myself down, I wrote about how I felt, listened to a Headspace sleepcast, and stared at the ceiling in the dark.
When I awoke the next morning, my anger had not subsided. I threw our belongings into our bags and rushed us out of the cottage and into my car. Once on the freeway, I drove at ninety miles per hour until we were back in Wichita, growling with anger periodically. Yes, I was growling, and yes, the person in the car with me was frightened. Thankfully, we made it home safely, and then, suddenly, a sense of despair enveloped me, and I retreated to my private space in the basement to cry.
As someone who was aware of the commonly cited symptoms of perimenopause, the years before we stop getting our periods when our hormones start to change, I eventually realized that my emotional rollercoaster was related to fluctuating hormone levels. I was already waking up drenched in sweat a few nights a month, and it had been years since I had consistently slept well. Intense anger, sadness, night sweats, and sleep difficulties are all symptoms associated with a decrease in levels of the female hormone estrogen, which generally begins to occur when women are in their 40s, though it can also happen earlier.
I listened to a podcast to try to learn more—it was an English-language interview between podcaster Mel Robbins and menopause expert Dr. Mary Claire Haver. Mel was indignant about how little women are told about the change of life, and Dr. Haver had long been on a mission to raise awareness, as demonstrated in her 2024 book, The New Menopause.
I made appointments at the office of my general practitioner and my gynecologist, the former being several weeks before the latter. At my GP’s office, I read my list of symptoms to a physician’s associate, and she recommended that I try an anti-psychotic medication. I said I would give it some thought, but because of all that I had read, I knew that it was an inappropriate response to a 47-year-old woman presenting with night sweats and mood swings.
When I finally saw my gynecologist, we discussed my symptoms, she reviewed my labs, and, seeing that nothing else seemed to be wrong with me, she diagnosed me with perimenopause. From there, we discussed my options and their risks and benefits. In my case, considering my medical history, age, and symptoms, the benefits of combination hormone replacement therapy (HRT), consisting of estrogen and another female hormone called progesterone, clearly outweighed the risks. She prescribed transdermal estrogen (a patch that I use on my abdomen) and oral progesterone (pills that I take every night).
One week into the treatment, I already felt better than I had in years. After a couple more weeks, I was a completely different person: calm, well-rested, clear-headed, and concerned about the well-being of others.
Throughout the process of seeking and attaining care, I wondered how the menopause experience would be for women who did not have access to information about symptoms and treatments, or who didn’t have a regular gynecologist, or who had difficulties assessing levels of risk as presented by western doctors.
One afternoon in May, I attended a workshop about menopause for Spanish-speaking women, organized by the community health worker organization Salud + Bienestar and held at the Evergreen Community Center and Library in Wichita’s traditional Latine neighborhood. The presentation was delivered in English by a board-certified gynecologist (the originally scheduled presenter, who spoke Spanish, was not able to make it), and a bilingual community health worker provided Spanish-language interpretation. The audience consisted of about twenty Latina women, primarily between the ages of forty and sixty-five.
The presenter discussed HRT as a possible remedy for menopause symptoms. She emphasized the risk of endometrial cancer associated with using estrogen alone for patients who have not had a hysterectomy (which is why patients with a uterus are given a combination of estrogen and progesterone), and the risk of blood clots associated with estrogen, particularly when taken orally (as opposed to on the skin using a patch or cream). When listening to her discussion of the risks, I wondered how the attendees were making sense of the delicate balance between risks and benefits.
After the presentation, just about everybody in attendance had a question. Since low estrogen can lead to decreased bone density, which increases the risk for osteoporosis, one participant wanted to know how she could prevent osteoporosis if she chose not to take the hormones. Another asked about the side effects of HRT. There were also testimonies and questions about specific symptoms.
