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21. Latin American Culture & Menopause with Dr. Gabriela Alvarado
63 Plays9 months ago
September is Perimenopause Awareness Month and October is Menopause Awareness Month!! And we are diving into all things perimenopause and menopause.
Did you know that in Costa Rica, hormone therapy for menopause is available through the Caja Costarricense de Seguro Social (CCSS) as part of its universal healthcare services? Women who are covered by the public healthcare system can access medical consultations and treatments, including hormone therapy, for menopausal symptoms. What a wonderful resource for women.
In this episode of Our Womanity with Dr. Rachel Pope, I am joined by Dr. Gabriela Alvarado to discuss perimenopause and menopause within the Latin American culture.
Dr. Gabriela Alvarado is a physician and an associate policy researcher at RAND who focuses on maternal health and sexual and reproductive health using a reproductive justice framework. Her research includes the use of innovative qualitative and community-centered approaches to understand and address drivers of disparities in different reproductive health outcomes such as contraceptive uptake, breastfeeding, maternal morbidity and mortality, maternal mental health, postpartum depression, access to health information (and misinformation), and access to abortion. Prior to RAND, she has worked in primary health care delivery, the health nonprofit sector, state government, and as a consultant for the Pan-American Health Organization.
She obtained her medical degree from the University of Costa Rica and has a masters in public health and anthropology from the London School of Hygiene and Tropical Medicine and Georgia State University. She completed her Ph.D. in policy analysis from the Pardee RAND Graduate School.
Featured in this episode:
- How different languages may not have a name for menopause or hot flashes
- Traditional roles for Latin American women
- Increase in various conditions once women move across the border to the US
- Lack of diversity in menopause research
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- Twitter: @drrpope
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Transcript
Introduction and Guest Background
00:00:00
Speaker
Welcome back everybody to ARWO Manatee. I am so excited to have Dr. Gabriela Alvarado here with us today. She's a physician and an associate policy researcher at RAND and she focuses on maternal health and sexual and reproductive health using a reproductive justice framework.
00:00:16
Speaker
Her research includes the use of innovative, qualitative, and community-centered approaches to understand and address drivers of disparities in different reproductive health outcomes, such as contraceptive uptake, breastfeeding, maternal mortality and morbidity, maternal mental health and postpartum depression, and access to health information and access to abortion. So you can see why I like her and why I want her to be on the show today. She's got a lot of expertise. She obtained her medical degree from the University of Costa Rica,
00:00:45
Speaker
and has master's in public health and anthropology from the London School of Hygiene and Tropical Medicine and Georgia State University. She completed her PhD in policy analysis from the party-ran graduate school. Of course, her views do not necessarily reflect those who employ her right now, but I think she's got excellent training and expertise to speak to menopause and the Latina population. and That's what we're going to be talking about today. so Welcome, Dr. Alvarado.
Menopause in Diverse Cultures
00:01:11
Speaker
It's great to be here.
00:01:12
Speaker
So tell us a little bit about your work and your experience and your research. I feel like, you know, the narrative that we see so much about, even though it's finally now coming to light for people to talk about menopause in general, the narrative that we typically see is that of the white woman. And I would love for our listeners to hear more narratives than just that. So I would love to hear from your experience and your research what you've found about menopause and paramenopause. Yeah, absolutely. I think drawing a little bit about kind of like the history of medicine and anthropological perspectives, it's only very recently that we really even understand a lot of what's going on during menopause. Like sex hormones weren't discovered until like the 1920s, which I'm sure you already know. And before that, it was like some, you know, interesting perceptions and ideas of
00:02:00
Speaker
what menopause meant and like back with like Greek philosophers and with their ideas of illnesses being a manifestation of imbalances and the humors, the whole idea of menopause. If you're no longer bleeding, that blood is accumulating and kind of going up to your brain and that's why you're kind of going a little bit loopy.
