S4 E5: Dr Nighat Arif – Menopause and South Asian Women

Menopause & South Asian Women

Dr Nighat Arif

Masala Podcast
Dr Nighat Arif: Menopause & South Asian women, S4 EP5

The menopause is in the news & in this episode, I explore why the menopause is even tougher for South Asian women. I speak with the incredible Dr. Nighat Arif, who is a Family GP with a specialist interest in the Menopause, Women’s Health and Family Planning.

Our chat is about menopause and how taboo the subject is in our culture. In some languages, there aren’t even words for some women’s body parts. And, in some cases there are but they are used as swear words or considered as foul.

Girls growing up in South Asian culture are taught that speaking of pleasure, sex, menopause, or even just body parts like breasts, are taboo. This means that women are too afraid to talk about their bodily functions and it leads to so many difficulties in their lives.

For instance, the menopause has a big impact on a woman’s life and worklife; the menopause symptoms she experiences can be severe enough that many women leave the workplace because they can’t cope. They feel uncomfortable and they don’t have a safe space to speak about it. It creates a snowball effect, because these women are supposed to be in their prime, in managerial positions making the choices to prevent this from happening.

What makes it even harder for women in their 40s, is that our culture sees them as old. And when they are perceived as such, they are made to believe that they don’t matter any more.

Though, it is not just the stigma we need to break. Dr. Nighat Arif tells us that certain menopause symptoms or signs of symptoms can be a hint to bigger problems further down the line. In fact, according to her, people of colour go through a tougher menopause.

We need to talk about menopause! We need to teach our daughters from a young age the stages that their body will go through, what symptoms to look out for and when to see a doctor. We must take care of our bodies!

Listen to the full podcast and hear Dr. Nighat Arif talk about the menopause so that we can open up the conversation and bring awareness to young & older women in South Asian culture – and beyond.


Here is a small list of resources. If you have any others that you think would be useful, please share via email and I’ll add here.

Dr Nighat Arif on Masala Podcast: Transcript

Dr. Nighat Arif 0:00
Men will say oh they age like a good wine. Women, it’s like over the age of 30 and they’re like she’s done for, which is absolutely ridiculous. And now modern medicine, women have decided to come forward and break the taboo. Muslim women like myself are saying, this has got nothing to do with faith, okay? Your faith isn’t being tested because you have these horrific symptoms, what I need is treatment, and now women are demanding a change.

Sangeeta Pillai 0:40
I’m Sangeeta Pillai and this is the Masala podcast, the Spotify original. This award-winning feminist podcast for and by South Asian women is all about cultural taboos, sex, sexuality, periods, mental health, menopause, nipple hair, shame, and many more taboos. Join me around my virtual kitchen table, as I talk with some inspiring women from around the world, exploring what it means to be a South Asian feminist today. I interviewed Dr. Nighat Arif in a proper studio, and it was lovely chatting face to face. This conversation on the menopause and perimenopause is really important, because far too many women are still suffering.
Nighat is a family GP, specializing in women’s health and family planning. She is a regular on BBC Breakfast this morning on ITV and is the host of the Sunday Breakfast show on BBC three counties radio. At a young age, Nighat and her family moved from Pakistan to Buckinghamshire. Nighat still remembers arriving in the UK, shivering in a summer dress and flip flops because her father had said the weather would be warm in April. Well, that didn’t scar Nighat, and she still lives in Buckinghamshire with her husband and three children. I love how passionate Nighat is about menopause care. And I hope you enjoy this episode. Let’s talk about the menopause. First of all, let’s talk about why it is such a big taboo.

