To improve women's health and longevity,  it will be important to increase global research, policy and programs on the health needs of midlife women, that is on women aged ~35-64. Midlife is a critical life stage during which women reach the end of reproductive life, transition through the menopause, and experience the onset of the chronic conditions and diseases of aging.

Although not all women experience bothersome menopausal symptoms, a significant subset of the population will experience bothersome hot flashes and onset or exacerbation of abnormal uterine bleeding, fatigue, sleep disturbances and other symptoms. Marked increases in menstrual flooding become a primary cause of hysterectomy. Furthermore, the endocrinologic transition that marks the end of reproductive life sets in motion a range of pathophysiologic changes, including bone loss and cardiometabolic alterations, that increase women’s risk of osteoporosis, fractures, heart disease, and mobility disabilities. Cardiovascular risks established during pregnancy are likely to manifest. Thus, clinical assessment and intervention to alter women’s risk profiles during this critical window are critical to promoting healthy aging. Yet research and programmatic focus on the midlife remains lacking, particularly in low and middle-income countries (LMICs).

Cohort studies of the natural history of menopause and midlife health conducted in higher income countries over the past two decades have greatly advanced understanding of menopausal symptoms and the differential contributions of aging versus reproductive aging to chronic disease risk.  Yet significant gaps remain in scientific knowledge including the determinants of the differential manifestation and timing of hot flashes, triggers for and conservative interventions for excessive menstrual bleeding, the shared pathophysiology that may underlie hot flashes and cardiovascular disease, and what accounts for fatigue. For example, numerous questions remain about hot flashes: Why do some women report hot flashes long before and long after menopause? Are these really “menopausal” hot flashes or are they attributable to different physiological processes? Why do hot flash frequency, severity and trajectories differ so markedly by race/ethnic groups? Data remain limited on marginalized race/ethnicities in most countries despite evidence that these women have differential risk profiles. Upwards of one quarter of women enter the midlife with a heavy symptom burden and compromised health potentially as a consequence of weathering, that is accelerated aging and health declines due to structural social, economic, and political marginalization.

Knowledge about the midlife experience in LMICs is much more limited, yet ensuring a healthy midlife transition is likely even more relevant for the longer-term survival of women in LMICs into old age. Many countries rely on the Demographic and Health Survey (DHS), or similar Reproductive Health Surveys, for information on population health. Yet, the DHS only interviews women aged 15-49 and thus provides no information on the contraceptive needs, maternal mortality risks, risk of excessive bleeding or cardiometabolic disease of women in their fifties. Not only are women in their fifties at higher risk of unintended pregnancies, they are also at higher risk of maternal death should they become pregnant. They also have significantly increased risk of cardiovascular events. Nonetheless, data are beginning to emerge from several smaller studies of menopause and its symptoms. As is true for menstrual morbidity, these studies suggest that, similar to what is observed in high-income countries, a meaningful subset of midlife women in LMICs do suffer from menopausal symptoms. Weathering is also likely to have taken its toll, making midlife a particularly critical moment to intervene and reset health trajectories.

In summary, to enhance women’s health and longevity, health policies and interventions will need to increase their focus on the critical period of the midlife. The development of a core set of menopause and midlife health indicators along with standardized instruments that have been cross-culturally validated would be an important step towards reaching this goal.