00:02:23
Speaker
And I feel that that idea of this association of menopause and mental health issues is like this stereotypical trope. And it carries over in a lot of like Westernized cultures. And it seeps into other environments. Also, it seeps into Latin American countries at a lesser degree. But I think that the predominant stereotype that manifests here, I think But one fascinating thing about menopause is that it is an objective and so subjective thing both at the same time, right? Like objectively, you can measure hormones, you can pinpoint the absence or presence of something But it's also a very subjective experience. And it's not something that we all experience in the same way, not even women within a certain demographic or culture or country all experience it. And there's all of these things that kind of feed into this, this menopausal experience, right? There's the physiology and the biology of yes, okay, there's no more estrogens. And we know those have
00:03:29
Speaker
direct impacts on our bodies, but there's also overlapping issues and from just the natural cycle of our life. There are other things that are also happening at that same time that don't necessarily have to do with the hormones, but are coinciding. You know, we're starting to see if we chose to have children, we're starting to see them leave our home. That has kind of like this compounded effect. You may be sad about your children leaving your home. Maybe it's not that you're depressed because you're a menopausal, but but it just kind of starts overlapping. And then you have like these just general ideas of role transitions, you know, who am I? um And, you know, like now with more women embedded in the workplace, it also means transitions in roles in the workplace. Am I working? Am I not working? When do I stop working? And all of that kind of,
00:04:20
Speaker
feeds into our experience of how we feel this process and this period of transition. yeah ah So I think more and more we see this realization, at least in Western cultures, of like it's not a deficiency disease, it's part of the life cycle process. right But there's other cultures that haven't really problematized it the same way that it's been done here. and So there's this very famous anthropological study done in Japan, trying to understand the experiences of post-menopausal women. And it's really interesting because they don't even have a word for hot flashes. Wow. that will That's crazy. They don't have the word for hot flashes. I think there's other languages is also in other Asian cultures. I think it was in Indonesia maybe. They have like this very long, it's like almost a sentence of like eight words to describe a hot flash because it's like a very descriptive, like a period of excessive heat. but and and There's no concise term, which kind of speaks to the fact that people don't really associate
00:05:26
Speaker
their menopausal experience with this particular symptom, right?
Cultural Variations in Menopause Experiences
00:05:30
Speaker
And having the words to draw from to explain these things and to add labels to our symptoms and experiences really shapes our experience. And that's like a big tenet of anthropology, right? Like we shape the language, but the language that we live in also shapes our experiences. The languages and the words that we have to describe what we're feeling are also going to influence how we're feeling. If we're feeling in a particular way and we don't have the words to express that we might kind of start feeling less that way because we don't have a way to pinpoint what that is or explain it or write it. And so in this study in Japan, they just had very, very few women report that they were having hot flashes. And when they explained their their experience with menopause, they have a word for menopause. Okay. But
00:06:21
Speaker
when they describe the symptoms they attribute it more to the fact that they're just aging and so they're like yeah it's like all of these aches and pains that come along with like having gray hair and your eyesight becoming worsened and it's this period of aging and they associate it less with like I stopped menstruating like that was it and that's why I'm feeling all these things they're like yeah I have headaches yeah my joints ache and yeah I'm tired and sometimes I get sad but that's because I'm getting older and I'm aging
00:06:58
Speaker
So it's really interesting to see how like this whole universe of of symptoms just looks very different depending on what the norm is, what we're kind of told this process is, the stereotypes that exist, and whether we kind of feel like we can fit it within those boundaries. So yeah, the the experience really is defined a lot by the socio-cultural environment that we're in. But I feel like that explanation also falls a little bit short in that it's not just the society or the culture that we're in and the explanations, but there's also like an extra layer of equity that I feel maybe isn't as addressed.
00:07:35
Speaker
But there are also a lot of disparities within unique cultures, and we see that here in the US. Within our same country, we see a lot of different experiences and a lot of different ways of coping with this and impacts to how we receive treatment, how we experience the disease depending on racial and ethnic conditions, socioeconomic status, all these other things. So it's like so many layers that feed into this menopausal experience.
00:08:04
Speaker
yeah that it just makes it a very unique and interesting process. That's so interesting. And, and you're totally right looking at the culture and how things may influence it. And then, you know, at the language and influencing the symptoms, because if you don't have a word for it, then maybe you don't think that's something that you should be expecting to start happening in your early fifties. It's fascinating. and So I know your experience is mostly with Latina women living in the US and Latina women outside, I guess in Latin America, women in Latin America. What have you noticed with their experience of perimenopause and menopause and the culture around it? Yeah, absolutely. I think my first encounters with menopause in general was practicing as a primary care doctor in rural Costa Rica and just encountering women that were coming in for their annual checkup and, you know, seeing on their medical history that they were doing hormone therapy and kind of figuring out what the next steps were. and i think That was one of my first kind of understanding like the cultural environment where that was set because in med school, you know, I just learned the guidelines like, oh, if this age, if that, it's uterus, no uterus, this dose. And for the first time, I was kind of embedded in, in this environment where I was in rural Costa Rica.
00:09:25
Speaker
First week in Latin America, there's a lot of machismo culture. And so there but is this idea of, you know, the woman being kind of in service to the man. Right. So it's, you know, the woman. It's hard to generalize. and I don't want to, you know.
00:09:40
Speaker
stereotype, but the the role of the woman is traditionally in the home. You have children. Your job is to have sex with your husband. and If you're not having sex with your husband, then he's going to go find that somewhere else. So a lot of these women that were come to me were terrified of losing their husbands during this period.