Dr. Nighat Arif 2:30
It is a taboo. And it’s been historically taboo because there’s a lot of stigma and shame attached to the symptoms that come with it. Women’s bodies are traditionally sexualized, and I’m going to call it for what it is we do have medicalized misogyny and the patriarchy that plays a huge role. And I don’t need to tell you about that or your listeners. The issue that we have is when you’ve got symptoms of vaginal dryness, or you’ve got symptoms of low libido, you’ve got issues around pain and aches and pains. And then you’ve got the psychological symptoms of the menopause. And there are over 41/42 different symptoms of the menopause.
The idea of us getting older is something that’s so hidden. And then if you transpose that into a community where women’s bodies or anything regarding gynaecological bits, so even a breast exam is sexualized or periods are sexualized, then you want to hide those changes that you’re going through in the midlife even more. And then on top of that, then you’ve got a shrouded internalized misogyny. So women don’t support women. And so they’ll say, well, I went through this, and I had no issues, why can’t you get through this? And so that shrouding of everything, staying underneath the veil remains. When a woman doesn’t support a woman, then you just stay silent, or everything that stays underneath a veil. So when that aspect remains, then there’s an area of silence.
And when there’s an area of silence, then I as the doctor don’t know. Because I learned from my patients and as researchers, as doctors, we only come across conditions or symptoms because patients come and tell us that’s the whole point of medicine. Medicine is not a science that always is an art. And so when a woman comes to tell me I don’t have that knowledge base as a doctor to say actually, all these symptoms could be related to the menopause. And the woman doesn’t have the knowledge base because the doctor says to her, oh, this is just getting old. I had a conversation in fact just two days ago with a woman, absolute intelligent lawyer, barrister, highly intelligent, grew up in this country and she goes to me to; Why do you talk about the menopause so much Nighat, it’s just getting old. It’s old age. You know, sadly, our grandmothers, aunts, our mothers went through this, and we never had an issue with it. Nobody ever spoke about it, and they’ve done absolutely fine. And they’ve lived till the age of 80.
My answer to that is this when we don’t actually recognize the symptoms, and a woman suffers and suffers in silence. So we’ve actually done a disservice to your mother, your grandmother, your aunts, and your cousins and all the women before you. And what we should be doing is not a disservice that carries on, because the symptoms are actually related to long-term complications. And now the data in the study shows that and the other thing that we found in South Asian communities is actually we are far worse off when it comes to the symptoms. So I’ll give you some statistics in the perimenopause, which is 10 years leading up to the menopause.
So that’s one year. So menopause is one year when you don’t have a period, perimenopause is you’re still having symptoms, and you’re having periods. So the symptoms are hot flashes, night sweats, irritability, palpitations, tinnitus, changing your smell, you get bowel changes, you get aches and pains, vaginal symptoms, recurrent urinary tract infections, and then the psychological symptoms that occur, loss of self-confidence, loss of self-esteem, loss of joy, depression, tearfulness.
And so those symptoms we know, especially when it comes to hot flashes, puts you at higher risk of having cardiovascular diseases, so women don’t know that actually, I can protect myself, 40 to 45 isn’t actually being old anymore. And when those symptoms occur, you’re impacted in the workplace. So one in ten women consider leaving their workplace. And you know what, that’s even more so within our ethnic minority and black women. So women are leaving the workplace because of this. Financially, they’re not getting up into the levels that they want to do.
They’re leaving their workplace where they could have had now the experience to have a managerial role, to be able to say, these are the changes that I want, but they leave. So, we’ve got a gap of individuals who aren’t filling those spaces, and there’s no inclusion where decisions are being made for you, because men are left or those that hang on our left. And so actually, we never move forward beyond that patriarchy beyond that misogyny, because it becomes the butt of all jokes. And the difficulty we have at the moment is that when you have all of this in a perfect concoction, it becomes difficult to talk about the menopause.

Sangeeta Pillai 7:16
Absolutely. And I think going back to something you said, so if within the South Asian culture, we don’t really talk about our bodies, we don’t talk about sex, we don’t talk about breasts and vaginas. And these are just never discussed. We don’t have words. And this is something we come up a lot like, I don’t know the word for breasts or vulvas in Malayalam or Punjabi, I’m sure. Maybe they exist, but it’s not part of our lexicon growing up.
So if you don’t refer to anything like this, how are you going to then talk about something that’s difficult within that like the menopause, right? Yeah. And I think the other thing that occurred to me when you were talking was that women thinking that, oh, if I’ve been through this, it’s a very- I think happens with other women as well-but particularly South Asian. Say, if you’ve suffered within a family or a relationship, you’re like, I’ve done it.
So these younger persons coming along now and saying that, oh, that doesn’t work. Like if I’ve done it, why can’t you put up with it, which is also another thing. And I just feel like it makes something that doesn’t need to be this difficult. And the other thing that struck me is like when you were talking about age, maybe our grandmothers at 50, their lives were pretty much over, maybe they had kids, they got married, very young, they had children, they had grandchildren, and they were considered old at that point. Like we women in our age, we’re in the prime of our lives, we’re working and we’re doing things and those who have got kids are in the middle of a very busy life.

Dr. Nighat Arif 8:46
And the concept has to change. For example, I don’t understand why we have this limitation within our mind that a woman that goes – Barapa is the word that they use. I hate that word. It’s such a horrible word to say aged. We use it in our language all the time. Yeah, we have a word for that. We don’t have a word for menopause. I mean, in Punjabi, it’s banji which means barren. We use English words to transpose them and it’s really awful, derogatory words to describe a woman’s vagina. We don’t have a word for vagina or vulva. I mean unless they’re really rude swear words.

Sangeeta Pillai 9:28
I don’t know in Malayalam what the words are, I’ve just heard the really rude words.