Many factors contribute to peoples’ ability to find and understand health information, consider that information from a critical perspective, and use it to make informed decisions about their health. The degree to which people have this ability is part of their personal health literacy, and personal health literacy is impacted by the ways that organizations provide information and support decision-making processes, designated as organizational health literacy.1
In our co-authored book, my colleagues and I point out that health literacy happens in interactions in specific contexts, and we argue in our concluding chapter that there is a need for an exploration of interventions to support health literacy in bilingual communities. The U.S. health care system and individual health care professionals have an important role in health literacy for individuals whose primary language is not English, and it goes beyond simply providing information in different languages. It also includes being sensitive to the multilingual and multicultural contexts in which discussions about health care decisions occur; and developing culturally and linguistically relevant strategies for engaging in conversations about health risk.
Menopause is a unique condition to consider with relation to health literacy because symptoms vary widely from person to person, and decisions about treatment are based on a complex set of risks and benefits. On one hand, patients’ risks of adverse health outcomes like osteoporosis and heart problems are increased by the deficiency in estrogen that comes with the menopausal transition; on the other hand, the estrogen treatment itself can increase some individuals’ risk of certain conditions, like blood clots and breast cancer. It’s complex and can be confusing.
In my case, I had assumed that the increased risk of breast cancer associated with HRT outweighed the benefits, but this was because I had heard about a study published in the early 2000s whose data was wildly misrepresented. This study caused a whole generation of women to believe that HRT significantly increased breast cancer risk and was only to be used in the most desperate of scenarios. Luckily for me, I was able to critically assess the information that I had heard from older women in my community by seeking out additional data. I exercised an advanced component of health literacy that Australian public health scholar Don Nutbeam called “critical literacy.”2
Our ability to understand and apply health information in our own lives and utilize that information to make informed decisions about our health goes far beyond our ability to read or our proficiency in the dominant language. As we learned from the COVID-19 pandemic, this is especially true for health risks about which rampant misinformation is being circulated. During the pandemic, individuals with low digital health literacy, or the ability to find and use information online to make health decisions, tended to have lower intention to get vaccinated, according to an article published in Frontiers in Public Health. Health decisions are also more challenging when they have to do with to topics that people just don’t talk about enough, like the menopause transition.
Now that American popular media is starting to take up the topic of menopause, as discussed in a recent New Yorker article, it’s time to figure out how to make the information accessible and usable for the populations who have been left behind in this recent craze. There is a need for greater research, clinician professional development, and systems of health communication to improve health literacy for women in midlife from multilingual communities.
Scholars like Yamnia I. Cortés and colleagues are beginning to conduct research to assess this need in Latine communities, and they plan to continue their work by investigating menopause messaging strategies and educational formats for midlife Latinas. Over twenty years ago, Rima Rudd identified adult education as an important context for improving health literacy in multilingual communities as she endeavored to bring together the fields of literacy and health, and my colleague Maricel Santos continues to inquire how health literacy can be incorporated into adult English language education. Meanwhile, Pilar Ortega, the CEO of the National Association of Medical Spanish, is working to raise the health literacy of Spanish-speaking health professionals in their interactions with patients. Future programs focusing on women in midlife can build on this robust base of work in applied linguistics, public health, and clinician education.
Here in Kansas, we can start to increase health literacy in interactions about menopause by improving education in the health professions so that general practitioners, cardiologists, physician associates, and other health care professionals are prepared to answer questions about menopause symptoms and treatment with linguistic and cultural responsiveness. We can also consider the challenges that individuals from multilingual communities across the state are experiencing when they seek information about menopause, find out where they go for that information, and ask what they believe about menopause care.
The menopause workshop I attended at Evergreen in May was the start of a very important conversation. The community has questions, and that is a valuable first step. At Alce su Voz, we deeply appreciate the women who attend our events and the events of our sister organization Salud + Bienestar, and we hope to collaborate on work to address menopause health literacy in multilingual communities in Kansas in the future.
Alce su voz is a community-engaged program at Wichita State University whose mission is to improve health equity for speakers of Spanish and Indigenous languages in the United States, with a focus on Kansas and the Midwest. For more information or to get involved, please send an email to alcesuvoz@wichita.edu. You can also join our email list and follow us on Facebook, Instagram, LinkedIn, and YouTube.
- Health Literacy in Healthy People 2030. U.S. Department of Health and Human Services. https://odphp.health.gov/healthypeople/priority-areas/health-literacy-healthy-people-2030 ↩︎
- Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15(3), 259–267. ↩︎