00:10:01
Speaker
That was their main concern and they were really clinging on to hormone therapy in trying to deal with issues of loss of libido, vaginal dryness, all of these things because they were terrified that if they could not provide the sexual encounter for their husbands on a regular basis, they would lose their husbands and they would end up the alone. Really, it was really hard and it was really challenging because the particular clinic that I worked with had a really high rotation. We had new doctors coming in almost every year because it was a mobile clinic. So it was exhausting. And what would happen was there was a little bit of a loss of continuity of care. And so people would just kind of keep prescribing what was being done and never really sit down and reassess. And I was encountering, you know, women 75 years old who had been on hormone therapy
00:10:55
Speaker
before 20 plus years. yeah And trying to have these conversations of, you know, there's there's a point where we need to start weaning you off this ideally a long time ago, but you shouldn't be on this because you can start getting to a point where the risks might outweigh the benefits. right And it was a really difficult, challenging conversation because there were all of these other expectations of what's going to happen if I'm not taking these hormones.
00:11:23
Speaker
This is blowing my mind because I feel like in my cultural context, I am constantly telling women, empower yourselves, start vaginal estrogen so you can enjoy sex again. Take it. Yeah. It's all about like taking matters into their own hands. And yet if I were to say the same thing in another cultural context, like the one that you're describing, I might actually be feeding into a completely misogynist. culture or like expectation of women, right? It's like, yeah, it's really my mind right now. Yeah. And I think, you know, and it it's like, it all depends. Like I've read other anthropological studies where when women get to that point, they see it as a relief. They're like, Oh my gosh.
00:12:05
Speaker
I've been waiting for this moment to come. I no longer have pregnancy scares. I don't have to buy menstrual products. I don't have to like all of these things. Women sometimes also talk about kind of getting like an elevated status in society because elder outranks women, right? Like, you know, like there's men and women not on equal grounds, but you do as a woman, if you enter this status as an elder in a society where elders are valued and appreciated and protected, then you do have like a little bump in status in your society. So it's something that also a lot of women look forward to.
00:12:47
Speaker
Yeah, no, that makes sense. So tell us a little bit about your work with the feminist center in
Community Work and Health Training
00:12:52
Speaker
Atlanta. You know, it sounds like a really interesting center, first of all, but tell us about the work that you were doing.
00:12:58
Speaker
Yeah, so I started volunteering with them back in 2016 when I was in grad school in Atlanta. They're a really great nonprofit organization. They are a women's clinic and also do a lot of advocacy around destruction and reproductive health. And they have this one program that's called Lifting La Kinga Voices. One of the things they do is they train lay community health workers that are termed promotores, which means like promoters of health.
00:13:25
Speaker
And these women receive training from the center on different things, like for example, birth control, prevention of sexually transmitted diseases, other like well women issues, and they are embedded in their community and so they can kind of direct people to appropriate resources.
00:13:46
Speaker
And earlier this month, I did a training with them on menopause because they hold the steering wheel and so they kind of feed back to the center what they hear in the community. And so they kind of lead the charge and they say, we're hearing this, so we need to be trained on this so that we can provide. servicess And one of these issues was was menopause, which I i found really interesting because I very rarely hear people talk about menopause. yeah And they were all like really interested. They wanted to be well informed. And the first half of our training was kind of a little bit of sharing experiences and talking about it. And one really fascinating thing was that most of them, there's like,
00:14:24
Speaker
a mix of ages, but a lot of the younger women, like maybe like 20s, 30s, they said they have no recollection of their mothers going through menopause. It was kind of very hush-hush, like not talked about, like you don't say anything about it. And so then they were like, I have no reference point to what is normal or not normal in a menopausal transition, because that was just not spoken about in our homes.
00:14:51
Speaker
And I thought about that and I found it really fascinating because it is part of like this whole just general perspective about how we just sleep menstruation under the rug, right? We just never talk about it and people get very uncomfortable and we don't talk about it when we get it for the first time. And you have to be all hush hush about it. And if you're going to walk to the restroom and you need to change a pad, you need to hide that pad and scrunch it up in your hand. No one can see your bad. Even though half of us menstruate every month. You can't see my bad. And it's just this pattern of hiding anything menstruation related. I think the only time we ever are kind of allowed to publicly talk about like this menstruation type event is childbirth.
00:15:41
Speaker
Right. Outside of childbirth, you can never discuss like blood coming out of your vagina. It's just completely not acceptable. And so I thought it was really interesting because then there just really was no, no reference point, no parameter. and And they talked about, you know, like we see media portrayals. Yeah. But we don't understand. And so I think to your point, right, like this, what happens here in the US, I think is very dictated by media portrayals, by stereotypes. And so you start seeing this phenomenon, which is really interesting, where women that come from other countries like Latin America,
00:16:17
Speaker
they come to the U.S. and after being embedded in this cultural environment for a bit, they start kind of having statistics that are more similar to white American women than their counterparts in their countries of origin. And you see this with all sorts of things like age to menopause, changes when you've been living in the U.S. for a while versus like, and it's the same, you know, genetic make makeup, we just moved across a border.