Dr. Nighat Arif 9:32
Same here and I don’t want to repeat those on a podcast because they’re offensive and that’s not how we should be limiting women to that because I’m sorry, but all of us came out of a vagina. There was a really lovely meme that I saw that said, you know, everybody has had this. So there’s a woman who says, my vagina is so precious that I’ve brought life from it. I’ve had enjoyment from it. And I’ve given my partner enjoyment for minutes. So why am I not looking after it? And I just thought to myself, that is so true.
In fact, we haul abuse at each other because of a woman’s genitalia. Maybe not to a degree that we use male genitalia, but we shouldn’t. And this this concept that if you’re over the age of 40, especially in the South Asian culture is, sex is no more. The idea that a 60-year-old or 70-year-old, or God forbid, an 80-year-old is having sex is like, oh my goodness, because what we do is we hide behind faith. And so when there are problems within those departments, they say you haven’t prayed hard enough, or you haven’t asked for forgiveness, or you’ve done something.
And unfortunately, we still have that within our culture, but missing the point, the fact that sex is so important, and it reduces so many other health conditions, and it’s vital for a couple. So, I often see Asian couples in my surgery, and the uncle will come in and he’ll say, to me, my blood pressure has been so high, my diabetes is out of control. And if you dig a little deeper, which I’ve started doing with some of my patients, and I’ll say to them, so how’s everything at home is your wife, okay? And he’ll say, well, no, we don’t sleep in the same bedroom anymore. She sleeps in a separate because she gets very hot at night. Or she’s always complaining of headaches, or she’s always complaining with aches and pains.
And that’s the other thing I realized that aches and pains, and pain is verbalize a lot more in South Asian women, or even black women because that’s seen as a physical thing. And it’s more acceptable. How many times have we heard that? Just growing up in our house where we’ve described a woman in our house as she’s lost her marbles? You know, she’s over the top. And unfortunately, I recognize that in my answer, my grandma, and I’m saying to everybody, this is the menopausal symptoms, like no, she’s getting old. And the concept that a woman should have a vitality or joy meant to her life, like men do. Men, we always say, oh, they age like a good wine. Women, it’s like over the age of 30. And they’re like, she’s done for, which is absolutely ridiculous. And now modern medicine, women have decided to come forward and break the taboo. Muslim women, like myself are saying, this has got nothing to do with faith, okay, your faith isn’t being tested. Because you have these horrific symptoms. What I need is treatment, and now women are demanding a change.

Sangeeta Pillai 12:24
When I was really young, older women seemed very old. I grew up in India, and we were taught that once you were past a certain age, your life was over. We were taught that as older women, all you could do was complain about your aches and pains and knit for your grandkids. And of course, pray morning, noon, and night. Because basically, you were just killing time. We were also taught that older women had no desires left for themselves.
That older women didn’t care about how they looked. They were supposed to wear really bland colours. Nothing too bright or attention grabbing. Okay. And older women were most definitely not meant to think about things like sex and orgasms. Hi, hi. I wonder if we could unpack for our listeners what the menopause and perimenopause is the various hormones that blend to it. Because a lot of women will say, Oh, it’s nothing to do with me. It’s like something that happens like most women that I speak to will say, Oh, it’s something that happens to really old women. Yeah, without really thinking about it, we’re all at some stage of this process. Yeah. And we’re going to have to find a way to understand it for ourselves, and also take steps to kind of fix it if there are issues. So could you just explain what this whole process is?

Dr. Nighat Arif 13:53
The first thing is, is there’s no age limit on menopausal symptoms. So those are symptoms that I recalled earlier. And you can have them with periods and without periods, if you just look at the definitions, and there is a whole range of definitions. So we have perimenopause, which starts roughly around the age of 40, the symptoms get worse, and you notice them around the age of 43 or 45. And so you have a reduction in oestrogen and progesterone. So those are the hormones that our ovaries produce.
Basically, our body just says to us, look, you’ve done your fertility years, now you don’t need these hormones, I’m going to reduce them because you’re in the next phase of your life. We transition as women all the time we go from birth all the way up to puberty and our hormones change and we start our period. And then when we’re in our period, we have pregnancies and every single time you have a pregnancy or breastfeeding, your boobs get bigger, then they go down again. And then your periods come back. So those are your fertility years. And then you hit the midlife which is when another transition happens because you’re past your fertility years now.
And so what happens is you get a reduction in oestrogen and progesterone and then testosterone as well, which is the third hormone. When you get a reduction in these hormones, oestrogen is really important. What it does is it, I always describe it as look, we need this because it lubricates our blood vessels. So from our head to our toe, around our heart, in our brain, around our kidneys, our gut, everywhere, it actually lubricates everything. Oestrogen is an immune modulator. So it helps your immune system fight off stuff. So we have difficulty fighting off infections when we’re later on in life. And so when these hormones are fluctuating this array of symptoms happen. And this can be a decade before you hit the menopause.
Menopause is one year without a period; post menopause is one year and one day without a period. But unpacking that further, you could go into the menopause really early one in 100, women go into menopause, below the age of 40. So the youngest girl is I think about 15. And she’s got primary ovarian insufficiency, basically the ovaries, we don’t know the cause yet, we think there might be a genetic cause or a biological reason. But the ovaries stopped working. So a 15-year-old in this country has menopausal symptoms. And then there’s such a thing as surgical menopause. Now, surgical menopause is when you’ve had surgery, to remove your ovaries or your womb, so known as a bilateral sailfin or oophorectomy and a hysterectomy. And if you have your ovaries removed, you’re plunged.
That’s it the day that you have it moved it’s straight into the menopause. And then we also have chemical menopause as well. So chemical menopause is we’ve given you something and say you’ve had some cancer treatment or something like that. And that’s plunged you into the menopause. And the symptoms arise because of that. So it’s not so straight cut is this is you know, old women. And unfortunately, it’s always packaged in a western voice. It’s rich, older women who are saying, look, I want my hormones. No, actually, this is a medical condition that happens to even younger women. And there are different facets to that. And that’s why HRT is vital for those women who are having a loss of their hormones.

