Navigating the neglected transition: menopause care disparities in Pakistan and South Asia across a multidimensional framework of risk, stigma, and therapeutic innovation

Abstract

Menopause is a universal physiological transition yet one of the most inequitably managed health events globally. In Pakistan and South Asia, women entering menopause face structural healthcare gaps, cultural barriers to care-seeking, provider knowledge deficits, and limited policy attention. With a mean age at natural menopause of approximately 47 years, Pakistani women experience a prolonged postmenopausal period that may amplify cardiovascular, skeletal, and metabolic risks; however, formal menopause care remains available to only a minority of symptomatic women. This narrative review was conducted according to the Scale for the Assessment of Narrative Review Articles (SANRA) framework. Literature searches were performed in PubMed, EMBASE, Scopus, and Google Scholar from 1990 through March 2025. Thirty-five references meeting predefined inclusion criteria were included. The review synthesizes evidence across six domains: vasomotor symptom epidemiology, menopausal hormone therapy (MHT) controversies, cardiovascular risk, osteoporosis burden, sociocultural barriers, and non-hormonal and digital therapeutic approaches. Vasomotor symptom prevalence in South Asian women is comparable to Western estimates of 50 to 74 percent, yet treatment uptake remains low. Postmenopausal osteoporosis affects 20 to 49 percent of Pakistani women, with a substantial burden of osteoporotic fractures. Pakistan also reports a comparatively elevated age-standardized ischemic heart disease mortality-to-prevalence ratio among women, although this finding requires cautious interpretation given heterogeneity in regional datasets. MHT prescribing is influenced by persistent concerns following the Women’s Health Initiative findings, despite evidence supporting its safety when initiated within the appropriate timing window. Fezolinetant and investigational elinzanetant represent emerging non-hormonal options; however, equitable access in LMICs remains unresolved. Pakistan’s Lady Health Worker network and digital platforms such as DoctHERS represent potential pathways for community outreach. Addressing this gap requires coordinated action across policy, clinical training, community engagement, and digital health infrastructure.