00:16:43
Speaker
yeah And we came here. So yeah, so we'll see like all of these changes in different conditions, how they're expressed and manifested from our countries of origins to here. So it happens with breast cancer, cervical cancer, moving over here seems to be a risk factor in and of itself. And it has all these, yeah it's the healthcare system, it's the diet, it's the jobs that we do. like Yeah, all these things. And so menopause is is also one of those where, you know, we cross over and it changes a little bit in comparison to to our countries of origin.
00:17:15
Speaker
That's so interesting. Would you postulate that you know a woman from Costa Rica would be seeking hormone therapy, like more would be more likely to seek hormone therapy in Costa Rica compared to if she moved to the US and we're living here now? Or do you think just the reasons are different? Or I guess what I'm getting at is like the medicalization of menopause, more to do with our American culture, or is it just different?
00:17:44
Speaker
I thought of something that I hadn't thought until now, but I think another big difference is access to care. There's universal healthcare in Costa Rica. So then that presents less as a barrier for women seeking care. So I feel that in Costa Rica, people people people love when people love the healthcare system. we We're very proud of it. yeah And people are very used to going to their primary care doctor and getting medicine because pro bunative care right like we yeah Yeah, we have this system, like I have access to it, it costs me nothing. So why wouldn't I take advantage of it? And so there's also like a high level of trust okay with the healthcare care system, which I think is very different than it is here.
Healthcare Access and Trust
00:18:30
Speaker
Once you come over here, I've done like focus groups and interviews with Latin American women who have come here and a lot of women have different migration statuses. And so if that's also kind of like a disincentive to maybe, unless it's an emergency, you might not want to kind of go to the doctor because maybe you're concerned about other things. yeah There's, you know, the costs as well, because in Costa Rica, you get hormone therapy, it costs you $0. Wow.
00:19:00
Speaker
Whereas here, depending on your insurance, right that might not be affordable. And if you have to pick between all these things in your home versus, you know, sucking it up and having some symptoms here and there, like you might not be able to afford it.
00:19:16
Speaker
I mean, even the appointment, right? Like, I can't even tell people what to expect to have to pay to see me as a patient, no less than what their medication is going to cost. It's just something that is so variable from person to person because of their insurance. Yeah. So I can imagine that it would be a deterrent, unfortunately. And thinking also about like the trust of the healthcare system, you know, like here in the US, there's many instances of pretty horrendous things being done to different populations. And so there is that bit of a baseline distrust of the health system. ah
00:19:52
Speaker
medications in general, we we see it risk with like the COVID vaccine, I think is like a really good example that kind of highlighted yeah the deep mistrust that people have. And, you know, something like hormone therapy, I think is a prime candidate for kind of pulling up that. Not sure. Yeah. Yeah. And then you, you know, throw in a language barrier. I always spent a little bit of time in, you know, other hospitals, not where I work currently, where there was a much larger population of Spanish speaking patients and just witnessing how informed consent was done. It was challenging. And, you know, I don't want to disparage what I saw other people doing necessarily, but I just felt like it was not the same as if, you know, both people were speaking the same language. And we do have.
00:20:38
Speaker
interpreting and translating services we have available in most hospitals. But I think when people are running from task to task and trying to have someone just sign a consent, unfortunately, there's a language barrier. I i think it people don't necessarily always get the information that they deserve. and Even the sensing process, if you think about it like from the perspective of a patient, it's so
Conclusion and Future Research
00:21:01
Speaker
overwhelming. right There's there's so much so much going on. When i've been patient when I had my baby, like a lot of things during my birthing process didn't go ideally. and Now, in hindsight, I'm like, I should have said this, I shouldn't have said that, but you just can't. You're in another place.
00:21:17
Speaker
Yeah, no, you're totally right. It's really challenging. Well, this has been fascinating. I would love to talk to you about all these other reproductive stages of lives because of your expertise in all of them. But you know, there's such a huge need for women's reproductive health research for advocacy. And I love the work that you're doing. And thanks for shedding light on menopause and pairing menopause, Latin American women and Of course, I know there's so much more information that's out there and more stories need to be told, but I love kind of at least starting to open up that conversation. So thank you for your time. Yes. Thank you for inviting me, Richa. And I think, yeah, most of the research, unfortunately, to date has been done by men. So we need more women to come in do research on these important topics because we kind of have an interesting point of view. Totally. I completely agree. Oh, thank you so much.