Sangeeta Pillai 17:02
Absolutely. And I think this is something I really want to emphasize that it’s not something that happens to white women. It’s not something that happens to really old women, it’s going to happen to every single one of us. Yeah. And the symptoms – correct me if I’m wrong- can start from around 40. And things start to change, and oestrogen levels start to drop, and progesterone levels start to change, right?

Dr. Nighat Arif 17:25
And they don’t all come at once. Women don’t just find that they just happen. Our bodies are fabulous. So if you think back when you were going through puberty, you didn’t just suddenly one day start having your periods, you might have felt like that. But actually your body was subtly changing for maybe five or six years before that. So your boobs start to develop, you got a little bit of puppy fat around your hips, your hips started to develop as well, you might have noticed that your hair consistency was a little bit different, your skin had changed a little bit, your mood was fluctuating. And then suddenly, one day you saw red as you pull down your panties. That is a period.
The same thing happens on the other side of life as well. And the concept that we have is that when women say these symptoms happen, it must be something else. A lot of women that I see around 40s and 50s is when they’ve got stresses, they’re looking after their parents who are older. Everybody runs to the woman in the house, don’t they? I mean, I am a doctor, but I still find that everybody will come to the woman. No matter how illiterate she is, they will still go to her for advice, especially when it means maternal care and medical care.
If you’re looking after your parents, your kids are now older and you’re thinking I need to get them married off now. And arranged marriages still work in a lot of South Asian communities. You’re now finding your feet in your career, the career that you worked so hard for you’ve done your periods, you’ve done your pregnancies, and God forbid you might have gone through miscarriages and all the complications with birth. Now you’re on the other side and you’re in your 40s and you’re thinking right, I’m in my realm, I’m the most experienced person in my group. And then the menopausal symptoms gradually come, and we dismiss it because they all come as these hotspots symptoms and this is why we’ve always had a difficulty of actually diagnosing it or even doctors being aware of it and giving that a consideration as a differential diagnosis.

Sangeeta Pillai 19:14
And I think the thing that I wanted to talk about personally for me as well I’ve only just figured that I was perimenopausal about four years ago suddenly got hit by really bad UTIs constantly and kept going to the GP and he kept him on antibiotics and all the usual cranberry this that this that it’s only now that I figured actually it was perimenopause. And I think because we talk about it so little, that these now I know they’re fairly common symptoms, it’s not an unusual symptom to have recurrent UTIs. That’s like indicative of the menopause, perimenopause. I remember saying to my GP and he’s like, no, this is not it because, you know, your periods are normal, whatever. And I think it’s so important therefore, to kind of bring it back to the work you do. And to talk about the symptoms like you’ve talked about, to talk about the various hormones in our bodies, and the role they play. You talk a lot about HRT now within South Asian communities, the women that I’ve spoken to everybody goes, oh, my God HRT cancer. So it’s not just us then.

