Beyond hormones: How social factors shape perimenopause

Our study, published in Climacteric, the flagship journal of the International Menopause Society, examined how life circumstances shape symptom experiences in over 12,000 female participants worldwide.

Perimenopause is the term for the years leading up to your final period and the 12 months beyond. Hormonal fluctuations drive the symptoms many people experience during this time, including hot flashes, mood changes, poor sleep, brain fog, and others. But our new research shows that hormones don’t tell the whole story.

Flo’s science team, together with collaborators from the Mayo Clinic’s Center for Women’s Health, reports on a large global survey of Flo app members to better understand how social and economic circumstances influence perimenopause symptoms.

Measuring life circumstances and perimenopause symptoms

We surveyed 12,382 Flo app members aged 35 and over from around the world. Of this group, just over 1 in 5 reported being in perimenopause. 

We measured symptom severity using the Menopause Rating Scale (MRS), a validated tool that scores symptoms across three areas: psychological (mood, anxiety, sleep, and memory changes), somatic (physical symptoms including hot flashes, joint pain, and heart palpitations), and urogenital (vaginal dryness, bladder symptoms, and changes to sexual function). Higher scores mean more severe symptoms.

Our survey respondents also reported whether their household income was enough to meet their household’s needs, whether they had any problems accessing healthcare, and their highest level of education, as well as their race or ethnicity. 

Experts refer to these factors as social determinants of health, which are everyday circumstances that can influence our health in ways that have nothing to do with biology. 

Income, healthcare access, and education

Among participants in perimenopause, not having enough household income was the factor most strongly linked to higher symptom severity.

Those who said their income was not sufficient to meet their household’s needs had an average total MRS score of 19.6. Scores above 16 are considered severe. Those who described their income as more than sufficient had an average score of 14.4. 

“Flo members in perimenopause who are navigating financial insecurity report symptom scores that are, on average, five points higher on the Menopause Rating Scale than those who have sufficient household income. This difference reflects a shift from moderate to severe symptom burden, and we saw it consistently across physical, psychological, and urogenital symptoms,” said Yella Hewings-Martin, PhD, lead research scientist at Flo and lead study author. 

“It tells us that for many users, their perimenopause experience is shaped by the material realities of their lives, in addition to their hormones,” she continued.  

Difficulty accessing healthcare was also strongly linked with higher symptom burden. Among those in perimenopause who reported barriers to getting medical help, such as cost, lack of insurance, transport difficulties, or language barriers, the average total MRS score was 18.7, compared with 15.8 among those without barriers. After income, healthcare access was the second biggest factor linked with symptom severity in this group.

On the other hand, higher levels of education were consistently linked with lower symptom scores. Among participants in perimenopause, those with doctorate degrees had the lowest average MRS scores at 12.6, compared with 18.3 among those who hadn’t completed high school. After income and healthcare access, education was the third factor most strongly linked with symptom severity in this group.

Race and ethnicity: A complex picture

We also found significant differences in symptom severity across racial and ethnic groups. Among participants in perimenopause, and after accounting for income, education, and healthcare access, Hispanic/Latina, Black, and Asian users all reported significantly lower overall symptom scores compared with white users. These findings differ from some previous studies and may be due to the global diversity of our participants.

Note that because this was a survey taken at a single point in time, we can describe these associations but can’t say for certain what drives them. Possible reasons that might explain the associations include not being able to access care or afford treatment for symptoms, as well as having low levels of knowledge about symptoms and treatment options. 

The sample also skewed toward white, well-educated users with sufficient income and healthcare access, which means the gaps we found may understate the reality for those most affected.

“Our research adds to a growing body of evidence that perimenopause is a health equity issue,” said Liudmila Zhaunova, PhD, Flo’s director of science. “Income, healthcare access, education, and ethnicity are all linked to how severely people experience perimenopause symptoms. Of course, they are not the only factors at play, but they do clearly matter. We hope this work contributes to a shift in how health systems think about midlife female health.”