Dr. Nighat Arif 20:21
But its more so within our communities because we have even less knowledge about HRT. But I wanted to go back on something that you just said earlier, you said you got recurrent UTIs. And I think we’ve done a massive disservice in medicine when it comes to UTIs. It’s not seen as a sexy subject, you know, urinary tract infections, a cardiologist. I’ll tell you a very quick story, actually. And this is a side point, I was a medical student, and I was going on a ward round. And we had a very famous cardiothoracic surgeon. And surgeons have a huge ego about them. And cardiothoracic surgery is basically you do surgery around the heart to fix the heart, put it back into the chest.
So technically, the patient is dead for a little while all this surgery is happening. And then the patient gets better because they have lots of valve surgery and things. And we were doing a ward round, and this is back in the days. I mean, I hope they don’t do ward rounds like this anymore. And a long corridor of patients had been eagerly waiting for this consultant to come through. We all were chasing his coattails as medical students because you’ve got a whole team, junior doctors, registrar’s research students, and then you’ve got the piddly medical students, which is me sort of running after him as he’s doing his ward round.
And this gentleman puts up his head from the end of the bed, which is the patient, and he goes to the consultant, am I going to be okay out of this surgery, because I’m really scared about having this cardiothoracic surgery. And he looked the patient in the eye and looked around at our group and he goes, man, there are only two people who can save you right now, God or me, and frankly, God isn’t here. The ego and just the facade, and we all stood there going what. And that is so hot and sexy. To know that you can do a profession where you can literally put someone to death. And then you’ve got UTIs.
What do you do? I look at wee all day. So the concept that you have around what’s sort of hot in medicine and what gets funding, or it gets research. It’s so based on sort of this sort of ego and its ego, and when it comes to medicine, unfortunately. And so we’ve done a huge disservice to women, but there is a genital urinary syndrome of the menopause or vaginal atrophy, which as you lose oestrogen, and we’ve got oestrogen receptors everywhere, if you recall, I said look, it’s like a lubricant, we need it. We’ve got receptors everywhere. And we’ve got lots of receptors around the vulva and our bladder. And so that bit of skin needs that love and tenderness and care because when you lose that oestrogen, the receptors, they shrink in size, and they shrink around the bladder and the urethra where wee is from, unfortunately, well fortunately, our anatomy as women is that our sewage works, and our water works. And our sexual orifices are all exactly in the same place. And so what happens is you get transmission of bugs.
So E coli, which is a bug that lives very commonly in the back passage, will transmit if you don’t have that level of coliform or protection or the pH is out of balance. Hence why UTIs are so common in perimenopause. So if a woman is in her 40s I mean, I wish I could do this with every woman I would say to her look, as my birthday gift to you, to stop you from getting your genital urinary syndrome of the menopause symptoms such as vaginal dryness, Valvo splitting, you know overproduction of vaginal secretions, itching, soreness when you’re having sex, soreness when you’re having smears, or you know, prolapse symptoms, recurrent urinary tract symptoms, all of these symptoms are the GSM symptoms. I’m going to give you a vaginal oestrogen, vaginal oestrogen, HRT will replenish the skin cells in around the vagina and the bladder, makes sex so much easier, stop your UTIs stop this recurrent need of antibiotics, which makes you feel horrific. And that is the treatment for it.
How often do we do that? Never. Yeah. Like never. And the thing is, is there’s this fear around HRT, yes. So I wanted to unpack the next bit of your question, which was, why don’t we have HRT? Okay, so, HRT has gone through so many rigmarole and different things. There are three letters that just mean hormone replacement therapy. So we talked about hormones which fluctuate, and you basically deplete or get lessened, and all you’re doing is you’re just supplementing yourself with hormones. We do that with hundreds of other conditions.
So if you have a thyroid problem, and you’re not producing enough thyroid, what do we do? We give you thyroxin just to supplement what you’re not making, so your health is better. People who are type two diabetics, and they are having insulin resistance and they’re not having enough insulin. What we do is we give them insulin and in type one diabetics, we do exactly the same. It’s just supplementation of a hormone. All we’re doing with HRT is giving that back. But the problem that we’ve had is that because of lack of research, lack of randomized control studies, various studies, which have been now deemed to be inaccurate, have the headlines passed around a media.
So the WHI study showed that women who were in a synthetic soy artificial made oestrogen, they had a higher risk of breast cancer. Now, I wanted to unpack this a little bit because women don’t understand sometimes, I think, breast cancer, so your risk of getting breast cancer in the UK, according to Cancer Research UK is one in eight. So as you get older, because breast cancer is a disease of age, though your risk increases. Why? Because the oestrogen that we produces women works on the breast receptors. I’m touching my breasts right now, but I have lots of receptors in my breasts. And those receptors will change every single time I have a period. So your boobs become a bit sore and tender, where you get inflammation, you’ll get change, where you get change, you’ll get mistakes and cells.
And unfortunately, those mistakes can turn into cancer. So this whole thing about oestrogen receptor cancers, well, of course, because your breasts are loads of oestrogen receptors in there. So it’s a tragic diagnosis. And its life-changing and life altering for so many women. But what the study showed that women who were exposed to synthetic oestrogen will actually their risk increases. And then we had the million women study, which sounds like, oh, my goodness, they studied that many women. But actually, that million women study was a retrospective study. So what they did is they looked at older women in the study, and then just sort of picked out the fact that, oh, there’s risks attached to clots or there’s risks attached to breast cancer. But actually, it’s a disease of age. So if you’re looking at a woman over the age of 60, unfortunately, she’s going to get breast cancer, was it the HRT that she was on, or the fact that it was at age, a woman who’s a smoker, she is going to have a higher chance of breast cancer, or woman with a BMI or body mass index of over 30 has a 50% higher chance of getting breast cancer, a woman who drinks more than the recommended limits, so 14 units of alcohol a week, so if she’s drinking more than that, she’ll have a higher increase incidence of breast cancer.
So when you’re looking at studies, are you just looking at HRT that she’s on? Are you looking at the other lifestyle factors, lifestyle factors or age, body weight, are you looking at those factors as well? And unfortunately, what happened was that the studies showed that there were risks attached to it. HRT has moved on. Yeah, so hormone replacement therapy, we now know, there’s body identical hormone replacement therapy, such as patches or gels. And in younger women, so below the age of 60, or, you know, in perimenopausal age, if they start taking HRT, oestrogen HRT so as a patch, or as a gel, or a spray, then actually their background risk doesn’t increase? Yes, there’s a little bit of risk of breast cancer, but it doesn’t increase massively.
And in younger women who don’t have a womb, if they’re on oestrogen, only, then actually, their risk doesn’t increase, and they don’t die from HRT related breast cancer either. So in fact, you’re getting all these benefits, your quality of life is better, your rate of depression decreases, your rate of heart disease decreases. Now there’s even data suggesting it can be protective against dementia, and it’s a treatment for osteoporosis, which affects a lot of South Asian women. So those benefits, we need to be saying, look, these are the benefits of HRT and those risks that you’re there. Actually, the risks are there anyway.
And so do you want a quality of life? Or do you want a quantity of life? And so that balance, that risk and benefit has to be very individually tailored to a woman. And then on top of that, not just body identical transdermal oestrogen. We’ve also got topical vaginal oestrogen, such as veggie foam, or veggie rocks, and that topical vaginal oestrogen, the data and the studies have shown that they do not increase your risk of breast cancer and do not increase your risk of recurrence of breast cancer. So even if you’ve had breast cancer, you can be on topical vaginal oestrogen to stop things like recurrent UTIs.

Sangeeta Pillai 29:21
This is absolutely brilliant. And I wish someone had told me this five years ago, because you know these four years of this constant antibiotic.

Dr. Nighat Arif 29:29
We’ve done you a disservice, and we’re doing a disservice still because this message isn’t going out to Asian women and Black women. And there’s this health inequality. And I think this is why I talk about it, and I do get people going well, this is bisharim, why are you talking about bisharim things? Because who wants to hear about vaginas? But it gets me because like you say five years you struggled, and you didn’t need to. It’s heart-breaking and it makes me angry.

Sangeeta Pillai 29:56
It makes me really angry. I work in feminism, female pleasure, sex, whatever. But even me with all the reading that I do didn’t connect the dots. And even when I connected the dots, the GP didn’t take me seriously, because I was the one that said, I think maybe this is perimenopause, because I’ve read that UTIs happen. And they were like, no that’s not what this is. So, it just makes me really angry.

Dr. Nighat Arif 30:20
So if we look at that, and we look at the data around ethnic minority women who seek help in the NHS, actually, we are doing them a disservice. And I keep using the word disservice, it could be worse than that. But we know from the 10-year analysis of ethnic minority women, we know from countless maternity reports, for outcomes for black moms, you know, four- or five-times higher risk of miscarriage and death to black moms and complications. And we know that there is, I mean, the Sage report that came out in just in the pandemic, which showed that Black and Asian ethnic minorities were far more disproportionately affected by COVID. I mean, this is in our life. And then a two years ago, I’m not talking about something that’s even old.
The fact that we have these health inequalities is underpinned by institutionalized racism. That’s not even me saying it, this is Sage saying it. So when we know that there are issues, unfortunately, this is why we have even more the fact that ethnic minority women are far more disadvantaged when it comes to things like women’s health, and menopausal care and menopause assistance in the workplace, and just their quality of life. So then the statistics will come out and say, well, why are ethnic minority women for example, dying 10 years younger than their white counterpart? Or why are we having more mistakes in ethnic minority women? And I always get the same answer from the women that I ask, they say, well, the doctor didn’t take me seriously.
And then you ask the doctors, and you say, well, why aren’t you taking these women seriously? And they’ll say, but the symptoms didn’t fit the profile that I’m used to. Why? Because we are researching white western women. And we are trans-imposing them into our ethnic minority women and saying, but you’re all the same. I mean, women are women. I don’t know. Don’t get me wrong. I’ll ask you a thing. And guaranteed I’ll ask you any intimate gynaecological problem. Even if I wasn’t a doctor, you would tell me the truth. You will tell me I have this I have this sex is this. I have these issues. And I’ll say to you, what do you want from me as a doctor? You will tell me.
The problem that happens is that I’m blinkered because I will look at my Western book. So only now are we seeing coloured images of women in their pregnancy state or eczema rashes in black communities. I’m still trying to source a video of lichen plainness and lichen silicosis around the vulva in coloured women and I can’t find it in any medical textbook. That’s a textbook that I grew up with learning because it’s always Caucasian, white skin. So how dare we then as doctors say, well, actually, there’s fewer good outcomes for ethnic minority women. Because actually, what there is, is that there’s institutionalized racism because we’ve never shown doctors in this country what these are the symptoms. And it was only when I started tracking some of the women I look after because I worked in Slough and Southall.
And I had a colleague of mine, a Pakistani colleague who said to me, as a patient, I was coming in recurrently with Abdo pain, and it turned out it was endometriosis. And that’s another bugbear of mine that I have with my Asian patients, because I think there’s, it’s criminal, the fact that we miss endometriosis for seven and a half years and worse so in ethnic minority people, because there’s this concept that women of colour are better with pain, or they don’t feel pain to the degree.

Sangeeta Pillai 33:50
I can tell you; we feel pain.

Dr. Nighat Arif 33:53
It’s shocking. And that stems from times of slavery when you know, Dr. Sims who brought out the Sims spec, he was saying that they experimented on black women saying women don’t feel pain the way that white women do, and they have a higher pain tolerance. Look, that is utterly ridiculous. But unfortunately, I’ve heard that in medicine, and had a Pakistani colleague who said to me she always has pain in her stomach. And I was like what is this? Grown up in this country? She had come from Pakistan had done her labs and things and I said to her what is this. So women who come from our culture who come in, complained of head-to-toe pain, so they’re over exaggerating their pain. And I was mortified. And I’m not even talking this was years ago, this was what maybe three or four years ago and I was literally livid.
Because the thing is, is we have colonialism which plays a huge role in the way that we perceive women. Women don’t support each other. And we have this thing that the white individual who has taught us this medicine is the right way. So we don’t question it. So I took to Twitter, and I said, I’m seeing lots of Asian women who are in my clinic, and they come in and complain of aches and pains. They don’t complain a flushes. So if I say to a woman, do you get flushes, she’ll say, stand in the heat in Pakistan, it’s 45 degrees, you’ll know what a flush is.
Because the concept of flush is in there, but she’ll tell you about aches and pains. And so when you look at that, and you think, oh, my goodness, that is absolutely right. Because your symptomology is slightly different. And we’ve never documented this. And then I put this out on Twitter, and then I had loads of other doctors going. And doctors from India, Bangladesh, going we gey at the same thing because they don’t complain or flushes so much, but they have aches and pains, recurrent UTIs, loss of libido, loss of desire, mood related symptoms, because they’re older? And we ask them to pray harder? Isn’t that awful? It makes me so angry but how have we, one, allowed this as a society and in ourselves as women? You’re an incredibly intelligent woman, Sangeeta. I follow you. And I think you do immense amount of work and you’re not afraid to talk about anything taboo, which is why I adore you. But yet even you felt that the doctor didn’t listen to you. Exactly. Imagine a woman who doesn’t speak English.

Sangeeta Pillai 36:45
I was just about to say that I’m like, okay, I’ve looked it up and I read it up. I’ve done my research, but I still turn up and then when it’s a GP, it was a male GP, when he says, I don’t think that’s what it is. I say, okay. So why am I not questioning it?

Dr. Nighat Arif 36:56
We have that concept of internalized sort of power. The doctors always know everything. And so the one thing I always say, and I laugh at this, because I’ll get women who come and say to me, and they’ll be like doctors always know everything, and I’m like no, this is a conversation. Yeah, I am not right. Yeah, you have to tell me what you want. And they’ll say, but I don’t know what I want. And then the best consultation is you give them an option. And I show them all the options. And I’ll say HRT, no HRT, localized vaginal oestrogen, diet, and exercise.
Which of those would you want to try first, and then try it and then come back to me. And that is shared care. The shared care plan without concept doesn’t exist. But what’s happened is, is we’ve educated that plan as doctors in the NHS, to know what services to get to our Caucasian population. So then 10 years down the line, the Marmot report comes out going, oh, ethnic minorities do far worse outcomes. You’ve never taught the community how to use the services within the NHS. They don’t realize that they have 10 minutes. They don’t realize that actually, their interpretation services that they can have. Language is a barrier, then their cultural heritage is a barrier, then the shame that is attached to it. The fact that they might not want to see a male GP and they are waiting for a female GP the number of times, I still get messages from women going I’ve got a breast lump. And can I wait to go and see a female GP Dr.. Arif, and I’m like, no, you see anyone, like you need to get this tested.

Sangeeta Pillai 38:29
I remember my mother in her mid to late 40s. And I remember how she also constantly had UTIs just like me. I remember her curled up in pain with a hot water bottle in bed. She drinks gallons of boiled barley water because that’s what the doctor told her to do. And of course, take those endless rounds of antibiotics. This carried on for many years. My poor mom. No one had told her about the menopause. So she suffered year after year after year. I really hope that the next generation of women are looked after better by their doctors and by society.
There’s something I want you to touch upon is the psychological impact of the menopause, which I don’t think we talk about so. Most women think menopause, they think hot flushes, right? That’s the thing that and if you don’t have the hot flushes, they’re like, oh, clearly I don’t have the hot flushes. So I’m not perimenopausal or menopausal. But that’s not truth at all as all the things you’re saying. But I think the psychological impact is something that’s really not discussed. So suddenly, like and again this happened to me. And now looking back I can put it on together. So four years ago suddenly depression anxiety out of nowhere, and it was like a car crash is what it felt like. And speaking to other women who’ve experienced similar things, again, it’s the perimenopause, menopause. Can you talk to us a little bit about the psychological impact of what happens when the hormones change?

Dr. Nighat Arif 40:19
Yeah, of course. So perimenopause at 10 years before you hit the menopause. And even in the menopause, one in four women will say I had no symptoms. Two out of four women will say I had some symptoms, with some psychological symptoms. One in four will feel suicidal. And I’ve seen that I’ve seen that walk through my door, where a woman is at the end of her tether, she has probably been to different GPS at the practice, and they’ve offered it antidepressants.
And she’s not because she’s actually just going through perimenopause, she’s on her knees and she’ll say, I wanted to drive the car off a cliff yesterday, or something stopped me or the sound of my kids’ voices. And that breaks my heart and it’s horrific. And it’s even more horrific the fact that we don’t acknowledge this within our community and the psychological symptoms, as you were saying, are overbearing, so it’s that low mood, tearfulness, the memory fog, you don’t remember things so well, you lose confidence, lack of self-esteem.
You don’t feel sexy, so your libido is not there. So you don’t want anyone to touch you or talk to you, irritability, anger. I went to a wedding recently as we came out of the pandemic. And now obviously now, I’m not so blinkered anymore. But I saw so many women, and they were just angry for no reason. They’re just irritable and angry and wafting a fan. And I was just thinking that this is menopause classic. And then they’ll say, I’m Insomniac, can’t sleep, the sleep symptoms is horrific. Because if you’re not charging your batteries, you’re feeling awful the next day.
And then on top of that, you’re so on edge, that you feel like this is never going to end, it’s 10 years of this. And how is this going to end because the hormones are fluctuating, oestrogen lubricates blood vessels around the brain. So we now have realized, I mean, we knew that our hormones affected our mood. We know that for our fertility years, we know it affects pregnancy. We know that very well. We’ve got so much stuff around how to look after your mental health and pregnancy. What do you think the woman just falls off a cliff at the age of 40? Why are we doing this for perimenopause, it’s ridiculous.

So we don’t really care about your surplus to access. So those psychological symptoms are worse. And for some of my patients, actually the only thing that they get are psychological symptoms. So the first line treatment, and this is according to NICE is that we should be offering women HRT hormone replacement therapy and getting their oestrogen level balanced, right? It is not like the silver bullet. I’m talking about HRT is, you know, all the benefits of it. I don’t want the listeners to think you know what, this is amazing. This is what I need, but it’s a part of the jigsaw, a great exercise, great diet, weight bearing exercises, which help the mental mind and also your physical strength as well. And talking to friends, seeking help when you need help. And those are the things that you should be resorting to first.
Unfortunately, because there are so many myths and fear around HRT, which we talked about earlier, doctors don’t want to prescribe it. Women don’t want to take it. I actively get women who come in and going no I don’t want to have HRT at all know because a, they don’t believe that they have psychological symptoms, number one. And b, they don’t believe that this is the menopause, they think it’s just because they need to pray harder.
And I keep coming back to this because this is a concept that I constantly get as an overtly Muslim woman who wears a hijab. Allah said that even in our faith, it says, with medicine, you have to do the both of them. They’re not either or. And so this concept has to be constantly challenged, even with the fabric of our community, that if you pray harder, you’ll get better or it’s a punishment. It’s not because now we do have modern science. And modern science, if you really want to say, well, this comes from a lonely way, this comes from God.
I’m a person of faith so I would have these conversations quite openly but those who are agnostic or don’t have faith. I mean, I know that these conversations will be very difficult, And we need to constantly challenge our concepts and our understanding behind that, because unfortunately, we do package in our culture, faith culture, with mental psychological symptoms.

Sangeeta Pillai 45:12
They are linked, isn’t it?

Dr. Nighat Arif 45:13
They are linked.

Sangeeta Pillai 45:14
So you’ve got so many amazing things you do. You’re on TV talking to us, you’re on your TikTok, you’re a GP. And I think before we started everything, I don’t know how you pack all of this in. But outside of all of these amazing things, is there anything else coming up that you want to talk about and share?

Dr. Nighat Arif 45:32
I do have some amazing projects, but I can’t tell too much. So please do follow me on my social media, or don’t follow me. But I will have some projects coming up. And will hopefully have a book coming out at some point as well. And more stuff with my TV work. But the core bit and this is I think the most significant thing is that my first love, and don’t tell my children this, oh, my husband is clinical medicine. At the core of it, I am an NHS GP. And I think that I will find it very hard to ever move away from that. So for me, the greatest thing is, is I still feel relatively like a baby in GP land. And I still feel I don’t know, enough. You know, it’s like the more you educate yourself, the less you know. So I’m in that sort of phrase of mind at the moment that I feel the more I do stuff, the less I feel I know about stuff. It only recently occurred to me that in the British Sign Language, women who are deaf, don’t have a word for menopause.

Sangeeta Pillai 46:42
Oh my god.

Dr. Nighat Arif 46:43
How crazy is that? The British Sign Language has words for everything, but not menopause. And we started doing telephone consultations in general practice. So how do I communicate with someone who’s deaf on the phone because they couldn’t come and see me. So there’s some work hopefully going to be done around that. So it’s things like that, that I just think oh my goodness. And I have a passion for learning and understanding things constantly. So no doubt, I’ll be learning a new skill at some point.

Sangeeta Pillai 47:17
I have no doubt that you’ll be doing an incredible thing, even more than you already are. And I can’t wait to see and hear all the wonderful stuff that I know you will be creating. Thank you so much, Dr. Nighat Arif today for being on Masala podcast.

Dr. Nighat Arif 47:30
Thank you for listening.

Sangeeta Pillai 47:31
It’s been an absolute honour and a joy to have you. I’m Sangeeta Pillai. Thank you for listening to the Masala Podcast, a Spotify original. Masala Podcast is part of my platform, Soul Sutras. What’s that all about? Soul Sutras is a network for South Asian women. A safe space to tell our story, to hear inspiring South Asian women challenging patriarchy, a space to be exactly the people we want to be and still feel like we belong in our culture, and our community. And ultimately, a space where we feel less alone. I’d love to hear from you. So do get in touch via email at soulsutras.co.uk or go to my website, soulsutras.co.uk. I’m also on Twitter, and Instagram. Just look for Soul Sutras. Masala podcast was created and presented by me Sangeeta Pillai produced, by Anushka Tate, opening music by Sonny Robertson.


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